The Awkward Feeling campaign: confronting poor hand hygiene to improve handwashing
A student workshop identified that a new system of ‘supporting, shaming and blaming’ would encourage healthcare professionals to wash their hands
Dean David Holyoake, PhD, MSc, PG Dip N, BSc (Hons), BA, Dip CPC, Dip Child Psychol, PG Ed, RMN, is a senior lecturer, University of Wolverhampton.
Holyoake D (2010) Rethinking traditional hand washing learning. Nursing Times; 106: 35, early online publication.
This article describes how a group of third year child branch student nurses at the University of Wolverhampton examined they way they perceived hand washing. During a three day workshop aimed at focusing on healthcare improvement, the students moved from regarding hand washing as a simple act of hygiene, to see it it as a social behavior, which is part of a larger organisational system.
Through analysing cultural messages, themes and the idea of organisational power, the students developed a new way of thinking about what health professionals do with their hands. All the anecdotes featured in this article are reflections from the students (whose names have been changed to protect their anonymity).
During the Hand Washing Experiment, the students challenged traditional health promotion messages - which focus on how the individual can make a difference – and explored how organisations allow cross infection to persist. The result was a collection of reflective accounts and socially orientated, hard-hitting posters.
Keywords Hand washing, Health promotion, Healthcare culture and systems
- This article has been double-blind peer reviewed.
What we learned from the ‘Awkward Feeling Campaign’
- There is a hierarchy of hand washing offenders across all locations;
- Some professionals will always claim to uphold the rules, but simply don’t;
- Hand washing is associated with voluntary and individualistic behaviour;
- Effective hand washing practice could be encouraged by giving it more of a ”community” emphasis so that it becomes the norm among healthcare social groups.
The Hand Washing Experiment was a module evaluation at the University of Wolverhampton. It was part of an initiative coordinated by the NHS Institute of Innovation and Improvement, which was established in 2005, with the purpose of promoting best practice in the NHS (Department of Health, 2005) and consisted of a three-day active workshop, during which the 22 students were asked to think about poignant issues they had encountered on their clinical placements.
From all the possible issues, the topic of hand washing soon dominated discussions. Each of the students had experienced at least seven clinical placements as part of their training and had a good understanding of many professional issues in healthcare, including hand washing. With the help of the author, they set about defining and analysing the improvement issues related to this seemingly straightforward and topical practice issue. It quickly became apparent that given the atmosphere and space to be critical, a spontaneous and infectious creativity flourished. This empowered the group to consider hand washing as something more than just the usual act of cleanliness and of personal responsibility to self and others.
More than just cleanliness
The workshop progressed into an analysis of how this seemingly individual behaviour can be analysed in terms of organizational rules and policies. This analysis involved morality, ethics and metaphysical philosophy, matters that cannot necessarily be proved through science or empirical observation.
Removed from the physical domain that hand washing tends to occupy, the students were able to engage in a type of community practice learning through exploration similar to Lave and Wenger’s (1991) model of situated learning. In the contained space of the classroom they were able to explore personal, unchartered territory. As Claire stated: “Once I’d decided to do a poster I just wanted it to be hard-hitting and thought provoking - especially when compared to the usual ‘dross’ you see in A&E departments.” Sally noted: “I started to realise that organisational culture has more of an impact on how individuals behave than I had originally thought.”
The two initial aims we focused on during the workshops were to re-think the motivators usually associated with hand washing and to produce personal accounts that reflected the different ways of thinking about it.
Typical thinking about hand washing
According to mainstream thinking and many healthcare professionals, the National Audit Office (2000) provides incontrovertible evidence that infection control is a cornerstone of good clinical practice and quality patient care (King, 2005; Storr et al, 2005; Teare et al, 1999). However, for many - including the students - it remains a mystery as to why so much good and long established knowledge is frequently ignored.
Each student produced a written account of how they had witnessed healthcare professionals failing to follow hand washing procedures and policies. Examples of their accounts will be familiar to many healthcare professionals (see box 1). However, it is in the fine detail of these accounts that the students were first offered a different insight into infection control and hand washing. This ”eureka” moment came from the idea that it is not necessarily the behaviour of individuals, but rather the relationship and nature of an individual’s position within organisations and that organisation’s culture that have the biggest impact on what healthcare professionals do. As Jane said, individuals need to feel empowered to be able to “tell other professionals, regardless of their superiority, to wash up”. This challenges many of the fundamental assumptions of autonomy, individuality, organisational power and free will posited in much healthcare thinking.
When Jill started to read some of the students’ accounts of hand washing she realised, “there was an alternative way of looking at infection control”. Similarly, Sam noted: “I used to think nurses and doctors were totally autonomous and did things because they cared and had a choice, but then I got to thinking that there might be more to it than just that.”
The “more to it” is the idea that individuals are defined and constructed by their environments. On the second day of the workshop, the students decided to explore the issue of systems and free will. In 2001, evidence based guidelines for infection control were published that highlighted the behaviour of individuals as being central to policy (Pratt et al, 2001). However, for the Hand Washing Experiment this questioning of free will was a huge leap to take, because it alluded to a new way of thinking about hand washing for the students.
Systems theory, power hierarchy and hand washing
Ideas about infection control and hand washing are not new. Contemporary references are available about protective agencies and administration of policies (Department of Health, 2002), traditional routes of infection control training (Tew et al, 2002) and personal and organisational competencies (King, 2005). The students considered how these ideas impacted on the nature of the nursing role. The main considerations were condensed into five basic premises about hand washing and infection control:
- Not all infections are preventable;
- Some infections are worse - in process and outcome - than others;
- Hand washing reduces the risk of cross infection;
- All NHS trusts should have policies and procedures regarding hand washing;
- Hand washing is simple, good practice and easily implemented.
“Of course, this leaves us with the question: why do so many healthcare professionals regularly neglect to wash their hands? Are they imbeciles, forgetful or too busy? Or is there a lack of washing facilities?” asked Jane.
Storr et al (2005) noted that the documents: Winning Ways (DH, 2003) and the Matron’s Charter (DH, 2004) outline the above broad areas and their importance in the control of infection. Jarvis (2004) stated that these documents highlight how implementing the above five points is the best way of enhancing patient care. There is also no shortage of important healthcare legislators emphasising the basic five premises, including the World Health Organization (2004), which stated that hand hygiene is the main player in the prevention of cross infection.
The availability of guidelines and scientific evidence seems to have a mixed effect on the way healthcare professionals behave. But by reframing our thinking about organisations as “systems” it is possible to provide a critical analysis different from the usual ideas about personal motivation and hygiene. Sally offered an analysis of why professionals put patients’ lives and their own at risk. “Because on a busy ward it’s one of the last things that you think of… it hasn’t got a particularly high status profile in the scheme of things… and there’s never enough peer pressure.”
The students quickly concluded that the lack of hand washing (perceived from reading each other’s accounts and from their own experience) could not be solely attributable to the usual reasons why professionals don’t wash their hands, such as being too busy, lack of facilities or forgetfulness. They began to consider the idea that collective and organisational rationale could offer a useful model to understanding a professional’s behaviour (see box 2). This highlighted the theoretical and everyday nursing real life effects of power, hierarchy and disciplinary esteem afforded to particular professional groups, such as doctors.
Even though there is a wish for professional equity and collaboration between healthcare professionals as highlighted by Goodman and Clemow (2008), there is also no doubt from the students’ accounts that multidisciplinary team (MDT) inequalities exist. Many students noted that some mentors, as well as doctors seem to act in a way that shows they are in the words of Jill: “at the top of the power tree, but at the bottom of the hand washing pile”.
The Institute for Healthcare Improvement (2005) refers to several measures being important for multidisciplinary teams when thinking about infection control. It states: the first priority is the production of a tool that adapts the principles of root cause analysis for the area of infection control; the second is the creation of tools and recommendations for raising patient confidence in hospital cleanliness levels; and the third is providing guidance on a “whole system” approach to infection control. For the students, these measures were about everything being “awkwardly red” – a colour that commonly symbolises danger, anger or blood.
Students taking part in the workshops felt that better hand washing practice would be encouraged if people felt embarrassed about allowing others to neglect hand hygiene. They also believed that a hand washing campaign should focus on the subtle and awkward interactions professionals have, which allow for those with differing degrees of social power to highlight and disapprove of bad practice. The overall idea was to provide an easily assimilated and pragmatic way to focus on the difficulties of social confrontation.
The ‘Awkward Feeling Campaign’
The theme that continued to drive the workshop by the third day was that organisational systems could have an impact over and above the autonomy of individuals. As Emma pointed out: “It’s a lot easier to blame individuals for not washing their hands. But when you as a student nurse are put in a position to have to ignore and therefore condone other people’s behavior it’s bad - just because you’re scared of being told off, failing or embarrassing the ward manager.”
These ideas developed into a main theme of ‘awkwardness’ and the obvious symbolism of ‘red embarrassment’. The ‘Awkward Feeling Campaign’ as it became known centered on the idea that if an individual’s behaviour is a result of systems, then a new system of ‘support, shame and blame’ offers an alternative approach. “It’s not about making the individual feel awkward about their behaviour per se, but the fact that they allow others - because of the system - to behave poorly by feeling powerless to confront the lack of hand washing behaviour,” said Beckie.
The campaign highlighted how simply telling practitioners to behave differently doesn’t always work. Instead, we all need permission to confront each other, irrespective of our social position. It is no longer the action, but rather the interaction that might make for better future hand washing practice.
The social norms of being polite were exploited by the campaign. Students openly criticised the maxim: “All cross infection can be eradicated by the simple washing of hands”, because in their experience the aggressive pursuit of rational and logical policies were unsatisfactory. The central question of whether peer pressure and even good old fashioned ‘shaming’ motivates people to wash their hands between patients and clinical areas led the group to consider issues to do with morals, personal ethics and the impact of the organisation on the behaviour of its employees.
The practice points (see box) formed the foundation of a poster campaign developed by the students. Many posters featured the word and/or colour red, to give them maximum impact. For example, one featured the slogan: “See red – but blind to infection”. Another depicted a nurse challenging authority with the words “I don’t care what type of consultant you are! I do care that you wash your grubby hands!”
Much has been written on the subject of hand washing. But the ‘Awkward Feeling Campaign’ offered a different way of exploring this well worn subject by being fairly honest about the idea that human beings always act in the best interests of others.
Currently, the governance of hospital hygiene is founded on the discretion of individually motivated spates of well meaning behaviour. Students involved in the campaign concluded their main achievement was being able to recognise the community responsibility of hand washing. No matter how mechanistic we attempt to make healthcare it must involve people, and people make mistakes and disrupt the best informed systems.
Through participating in the workshop the students learned that no matter what they are told, they are just a small part of a big system. This system has a habit of neglecting the fact that students often feel powerless, are sometimes intimidated by authority figures and can feel unable to make a difference when it comes to other people’s actions. The students were also able to explore just how powerless some healthcare professionals feel over such an obvious professional standard as infection control.
We learned that it is possible to take a seemingly straight forward subject such as hand washing and look at it in a different way. Most of the students had seen it as a personal responsibility, while some practitioners did not. The workshops allowed students to consider how individual practitioners interact with and relate to the organisations in which they work. It also enabled them to make reflective accounts and to produce hard hitting posters (although these have yet to be deployed).
The students learned that the way multidisciplinary groups interact and the power they constitute within systems has far more of an impact on behaviour than we generally give credit. Perhaps the simple act of hand washing could be promoted by creating environments where professionals are allowed to gently confront one another.
Box 1. Hand washing: the student experience
“It was on a neonatal ward when the doctors were on a ward round. They were going to a mother who had twins. The consultant walked into the room and went straight to the patient, but the mum stopped him and said that he needed to wash his hands before assessing her two babies. I think that the mother was empowered enough by the hand hygiene being very effectively done by the ward sister.” Jessie, student.
“During my placement on the neonatal unit I found that infection control was extremely good. The nurses on the unit are extremely strict and ensure that when anyone comes to the unit they must wash their hands and remove coats. I also observed nurses doing an audit on how often doctors washed their hands.” Ana, student.
“At my last placement there was a sign near the entrance advising all those who enter the ward to wash their hands using the alcohol gel provided. However, no one who entered the ward used the gel because it was sited too high at head height!” Kelly, student.
Box 2. Why professionals don’t wash their hands
- Colleagues ignore and condone their behavior;
- Hospital hierarchy transposes clinical care needs;
- Culture promotes a sense of ‘more important things’
- Professionals are duped by local and national guidelines into under-playing the impact culture has on individual behavior;
- Culture sends mixed messages.
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