By Kelly Teal
While not every instance of healthcare-associated infection (HAI) can be pinned on staff hygiene, too many occurrences can be attributed to the very people who are supposed to protect patients. And that is why the reality of insufficient attention to handwashing, PPE donning and doffing, and other areas of infection prevention, remains so baffling. The big question is “why” – why do some staff cut corners when they well know the consequences of not adhering to standard processes for basic hand hygiene and activities such as PPE donning/doffing? The answers vary but often boil down to one simple reality: human nature. People get in a hurry and take the chance that no one is watching them, says Mary Lou Love, MSN, RN, the veteran director of infection control for Doctors Hospital at Renaissance in Edinburg, Texas. For starters, people generally adhere to requirements for a while and then fall back into their old ways. “I think, like anything else, you start off, then get to the point that it is working, and then a couple of months go by,” Love explains. Since infection control – which has limited resources – tends to oversee compliance monitoring on a regular basis people “go back to their habits” without constant enforcement, Love says.
Thus, when it comes to determining the most effective approach to ensuring compliance with infection prevention rules, there are different schools of thought. Does motivational work best? Or punitive? Or a mix? Love, who holds multiple years of experience in the field of infection prevention, has found there’s only one way to go: Zero tolerance. “There are consequences,” she says, adding, “This form is certainly not motivational but it works.”
At Doctors Hospital at Renaissance, the first time someone – including doctors and surgeons – is caught not washing their hands, for example, that person is sent home on a “non-compliance” notice. The second incident results in a verbal warning, followed by one in writing. The third time, notification goes up to the director, and the person who committed the infraction is again written up and then sent home without pay. That last part really stings. “No one wants to affect their salary,” Love says.
But improving compliance rates requires effort from more than just the infection prevention department. Other facility leaders, from directors to executives, need to be on board, Love says. “We need buy-in by directors, not only in infection control, but administration needs to back us up,” Love says. If these key influencers do not support compliance endeavors, success will be difficult, if not impossible, to achieve. “We can do all the monitoring and reporting, and we are back to non-compliance” without the backing of these professionals, Love says. When directors do help enforce infection-prevention compliance, outcomes tend to improve. That’s because the various warnings become part of the employee’s record, “and annual evaluations and raises will be affected,” Love says.
All of this applies even – or especially – to the cream of the crop: doctors and surgeons. “Medical staff needs to say to MDs, ‘You will be suspended after so many times’,” Love says.
Additional methods for ensuring compliance help although they are unlikely to fix the root of the problem.
Securing volunteers to serve as “secret shoppers,” keeping an eye on hand hygiene and PPE technique, improves compliance rates, at least temporarily. There simply are not enough volunteers to go around on a consistent basis and when people leave the role, their impact will be obvious. “We had 76 percent compliance last year,” Love says. “This year we started with 90 percent compliance. Then we lost our secret shopper. This was how we were getting our true numbers.”
Short of having an infection preventionist or other human monitor present in every room at every surgery or food serving or IV check, and so on, hospitals should have fallback safeguards in place. Love recommends hanging signs and placing sanitizer stations, fully stocked, throughout the facility. On top of that, she says peer pressure helps boost infection-prevention compliance. Again, however, that only goes so far as people with seemingly less-important titles, or in different areas of specialty, may be less likely to call out their superiors. For example, “MDs tend to get away from [compliance] because nurses are afraid to tell them,” Love says.
Next, keep imparting to staff the message that slacking on hand hygiene, as one critical example, could hurt someone workers, of all levels and ranks, love. “It could be your family that is getting the blood stream infection, etc., because you failed to wash your hands,” Love says. “It’s such a simple way to enforce prevention of infections.” At Doctors Hospital at Renaissance, Love hammers this home during the education health fair. The infection control department shows a film where a patient is admitted and eventually dies because staff did not wash their hands along the way. “This was shown to every nurse,” Love says of the film’s debut. “At the end I said, ‘This could be your mother, daughter, best friend. It’s in your hands. I ended my presentation with, ‘And of course, not on my watch.’”
Still, Love contends, hospitals need to start replacing monitoring by the infection control department with electronic means, and soon. “The staff know us, they see us coming, they start washing their hands,” she says. But obtaining these types of tools is hard because finance departments turn down requests due to cost, she adds. As long as that refusal continues, hospital administrators should expect infection-prevention compliance numbers to fluctuate. “They should know that until we have the electronic tools…and backup to do this with our recommendations, this will continue to be a problem,” Love says.
There is another option that could fill the gap. Psychological intervention has shown promise in rewiring human predilection for cutting corners and it is less expensive than buying new equipment.
Five years ago, Jaggi, et al. (2013) concluded that focusing on the power of the mind and improving psychological competencies in infection preventionists can boost compliance and reduce HAIs. Researchers deduced this after discovering that non-compliance goes back to psychological barriers, preconceived notions, cultural influences and ineffective time management – not lack of resources or knowledge.
To find out how the brain factors into infection-prevention compliance, researchers had a psychologist teach soft skills and focus on harnessing the power of the mind for better time management and team collaboration. Once study participants (infection control team leaders) underwent lectures and simulations, 10 of the 12 (83.3 percent) came away with higher behavioral competencies. These improvements particularly showed in the following areas: powers of negotiation; ability to get along with peers, juniors and seniors; leadership skills; communication skills and emotional intelligence.
In addition, in all other, separate parameters considered for assessments, participants showed a significant increase (p<0..05). Most importantly, researchers observed a positive correlation between the growth in competencies and compliance with infection control guidelines and, thus, a reduction in HAIs. Researchers further concluded that this approach is cost-effective and rational. That cost-effective part is key, especially for facilities that don’t have the budget to buy the electronic tools Love suggests.
Reference: N Jaggi, P Nirwan, E Naryana and KP Kaur. Poster presentation P187 at the 2nd International Conference on Prevention and Infection Control (ICPIC 2013): Harnessing the power of the mind to reduce healthcare associated infections - a cost effective approach in low-resource settings. Antimicrobial Resistance and Infection Control 2013, 2(Suppl 1):P187 doi:10.1186/2047-2994-2-S1-P187