By Gary Evans, Medical Writer
Much of infection control work — a frustrating portion to many IPs — is trying to change human behavior. One need look no further than the historic struggle with hand hygiene and the various carrots and sticks that have been dangled and cracked in the name of compliance for decades.
In what was more like a TED talk (https://www.ted.com/) than an infection control lecture, a veteran epidemiologist recently took a holistic, somewhat psychological view of these challenges, addressing diverse topics from mindfulness to motivation in a fascinating closing plenary at the recent APIC conference in Portland.
For example, mindfulness — a hot topic across a variety of fields — has been suggested as a buffer to burnout in healthcare and shows initial signs of having positive implications for infection prevention, said Sanjay Saint, MD, MPH, chief of medicine at the VA Ann Arbor Healthcare System and director of the University of Michigan Patient Safety Enhancement Program.
“Mindfulness is the awareness that arises by paying attention on purpose in the present moment, nonjudgmentally,” he said. “Being fully present, fully aware, and fully engaged.”
In a study that has not yet been published, Saint and colleagues conducted a systematic literature review of brief mindfulness practices for healthcare providers.
“There were a total of 14 studies,” he said. “Nine showed improvement — positive change in healthcare worker stress, anxiety, resiliency, or burnout. The bottom line is that brief mindfulness interventions show promise in improving healthcare worker well-being. This idea of mindfulness and wellness is something that APIC could take the lead on. We have to put the oxygen mask on ourselves before assisting others.”
To focus the study specifically on infection prevention, Saint and colleagues asked the question, “Could hand hygiene compliance be increased by tying it to a brief moment of mindfulness?”
They conducted a quasi-experimental study with a control group and two simple components in the intervention arm.
“The first [component] is we had the medical team, medical residents, and medical students and the attending physician watch Andy Puddicombe’s TED talk, ‘All it takes is 10 mindful minutes.’ [The TED talk can be viewed at: http://bit.ly/1ApYvfJ.] It’s been watched over a million times. And the second [component] is we held brief, guided discussions on ways to use mindfulness to enhance awareness and enhance patient safety. We told our residents and students, ‘Let’s use hand hygiene as an external cue to prompt a moment of mindfulness as we enter and exit the patient rooms. What if we use that alcohol-based hand rub to remind ourselves that we are about to take care of a vulnerable patient? These next 10 minutes are really important to them and their family, so be present.’”
The intervention yielded an 11% increase in hand hygiene compliance, going from 72% to 83% in an effect that was statistically significant, he said. There was a less tangible improvement in “feelings” associated with the hand hygiene performed mindfully. “It was small but it was moving in the right direction, so I think that there is something to this,” Saint said.
Another psychological technique for motivating change is the so-called “framing effect,” which can be used to communicate, he said.
“Framing effects, and this comes from the cognitive psychological field, occur when a different conclusion is drawn from the same information depending entirely on how that information is presented to the audience,” he said. “Some believe that we as humans are ‘cognitive misers’ and we prefer to do as little thinking as possible. I realize that some of us are more miserly than others. Frames provide a quick way to process huge amounts of information.”
For example, one undertakes a hand hygiene initiative at a hospital, as the supervisors are demanding better performance due to historic lax compliance or a spike in infection rates.
“So, the nurse unit manager calls a meeting of his or her troops, and they can frame the discussion in different ways,” Saint said. “I’ll just give you two examples. The first is they can say, ‘You know what, it seems like our rates are lousy and the bosses want us to improve. Make sure you wash your hands.”
The same message with a different frame is, “We went into healthcare to help patients, especially the most vulnerable patients, and those are the patients on our unit,” Saint said. “Unfortunately, our low hand hygiene rates are undermining our goals. Let’s prove that we can be the best performing unit in the hospital, and be a regional, if not a national, example of how to wash our hands. What do you say?”
Saint has tried both framing effects and another approach called motivational interviewing. The latter is attempting to change behavior by engaging in a non-judgmental, empathetic conversation with a “resister,” he says. (For more information, see the scenario in this issue). This is opposed to just telling people they need to change, which typically elicits a defensive “righting reflex,” he explained. “People get dug in.”
It’s no coincidence that Saint has come to search beyond the normal tactics in an attempt to change human behavior and protect patients. Having spent two decades of his career trying to reduce catheter-associated urinary tract infections (CAUTIs), Saint has had to convince people that the “Rodney Dangerfield” of infections can have serious effects on patients and is important to prevent.
His research has revealed that catheters are too often placed and forgotten, where they can seed an infection if ignored long enough. Sometimes there is no medical record indicating catherization, though there is a Foley attached to the patient.
“We call this phenomenon the ‘immaculate catherization,’” he joked. Saint also emphasizes the non-infectious harms of the Foley, including that it functions as a one-point of restraint, tethering the patient to the bed and leading to other complications and increasing length of stay.
Fortunately, the misconception that it is a nuisance infection that can be easily treated with an antibiotic is gradually giving way in an era of drug stewardship and seeing patients as satisfied customers. CAUTIs have also become a major target for prevention by the CDC, in part because use of antibiotics drives resistance and sets up Clostridium difficile infections.
Culture Is King
In attempting change that will improve infection prevention and patient safety, IPs must be cognizant of the work culture at their facility, he said.
“Culture eats strategy for breakfast and lunch,” Saint said, showing a slide of a Korean Air 747 commercial aircraft in perfect condition on the runway. In the next slide it is in ruins, having crashed upon attempting to land in Guam on Aug. 5, 1997. The weather played a role, but the prevailing work culture at the airline also heavily contributed to the disaster, he said, recalling the incident as described in Malcolm Gladwell’s book, “Outliers.”
“There was a long list of crashes involving Korean Air,” he said. “In fact, crashes on Korean Air were 17 times higher than for American or United during the exact same period. Communication was cited in many of the accidents, just like the communication is cited in many of the root cause analyses that occur in hospitals across this country.”
Weather conditions made instrument readings critical, but the captain was not correctly following the gauges, and ignoring the subtle cues of his first officer and flight engineer.
“The captain was tired and wasn’t interested in what this first officer or his flight engineer were trying to tell him,” Saint said. “They were picking up signals that the flight engineer and the first officer kind of knew were not coming from the airport, but coming from a different place. But the captain thought it was coming from the airport. Again, the first officer and the engineer gave him subtle clues, but in Korea, just like in Japan, the culture is one in which the listener is expected to pick up on subtle cues.”
Thus, if something is not communicated, it is the fault of the listener, not the speaker.
“In English, it is very different,” Saint said. “If you are not understanding what I’m saying, that is on me.”
Another cultural aspect that played into the incident is that there are very strict rules in many Asian countries on how one can speak to superiors, he added. In retrospect, Korean Air acknowledged that their culture had a very high “power-distance” between supervisor and the subordinate, he noted.
Analyzing the crash and looking at the larger pattern of accidents, the airline came across an answer that has resulted in a perfect safety record since 1999: All fight communications were switched to English.
“Instead of using their native language, English was chosen, allowing the crew to have a completely different identity,” Saint told APIC attendees. “Korean Air believes its success was because it acknowledged the importance of its cultural legacy.”
The other aspect of this is the “power-distance” cultural dynamic, which can vary by countries, regions, and even individual hospitals.
“The power-distance index is the extent to which the less powerful members of society accept that power is distributed unequally,” he explained. “People in these societies accept a hierarchical order in which everybody has a place, and which needs no further justification. In societies with low power distance, people strive to equalize the distribution of power.”
Using nations as an example, Russia was at the top in power distance, and the more egalitarian Scandinavian countries at the bottom.
“Even though we talked about national cultures, there are some parts of the U.S. where the power distance is probably higher than others,” Saint said. “There are probably some units in your hospital where the power distance is higher than other units. What’s the relevance to what we do? Subordinates in countries, or hospitals within those countries with high power distance tend not to speak up when something is wrong. This applies to nurses speaking up to docs, frontline clinicians speaking up to executives, or patients speaking up to healthcare workers.”
Even though the power-distance in the United States may be low in general, Saint said he has visited hospitals where that is far from the case.
“Where orthopedic surgeons will tell the nurses who remind them to remove the catheter after one or two days post-hip transplantation, ‘First go to medical school, and then tell me how to practice medicine,’” Saint said. “We’ve all heard that.”
Yet, in some facilities that empower nurses to order Foley removal, the result is often lower CAUTI rates, he notes. “A nurse-initiated Foley removal protocol, which a lot of hospitals now have, works much better in hospitals with low power distance,” Saint said. “So, it is important as you roll out initiatives — especially if it relies upon an [employee] to do the right thing and to speak up — to understand the power distance at your hospital or in the particular unit.”
Mission and Purpose
The power of a mission statement can congeal these individual attempts at change around a core idea. “The best ones are obvious and are short,” he said. “The Humane Society: ‘Celebrating animals, confronting cruelty.’ Four words.”
The statement Saint and colleagues have adopted at the Ann Arbor VA is, “Treat every veteran like a family member.”
“Seven words — this captures what we do and why we work for a VA hospital,” he said. “I’ve learned from site visits from around the country that it is easier to implement infection control practices in hospitals that are mission-based.”
Institutional mission distills down to personal mission, which for work would typically be answered by “money.” However, that only goes so far, said Saint, citing the findings in Daniel Pink’s book “Drive.”
“He argues that that the best use of money, as a motivator, is to pay people enough to take the issue of money off the table,” Saint said. “You don’t offend them by paying them too little, but once you pay them enough it turns out there are three factors that lead to better performance, not to mention increased personal satisfaction.”
The first of these is “autonomy” — the desire to be self-directed.
“I think that applies to a lot of infection preventionists,” he said. “The desire to be self-directed. People need autonomy over task, time, team, and techniques. I think we have that in infection prevention — not as much of it as we would like, but we have this.”
The second factor in personal satisfaction is “mastery,” more in the sense of seeking to ever improve than to reach the summit.
“It is, in fact, impossible to fully realize, which makes it simultaneously frustrating and alluring,” Saint said. “Anyone who is an athlete understands this. Anyone who plays a musical instrument, anyone who’s an artist. The reason we keep going back is because we know we can never truly master something. That’s why I love internal medicine — you can’t know everything. This is also true of infection prevention — success lies in the attempt of getting to zero.”
The final factor is “purpose,” meaning you are serving something beyond yourself.
“We know that the richest experiences in our lives are not when we are clamoring for validation from others, but when you’re listening to our own voice,” he said. “Doing something that matters and doing it well. And doing it in the service of a cause larger than ourselves. This is our jobs. This is what we do for a living.”