Behavior modification and infection control

What are the key concepts related to behavior modification and infection control?

Behavior modification is the use of empirically demonstrated methods to improve or change behavior. There are generally three primary levels of influence related to behavior modification and infection control in healthcare facilities: 1) Intrapersonal factors (e.g., individual characteristics – healthcare personnel knowledge, skills, attitudes, perceptions); 2) Interpersonal factors (e.g., friends, peers, role-models); and 3) Institutional or Organizational factors (e.g., rules, policies, norms, culture). Including these three levels of influence in infection control interventions is key to prevention efforts in healthcare facilities.

What principles of behavior modification are necessary for effective infection control?

On an individual level, healthcare personnel (HCP) should have the necessary knowledge, skills, and abilities to implement effective infection control practices. Research suggests that increasing the knowledge base of HCP may influence their perceptions and motivate them to change behavior – this includes providing access to information that supports learning and problem solving activities.

However, increasing knowledge alone may not be sufficient for effective infection control and may be insufficient to effect sustained change especially considering the multi-factorial nature of the problem of healthcare-associated infections.

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Use of skill building, peer-to-peer role modeling, and champions on an interpersonal level have been shown to positively influence implementation of key infection control practices.

On an institutional level, healthcare facilities should work to foster organizational attributes such as leadership support, interdisciplinary teamwork, and communication. In addition, efforts should be made to promote HCP job satisfaction.

Efforts also should be made to engineer and implement systems throughout the organization that prompt, reinforce, and facilitate best practices (e.g., prescribing practices) so that infection control and prevention is embedded in all aspects of care.

This includes providing the necessary resources so that HCP have reliable and easy access to supplies (e.g., alcohol-based rub). Healthcare institutions need to implement sustainable systems that promote shared knowledge and provide HCP with an architecture that prompts and facilitates appropriate behavior (e.g., antimicrobial stewardship decision systems).On the inter-institutional level, there is some evidence that interfacility collaboration, such as participation in multicenter quality improvement collaboratives, can influence organizational learning and organizational culture in ways that facilitate improved infection control practices among HCP.

What are the consequences of ignoring behavior modification and infection control?

Studies have found that HCP factors such as knowledge, attitudes, and perceptions (e.g., perceived benefits and barriers) are likely to influence changes in behaviors and practices of HCP. If HCP do not have the necessary knowledge to perform appropriate infection control practices and/or perceive that there is not a problem or they are not at risk (personally or to their patients), then infection prevention practices may be compromised.

If a healthcare facility lacks role models or champions, appropriate HCP infection control skills may be limited and best practices to prevent healthcare-associated infections may not be consistently implemented.

Having weak or poor levels of organizational culture factors (e.g., leadership, teamwork, communication) also have been shown to be risks for infection control problems and adverse patient outcomes.

What other information supports the conclusions of studies on behavior modification and infection control, e.g., case control studies and case series?

There is limited quantitative data regarding behavioral modification and infection control published to date. There are however a few large studies that purport success for preventing infections through behavior modification but the causal link and association between the modified behavior and the infection control area of interest are not well established. For example, data from a large multicenter collaborative cohort study which included daily goals sheets to improve clinician-to-clinician communication and a comprehensive unit-based safety program to improve organizational culture resulted in a sustained reduction in the rate of catheter-related bloodstream infection of 66% at 16-18 months after implementation.

In addition, a program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a significant and sustained decrease in healthcare-associated MRSA transmissions and infections in VA hospitals nationwide; ‘Positive Deviance’ was the approach recommended to achieve culture change with a goal that infection control and prevention would become the responsibility of everyone involved in the care of patients at the VA.

Summary of current controversies.

The use of technology to monitor individual HCP behavior is currently an area of controversy raising potential ethical questions regarding privacy. Studies are underway using electronic medical record logs to reduce observer bias in monitoring HCP behavior.

A number of electronic monitoring devices also have been utilized with more under development. Many of these use technology such as radio-frequency identification (RFID) or motion sensors to measure adherence to recommended infection control behaviors (e.g., hand hygiene). However, these approaches can be expensive and create a number of both technical as well as ethical challenges. Access to data, confidentiality, and HCP privacy issues remain unresolved.

Mandates for infection control practices are becoming more common both nationally and locally. Mandating appropriate behavior such as influenza vaccination is an area of controversy and may result in penalty and/or disciplinary action (to the facility or individual HCP) with some viewing such measures as an invasion of civil liberties. Another controversy in the area of behavior modification and infection control is patient empowerment with questions focusing on issues such as the potential impact on the patient-HCP relationship. Several articles have been published outlining the behavioral considerations surrounding patient involvement or empowerment as a strategy to improve HCP hand hygiene behavior with accompanying tools to facilitate change such as the Centers for Disease Control and Prevention’s Hand Hygiene Saves Lives video.

What are the key conclusions for clinical trials and meta-analyses that inform behaviour modification and infection control?

There are no clinical trials, meta-analyses, or case-control studies specifically related to behavior modification and infection control. There are, however, many studies published to date that relate to infection control and modifying an associated behavior, such as handhygiene (please note reference list). In addition, there are several references available regarding organizational culture in healthcare. Below are selected examples of studies that support important concepts in behavior modification. The examples are presented by level of behavioral influence (intrapersonal, interpersonal, and organizational) noting that no one level of influence is truly mutually exclusive of the other. See Table I.

Table I.
Study Design/Methods Summary
Giblin, 2004, Arch Intern Med. Focus groups and survey Perceptions of the problem are important: Clinicians were significantly more likely to perceive that antimicrobial resistance was a problem nationally than in their own institution or practice.
Whitby, 2006, Infect Control Hosp Epidemiol. Focus groups and survey Attitudes regarding risk of infection are a behavioral determinant: Guided by theTheory of Planned Behavior, nurses handwashing intention was modeled and behavioral determinants were reported such as belief in both the risk (‘hierarchy of risk’) and benefit of the activity.
Bouadma 2010, Intensive Care Med. Surveys Knowledge matters: A multi-faceted program to improve compliance with VAP-prevention behaviors in a MICU was implemented and knowledge was assessed; education had its greatest impact on HCP with the lowest cognitive profiles, suggesting that targeted interventions to improve infection control behavior may be more effective.
Erasmus, 2009, Infect Control Hosp Epidemiol. Focus groups and interviews See one, do one, teach one: A qualitative study across five hospitals in the Netherlands assessed behavioral determinants of HCP hand hygiene using Theory of Planned Behavior as a framework with the lack of positive role models among and social norms established by senior HCP serving as a barrier to behavioral compliance.
Jang, 2010, Infect Control Hosp Epidemiol. Focus groups Set an example: HCP from a large acute care tertiary hospital in Canada reported that other HCP adherence to hand hygiene influenced their own hand hygiene behavior. In addition, few HCP reported feeling comfortable reminding and encouraging others to practice prevention behaviors such as cleaning hands.
Damschroder, 2009, Qual Saf Health Care. Interviews (sequential mixed methods study) Champion a cause: Telephone interviews were conducted in 14 hospitals during the first phase followed by six site visits and additional interviews. Types and numbers of champions reported varied especially with the type of infection control practice implemented. For practices that require significant behavioral change, a coalition of champions was recommended.
Griffiths, 2009, J Hosp Infect. Literature review Leadership is essential for infection prevention: Majority of studies reviewed were observational and direct evidence was limited for the relationship between organizational factors and infection control outcomes. However, across the different studies, positive leadership was cited as a necessary prerequisite for effective infection control behavior.
Jain, 2006, Qual Saf Health Care. Hypothesis generating study using small tests of change Every HCP has a voice in infection prevention: Lessons learned were shared following changes in the system of care in a medical-surgical ICU that focused on a team decision making process (welcoming input from every team member), administrative support and physician buy-in; however, culture change was not directly measured in this study.
Saint, 2010, Infect Control Hosp Epidemiol. Interviews What makes a good leader?: A series of qualitative interviews across multiple US hospitals evaluated the behaviors of successful leaders in infection prevention and found that they were those who cultivated a culture of clinical excellence and effective communication to HCP, were solution oriented and focused on overcoming barriers, thought strategically but acted locally, and were inspiring so as to motivate HCP.
Controversies in detail.

Many efforts to measure HCP behavior and adherence to recommended infection control practices require direct human observation. However, this approach is not only labor intensive but can be subject to observer effects that affect both the reliability and validity of the measurement. A number of new technologies have been created and are under development to directly measure adherence to HCP behaviors such as hand hygiene. These methods allow for direct and quick collection of data as well as report generation and feedback at either the unit or individual level. However, controversies remain at this time including but not limited to ethical and privacy concerns. Unintended consequences of HCP behavior being monitored should be noted and safeguards employed to protect HCP privacy (e.g., data only to be used for reporting hand hygiene and not for punitive actions related to individual HCP performance).

Furthermore, there is little published data on whether these new technologies are sustainable and how these technologies are perceived, accepted, and used by HCP. Transparent communication with HCP about the intended use of the data and addressing any concerns regarding privacy (e.g., “Big Brother”) is recommended. Successful implementation of any new technology is dependent on the acceptability by the HCP who use it and therefore further development and field testing is necessary before deployment can be recommended.

While involvement of patients in hand hygiene programs for HCP has been demonstrated to be effective, and also promoted and incorporated into national campaigns, one evaluation found less than a third of patients and public wanted to be involved. Further study of the approach of engaging patients is required before its widespread application will result in acceptance. A barrier to consider is the applicability of this approach when there is a seriously ill patient who may be ventilated and/or unconscious and who is often at most risk of cross-infection. Furthermore, whether patients reminding HCPs that they have to perform hand hygiene before care would interfere with the patient–HCP relationship remains to be properly assessed.

Mandates for infection control practices are becoming more common both nationally and locally and is an area of controversy. Discussion continues around the ethics and legality of mandates for infection control behaviors. For example, some have argued that mandatory influenza vaccination is coercive and a potential ethical invasion of civil liberties which may negatively impact the HCP employee-employer relationship as well as divert focus away from other important infection control behaviors (e.g., hand hygiene, use of face masks, staying home when sick). While others, such as the Society for Healthcare Epidemiology of America (SHEA), have endorsed such polices citing examples of healthcare facilities across the United States that have moved successfully to a mandatory influenza vaccination policy (e.g., requiring influenza vaccination of HCP as a condition of employment) achieving HCP vaccination rates >95%.

On the other side of the ‘carrot-or-stick’ controversy, the use of positive reinforcement and motivating incentives (e.g., chocolate bars, monthly prizes) in changing HCP behavior has been recently shown to be an effective strategy for improving hand hygiene compliance. The controversy continues as to how best to modify behavior and the appropriate balance between positive reinforcement and negative consequences (e.g., holding HCP with “repeated violations” accountable for their actions [inactions]).

What national and international guidelines exist related to behavior modification and infection control?

Many national and international guidelines exist related to infection control and prevention with several emphasizing the importance of behavioral modification whether the change involves antimicrobial prescribing practices or hand hygiene.

The 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections recommend using “hospital-specific or collaborative performance improvement initiatives in which multi-faceted strategies are “bundled” together to improve compliance with evidence-based recommended practices.” This includes a focus on institutional culture with feedback to the clinical teams as well as buy-in from leadership.

The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings outlines several factors that may affect the transmission of infectious agents in healthcare settings, including a safety culture where leadership makes infection prevention an institutional priority.

The 2006 Guideline for the Management of Multidrug-Resistant Organisms (MDROs) in Healthcare Settings also recommends the importance of both administrative support and education with the focus on interventions that encourage a change in behavior through improved understanding of the problem of MDROs and creation of a culture that supports and promotes prevention.

Furthermore, the 2002 Guideline for Hand Hygiene in Healthcare Settings and the 2009 WHO Guidelines on Hand Hygiene in Health Care both discuss in great detail the influence of behavior modification on the infection control practice of hand hygiene detailing the importance of multi-level, multi-modal, and multidisciplinary behavior change strategies.

What other consensus group statements exist, and what do key leaders advise?

Groups such as the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Disease Society of America (IDSA) have proposed a call to action to move toward the elimination of healthcare-associated infections which includes improving both individual and organizational accountabilities through leadership support at the highest levels, education and engagement of HCP, feedback, and local and statewide collaborative efforts to share best practices.

An essential component noted in this call to action was the influence of leadership and the importance of an organizational culture of safety in the healthcare facility which allows HCP to feel empowered in infection prevention efforts. In addition, the Institute for Healthcare Improvement (IHI) continues to advise on the integration of behavioral modification strategies in to their healthcare-associated infection prevention activities while using their models for organizational improvement.


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