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FOCUS ON TOMORROW RESEARCH FUNDED BY WORKSAFEBC

Measuring the Effectiveness of a Hand Hygiene Campaign on Health Care Workers’ Knowledge, Attitudes and Intention to Comply with Hand Hygiene Guidelines March 2007 Principal Investigator/Applicant

Dr. Elizabeth Bryce

RS2005-SC09

WCB Final Report Measuring the Effectiveness of a Hand Hygiene Campaign on Health Care Workers’ Knowledge, Attitudes and Intention to Comply with Hand Hygiene Guidelines Dr. Elizabeth Bryce (Principal Investigator) and Co-Investigators Leslie Forrester, Anne Mediaa and Linda Kingsbury March 31, 2007

Table of Contents Main Research Findings and Policy/Prevention Implications

2

Executive Summary

3

Final Report

6

Research Problem / Context Purpose and Objectives

6 8

Methodology Study Participants Social Marketing Intervention

8 9 9

Research Findings Poster Contest Analysis Distribution of Campaign Promotional Items Staff Surveys Survey Respondents Poster Effectiveness Awareness of the Importance of Hand Hygiene Hand Hygiene Products: Utilization, Preference and Accessibility Focus Groups

10 10 13 13 13 15 18 20 23

Implications for Future Research on Occupational Health

27

Policy and Prevention Policy and Prevention Implications Arising from the Research Relevant User Groups for the Research Results Policy-related Interactions Undertaken

27 27 27 28

Dissemination/Knowledge Transfer

28

References

31

Appendices Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5:

Quality Assurance Surveys Poster Contest Advertisement Staff Surveys Individual Poster Effectiveness Scores Focus Group Protocol and Questionnaire

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Main Research Findings and Policy/Prevention Implications •

Quality assurance surveys of the Infection Control Practitioners involved in implementing the campaign showed that the campaign was well received by the target audience.



Adoption of a social marketing intervention strategy was effective in obtaining and ensuring ongoing healthcare worker (HCW) engagement as demonstrated by their participation in the poster contest, staff surveys and focus groups as well as their high interest in the campaign promotional items.



The vast majority (80%) of survey respondents completed surveys electronically suggesting that electronic survey tools are an effective means of reaching a large segment of the HCW population.



HCWs appeared to be well aware of the importance of hand hygiene at the start of the campaign and scored high on intention to adhere to hand hygiene guidelines (individual factors).



There was increased utilization of all hand hygiene products likely as a result of increased accessibility (environmental factor). Distributing portable hand hygiene carabineers and increasing the number of wall dispensers throughout the campaign improved accessibility. HCWs prefer soap and water to alcohol based products despite the fact that the latter are more time efficient and time constraints are frequently reported as a barrier to hand hygiene compliance. Research needs to be conducted to determine what factors influence HCW preferences for hand hygiene products



HCWs best relate to a gain-framed informational presentation of key messages that provide a rationale as to the importance of hand hygiene. HCWs reported that routinely changing posters was an effective means of reminding staff of the importance of clean hands.



Administration actively participated in the campaign as evidenced by the overall 20-25% response to the surveys. Management response was poor initially but improved with time.



HCWs reported no change in the number of patients/residents or visitors inquiring about whether they had washed their hands or for information on hand washing. This could represent reluctance on the part of the patient/visitor to query a HCW who may be seen to be in a position of authority or “power”. Alternatively, it may indicate a need to more actively engage the patient and visitor populations in future campaigns, possibly through Vancouver Coastal Health (VCH) Community Engagement team.



Physicians remain a group that is difficult to influence in terms of behaviour change. A positive response to the portable alcohol hand rub dispensers was received from this group addressing at least one environmental impediment to improved hand hygiene. Future efforts could examine the role of physician mentorship/leadership as a method to improve hand hygiene in this population.



Focus groups confirmed that time constraints, workload issues, and inappropriate glove use remain as barriers to compliance with hand hygiene. However, the visible support from administration was clearly recognized (organizational factor) and appreciated, as was the provision of additional hand hygiene supplies (environmental factors). All groups in the focus group discussions raised the issue of inappropriate glove use. More research and education needs to be undertaken in this area.

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Executive Summary The most important factor in infection prevention and control is frequent and appropriate hand hygiene. The meticulous practice of this activity reduces cross-infection between patients and minimizes the risk of transmission of infectious agents to healthcare workers (HCWs). Unfortunately compliance with this simple activity is poor in the health care setting.

Traditionally, hand hygiene campaigns have focused almost exclusively on increasing awareness among HCWs. Ongoing compliance with hand hygiene guidelines, however, extends beyond educating the HCW. Successful application of desired policies and procedures require a good understanding of what is required and why (individual factors); a workplace that promotes a safety climate which promotes appropriate hand hygiene behaviour (organizational factors); and an environment that provides the resources, equipment and supplies required for compliance (environmental factors) (Carlon, Geilen and McDonald, 1997).

In the fall of 2005, Vancouver Coastal Health (VCH) launched a one-year regional hand hygiene campaign “Clean Hands for Life” involving all directly funded acute and long-term care facilities (over 13,000 HCWs). The campaign provided an opportunity to prospectively follow the factors that influence compliance, affect behaviour and contribute to increased awareness among HCWs. Specifically, the objectives of this grant as it pertained to the campaign were to: 1. identify individual, environmental and organizational factors that influence HCWs intent to comply with health care facility hand hygiene guidelines; 2. identify differences in beliefs and attitudes towards hand hygiene between various groups of HCWs; and 3. identify the factors which contribute to the success and/or failure of a regional hand hygiene campaign

The campaign was clearly successful as evidenced by the excellent response to surveys, poster contests and promotional items. Organizational (e.g. management support) and environmental (e.g. access to hand hygiene agents) factors were the areas most positively affected by the initiative. Individual factors (as measured by knowledge of outcomes and intent to comply with hand hygiene)

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were already high at the start of the campaign and remained unchanged throughout the it’s course. This suggests that individual factors are less important to target than addressing the environmental and organizational barriers that may exist. It further suggests that hand hygiene programs should focus less on addressing individual attitudes and beliefs and more on ensuring that facility policies and directives are clear, individuals understand when and how to clean their hands, and resources are readily accessible to do so. Individual factors that do need to be considered (as discussed in the focus groups) were the need to consult HCWs on the placement of hand hygiene stations in clinical areas in order to improve accessibility and compliance (environmental factor) and the need to consult them on the hand hygiene products used in the facilities.

Attempts to reach physicians throughout the course of the campaign met with little success – only the portable hand hygiene carabiners met with a positive response (in fact supply could not keep up with demand). Healthcare workers also reported that few visitors or patients asked them about the campaign or any aspect of hand hygiene. In retrospect, the role of physician mentors and the need to involve community engagement teams may have met with more success and will be a focus of the next phase of our hand hygiene initiatives.

The role of management support was considered to be very important to the campaign. An example of this was the quick response to staff comments regarding the lack of alcohol hand rub dispensers at facility entrances with the placement of “the Bug Stops Here” doorstopper poster. Dispensers were quickly placed at the entrances and exits to the facilities. This was noted and appreciated by staff in the surveys and in the focus group comments.

The poster contests clearly indicated that staff felt that messages should be portrayed in a positive, informational gain-framed manner. Staff responded well (as reported in the surveys) to messages that provided a rationale for the activity promoted. Very few posters designed by HCWs were negatively framed for content (i.e. negative result when the promoted action does not occur). The campaign did not specifically explore the impact of negatively framed messages and it may be interesting to examine whether this type of marketing, by taking HCWs out of their “comfort zone”, results in a positive behaviour change or increased reflection as to the consequences of noncompliance.

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HCWs repeatedly reported in the focus groups (and confirmed in our survey findings) that knowledge and intent was there. They further reported that the observed disconnect between knowledge and behaviour was the result of time constraints and other barriers. Our research findings lend support to the PRECEDE model of health promotion which outlines that health behaviour is complex and influenced by a variety of factors including individual, organizational and environmental factors. To be effective, a behaviour change intervention must take into consideration all of these factors. In the past, hand hygiene campaigns have focused almost exclusively on the HCW -- these interventions may have seen modest increases in compliance but these increases were not sustainable. In order to be sustainable, all factors (organizational and environmental) need to be addressed.

Social marketing as a method to promote the hand hygiene campaign was viewed by HCWs as a very successful approach. In order to complete the cycle of this type of marketing campaign, the promoters (i.e. infection control) will need to retarget certain groups (e.g. physicians, patients and visitors); consider different approaches such as physician mentors and community engagement; create additional posters with new messaging (which may include negative gain framed messaging similar to seat belt advertisements that portray the consequence of not performing an action) and possibly have poster holidays to ensure that “tolerance” to the messaging does not occur. Similar to commercial enterprises, infection control will need to resurvey the target groups to determine the impact of these changes and adjust their interventions accordingly, all the while considering the triad of environmental, organizational and individual factors that must be reinforced to truly cause a change in safety climate.

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Final Report Research Problem / Context The most important factor in infection prevention and control is frequent and appropriate hand hygiene. The meticulous practice of this activity reduces cross-infection between patients and minimizes the risk of transmission of infectious agents to health care workers (HCWs). Yet, unfortunately compliance with this simple activity is poor in the health care setting. The issue of noncompliance is multifactorial, with factors such as overworked staff, too few sinks, inadequate numbers of or inaccessible antiseptic hand rubs, perception of hand hygiene as a low priority activity, and lack of an enabling safety climate to foster good hand hygiene all contributing to this HCW and patient safety problem.

Traditionally, hand hygiene campaigns have focused almost exclusively on increasing awareness among HCWs. Ongoing compliance with hand hygiene guidelines, however, extends beyond educating the HCW. The healthcare facility needs to be equipped to ensure adequate access to hand hygiene stations and products, and management needs to foster a safety climate which promotes appropriate hand hygiene behaviour (Pittet et al. 2004; Pittet et al. 1999; Larson 1994; Kretzer and Larson 1980).

Historically, HCWs have always been at increased risk of exposure to infections and historically little attention has been paid to their occupational risk. The most common route of transmission for infectious diseases is unwashed hands.

Antibiotic resistant organisms (AROs) such as Methicilin Resistant

Staphylococcus aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE) are recent examples of HCWs’ risk of acquisition through patient contact and subsequent HCW colonization. Little effort has, however, been made at soliciting the HCW’s perception of the key features that could lead to a change in behaviour.

The ability and willingness to comply with hand hygiene infection control guidelines involves a number of factors, the majority of which can be explained by the PRECEDE model of health promotion (Green et al. 1980; DeJoy 1986). This model examines the characteristics that promote the application of selfprotective behaviour at work. Successful application of desired policies and procedures require a good understanding of what is required and why (individual factors); a workplace that promotes a safety

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climate, clearly outlines expectations for performance, and provides training/educational programs to facilitate compliance (organizational factors); and an environment that provides the resources, equipment/supplies and accessibility to the required items for compliance (environmental factors) (Carlon Geilen and McDonald, 1997).

Several studies have described the predictors of compliance with hand hygiene in this manner. These include environmental factors such as lack of access of sinks or antiseptic hand rubs; work load and insufficient time for hand hygiene, individual factors such as lack of recognition of the importance of hand hygiene in preventing infection; lack of perceived risk to oneself; patient needs taking priority over hand hygiene; the use of gloves in the misplaced perception that this is a suitable alternative for cleaning hands; and organizational factors such as lack of visible support by administration for hand hygiene; insufficient educational material and/or training on the how, why and when of hand cleaning, and the absence of a visible role model at the senior medical and administrative level (Pittet et al. 1999; Pittet and Boyce 2001; Boyce 1999).

The multiple factors that affect compliance have led at least one group of observers to suggest that interventions aimed at improving compliance focus on selected HCW groups or patient care areas are likely to be more successful than wide-scale initiatives (Pittet et al, 2004). However, in our opinion, HCWs rarely remain situated in any one patient area, professions interact rather than work in isolation, and patients and their families are increasingly aware of the importance of hand hygiene and are sensitive to any differences in practice. Isolated initiatives do not address nor correct underlying systemic issues that negatively impact on HCWs compliance with hand hygiene guidelines.

One approach that has received growing attention among behaviour-change focused program planners is social marketing. Social marketing has been defined as “the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of their society.” (Andreason 1995). The key features that distinguish social marketing from more conventional behaviour-change programs is the marketing expertise that goes into the planning and development of

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the intervention strategies and messages, as well as the detailed evaluation of the intervention during and following its implementation (Zimmerman 2005).

There are four key areas of focus in a social marketing campaign: (1) the target problem the campaign will address; (2) the target audience; (3) the messages to be directed at the audience; and (4) the channels of communication that will deliver the messages (Zimmerman 2005). Review of the literature clearly identifies the target problem and the target audience -- that is, poor compliance with hand hygiene guidelines among HCWs. In establishing the messages and determining the channels of communication it is necessary to return to the conceptual framework. To successfully increase compliance with hand hygiene guidelines among HCWs, the messaging and modes of communication need to strategically combine and integrate the individual, organizational and environmental factors in such a way as to positively influence the behaviour.

Purpose and Objectives The purpose of the research project was to measure the effectiveness of specific aspects of the Clean Hands for Life™ hand hygiene campaign on HCW’s knowledge, attitudes and intent to comply with hand hygiene guidelines. The objectives of the research were as follows:

1. To identify individual, environmental and organizational factors that influence HCWs intent to comply with health care facility hand hygiene guidelines; 2. To identify differences in beliefs and attitudes towards hand hygiene between various groups of HCWs; and 3. To identify the factors which contribute to the success and/or failure of a regional hand hygiene campaign.

Methodology In the fall 2005, VCH launched a regional hand hygiene campaign entitled Clean Hands for Life™. The campaign provided an ideal opportunity to prospectively follow the factors that influence compliance, affect behaviour and contribute to increased awareness among HCWs.

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The goal of the research was to promote awareness of the importance of hand hygiene in preventing healthcare associated infections and to identify the factors that positively influence HCWs to comply with hand hygiene guidelines. Identification and better understanding of the factors that influence compliance will lead to the refinement and improvement of hand hygiene and other infection control interventions which will in turn reduce the risk of exposure to infectious agents thereby reducing the incidence of occupational illness and disease among HCWs and improving patient safety.

Study Participants The campaign involved all directly funded acute and long-term care facilities within the Vancouver Coastal Health Authority (VCH) targeting approximately 13,249 healthcare and contracted service workers. All VCH employees were eligible to participate. Ethical approval for the study was obtained from the Behavioural Research Ethics Board (BREB) of the University of British Columbia.

Social Marketing Intervention As illustrated in Figure 1, improving HCW hand hygiene behaviour involves not only targeting individual factors such as increasing knowledge and awareness, but also involves addressing environmental and organizational factors. Important environmental factors include increasing accessibility to hand hygiene stations, whereas key organizational factors include the fostering of a patient safety climate in the health care facility supported by senior administration.

Targeting each of these factors, the goals of the

campaign were:

1. Individual Factors: Increase awareness of the importance of hand hygiene through the use of posters, campaign promotional items, poster contests, staff surveys and focus groups. 2. Environmental Factors: Increase the number of both wall mounted and portable antiseptic dispensers. 3. Organizational Factors: Obtain visible commitment of Senior Administration, increasing the perception of hand hygiene as a priority issue, and increasing awareness and access to hand hygiene programs.

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Figure 1: Individual, Organizational and Environmental Factors Influencing Hand Hygiene Behaviour

In addition to targeting the above factors, the social marketing intervention also promoted and encouraged consumer engagement through continuous monitoring of, and communication with HCWs and Infection Control Practitioners (ICPs) to ensure that the intervention’s goals and strategies were optimally aligned with the target population. To ensure successful implementation of the campaign, quality assurance surveys of ICPs were conducted at three points during the early stages of the campaign. The results of these surveys are in Appendix 1.

Research Findings Measuring the effectiveness of an ongoing, multifaceted campaign is challenging, as direct measures of effectiveness are not available. To compensate for this, we have developed a comprehensive evaluation plan involving: (1) poster contest analysis; (2) staff surveys; (3) quality assurance surveys; (4) evaluation in product utilization changes over time; and (5) focus groups. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, Versions 13 & 14, Chicago, Illinois).

Poster Contest Analysis To promote ongoing engagement and participation of the target population, we held two poster contests. One contest targeted HCWs specifically, whereas the other targeted children of HCWs. The adult poster contest was open to submissions from September 27, 2005 through November 8, 2005. The rules for poster submissions are in Appendix 2. A total of 43 adult posters were received. Two were rejected due to noncompliance with poster submission/contest rules, leaving a total of 41 eligible posters. All eligible posters were analyzed.

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We replicated the methodology developed by Jenner (2005) for the poster analysis.

Prior to

implementing the evaluation tool, the co-investigators tested the methodology by analyzing five of the posters developed by Bayer Healthcare (Canada) for the purpose of promoting hand hygiene within the regions’ facilities during the Clean Hands for Life™ campaign.

Adopting the methodology the posters were analyzed independently by two of the co-investigators. The co-investigators then met to discuss their respective results.

Percent agreement between the two

investigators was 92%. Each poster was first analyzed for the theoretical principles of message framing (Tversky and Kahneman 1981). Was the poster loss framed or gain framed? Were threats or fear appeals used? Was personal responsibility targeted?

TABLE 1: Message Framing of HCW Poster Contest Submissions Message Framing of HCW Posters (N=41) Gain Framed Loss Framed Neither Gain nor Loss Framed Personal Responsibility Threat or Fear Appeals

N (%) 34 (83%) 3 (7%) 4 (8%) 15 (37%) 5 (12%)

As illustrated in Table 1, 34 of the 41 posters were gain framed (83%) and 15 (37%) targeted personal responsibility. In order to better understand the nature of the messaging, both loss-framed and gainframed posters were divided further into two categories related to their anticipated outcome (See Table 2).

TABLE 2: Categorization of Messages by Anticipated Outcome Gain Framed Messages Attaining a desirable outcome Avoiding an undesirable outcome Loss Framed Messages Attaining an undesirable outcome Avoiding a desirable outcome

Examples Cleaning your hands will help prevent cross-infection Cleaning your hands will decrease the risk of spreading infection Examples Unclean hands increase the risk of cross-infection Unclean hands will not reduce the cross-infection rate

In total we identified 67 gain-framed and 3 loss-framed messages.

The majority (63%) of gain-framed

messages related to “attaining a desirable outcome” whereas the remainder (37%) related to “avoiding an undesirable outcome”. Two of the three loss-framed messages were related to “attaining a desirable

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outcome”. These findings suggest that HCWs relate best to a gain-framed professional presentation of key messages and that hand hygiene posters should be developed with this in mind.

A more detailed analysis of the messages derived from the posters was performed. Messages were categorized in accordance with the categories Jenner (2005) reported (Instructional through Conscience Raising). Where a message did not fit one of the Jenner categories, emergent categories were created.

a) Instructional (either humorous or non-humorous): Where the viewer was instructed to action (e.g. Clean your hands). b) Informational: Where the viewer was instructed to action (as above) but was also provided with a reason to follow the instruction. c) Training: Where the viewer was told how to follow an instruction (e.g. This is how you clean your hands). d) Conscience raising: Where the poster attempted to raise the viewer’s sense of social responsibility for hand cleaning. e) Emergent categories: Posters that did not fit into one of the four categories above. New categories were suggested for these. As shown in Table 3, the majority of messages fell into the categories of “Informational” and the emergent category of “Clean Hands for Life”. Informational messages instructed the viewer to action (e.g., wash your hands) but also provided a reason to do so (e.g., to prevent infection). Two emergent categories emerged from the analysis: “Clean Hands for Life” and Educational. The emergence of a category for “Clean Hands for Life” is not surprising and was expected, as one of the rules for the poster contest was that contestants needed to incorporate the slogan of the campaign into the poster.

TABLE 3: Categorization of Messages from HCW Poster Contest Submissions Category Instructional Informational Training Conscience Raising “Clean Hands for Life” Educational Total

Gain-Framed N (%) 2 (3%) 22 (34%) 6 (9%) 11 (17%) 23 (36%) ---64

Loss-Framed N (%) ---1 (33%) ---1 (33%) ---1 (33%) 3

Total N (%) 2 (3%) 23 (34%) 6 (9%) 12 (18%) 23 (34%) 1 (1%) 67

The findings further support the conclusion that HCWs relate best to gain-framed messaging which is both informational and conscience raising and which provide a strong rationale as to the importance of hand hygiene. To be most effective, the development of posters aimed at encouraging compliance

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and/or behaviour change should take into account the messaging and communication preferences of the target audience. Pardoxically, however, some of the more successful advertisement campaigns have presented information in thought-provoking negatively gained framed messages (e.g. consequences of not using seatbelts or bicycle helmets). Future campaigns may wish to explore the impact of creating a few such posters that take HCWs out of their comfort zone as to whether this provides an impetus for further reflection as to the importance of hand hygiene.

Distribution of Campaign Promotional Items In addition to using posters to increase awareness of the importance of hand hygiene among HCWs, the campaign also involved the distribution of several promotional items.

Promotional items included:

lanyards, buttons (two types in two different shapes), fridge magnets (two types in two different sizes), stickers, hand washing pamphlets, and personal antiseptic hand gel carabineers.

In total 800 lanyards, 3,000 buttons, 3,000 fridge magnets, 3,000 pamphlets, 10,000 stickers and 12,000 carabineers were distributed over the course of the campaign. The lanyards and carabineers were the best received of the promotional items; the demand exceeded our supply.

Staff Surveys An important aspect of the evaluation of the Clean Hands for Life campaign involved conducting staff surveys: baseline, mid-campaign and post-campaign (See Appendix 3). Surveys were made available in both electronic and print formats.

The majority of respondents (80%) completed the surveys

electronically. Surveys were available to staff for one month for completion, with the exception of the post-campaign survey (Survey III), which was available for 19 days. Unfortunately, delays in printing and technical problems delayed the release of the last survey. Five cash prizes of $100 were offered as incentives for each of the surveys.

Survey Respondents In total 5452 surveys were returned with an overall response rate of approximately 13.7%. Individual response rates and respondent demographic profiles for each of the surveys are presented in Table 4. Of the total respondents 80-85%s were female. With the exception of the oldest respondents in the 60-69

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year age group (3-4%) for all surveys, and the youngest respondents in the 19-29 (14-15%) in Survey II and III, respondents were divided evenly in each of the remaining age groups at 25-30%. Overall, 2899 (55%) of respondents reported that they provide direct patient care; 2397 (44%) reported that they did not.

Nursing staff made up approximately 35%, whereas only 1-1.5% of all respondents were medical doctors. Administrative support comprised 20-25% of respondents across all three surveys. The next largest group in all three surveys was the physiotherapists/occupational therapists at 6% of the total. Housekeeping and trades were negligibly represented in Survey II and Survey III, but in Survey I formed 1.5% of the total. Management was poorly represented in Survey I, but formed 3-5% of the total respondents in Survey II and Survey III. All professions surveyed were represented in the survey-specific samples.

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TABLE 4: Demographic Profile for Staff Surveys I, II, III DEMOGRAPHICS Female Male AGE GROUP 19-29 30-39 40-49 50-59 60-69 HSDA North Shore/ Coast Garibaldi Richmond Vancouver Other DIRECT PATIENT CARE Provide Direct Patient Care OCCUPATION Administrative Support Dietician Educator Food Services Housekeeping Licensed Practical Nurse Management Medical Doctor Pharmacist Physiotherapist / Occupational Therapist Psychologist Registered Care Aid Registered Nurse Respiratory Therapist Security Social Worker Student / Volunteer Technologist / Technician Ultrasound / Radiology Technician Other TOTAL (response rate*)

SURVEY I 2145 410

SURVEY II 1394 227

SURVEY III 1046 155

360 638 823 657 94

244 428 499 413 52

203 285 383 285 52

482 287 1738 55

372 290 934 43

311 177 670 24

1374 (53.2%)

641 (38.8%)

884 (72.5%)

480 2 1 9 64 80 5 38 25 151 2 61 808 26 7 7 30 81 39 643 2583 (19.5%)

241 22 20 4 1 50 75 15 22 104 3 21 497 17 7 39 13 101 14 374 1650 (12.5%)

169 11 18 2 1 34 40 19 26 67 1 13 323 14 3 26 14 89 15 329 1219 (9.2%)

* Calculated using a denominator of 13,249 representing approximately 11,949 VCH active staff and 1,300 contracted workers.

Staff participation in the surveys varied by occupational group and it is clear that there is an ongoing need to find ways to access the physician population. An important component of successfully establishing a positive patient and HCW safety climate is strong organizational support which was demonstrated in this campaign by the active participation of administration.

Poster Effectiveness A significant component of the Clean Hands for Life campaign involved regular changing of hand hygiene posters in each of the directly funded acute and long-term care facilities within the region. Ten novel posters were developed by Bayer Healthcare (Canada), in partnership with the Hand Hygiene

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Campaign Steering Committee for the purposes of the campaign. Posters were rotated in sequence every four to six weeks so that each facility had the same poster up at the same time, and for the same duration.

One aspect of measuring the effectiveness of the posters is to assess whether or not the target audience had noticed them. At baseline (Survey I) we asked survey respondents the question “Have you noticed hand hygiene posters”. As illustrated in Table 5, the vast majority (82.8%) reported that they had noticed hand hygiene posters. For surveys II and III, we asked respondents whether they had specifically noticed each of the individual campaign posters (five posters per survey). Responses for each of the posters were aggregated and show that 53.4% of Survey II and 61.7% of Survey III respondents reported that they had noticed the campaign posters. Chi-square analysis (with Yates correction) comparing the observed frequencies for “Yes” and “No/Not Sure” responses on Surveys II and III was highly significant 2

( = 17.36; p < .0001) indicating that the higher proportion of respondents reporting that they had noticed the posters is much greater than what would be expected by chance alone. The poorer results from Survey II and III re noticing the specific posters may suggest that tolerance to the posters occurred during the course of the campaign, and perhaps poster holidays may be required for prolonged initiatives.

TABLE 5: Number and Proportion of Respondents who noticed the Posters by Survey Notice Posters? Yes No Not Sure Missing Total

Survey I 2139 (82.8%) 162 (6.3%) 59 (2.3%) 223 (8.6%) 2583

Survey II 880 (53.3%) 490 (29.7%) 137 (8.3%) 143 (8.7%) 1650

Survey III 752 (61.7%) 277 (22.7%) 103 (8.5%) 87 (7.1%) 1219

In addition to asking whether they had noticed the posters, respondents of Surveys II and III were asked to evaluate the effectiveness of each of the posters. The first five posters were evaluated in Survey II and the remaining five posters in Survey III. Using a 7-point Likert scale where a value of 1 represented “not effective” and a score of 7 represented “very effective” respondents evaluated the posters in terms of their effectiveness in (1) educating staff on the importance of hand hygiene; (2) making you think about your own hand hygiene; (3) motivating you to clean your hands; and (4) reminding you to clean your hands?

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FIGURE 2: Mean Overall Poster Effectiveness Scores

Effectiveness Score

Overall Mean Effectiveness Scores

7 6 5 4 3 2 1 0 1

2

3

4

5

6

7

8

9

10

Poster Number

As illustrated in Figure 2, all ten of the posters scored very well in terms of effectiveness with a range in overall mean effectiveness scores of 4.65 and 5.59.

Table 6 shows the mean composite effectiveness score for each of the posters along with the 95% confidence intervals. The poster “Washing your Hands is a Lifeline” scored significantly lower than all of the other posters. ‘The Bug Stops Here’ poster received the highest mean score in educating staff on the importance of hand hygiene, in making you think about your own hand hygiene, in motivating you to clean your hands, and in reminding you to clean your hands. The individual effectiveness scores are available in Appendix 4.

TABLE 6: Composite Mean Scores for Campaign Posters No. 1 2 3 4 5 6 7 8 9 10

POSTER Unite Against Germs The Bug Stops Here Can you Spot the Clean Hand? Washing your Hands is a Lifeline All for One and One for All Guard Against Infection Clean your Hands Spread Compassion not Infection Stop Infections The Solution is at your Fingertips

MEAN 20.87 21.97 21.48 18.59 19.27 20.19 22.36 19.73 21.62 21.80

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95% CI 20.58-21.16 21.71-22.22 21.18-21.78 18.26-18.92 18.93-19.60 19.85-20.54 22.05-22.68 19.35-20.11 21.29-21.95 21.46-22.15

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Awareness of the Importance of Hand Hygiene A primary objective of the Clean Hands for Life campaign was to promote awareness of the importance of hand hygiene in preventing hospital-associated infections.

To measure HCW’s knowledge and

understanding of the importance of hand hygiene we asked survey respondents in all three surveys to answer two sets of questions. The first set (N=8 items) assessed knowledge of outcomes associated with 1

appropriate hand hygiene behaviour, whereas the second set (N=6 items ) assessed intentions to comply with hand hygiene guidelines in a variety of situations. Each item was measured on a 7-point Likert scale with a score of 1 representing “very unlikely” and 7 “very likely”. Table 7 shows the means and standard deviations on intentions and outcomes for those providing direct versus non-direct patient care for each of the three surveys.

TABLE 7: Mean Scores on Outcomes and Intentions by Survey Knowledge of hand hygiene outcomes* Direct patient care • Mean (standard deviation) • Sample size Non direct patient care • Mean scores • Sample size Intention to comply with hand hygiene guidelines** Direct patient care • Mean (standard deviation) • Sample size Non direct patient care • Mean scores • Sample size * maximum score is 56

Survey I

Survey II

Survey III

48.2 (5.3) 1291

48.3 (5.0) 866

48.6 (4.6) 627

47.5 (5.2) 982 Survey I

47.2 (5.0) 682 Survey II

47.1 (4.9) 535 Survey III

37.7 (4.7) 1270

37.6 (4.3) 858

37.8 (4.3) 622

38.0 (4.8) 933

37.7 (4.5) 663

37.8 (4.3) 519

** maximum score is 42

Overall knowledge of outcomes and intention to hand wash scores were very high for both those that provide direct patient care and those that do not. Out of a possible score of 56, the average score for all three surveys was 48.4 (86.4%) for those providing direct patient care and 47.2 (84.4%) for those not providing direct patient care. Similarly, high scores were observed on intention to comply with hand hygiene guidelines. Out of a possible score of 42, the average score for those providing direct patient care was 37.4 (89.8%) and 37.8 (90%) for those providing non-direct patient care.

1

Note: Survey I had 8 “intention” items; 2 items (#4 & 8) were excluded in Surveys II and III based on negative feedback from survey respondents.

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A significant difference on knowledge of outcomes between HCWs that provide direct patient care versus those that do not [t (1,4981) = 6.973, p < .0001] with those providing direct patient care scoring significantly higher (mean = 48.3) than those that do not (mean = 47.3). No significant differences were observed on intention scores.

When outcomes and intentions scores were analyzed for changes

between baseline and mid-campaign and baseline and post-campaign surveys, no significant differences were detected for either those that provide direct patient care or those who do not.

The failure to detect

changes between surveys is likely due to the fact that knowledge and intention scores were already high at baseline and the measurement tool was not sensitive enough to detect small gains.

Another way to evaluate whether the campaign was effective in increasing awareness of the importance of hand hygiene is to determine if it influenced the behaviour of patients, residents and visitors. In all three surveys we asked those HCWs who reported that they provide direct patient care whether, in the last week, a patient, resident or visitor had asked them: (1) if they had cleaned their hands before caring for them or their loved one; and (2) for information on hand cleaning.

TABLE 8: Proportion of HCWs asked about Hand Hygiene by Survey Asked if you had washed your hands? • Yes • No • Don’t Remember Totals Asked for information on hand hygiene? • Yes • No • Don’t Remember Totals

Survey I 3.2% 96.6% 0.1% 1372 Survey I 7.0% 93.0% NA 1371

Survey II 2.8% 96.9% 0.2% 884 Survey II 7.7% 92.2% 0.1% 884

Survey III 0.9% 99.1% NA 640 Survey III 7.3% 92.5% 0.2% 640

Average 2.6% 97.3% 0.1% 2896 Average 7.3% 92.6% 0.1% 2895

As illustrated in Table 8, on average, only 2.6% of HCWs reported that a patient/resident or visitor had asked them about their hand hygiene before providing care.

Similarly, only 7.3% reported that a

patient/resident or visitor had inquired about information on hand hygiene. These findings may reflect reluctance on the part of the patient, resident or visitor to ask a HCW who may be seen to be in a position of authority. In order to actively engage the patient and visitor populations future campaigns will require more targeted intervention strategies.

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Hand Hygiene Products: Utilization, Preference and Accessibility The use of product purchase data through VCH Supply Chain to evaluate whether there has been an increase in hand hygiene product utilization from baseline to post-campaign has proven to be very problematic. Several changes have occurred over the two year period of interest (1 year prior and 1 year campaign) including the direct purchase of relevant supplies by Aramark (housekeeping services have been subcontracted out to Aramark) through their housekeeping system. These data are not available for analysis. Further to this, during this time period VCH Supply Chain has consolidated and standardized the purchase of supplies meaning that some supplies have been discontinued while others have been introduced.

Changes in practice and product purchase affect both historical data as well as data

available over the course of the hand hygiene campaign making comparisons impossible.

In Surveys I and III, we asked respondents to assess the hand hygiene products made available to them for use (soap and water, alcohol hand rub, and personal portable alcohol hand rub). Specifically, we asked respondents to: (1) report which products they had used in the last week; (2) rank order their preference of products; and (3) rate the accessibility of products.

Products Used in the Last Week Examining the aggregate data for Surveys I and III, the results show that soap and water was used by the vast majority of respondents (average 89.5%) followed by alcohol hand gel from wall dispensers (57.3%) and personal portable alcohol hand gel (39.7%).

Table 10 presents the results for Survey I and Survey III separately for those that provide direct patient care versus non-direct patient care. Examination of the confidence intervals (calculated using the Wald method) for those providing direct patient care, a significant increase in the reported use of alcohol hand gel from wall dispensers was observed from baseline to post-campaign.

For those providing non-direct

patient care, a significant increase in the reported use of all three hand hygiene products was observed from baseline to post campaign.

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TABLE 10: Hand Hygiene Products Used in the Last Week by Direct Patient Care and Survey Direct Patient Care Products Survey I [95% CI] Soap and Water 94.9% [93.6-96.0] Alcohol Gel (wall dispensers)* 64.5% [61.9-67.0] Alcohol Gel (personal portable) 49.1% [46.4-51.7] Totals 1374 Non Direct Patient Care Products Survey I [95% CI] Soap and Water* 85.6% [83.5-87.6] Alcohol Gel (wall dispensers)* 42.6% [39.8-45.6] Alcohol Gel (personal portable)* 28.7% [26.2-31.4] Totals 1128 * Denotes a significant difference in proportions.

Survey III [95% CI] 93.3% [91.1-95.0] 72.5% [69.0-75.9] 44.0% [40.2-47.9] 641 Survey III [95% CI] 91.0% [88.3-93.1] 50.7% [46.6-54.7] 38.3% [34.4-42.4] 556

Hand Hygiene Product Preferences As illustrated in Table 11, the vast majority of respondents ranked soap and water as their “most preferred” hand hygiene product whereas personal portable alcohol hand gel was least frequently ranked as the preferred product. These results were true for both those that provide direct patient care and those that do not. When examined for differences between baseline and post campaign, a significant decrease in preference for soap and water was observed for those providing direct patient care.

TABLE 11: Most Preferred Hand Hygiene Product by Direct Patient Care and Survey Direct Patient Care Products Survey I [95% CI] Soap and Water* 81.3% [79.2-83.3] Alcohol Gel (wall dispensers) 9.8% [8.7-11.5] Alcohol Gel (personal portable) 5.2% [4.2-6.7] Totals 1374 Non Direct Patient Care Products Survey I [95% CI] Soap and Water 71.5% [68.8-74.0] Alcohol Gel (wall dispensers) 9.8% [8.2-11.7] Alcohol Gel (personal portable) 5.9% [4.7-7.5] Totals 1128 * Denotes a significant difference in proportions.

Survey III [95% CI] 77.5% [74.1-80.6] 11.2% [9.0-13.9] 5.6% [4.1-7.7] 641 Survey III [95% CI] 75.4% [71.6-78.8] 10.1% [7.8-12.9] 5.9% [4.2-8.2] 556

The lower preference for alcohol hand rub products despite the fact that they are quicker to use than soap and water is interesting especially when time constraints are frequently reported as barriers to hand hygiene. Future research needs to be conducted on the factors that influence HCWs preferences for hand hygiene products.

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Hand Hygiene Product Accessibility Surveys I and III contained questions aimed at measuring access to hand hygiene products. Accessibility was measured on a 7-point Likert scale where a score of 1 corresponded to “very inaccessible” and a score of 7 corresponded to “very accessible”.

TABLE 12: Means and Standard Deviations for Access to Hand Hygiene Products Direct Patient Care Products Soap and Water Alcohol Gel (wall dispensers) Alcohol Gel (personal portable)* Non Direct Patient Care Products Soap and Water Alcohol Gel (wall dispensers) Alcohol Gel (personal portable) * Denotes a significant difference.

Survey I (SD) 6.15 (1.38) 5.13 (2.07) 4.68 (2.16)

Survey III (SD) 6.05 (1.39) 5.47 (1.71) 4.26 (2.16)

Survey I (SD) 6.18 (1.45) 4.73 (2.23) 3.95 (2.26)

Survey III (SD) 6.00 (1.53) 5.26 (1.85) 4.15 (2.25)

As illustrated in Table 12, for both those that provide direct patient care and those that do not, access was greatest for soap and water and lowest for personal portable alcohol hand gel. Analysis of Variance (ANOVA) was performed to test whether significant differences existed on access scores between Survey I and Survey III. Soap and Water: No significant difference in mean access scores for soap and water were observed between Survey I and Survey III for those providing direct patient care (F (1,1928) = 4.02, p = .147). Results for those providing non-direct patient care were not interpretable, as the assumption of homogeneity of variance was not satisfied. Alcohol Gel (Wall Dispensers): Tests to determine whether significant differences existed between Survey I and Survey III were not possible as the assumption of homogeneity of variance was not satisfied. Alcohol Gel (Personal Portable): Significant differences were observed for access to portable alcohol hand gel for those providing direct patient care (F (1,1899) = 15.49; p < .0001) whereas the results were not significant for those providing non-direct patient care (F (1,1453) = 13.98; p = .098).

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Focus Groups The objective of the focus groups was to identify individual, environmental and organizational factors that influence HCWs intent to comply with health care facility hand hygiene guidelines. The methodology and focus group questions may be found in Appendix 5. HCWs from across the region were invited to participate in the focus group sessions. Incentives for participation were two cash prizes of $250.00 each. Refreshments (including pizza lunches) were provided and parking costs reimbursed. Unfortunately, the response from interested HCWs did not permit stratified random sampling by occupational group as described in our protocol. Consequently, all staff who indicated an interest were invited to participate.

A series of 14 focus groups, involving a total of 49 individuals, were conducted across the region between July 10, 2006 and July 26, 2006, inclusive. Focus groups ranged in size from one to seven participants. 2

In terms of distribution by facility type nine focus groups were conducted involving staff from acute care facilities; four from long-term care or rehabilitation facilities; and one from an outpatient clinic. Focus group discussions lasted approximately 45 minutes.

Each focus group session had one facilitator. The facilitator read one question at a time and allowed the group to complete its discussion before moving to the next question. When requested, the facilitator provided clarification but did not interfere with the discussion. At the end of the session, the facilitator summarized the discussion and provided participants an opportunity to add to the discussion or to clarify issues. All focus group sessions were recorded and transcribed. The transcripts were analyzed using qualitative methods.

Two researchers coded the transcripts according to emergent themes and

subthemes. Individual variables were tracked for the number of times each was discussed and totals used to weight the importance of each of the identified themes. Quotations were compiled that best represented the discussions of the group.

2

Focus groups were held in Vancouver General Hospital (N=3), Lion’s Gate Hospital (N=1), Richmond General Hospital (N=1), St. Mary’s Hospital (N=1), Squamish Hospital (N=1), Powell River Hospital (N=1), Bella Coola General Hospital (N=1), GF Strong (N=1), George Pearson Centre (N=1), Banfield Pavilion (N=1), Evergreen House, LGH (N=1), and Whistler Clinic (N=1).

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Effectiveness of the Campaign Slogan To evaluate the effectiveness of the campaign slogan, we asked focus group participants “What comes to mind when you hear the phrase Clean Hands for Life?” Table 13 outlines the themes that emerged from the discussions. All groups mentioned that they thought that the phrase was related to the concept of preventing infection. One participant summarized it well with the following: ….in a hospital environment how such an insignificant activity can make such a big difference with regards to life and death – passing on potentially fatal infections.

Most groups recognized that the phrase was the campaign slogan and was related to the campaign posters and other promotional items. Many participants mentioned that, though especially important within the healthcare setting, hand hygiene should be a way of life that is equally important outside of the work environment for enhancing quality and length of life.

TABLE 13: Themes Associated with the Campaign Slogan What comes to mind when you hear the phrase “Clean hands for life”? Prevention of transmission of infection to others, oneself, to patients within the Prevention of infection hospital environment, as well as to persons within the community (N=23) Recognition that the phrase was the slogan for the campaign (N=15) Campaign slogan Hand hygiene is an important aspect of your life both at work and beyond. Way of life Hand hygiene is a way of living your life; it becomes a habit (N=11) Campaign posters

Recognition that the posters are part of the campaign (N=8)

Living a longer life

Equating clean hands with living a longer and more healthy life (N=7) Recognition that the phrase relates to handwashing and the need to keep your hands clean (N=6) Identification that hand hygiene is particularly important within the healthcare setting (N=5)

Handwashing Healthcare setting

Factors Associated with Compliance with Hand Hygiene Guidelines

Focus group participants

discussed three questions related to individual, organizational and environmental factors and their importance in influencing HCW compliance with hand hygiene guidelines. A summary of the key factors identified by health care workers is provided in Table 14. Individual Factors: When asked “Do you think that HCWs have a good understanding of the importance of appropriate hand hygiene?” most participants agreed that HCWs do have a good understanding, though many did not. Others noted that understanding varies by professional group and that knowledge does not necessarily translate into practice. One participant summarized the disconnect between knowledge and practice particularly well:

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“I think sometimes we know what the best practice is in nursing, but I think sometimes, we don’t always do the best practice, because of time constraints, or emergencies, or different things”.

Almost all groups raised the issue of inappropriate glove use and that there needed to be more attention paid to this problem. One participant’s comments summarized the discussions well: “There are still some people that seem to think that putting on a pair of gloves is a replacement for washing hands and it is not. The word needs to get out more”.

Organizational Factors: As outlined in Table 14, five major organizational factors were identified in the focus group discussions. For the most part, focus group participants felt that the organization was very supportive of appropriate hand hygiene as demonstrated by (1) the organization’s commitment to the hand hygiene campaign; (2) management’s encouragement to adhere to hand hygiene guidelines; (3) management providing access to hand hygiene products and addressing concerns regarding products in a timely manner; as well as (4) the observed increase in dedicated Infection Control Practitioners. One group summarized their thoughts nicely: “There has been a lot of support from our higher ups, trying to address any issues that have complicated the process of hand washing”. Time constraints and workload issues, however, were identified as an impediment to appropriate hand hygiene behaviour, as was the observation of empty alcohol hand rub dispensers. Speaking to the issue of empty dispensers, one participant said: “What’s the point of having these dispensers around if they are empty?” Environmental Factors: Four major environmental factors emerged in the focus group discussions. Of these, two were barriers to appropriate hand hygiene behaviour, namely physical environment and washrooms. In terms of the physical environment, several barriers were identified including inappropriate placement of sinks, traffic flow issues in some of the clinical areas, inaccessibility of wall dispensers for wheelchair-dependent persons, as well as general lack of cleanliness, particularly in non-clinical areas. During renovation and construction, it was noted that hand hygiene stations are less accessible in the affected areas. Finally, almost all groups commented on problems related to washrooms within their facilities. One participant summarized their observations with the following statement:

“Across the region, I have encountered washrooms without paper towels and without soap, and so you know that they are not washing their hands, if there is no way to wash them properly.”

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TABLE 14: Summary of Key Factors Identified by Health Care Workers Individual Factors Knowledge and understanding of the importance of appropriate hand hygiene Inappropriate glove use

• • • • •

HCWs do have a good understanding. HCWs do not have a good understanding. HCWs do understand but do not but that into practice. Variability in understanding between professional groups. Staff believe gloves are a replacement for hand washing.

Organizational Factors Time constraints



Hand hygiene campaign



Workload issues compromise the HCWs ability to comply with hand hygiene guidelines. The organization has demonstrated support through the implementation of the hand hygiene campaign. The campaign has been effective in increasing awareness of the importance of hand hygiene. The promotional items serve to remind staff to wash their hands. Management encourages and reminds staff to wash their hands particularly when there is an outbreak. The organization ensures that HCWs have access to appropriate hand hygiene products. Management responds promptly to staff concerns regarding products and works to provide alternatives (changes in soap, providing hand cream). Alcohol hand rub dispensers are sometimes empty. The organization has provided additional infection control resources including dedicated Infection Control Practitioners. The organization encourages individuals to take a leadership role in infection control.



Encouraged to wash hands Access to hand hygiene products

• • • •

Infection control leadership

• • •

Environmental Factors Access to hand hygiene products Physical environment

• •

• • • • Washrooms

• •

Public awareness

• • •

Hand hygiene products are available in the immediate work environment. The physical design often compromises appropriate hand washing (e.g., traffic flow, lack of washrooms in patient rooms, placement of sinks, hand washing stations). During renovation/new construction hand washing stations are less accessible. Wheelchair access to wall dispensers is a problem. With renovation/new construction there is an opportunity to increase the number of hand washing stations (e.g., more sinks). Lack of cleanliness of work environment (shared computers and phones are visibly dirty, floors in non-clinical areas are dirty). Washrooms frequently lack paper towels and soap for appropriate hand hygiene. Garbage cans should be placed outside of washrooms to discard paper towels used to open the door. Washrooms doors compromise appropriate hand hygiene. There is increased awareness among the public (i.e., public use the alcohol hand rub more often). There is not enough public awareness (i.e., the public does not comply with hand washing signage).

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Implications for Future Research on Occupational Health The findings from the present research project have several implications for future research on occupational health, including:



This research has demonstrated that social marketing interventions are an effective way to engage and reach a large HCW population. The inclusion of marketing expertise during the planning and development phase of the intervention and the ongoing evaluation of the intervention throughout its implementation are key factors in its success.



Our research showed a very low rate of physician participation. Future research needs to specifically target hard to reach populations.

Specially designed interventions with different incentives for

participation may be required. •

All groups in the focus group discussions raised the issue of inappropriate glove use. More research and education needs to be undertaken in this area.



Our research showed that HCWs prefer soap and water to alcohol based hand hygiene products despite the fact that the latter are much more time efficient and time constraints are frequently reported as a barrier to hand hygiene compliance. Research needs to be conducted to determine what factors influence HCW preferences for hand hygiene products.

Policy and Prevention Policy and Prevention Implications Arising from the Research •

In developing behaviour-change interventions, it is essential that planners take into consideration the various factors that influence the behaviour of their target audience (i.e., individual, organizational and environmental factors).



There is a need to establish effective mentorship programs so that appropriate hand hygiene is learned from the start and reinforced throughout the career of a HCW.



Management needs to continue to encourage staff to become hand hygiene and infection control champions. Peer encouragement and support are required for sustained behaviour change.

Relevant User Groups for the Research Results The results of this research are relevant to various groups including: •

Hospitals and other healthcare facilities that wish to develop and implement hand hygiene interventions for HCWs.



Workplaces that wish to influence employee behaviour and/or compliance with workplace policies and guidelines.



Groups targeting hand hygiene behaviour of employees, student populations, as well as healthcare patient, resident and visitor populations.

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Policy-related Interactions Undertaken The campaign received favourable attention from management and HCWs of the region’s participating healthcare facilities as well as the larger community. The significant response and request for resources and promotional items from community and public health groups was not anticipated. Infection Control worked with its community partners to share its limited resources and to refine communications and planning policies.

The Clean Hands for Life campaign raised the profile of infection control across the region. The Infection Control team is seen as an authority on hand hygiene and consulted more frequently. It is anticipated that infection control will be invited more frequently to assist in the policy planning of various groups including Facilities Management, Supply and Purchasing, Housekeeping, Physical Design and Engineering.

Dissemination/Knowledge Transfer Numerous steps were taken over the course of the Clean Hands for Life campaign to inform and engage the HCW population. The campaign was officially launched with a news release on October 13, 2005. Media coverage following the press release included:



October 14, 2005 -- The Daily Courier (Kelowna), Page A02 (also Penticton Herald) “Hospitals aim to lower infection rates”.



October 14, 2005 – Broadcast News 08:50 “Handwashing”.



October 14, 2005 – The Canadian Press 01:03 “Vancouver area hospitals start handwashing campaign to lower infection rates”.



October 15, 2005 – Vancouver Sun, Page B03 “Lower mainland “clean hands” campaign kicks off”.

The campaign was featured in the following issues of the “Current” Magazine (Current is the official newsletter of VCH):



September 2005 (Vol. 3, No. 8) – VCH Promotes its Infection Control Hand Hygiene Campaign Clean Hands for Life.



October 2005 (Vol. 3, No. 9) – Clean Hands for Life



November 2005 (Vol. 3, No. 2) – Good Hand Hygiene Supports Infection Control.



February 2006 (Vol. 4, No. 2) -- Clean Hands for Life Poster Contest Winners Announced.

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July/August 2006 (Vol. 4, No. 7) – The Power is in Your Hands: Portable Hand Rub Dispensers Increase Hand Hygiene and tips for Keeping Your Hands Clean.



July/August 2006 (Vol. 4, No. 7) -- Clean Hands for Life Campaign and Staff Recognized for Good Infection Control Practice.

The campaign was also featured in “Spotlight”. Spotlight features weekly highlights on the VCH intranet site.



October 17, 2005 -- Clean Hands for Life Campaign.



January 24, 2006 -- Clean Hands for Life Poster Contest Winners Announced.

Though not directly related to the present research investigation, one of the winning posters from the children’s Clean Hands for Life poster contest was selected for use by the Vancouver School Board as a tool to promote hand hygiene among students. Further, one of the posters was awarded third place in the international media “Awe Awards” competition for medical products.

Preliminary results and lessons learned from the campaign have been shared at both national and international meetings and conferences:



March 1, 2006 – Two members of the team were invited, along with representatives from the UK, Switzerland, United States and other areas of Canada, to present at the Hand Hygiene Consensus Building Workshop in Toronto.

The purpose of the workshop was to gather

information for the development of a hand hygiene campaign for the province of Ontario. •

May 9, 2006 – “Social Marketing Contributes to the Success of a Regional Hand Hygiene Campaign” poster presentation at CHICA National Education Conference, London, Ontario.



June 18, 2006 – “Measuring the Effectiveness of a Regional Hand Hygiene Campaign on Healthcare Workers Knowledge, Attitudes and Intention to Comply with Hand Hygiene nd

Guidelines” oral presentation at the 2 •

International Infection Control Conference, Hong Kong.

October 19, 2006 – “Clean Hands for Life: Evaluating the Effectiveness of a Regional Hand Hygiene Campaign” poster presentation at Halifax 6: The Canadian Healthcare Safety Symposium, Vancouver, BC.

In addition to the above, the Clean Hands for Life team has been involved in the development of an implementation guide and video to assist other hospitals in the successful implementation of the campaign.

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The following communications are planned for sharing the final results of the campaign: •

Current Magazine and Spotlight – sharing the results with the HCW population.



Press release with the goal of sharing the results with the wider VCH community.



Report to the VP of Patient Safety and Executive Summary for the Senior Executive Team of VCH.



Report to Occupational Health and Safety

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References Andreason, AR. (1995). Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. Jossey-Bass Publishers: San Francisco. Boyce J. (1999). It is time for action: improving hand hygiene in hospitals. Ann Intern Med 130: 153-143. Carlon Geilen, A., McDonald, EM (1997). The PRECEDE-PROCEED planning model In Health Behaviour and Health Education: Theory, Research and Practice, 2

nd

ed. K. Glanz, FM Lewis, and BK

Rimer Editors. Jossey-Bass Publishers: San Francisco. DeJoy D A (1986). Behavioral-Diagnostic models for fostering self-protective behavior in the workplace, In Trends in Ergonomics/Human Factors III, W. Karwowski, Editor.

Elsevier Science

Publishers BV: North-Holland. P. 907-917. Green LW, Kreuter M, Deed S (1980). Health Education Planning: A Diagnostic Approach. Palo Alto, CA: Mayfield. Jenner, EA. Jones, F. Fletcher B et al. (2005). Hand hygiene posters: motivators or mixed messages. J Hosp Infect 60:218-225. Kretzer EK, Larson EL. (1998). Behavioral interventions to improve infection control practices. Am J Infect Control 26: 245-53. Larson El. (1994). APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23:251-69. Pittet D, Mourouga P, Perneger TV. (1999). Compliance with handwashing in a teaching hospital. Ann Intern Med 130:126-130. Pittet D, Boyce JM. (2001). Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infectious Dis April: 9-20. Pittet D, Simon A, Hugonnet S et al. (2004). Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 141:1-9. Tversky and Kahneman (1981). The framing of decisions and the psychology of choice. Science 211 (4481): 453-458. Zimmerman, R (2005). Social marketing strategies for campus prevention of alcohol and other drug problems. (accessed September 01, 2005) http://phoenix.edc.org/hec/pubs/soc-marketing-strat.html

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Appendices Appendix 1: Quality Assurance Surveys Surveys were sent to the Infection Control Practitioners (ICPs) at each of the participating facilities, on three different occasions during the campaign for the purpose of identifying problems that may negatively impact the implementation of the campaign. Ten questions were completed in each survey, with most ICPs reporting from several sites. The following is a summary of the survey results. •

All sites received posters and promotional items on time and in good condition, with the exception of the personal hand gel dispensers. A few of these were broken when they were received.



Only two ICP’s reported difficulties in putting up the posters in their facilities on time, due to lack of adequate assistance.



All of the products were well received at most of the facilities, and frequent requests for more promotional items. Only one ICP reported that the lanyards were difficult to give away and two ICPs felt that they had received too many buttons.



Several ICPs suggested that funds should be allocated in campaigns of this type to pay for the placement of posters and the delivery of materials.



Of the promotional items the personal hand gel dispensers and the lanyards were most appreciated.



Posters were very well liked. Comments like ‘very colourful’, ‘effective’, and ‘glad someone is drawing attention to hand hygiene’ were reported.



Many ICPs informed us that they had received requests from community facilities such as educational sites, ambulance services, public health and community centres for promotional materials and for posters. Patients and visitors made requests to the ICPs for both posters and promotional items.



Suggestions for improvements in the campaign were solicited. Two ICPs suggested in-services on hand hygiene, with information on techniques, products and length of time required to properly wash hands as an added feature of the campaign. ‘Hand gel should be available at all entrances’ and ‘posters on hand hygiene should be placed above all sinks’ were additional suggestions.

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Appendix 2: Poster Contest Advertisement

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Appendix 3: Staff Surveys

Staff Survey I On October 13th, Vancouver Coastal Health Infection Control, in collaboration with Bayer Healthcare (Canada), launched a year-long hand hygiene campaign entitled “Clean Hands for Life”. The goal of the campaign is to increase awareness and compliance with proper hand cleaning. One of the ways we are assessing the success of the “Clean Hands for Life” campaign is by conducting staff surveys for quality assurance purposes. The Staff Survey takes approximately 5-7 minutes to complete. All staff that complete the survey by 5:00 pm on Wednesday, December 14, 2005 will be entered into a draw for one of five $100 prizes. The Infection Control team thanks you in advance for your time.

1. What is your gender? 2. How old are you?

Female 19-29

Male 30-39

40-49

50-59

60-69

3. What is your present occupation (check one) Registered Nurse Licensed Practical Nurse Registered Care Aid Pharmacist Lab Technologist/Technician M.D. (intern/resident/fellow) M.D. (attending/staff/consulting) Housekeeping Security Food Services

Occupational Therapist Physiotherapist Respiratory Therapist Radiology Technician Anesthesiologist Student Office personnel Volunteer Other __________________________

4. Which facility do you normally work at? (check one) North Shore/Coast Garibaldi Bella Coola General Hospital RW Large Memorial Hospital Powell River General Hospital Powell River Evergreen Powell River Glacier Apts Powell River O Devaud Sechelt Saint Mary’s Hospital Sechelt Totem Lodge Sechelt Shorncliffe Whistler Health Care Centre

Gibsons Kiwanis Village Care Centre Lion’s Gate Hospital LGH Evergreen North Shore Cedar View North Shore Cedar Garden North Shore Kiwanis Squamish General Hospital Squamish Hilltop House Squamish Iris Place Pemberton Health Centre

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Vancouver Vancouver General Hospital UBC Hospital VGH Banfield UBC Purdy George Pearson Centre GF Strong Rehab Centre

Dogwood Lodge Richmond Richmond Hospital Lions Manor Minoru Lodge Other ___________________________(please specify)

5. Do you work at more than one facility?

Yes

No

6. How many hours do you normally work per week, including overtime (check one) Less than 10 hours 10 – 20 hours 21-30 hours 31-40 hours

41-50 hours 51-60 hours More than 60 hours

7. How confident are you in your knowledge of the unit’s/hospital’s hand hygiene guidelines for when and how to clean your hands?

very unconfident

1

2

3

4

5

6

8. Do you have direct (hands-on) patient/resident contact?

7

very confident

Yes

No

IF YES, 9. In the last week has a patient/resident or visitor asked you if you cleaned your hands before providing them (or their loved one) direct care? Yes No 10. In the last week has a patient/resident or visitor asked you for information on hand cleaning? Yes No We are interested in what you think about hand hygiene and outcomes that might occur when you follow your unit’s/hospital’s guidelines for how and when to clean your hands. For each of the items below, please circle the number that best describes your thoughts. When I follow the unit’s/hospital’s guidelines for when and how to clean your hands: 1. Patients/residents will get fewer health care related infections

very unlikely

1

2

3

4

5

6

7

very likely

7

very likely

2. I will not be able to perform all of my assigned duties on time

very unlikely

1

2

3

4

5

6

3. My hands will become dry, cracked and reddened

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very unlikely

1

2

3

4

5

6

7

very likely

5

6

7

very likely

4. I will protect myself from getting infections (e.g. flu)

very unlikely

1

2

3

4

5. I will protect my family and/or persons I live with from many of the infections carried by patients/residents

very unlikely

1

2

3

4

5

6

7

very likely

6. I will feel a sense of satisfaction about my activities to protect patients/residents from infections

very unlikely

1

2

3

4

5

6

7

very likely

5

6

7

very likely

5

6

7

very likely

7. I will influence the hand cleaning behaviour of other staff

very unlikely

1

2

3

4

8. I will be meeting the expectations of patients/residents

very unlikely

1

2

3

4

Hand Hygiene is Simple, Effective and Saves Lives!

36

We are interested in your intention to follow the unit’s/hospital’s guidelines for when and how to clean your hands. For each of the items below, please circle the number that most closely describes your intentions.

I intend to follow the unit’s/hospital’s guidelines for when and how to clean your hands

1. In every situation where it is recommended

very unlikely

1

2

3

4

5

6

7

very likely

3

4

5

6

7

very likely

2

3

4

5

6

7

very likely

1

2

3

4

5

6

7

very likely

1

2

3

4

5

6

7

very likely

2

3

4

5

6

7

very likely

4

5

6

7

very likely

2. When asked by a patient/resident or their family

very unlikely

1

2

3. When a patient/resident has an infection

very unlikely

1

4. When reminded by Infection Control

very unlikely

5. When there is enough time

very unlikely

6. When my hands are sore or chapped

very unlikely

1

7. When there is a patient/resident crisis situation

very unlikely

1

2

3

Hand Hygiene is Simple, Effective and Saves Lives!

37

8. When the patient/resident is in isolation

very unlikely

1

2

3

4

5

6

7

very likely

Posters are commonly used to communicate the importance of hand hygiene to staff, patients/residents and visitors. We are interested in your assessment as to the effectiveness of the posters in communicating this message. 1. Have you noticed hand hygiene posters? Yes

No

Not sure

IF YES, 2. How often do you think that the posters are changed? Every 2 weeks Every 6 months

Monthly Yearly

Every 3 months Have not noticed

3. How effective are the posters in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

4. How effective are the posters in educating patients/residents and visitors on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

5. How effective are the posters in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

6. How effective are the posters in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

7. How effective are the posters in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

38

Units and hospitals make available different products to support good hand hygiene. We are interested in your assessment of these products. 1. Which hand cleaning products have you used in the last week at work? (Check all that apply) Soap and water Alcohol hand rub (portable - personal) Alcohol hand rub (wall dispensers)

2. Please rank your preference for each of the hand cleaning products with “1” being your most preferred and “3” being least preferred. ____ ____

Soap and water Alcohol hand rub (portable – personal)

____

Alcohol hand rub (wall dispensers)

3. How accessible are the unit’s/hospital’s hand cleaning products? Soap and Water very inaccessible

1

2

3

4

5

6

7

very accessible

5

6

7

very accessible

5

6

7

very accessible

Alcohol hand rub (portable - personal)

very inaccessible

1

2

3

4

Alcohol hand rub (wall dispensers) very inaccessible

1

2

3

4

4. How well do the unit’s/hospital’s hand cleaning products promote compliance with hand cleaning guidelines? Soap and Water

very ineffective

1

2

3

4

5

6

7

very effective

5

6

7

very effective

Alcohol hand rub (portable - personal)

very ineffective

1

2

3

4

Hand Hygiene is Simple, Effective and Saves Lives!

39

Alcohol hand rub (wall dispensers) very ineffective

1

2

3

4

5

6

7

very effective

5. How gentle on the hands are the unit’s/hospital’s hand cleaning products

Soap and Water not gentle

1

2

3

4

5

6

7

very gentle

5

6

7

very gentle

5

6

7

very gentle

Alcohol hand rub (portable – personal)

not gentle

1

2

3

4

Alcohol hand rub (wall dispensers) not gentle

1

2

3

4

Do you have any comments? ____________________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________

We thank you for your time. To enroll in the draw for one of five $100 prizes, please provide your contact information on the following page. This information will not be linked to your questionnaire responses. The draw will take place on December 19, 2005. Good luck!

Hand Hygiene is Simple, Effective and Saves Lives!

40

Entry form for the Draw

Name: _____________________________________________________ Facility: ___________________________________________________ Telephone: _________________________________________________

Hand Hygiene is Simple, Effective and Saves Lives!

41

Staff Survey II Vancouver Coastal Health Infection Control, in collaboration with Bayer Healthcare (Canada), launched a year-long hand hygiene campaign entitled “Clean Hands for Life” back in October of 2005. We are now at the midpoint of the campaign. The goal is to increase awareness and compliance with proper hand cleaning. One of the ways we are assessing the success of the “Clean Hands for Life” campaign is by conducting staff surveys for quality assurance purposes. The Staff Survey takes approximately 5-7 minutes to complete. All staff that return their completed survey by 5:00 pm July 10, 2006 will be entered into a draw for one of five $100 prizes. The Infection Control team thanks you in advance for your time.

11. What is your gender? 12. How old are you?

Female 19-29

Male 30-39

40-49

50-59

60-69

13. What is your present occupation? (check one) Administrative support Dietician Educator Food services Housekeeping Licensed Practical Nurse Management Medical Doctor Pharmacist Physiotherapist/Occupational therapist

Psychologist Registered Care Aid Registered Nurse Respiratory Therapist Security Social Worker Student/volunteer Technologist/Technician Ultrasound/Radiology Technician Other __________________________ (Please specify)

14. Which facility do you normally work at? (check one) North Shore/Coast Garibaldi Bella Coola General Hospital Gibsons Kiwanis Village Care Centre Lion’s Gate Hospital LGH Evergreen North Shore Cedar Garden North Shore Cedar View North Shore Kiwanis Pemberton Health Centre Powell River Evergreen Powell River General Hospital

Hand Hygiene is Simple, Effective and Saves Lives!

Powell River Glacier Apartments Powell River O Devaud RW Large Memorial Hospital Sechelt Saint Mary’s Hospital Sechelt Shorncliffe Sechelt Totem Lodge Squamish General Hospital Squamish Hilltop House Squamish Iris Place Whistler Health Care Centre

42

Vancouver Dogwood Lodge George Pearson Centre GF Strong Rehab Centre UBC Hospital UBC Purdy Vancouver General Hospital VGH Banfield Richmond Richmond Hospital Lions Manor Minoru Lodge Other ____________________ (please specify)

Hand Hygiene is Simple, Effective and Saves Lives!

43

15. How many hours do you normally work per week, including overtime (check one) Less than 10 hours 10 – 20 hours 21-30 hours 31-40 hours

41-50 hours 51-60 hours More than 60 hours

16. How confident are you in your knowledge of the unit’s/hospital’s hand hygiene guidelines for when and how to clean your hands?

very unconfident

1

2

3

4

5

6

17. Do you have direct (hands-on) patient/resident contact?

7

very confident

Yes

No

IF YES, 18. In the last week has a patient/resident or visitor asked you if you cleaned your hands before providing them (or their loved one) direct care? Yes No 19. In the last week has a patient/resident or visitor asked you for information on hand cleaning? Yes No We are interested in what you think about hand hygiene and outcomes that might occur when you follow your unit’s/hospital’s guidelines for how and when to clean your hands. For each of the items below, please circle the number that best describes your thoughts. When I follow the unit’s/hospital’s guidelines for when and how to clean your hands: 9. Patients/residents will get fewer health care related infections

very unlikely

1

2

3

4

5

6

7

very likely

10. I will not be able to perform all of my assigned duties on time

very unlikely

1

2

3

4

5

6

7

very likely

4

5

6

7

very likely

11. My hands will become dry, cracked and reddened

very unlikely

1

2

3

Hand Hygiene is Simple, Effective and Saves Lives!

44

12. I will protect myself from getting infections (e.g. flu)

very unlikely

1

2

3

4

5

6

7

very likely

13. I will protect my family and/or persons I live with from many of the infections carried by patients/residents

very unlikely

1

2

3

4

5

6

7

very likely

14. I will feel a sense of satisfaction about my activities to protect patients/residents from infections

very unlikely

1

2

3

4

5

6

7

very likely

5

6

7

very likely

5

6

7

very likely

15. I will influence the hand cleaning behaviour of other staff

very unlikely

1

2

3

4

16. I will be meeting the expectations of patients/residents

very unlikely

1

2

3

4

Hand Hygiene is Simple, Effective and Saves Lives!

45

We are interested in your intention to follow the unit’s/hospital’s guidelines for when and how to clean your hands. For each of the items below, please circle the number that most closely describes your intentions.

I intend to follow the unit’s/hospital’s guidelines for when and how to clean your hands

9. In every situation where it is recommended

very unlikely

1

2

3

4

5

6

7

very likely

3

4

5

6

7

very likely

10. When asked by a patient/resident or their family

very unlikely

1

2

11. When a patient/resident has an infection

very unlikely

1

2

3

4

5

6

7

very likely

1

2

3

4

5

6

7

very likely

2

3

4

5

6

7

very likely

4

5

6

7

very likely

12. When there is enough time

very unlikely

13. When my hands are sore or chapped

very unlikely

1

14. When there is a patient/resident crisis situation

very unlikely

1

2

3

Hand Hygiene is Simple, Effective and Saves Lives!

46

Section D – Hand Hygiene Posters Posters are commonly used to communicate the importance of hand hygiene to staff, patients/residents and visitors. We are interested in your assessment as to the effectiveness of the posters in communicating this message. A 8. Have you noticed this poster?

Yes

No

Not sure

9. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

10. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

11. How effective THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

12. How effective THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

47

B. 13. Have you noticed this poster?

Yes

No

Not sure

14. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

15. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

16. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

17. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

48

C 18. Have you noticed this poster?

Yes

No

Not sure

19. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

20. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

21. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

22. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

49

D. 23. Have you noticed this poster?

Yes

No

Not sure

24. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

25. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

26. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

27. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

50

E. Have you noticed this poster?

Yes

No

Not sure

28. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

29. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

30. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

31. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

51

Do you have any comments? ____________________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________

We thank you for your time. To enroll in the draw for one of five $100 prizes, please provide your contact information on the following page. This information will not be linked to your questionnaire responses. The draw will take place on July 21, 2006. Good luck!

Entry form for the Draw

Name: _____________________________________________________ Facility: ___________________________________________________ Telephone: _________________________________________________

Hand Hygiene is Simple, Effective and Saves Lives!

52

Staff Survey III On October 13, 2006 Vancouver Coastal Health Infection Control, in collaboration with Bayer Healthcare (Canada), launched a year-long hand hygiene campaign entitled “Clean Hands for Life”. The goal of the campaign was to increase awareness and compliance with proper hand cleaning. One of the ways we are assessing the success of the “Clean Hands for Life” campaign is by conducting staff surveys for quality assurance purposes. The Staff Survey takes approximately 5-7 minutes to complete. Your responses will be coded and will not be linked to you or your email address. All staff that return their completed survey by 5:00 pm Monday, February 5, 2007 will be entered into a draw for one of five $100 prizes. The Infection Control team thanks you in advance for your time.

1. What is your gender? 2. How old are you?

Female 19-29

Male 30-39

40-49

50-59

60-69

3. What is your present occupation? (check one) Administrative support Dietician Educator Food services Housekeeping Licensed Practical Nurse Management Medical Doctor Pharmacist Physiotherapist/Occupational therapist

Psychologist Registered Care Aid Registered Nurse Respiratory Therapist Security Social Worker Student/volunteer Technologist/Technician Ultrasound/Radiology Technician Other __________________________ (Please specify)

4. Which facility do you normally work at? (check one) North Shore/Coast Garibaldi Bella Coola General Hospital Gibsons Kiwanis Village Care Centre Lion’s Gate Hospital LGH Evergreen North Shore Cedar Garden North Shore Cedar View North Shore Kiwanis Pemberton Health Centre Powell River Evergreen Powell River General Hospital

Hand Hygiene is Simple, Effective and Saves Lives!

Powell River Glacier Apartments Powell River O Devaud RW Large Memorial Hospital Sechelt Saint Mary’s Hospital Sechelt Shorncliffe Sechelt Totem Lodge Squamish General Hospital Squamish Hilltop House Squamish Iris Place Whistler Health Care Centre

53

Vancouver Dogwood Lodge George Pearson Centre GF Strong Rehab Centre UBC Hospital UBC Purdy Vancouver General Hospital VGH Banfield Richmond Richmond Hospital Lions Manor Minoru Lodge Other ________________________ (Please specify)

Hand Hygiene is Simple, Effective and Saves Lives!

54

5. How many hours do you normally work per week, including overtime (check one) Less than 10 hours 10 – 20 hours 21-30 hours 31-40 hours

41-50 hours 51-60 hours More than 60 hours

6. How confident are you in your knowledge of the unit’s/hospital’s hand hygiene guidelines for when and how to clean your hands?

very unconfident

1

2

3

4

5

6

7. Do you have direct (hands-on) patient/resident contact?

7

very confident

Yes

No

IF YES, 8. In the last week has a patient/resident or visitor asked you if you cleaned your hands before providing them (or their loved one) direct care? Yes No 9. In the last week has a patient/resident or visitor asked you for information on hand cleaning? Yes No We are interested in what you think about hand hygiene and outcomes. For each of the items below, please circle the number that best describes your thoughts. When I follow the unit’s/hospital’s guidelines for when and how to clean your hands: 17. Patients/residents will get fewer health care related infections

very unlikely

1

2

3

4

5

6

7

very likely

18. I will not be able to perform all of my assigned duties on time

very unlikely

1

2

3

4

5

6

7

very likely

4

5

6

7

very likely

19. My hands will become dry, cracked and reddened

very unlikely

1

2

3

20. I will protect myself from getting infections (e.g. flu)

very unlikely

1

2

3

4

5

6

7

very likely

21. I will protect my family and/or persons I live with from many of the infections carried by patients/residents

very unlikely

1

2

3

4

5

6

7

very likely

22. I will feel a sense of satisfaction about my activities to protect patients/residents from infections

very unlikely

1

2

3

4

5

6

7

very likely

5

6

7

very likely

5

6

7

very likely

23. I will influence the hand cleaning behaviour of other staff

very unlikely

1

2

3

4

24. I will be meeting the expectations of patients/residents

very unlikely

1

2

3

4

We are interested in your intention to follow the unit’s/hospital’s guidelines for when and how to clean your hands. For each of the items below, please circle the number that most closely describes your intentions.

Hand Hygiene is Simple, Effective and Saves Lives!

56

I intend to follow the unit’s/hospital’s guidelines for when and how to clean your hands

15. In every situation where it is recommended

very unlikely

1

2

3

4

5

6

7

very likely

3

4

5

6

7

very likely

16. When asked by a patient/resident or their family

very unlikely

1

2

17. When a patient/resident has an infection

very unlikely

1

2

3

4

5

6

7

very likely

1

2

3

4

5

6

7

very likely

2

3

4

5

6

7

very likely

4

5

6

7

very likely

18. When there is enough time

very unlikely

19. When my hands are sore or chapped

very unlikely

1

20. When there is a patient/resident crisis situation

very unlikely

1

2

3

Hand Hygiene is Simple, Effective and Saves Lives!

57

Posters are commonly used to communicate the importance of hand hygiene to staff, patients/residents and visitors. We are interested in your assessment as to the effectiveness of the posters in communicating this message. 32. Have you noticed this poster?

Yes

No

Not sure

33. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

34. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

35. How effective THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

36. How effective THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

58

37. Have you noticed this poster?

Yes

No

Not sure

38. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

39. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

40. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

41. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

59

42. Have you noticed this poster?

Yes

No

Not sure

43. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

44. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

45. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

46. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

60

47. Have you noticed this poster?

Yes

No

Not sure

48. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

49. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

50. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

51. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

Hand Hygiene is Simple, Effective and Saves Lives!

6

7

very effective

61

52. Have you noticed this poster?

Yes

No

Not sure

53. How effective is THIS POSTER in educating staff on the importance of hand hygiene? not effective

1

2

3

4

5

6

7

very effective

54. How effective is THIS POSTER in making you think about your own hand cleaning? not effective

1

2

3

4

5

6

7

very effective

55. How effective is THIS POSTER in motivating you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

56. How effective is THIS POSTER in reminding you to clean your hands?

not effective

1

2

3

4

5

6

7

very effective

Units and hospitals make available different products to support good hand hygiene. We are interested in your assessment of these products.

Hand Hygiene is Simple, Effective and Saves Lives!

62

26. Which hand cleaning products have you used in the last week at work? (Check all that apply) Soap and water Alcohol hand rub (portable - personal) Alcohol hand rub (wall dispensers)

27. Please rank your preference for each of the hand cleaning products with “1” being your most preferred and “3” being least preferred. ____ ____

Soap and water Alcohol hand rub (portable – personal)

____

Alcohol hand rub (wall dispensers)

28. How accessible are the unit’s/hospital’s hand cleaning products? Soap and Water very inaccessible

1

2

3

4

5

6

7

very accessible

5

6

7

very accessible

5

6

7

very accessible

Alcohol hand rub (portable - personal)

very inaccessible

1

2

3

4

Alcohol hand rub (wall dispensers) very inaccessible

1

2

3

4

Hand Hygiene is Simple, Effective and Saves Lives!

63

Do you have any comments? ____________________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________

We thank you for your time. To enroll in the draw for one of five $100 prizes, please provide your contact information on the following page. This information will not be linked to your questionnaire responses. The draw will take place on February 12, 2007. Good luck!

Are you interested in learning more about infection control? Why not try our animated online course Infection Control: Basics. It's free, takes about 30 minutes and you may be eligible to win a prize. Find the link on the Course Catalogue and Registration System (CCRS) through the VCH Intranet-Clinical or Employee tabs.

Entry form for the Draw

Name: _____________________________________________________ Facility: ___________________________________________________ Telephone: _________________________________________________

Hand Hygiene is Simple, Effective and Saves Lives!

64

Appendix 4: Individual Poster Effectiveness Scores

Posters used in Survey II Poster 1

TABLE 3: Poster Effectiveness results from Survey II, Poster I Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.1

5.0

How effective is this poster in making you think about your own hand hygiene?

5.3

6.0

How effective is this poster in motivating you to clean your hands?

5.1

5.0

How effective is this poster in reminding you to clean your hands?

5.4

6.0

Hand Hygiene is Simple, Effective and Saves Lives!

65

Poster 2

TABLE 4: Poster Effectiveness results from Survey II, Poster 2 Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.6

6.0

How effective is this poster in making you think about your own hand hygiene?

5.8

6.0

How effective is this poster in motivating you to clean your hands?

5.7

6.0

How effective is this poster in reminding you to clean your hands?

5.8

6.0

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.3

5.0

How effective is this poster in making you think about your own hand hygiene?

5.4

6.0

How effective is this poster in motivating you to clean your hands?

5.3

6.0

How effective is this poster in reminding you to clean your hands?

5.4

6.0

Poster 3

TABLE 5: Poster Effectiveness results from Survey II, Poster 3 Poster Effectiveness: Survey Items

Hand Hygiene is Simple, Effective and Saves Lives!

66

Poster 4:

TABLE 6: Poster Effectiveness results from Survey II, Poster 4 Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

4.6

5.0

How effective is this poster in making you think about your own hand hygiene?

4.7

5.0

How effective is this poster in motivating you to clean your hands?

4.6

5.0

How effective is this poster in reminding you to clean your hands?

4.7

5.0

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

4.8

5.0

How effective is this poster in making you think about your own hand hygiene?

4.8

5.0

How effective is this poster in motivating you to clean your hands?

4.8

5.0

How effective is this poster in reminding you to clean your hands?

4.9

5.0

Poster 5

TABLE 7: Poster Effectiveness results from Survey II, Poster 5 Poster Effectiveness: Survey Items

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Posters used in Survey III Poster 6

TABLE 8: Poster Effectiveness results from Survey III, Poster 6 Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

4.9

5.0

How effective is this poster in making you think about your own hand hygiene?

5.1

5.0

How effective is this poster in motivating you to clean your hands?

4.9

5.0

How effective is this poster in reminding you to clean your hands?

5.3

6.0

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Poster 7

TABLE 9: Poster Effectiveness results from Survey III, Poster 7 Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.4

6.0

How effective is this poster in making you think about your own hand hygiene?

5.7

6.0

How effective is this poster in motivating you to clean your hands?

5.5

6.0

How effective is this poster in reminding you to clean your hands?

5.8

6.0

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

4.9

5.0

How effective is this poster in making you think about your own hand hygiene?

5.0

5.0

How effective is this poster in motivating you to clean your hands?

4.9

5.0

How effective is this poster in reminding you to clean your hands?

5.0

5.0

Poster 8

TABLE 10: Poster Effectiveness results from Survey III, Poster 8 Poster Effectiveness: Survey Items

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Poster 9

TABLE 11: Poster Effectiveness results from Survey III, Poster 9 Poster Effectiveness: Survey Items

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.4

5.0

How effective is this poster in making you think about your own hand hygiene?

5.4

6.0

How effective is this poster in motivating you to clean your hands?

5.4

6.0

How effective is this poster in reminding you to clean your hands?

5.5

6.0

Mean

Median

How effective is this poster in educating staff on the importance of hand hygiene?

5.4

6.0

How effective is this poster in making you think about your own hand hygiene?

5.5

6.0

How effective is this poster in motivating you to clean your hands?

5.4

6.0

How effective is this poster in reminding you to clean your hands?

5.5

6.0

Poster 10

TABLE 12: Poster Effectiveness results from Survey III, Poster 10 Poster Effectiveness: Survey Items

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Appendix 5: Focus Group Protocol and Questionnaire Background Information The most important factor in infection prevention and control is frequent and appropriate hand hygiene. The meticulous practice of this activity reduces cross-infection between patients and minimizes the risk of transmission of infectious agents to health care workers (HCWs). Yet, unfortunately compliance with this simple activity is poor in the health care setting. The issue of noncompliance is multifactorial, with factors such as overworked staff, too few sinks, inadequate numbers of or inaccessible antiseptic hand rubs, perception of hand hygiene as a low priority activity, and lack of an enabling safety climate to foster good hand hygiene all contributing to this HCW and patient safety problem. Many excellent articles have described these compliance issues, but few comprehensive programs have 1-4 addressed the full scope of the problem. Vancouver Coastal Health (VCH) launched a regional hand hygiene campaign “Clean Hands for Life” in October 2005 that focuses on HCWs, but also includes patients/residents and their visitors. This campaign provides an ideal opportunity to prospectively follow the factors that influence compliance, affect behaviour and contribute to increasing awareness among HCWs and patients/residents. Information obtained from detailing the individual, organizational and environmental factors influencing HCWs’ intent to comply with health care facility hand hygiene guidelines can be extrapolated and used in a variety of workplace settings and educational programs.

Purpose and Objectives The purpose of the proposed research project is to measure the effectiveness of specific aspects of a regional hand hygiene campaign on HCW’s knowledge, attitudes and intent to comply with hand hygiene guidelines. The objectives of the research are as follows: (1) To identify individual, environmental and organizational factors that influence HCWs intent to comply with health care facility hand hygiene guidelines; (2) to identify differences in beliefs and attitudes towards hand hygiene between various groups of HCWs; and (3) to identify factors that contribute to the success and/or failure of a regional hand hygiene campaign.

Theoretical Approach The ability and willingness to comply with hand hygiene control guidelines involves a number of factors, 5,6 the majority of which can be explained by the PRECEDE model of health promotion. This model examines the characteristics that promote the application of self-protective behaviour at work. Successful application of desired policies and procedures require a good understanding of what is required and why (individual factors); a workplace that promotes a safety climate, clearly outlines expectations for performance, and provides training/educational programs to facilitate compliance (organizational factors); and an environment that provides the resources, equipment/supplies and accessibility to the required items for compliance (environmental factors).

Focus Group Methodology Target population: Fourteen focus groups will be held, each made of 8-10 participants for a total of 112 to 140 participants. Participants will be recruited from facilities throughout the region including employees/staff working in a acute-care hospitals, rehabilitation/transitional care, and long-term care facilities. Clinical nursing staff, physicians, medical technologists, hospital management and allied support staff, among others, will be targeted.

a

The locations of these focus groups will be in Vancouver General Hospital, Richmond Hospital, Lions Gate Hospital, St. Mary’s Hospital, Squamish Hospital, Whistler Clinic, Powell River Hospital, Minoru Lodge, GF Strong, Purdy Pavilion, George Pearson Centre, Evergreen Lodge, Bella Coola General Hospital and R.W. Large Memorial Hospital.

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Sampling: As noted above, focus groups will be conducted throughout the region to ensure comprehensive geographical and level of care (acute care, long term care etc.) representation. Stratified random sampling will be used to recruit HCWs for focus group participation to maximize representation from relevant occupational groups. Invitation letters will be sent to HCWs either electronically or in print, depending on the employees’ access to email (Appendix 1). Consent to Participate: Participation in the study is completely voluntary. Participants may withdraw from the study at any time without consequence. A consent form will be appended to the invitation letter, to be signed at the focus group (Appendix 2). Those that accept the invitation will be contacted, (eg, e-mail, phone or letter), to confirm availability and participation, and to provide details concerning date and time of the focus group meeting. Investigators: Focus groups will be facilitated by Leslie Forrester, BA (Hons.), MA, MSc (Regional Hospital Epidemiologist) – 604-875-4111, local 61455) and Anne Mediaa, BSc, IPCC (Senior Research Assistant) – 604-875-4111, local 66072. Confidentiality and Data Retention: Focus group sessions will be recorded electronically. All participants will be informed that confidentiality will be maintained; data will be stored on a password-protected computer in a secured office within the Vancouver General Hospital Microbiology Lab that is also secure. Data will be backed up on the server in accordance with Vancouver Coastal Health policy. Data collected from each session will be retained in a confidential manner for five years as per UBC policy #89, ‘Research and Other Studies Involving Human Subjects’, and then destroyed. The first name, only, of each participant will be required for the purposes of facilitating transcription. To this end participants will be requested to identify themselves prior to speaking. The questions (Appendix 3) will be used for all focus groups to ensure consistency in methodology across sessions. Time Commitment and Incentives: Each session will be about 60 minutes in length. Participants will be reimbursed the costs of parking, if required. Refreshments will be provided at each focus group meeting.

References

1.

Ann Intern Med 1999;130:126 Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. -130.

2.

Pittet D, Simon A, Hugonnet S et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141:1-9.

3.

Larson EL APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1994:23:251-69.

4.

Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices. Am J Infect Control 1998; 26:245-53

5.

Green LW, M. Kreuter and Deed S, Health Education Planning: A Diagnostic Approach. 1980, Palo Alto, CA: Mayfield.

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6.

DeJoy D A Behavioral-Diagnostic Model for Fostering Self-Protective Behavior in the Workplace, in Trends in Ergonomics/Human Factors III, W. Karwowski, Editor. 1986, Elsevier Science Publishers BV: North-Holland. P. 907917.

Focus Group Questions 1. What comes to mind when you hear the phrase “Clean Hands for Life”?

b

Individual factors: 2. Do you think that health care workers have a good understanding of the importance of c.. appropriate hand hygiene? - If not, why not? If yes, how? - Can you provide me with some examples? - What do you think is appropriate hand hygiene? - What about patients? Residents? Visitors? Others? Organizational factors: 3. Would you say that the facility has been supportive of appropriate hand hygiene behavior among d health care workers? - If not, why not? If yes, how? - Can you give examples? - What about with patients? Residents? Visitors? Others? Environmental factors: e 4. Do you think that your work environment supports appropriate hand hygiene behaviour? - If not, why not? If yes, how? - Are hand hygiene stations (sinks, Microsan dispensers, etc) accessible to everyone? - What about visitors? Patients? Disabled? Others? - How do patient care areas compare to common areas? - Are Microsan and soap dispensers kept filled? At this point in the focus group exercise the moderator will summarize the discussion. f 5. To summarize do you have any comments you would like to make? - Observations? - Recommendations for improving the hand hygiene campaign? - If, yes, how? If no, why not?

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