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Staff compliance with infection control practices: application of behavioural sciences
Journal
of Hospital
Staff
Infection
compliance application
(1995)
30 (Supplement),
with infection of behavioural W. H.
Department
107-l
of Microbiology,
15
control practices: sciences
Seto
Queen Mary Hospital, Kong, Hong Kong
University
of Hong
Summary:
Microbiology and epidemiology have made significant contributions to the field of Infection Control. Most nosocomial infections which can be prevented are related to inappropriate patient care practices. However, it is extremely difficult to implement new infection control policies. To achieve staff compliance, infection control should learn from the behavioural sciences. Three related fields have been shown to be helpful in this respect: social psychology, consumer behaviour and organizational behaviour. Basic concepts from all three fields can be applied to the work of infection control for achieving staff compliance; the use of social power and the reasoned action model from the field of social psychology; the use of participatory decision-making from organizational behaviour; and the opinion leaders from consumer behaviour. Keywords:
Compliance;
policies;
behavioural
science;
patient
care
practices.
Introduction
Traditionally, the development of hospital infection control is largely dependent on the two related fields of microbiology and epidemiology which are essential for understanding the pathogenesis and spread of infectious diseases. However, in recent years, there is growing realization that such technical understanding of infections alone may be insufficient for infection control. Most hospital-acquired infections are endemic and are related to inappropriate patient-care practices (PCPs).’ These are often simple procedures, like the recapping of needles or the handling of patients with unwashed hands, but are extremely difficult to correct.2 However, unless these inappropriate PCPs are altered, infection control guidelines and policies cannot be successfully implemented. Education has always been an integral part of infection control, but it must be conducted in such a way that practices are altered within the realms of the behavioural sciences. The application of the behavioural sciences is therefore timely and crucial for the continuing practice of hospital infection control. Development
of the behavioural
sciences
in infection
control
Although alteration of PCPs is vital for prevention nosocomial infection, there are few original studies on this subject. The pioneers, as in many 0 1995 The Hospital
01954701/95/060107+09$08.00/0
107
Infection
Society
108
W. H. Seto
Table
I. Reports
of nurses and house-keeping secure their compliance
staff on the power base which to infection control policies Hong
Staff Power 1. 2. 3. 4. 5. 6.
base
Coercive Reward Legitimate Expert Referent Informational
*Differences Groups correction.
(%)
the
same
(a) and row
with
(b)
are significant different
superscript
USA
House-keeping (%) staff n = 140 (b)
l(O.01)” 8 (5.6) 10 (7.0)
between in
nurses n=142 (4
Kong*
11 12 42 30 12 33 (P
will
most
likely
(SENIC)’
Staff
nurses
n=7069 %
(7.9)b (8.6) (30)b (21.4) (8.6)* (23.6)
0.3 0.1 2.1 56.1 4.4 36.9
x*=53). significantly
(PiO.05)
by
x2 with
Yates’
areas of infection control are workers in the Study on the Efficacy of Nosocomial Infection Control (SENIC) project. The SENIC workers investigated the role of social power, defined as the potential ability of an influencing agent to change the cognitions, attitudes or behaviour of another person (the target), in infection control.3 There are six bases for social power and they were first described by the social psychologists, French and Raven.4 The SENIC definitions for these bases of power are: 1. Coercive power-stems from the ability of the influencing agent to mediate punishment for the target. 2. Reward power-stems from the ability to mediate rewards. 3. Legitimate power-stems from the target’s acceptance of a role relationship with the agent that obligates the target to comply with the agent’s request. 4. Expert power-stems from the target’s attribution of superior knowledge or ability to the agent. 5. Referent power-stems from the target’s utilization of others as a ‘frame of reference’ to evaluate his/her behaviour. 6. Informational power-stems from the persuasiveness of the information communicated by the agent to the target. In the SENIC project, 7046 nurses were surveyed to discover the base of power most likely to secure the compliance of the subjects.3 A similar survey was conducted in Hong Kong among nurses and house-keeping staff’ and the results of the two surveys are shown in Table I. Strict comparison between the results of the two surveys is not possible because there is no evidence that the two samples of nurses are comparable.
Staff compliance
to policies
109
Nevertheless, both studies do show that for nurses, the best responses are for informational and expert power. Therefore, infection control nurses (ICNs) should exercise these powers to enhance compliance with infection control policies. As suggested by Haley et al. this should include the provision of ‘relevant references and convincing information’ including local surveillance data.’ A significant finding in the Hong Kong study are the differences in response between house-keeping staff (HKS) and nurses. This is not altogether unexpected, because the two groups differ in many aspects, especially educational background and working culture. It is important for ICNs to appreciate that HKS are more responsive to legimitate and coercive power; and less to informational power. Therefore to influence the HKS, it would be better to present the request as coming from a legitimate superior and evidence of their supervisor’s endorsement should always be shown. Utilizing
the results
of behavioural
science
research
The study on social power by the SENIC workers is a possible model for future development. The results of behavioural science research in other fields could also be adopted for the purpose of infection control. However, it is important to be selective because the spectrum of behavioural science research is rather broad. There are three fields of studies in the behavioural sciences which may be relevant for infection control. These are the fields of social psychology, organizational behaviour and consumer behaviour. Social psychology is defined as the scientific study of how people think about, influence, and relate to one another.6 In the field of social psychology, topics like attitude change, social influence and social compliance have been thoroughly investigated and many of these data may be relevant for the alterations of PCPs. Organizational behaviour is the study and application of knowledge about how people act within organizations7 and is considered an integral part of management science. The hospital is a large and complex organization and obviously, there will be ideas and concepts in organization behaviour which will be relevant for infection control. Consumer behaviour is the study of how and why consumers buy and consume.’ In this field of study, much is done to understand human behaviour in the context of marketing a product. New policies are often introduced in infection control, and various methods and ideas, identified in consumer behaviour could be used to persuade hospital staff to comply with a policy. In the remaining portion of this chapter, a classical theory from each of the three specialties will be presented. Three studies will be described in which these theories were evaluated for achieving staff compliance of infection control policies in the hospital.
110 Table
W. H. Seto II.
Discontinuation
of recapping
in 208 nurses
5 weeks Nurses
Groupings
after
introduction
with
of sharps
no recapping
All nurses (% of n)
Agreeables (% of n,)
Non-agreeables (% of nz)
A Simple announcement n=62 Agreeables (n,) = 23 Non-agreeables (nz) = 39
13 (21)
7 (30)
6 (15)*
B Passive method n=79 Agreeables (n,) = 55 Non-agreeables (n2) = 24
52 (66)
47 (85)”
5 (21)*
C Active and passive method n=67 Agreeables (nl) = 27 Non-agreeables (nz) = 40
57 (85)
24 (89)’
33 (83)
*Differences
between
The
rows
reasoned
are
all
significant
action
(P~0.05)
except
model-predicting
for
numbers
boxes
with
asterisk.
staff compliance
When a new policy is implemented, it would be an advantage if the infection control team could identify ahead of time those staff who will comply, and predict what is required in the in-service education programme. A classical theory in social psychology is the theory of reasoned action by Azjen and Fishbein.’ This theory assumes that people behave rationally and that generally, the intention to act is the result of considerable mental deliberation. The theory states that this behavioural intent is a good predictor of actual behaviour. A study was conducted to assesswhether this is true in the hospital, and the impact of in-service education on those with or without behavioural intent.” A policy was introduced to stop the recapping of needles and nine randomly selected wards were divided into three groups (A, B and C) of three wards each. From an initial survey, the recapping practices of nurses were ascertained, and they were divided into those with the behavioural intent to discontinue with the practice (the ‘agreeables’), and those without (the ‘non-agreeables’). Methods utilized to introduce the policy included simple announcement through the nursing hierarchy in group A (control), passive method (posters and pamphlets) were added in group B and both passive and active method (in-service lectures) in group C. Five weeks later, behavioural change was assessed by another survey and the result is shown in Table II. As shown, 59% (122) of the nurses had discontinued the recapping practice and the largest proportion occurred in group C (active and passive
Staff compliance
to policies
111
method) with 85%, followed by 66% in group B (passive method) and finally the 21% in group A (simple announcement). Change in the recapping practice of the ‘agreeables’ and ‘non-agreeables’ was also analysed and for the ‘agreeables’, group B (posters and pamphlets) with 85% change, was superior to that of group A (simple announcement) with only 30% change (RO.001, Z=4.80). The addition of the active method (in-service lecture) in group C showed no significant improvement (P=O*67, Z=O*43) over the passive method (group B). In contrast, for the ‘non-agreeables’, the 21% change observed for group B (posters and pamphlets) was not significantly higher (P=O*58, Z=O.55) than the 15% change observed for simple announcement (group A). However when an in-service lecture (group C) was included, the change of 83% was significantly higher (RO.001, Z= 0.86) than the 21% in group B. The results of group A show that communication through the nursing hierarchy is rather ineffective. for those with the behavioural intent (the agreeables), it is a matter of getting the message to them, which is the function of the poster and pamphlets. Further persuasion by the in-service lectures showed no additional effects. However, for those without the intent (the non-agreeables), active persuasion by the in-service lecture is needed. Before the introduction of a new policy, it may be worthwhile conducting a survey to assess the proportion of staff already with the behavioural intent. If these are the majority, then an in-service lecture is probably not needed, and the passive method would be sufficient. Participatory
decision-making
A topic under intense study in organization behaviour since the 1930s” is participatory decision-making (PDM), which is defined by Vroom and Jago as ‘exerting influence resulting from the employee’s assuming an active role in a decision-making process’.” Vroom and Yetton” described five types of PDMs, a classification that is widely used in the organizational behaviour13 and these are: 1. Autocratic I-no participation. The decision is made solely by the administrator, and no attempt is made to request information or consult the opinion of subordinates. 2. Autocratic II-requesting information. The decision is made solely by the administrator, but the necessary information was collected by specific requests to the subordinates. 3. Consultative I-individual opinion. The decision is finally made by the administrator after consultation with subordinates who are approached individually for their opinions and suggestions. 4. Consultative II-group opinion. The decision is finally made by the administrator after consultation with subordinates who are invited to contribute their opinions and suggestions in a group discussion.
112 Table
Types 1. 2. 3. 4. 5.
W. H. Seto III.
(a) Nurses’
(b)
(PDM)
currently
Frequency n=251 I-no participation II-requesting information I-individual opinions II-group discussion participation
Compliance
score of nurses
of PDM
Personal opinion Group discussion Full PDM Representatives
80 100 38 32 1
to the type
of PDM
when
implementing
(%)
(32) (40) (15) (13)
a new policy
Compliance
1. No participation 2. Request information 3. 4. 5. 6.
of the type of participatory decision-making practised in Queen Mary Hospital
of PDM
Autocratic Autocratic Consultative Consultative Group-full
Types
description
score
;:za 3.1” ;:; full
PDM
6.1
Differences in response to the types of PDM was significant by Friedman’s statistics (P
5. Group-full participation. Subordinates are invited to contribute their opinions and suggestions in a group discussion, and the decision is made according to the consensus of the entire group. Numerous studies in various organizations have documented that PDM can enhance the satisfaction and productivity of employees13 and it is reasonable to believe that PDM can also be effective in influencing nurses for infection control. A survey by personal interview was conducted in Queen Mary Hospital, involving a random sample of 251 nurses, on the response to PDM for the implementation of infection control policies. In the first question, respondents were presented with the five types of PDM as described above (except that ‘nurses in the wards’ were substituted for ‘subordinates’), and were requested to indicate the type of PDM ‘which best describes the current practice in the hospital when new policies involving patient-care practices are introduced’. Table III(a) shows the responses to question 1, which indicate that most respondents (72%) felt that autocratic types of PDM best described the current practice in the hospital while only 1% indicated that full PDM was practised. The second question had the following statement: ‘A new infection control policy is now being implemented in your ward. How will the following types of PDM affect your compliance to the new policy?’ Nurses
Staff compliance
to policies
113
were requested to indicate their response in a 7-point ordered scale. For question 2, a new type of PDM was added to the list. Ward representatives are often invited to join a central decision-making group in the hospital and it is useful to assess the effectiveness of PDM when only these representatives are allowed to vote. This type of PDM was designated representative full PDM. Table III(b) sh ows the responses to the second question. The greatest response was to full PDM and the least to ‘no participation’. There was however two interesting observations. The responses to type B, C and D showed no significant difference, but there was a drastic increase in response to full PDM. It seems that nurses were not overly impressed if the infection control unit just consulted them without giving them the power to vote. The second was that representative full PDM had a very positive response which is even higher than full PDM. This is important because the infection control unit cannot conduct a hospital-wide referendum for every new policy, but it is possible to request ward representatives to vote on behalf of their colleagues. There is potential for the use of PDM to enhance staff compliance. It is an avenue that deserves further research in infection control.
The
use of ward
opinion
leaders
Consumer behaviour research has shown that within social groups, there are individuals who exert a significant amount of social influence over others. These individuals are known as opinion leaders14 and in the process of communication, new information must often be accepted by these opinion leaders (OLs) before it can be effectively transmitted to the entire group. Although this concept is now widely recognized in management and marketing research, it has never been applied in the context of infection control. Perhaps the impact of in-service education by the infection control team could be enhanced by involving these opinion leaders in the wards. A study was conducted in Hong Kong in which OLs in the wards were identified and then enlisted to assist in the in-service educational programme for infection control.” A guideline on urinary catheter-care was introduced in two groups (A and B) of three randomly allocated wards. Two OLs per ward were identified by nurses in group A, using a sociometric method, a scoring system where nurses in the wards are used for identifying them. For education, in-service lectures were conducted in both groups A and B, and the OLs’ where requested to conduct demonstration tutorials for all nurses (in small groups of 6-8) in group A. Before the education program, training sessions were conducted for the OLs, in which the new guideline and a standard format for the demonstration tutorial were presented and discussed. Before and after the education programme, the guideline’s frequency of
114
W. H. Seto Table
IV. Results
Group A opinion leader Group C lecture only Statistical comparison n =total
number
of practices
of the education
and
lecture
programme
involving
Direct
observation
Before
education
opinion for
62% (n = 90) 69% (n=90) P=O.34, x2=0+39
leaders
incorrect After
practices education
42% (n=151) 62% (n=253) PCO.01, x2=15.8
assessed.
practice was assessed by direct observation of incorrect patient-care practices. Three practices which could be evaluated unobtrusively were selected: improper securing of catheters, kinking in the catheters or collection tubes, and the use of urine bags without a drainage spigot. Before the new guidelines, urine bags with no draining spigot were routinely used. These were changed daily, which was incorrect because the closed drainage system was broken. The result of the study is shown in Table IV. As shown the percentage of incorrect patient-care practices in the two groups, before the education programme, were comparable (P=O*34, x2=0.89). After the education programme, the percentage in group A involving the OLs was 42%, which was significantly lower (P~0.01, x2 = 15.8) than the 62% in group B. This indicates that the OLs were probably effective in enhancing the impact of the education programme in group A. The efficacy of the OLs is predictable. Infection control procedures are often an integral part of the patient-care practices in the ward and it is an advantage to involve the ward staff as instructors in the education process. They are already familiar with their colleagues in the wards and after the education programme they can continue to motivate the nurses to comply with the new policy. The involvement of the ward staff as active participants of the infection control programme is a growing trend in infection control. In the same category is the proposal of the ‘liaison nurse’ in every ward16 and the setting up of satellite infection control committees.” Behavioural
sciences-a
new
frontier
in infection
control
The study of the behavioural sciences in infection control is still in its infancy. A wealth of information has already been accumulated in psychological research which can be applied in infection control. In such investigation, the individuality of the hospital staff must be respected. They must not be manipulated simply to achieve compliance. The intent is rather to coach them in the right direction so that ultimately the patient will benefit.
Staff
compliance
to policies
115
References 1
2. 3.
4. 5.
10 11. 12. 13. 14. 15.
16. 17.
Haley RW, Garner JS. Infection surveillance and control programs. In: Bennett JV, Brachman PS, Eds. Hospital Infection, 2nd edn. Boston: Little Brown & Co. 1986; 39-50. Albert RK, Condie MS. Hand washing patterns in medicine intensive care units. N EngJ Med 1981 304: 1465-1466. Raven BH, Haley RW. Social influence and compliance of hospital nurses with infection control policies. In: Eiser RJ, Ed. Social Psychology and Behavioral Medicine. Chichester: John Wiley 1982; 413-438. French JRP, Raven BH. The bases of social power. In: Cartwright D, Ed. Studies in Social Power. Ann Arbor: University of Michigan 1959; 150-167. Seto WH, Ching TY, Chu YB, Seto WL. Social power and the motivation for compliance of nurses and house-keeping staff with infection control policies. Am J Infect Control 1991; 2: 42-44. Myers DG. Introducing social psychology. In: Social Psychology, 2nd edn. New York: McGraw Hill 1988; l-32. Davis K, Newstrom JW. Working with people. In: Human Behavior at Work: Organizationa2 Behavior, 7th edn. New York: McGraw-Hill 1985; l-20. Howard JA. Study of consumer behavior. In: Consumer Behavior in Marketing Strategy. Englewood Cliffs: Prentice-Hall 1989; l-l 0. Ajzen I, Fishbein M. A theory of reasoned action-theoretical implications. In: Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs: Prentice-Hall 1980; 78-92. Seto WH, Ching TY, Fung JPM, Fielding R. The role of communication in the alteration of patient-care practices-a prospective study. J Hosp Infect 1989; 14: 29-37. Vroom VH, Jago AG. On the validity of the Vroom? Yetton model. J Appl Psycho1 1978; 63: 151-162. Vroom VH, Yetton PW. Leadership and Decision-making. Pittsburgh, Pennsylvania: University of Pittsburgh Press. Miller KI, Monge PR. Participation: satisfaction and productivity: a meta-analytic review. Acad ManagJ 1986; 29: 727-753. Myers JH, Robertson TS. Dimensions of opinion leadership. J Marketing Res 1972; 9: 41-46. Seto WH, Ching TY, Yuen KY, Chu YB, Seto WL. The enhancement of infection control in-service education by ward opinion leaders. Am J Infect Control 1991; 19: 86-91. Ching TY, Seto WH: Evaluating the efficacy of the infection control liaison nurse in the hospital. J Adv Nurs 1990; 15: 1128-1131. Ford-Jones EL, Mindorff CM, Gold R. Satellite infection control committees within the hospital: decentralizing for action. Infect Control Hosp Epidemioll989; 10: 368-370.
of Hospital
Staff
Infection
compliance application
(1995)
30 (Supplement),
with infection of behavioural W. H.
Department
107-l
of Microbiology,
15
control practices: sciences
Seto
Queen Mary Hospital, Kong, Hong Kong
University
of Hong
Summary:
Microbiology and epidemiology have made significant contributions to the field of Infection Control. Most nosocomial infections which can be prevented are related to inappropriate patient care practices. However, it is extremely difficult to implement new infection control policies. To achieve staff compliance, infection control should learn from the behavioural sciences. Three related fields have been shown to be helpful in this respect: social psychology, consumer behaviour and organizational behaviour. Basic concepts from all three fields can be applied to the work of infection control for achieving staff compliance; the use of social power and the reasoned action model from the field of social psychology; the use of participatory decision-making from organizational behaviour; and the opinion leaders from consumer behaviour. Keywords:
Compliance;
policies;
behavioural
science;
patient
care
practices.
Introduction
Traditionally, the development of hospital infection control is largely dependent on the two related fields of microbiology and epidemiology which are essential for understanding the pathogenesis and spread of infectious diseases. However, in recent years, there is growing realization that such technical understanding of infections alone may be insufficient for infection control. Most hospital-acquired infections are endemic and are related to inappropriate patient-care practices (PCPs).’ These are often simple procedures, like the recapping of needles or the handling of patients with unwashed hands, but are extremely difficult to correct.2 However, unless these inappropriate PCPs are altered, infection control guidelines and policies cannot be successfully implemented. Education has always been an integral part of infection control, but it must be conducted in such a way that practices are altered within the realms of the behavioural sciences. The application of the behavioural sciences is therefore timely and crucial for the continuing practice of hospital infection control. Development
of the behavioural
sciences
in infection
control
Although alteration of PCPs is vital for prevention nosocomial infection, there are few original studies on this subject. The pioneers, as in many 0 1995 The Hospital
01954701/95/060107+09$08.00/0
107
Infection
Society
108
W. H. Seto
Table
I. Reports
of nurses and house-keeping secure their compliance
staff on the power base which to infection control policies Hong
Staff Power 1. 2. 3. 4. 5. 6.
base
Coercive Reward Legitimate Expert Referent Informational
*Differences Groups correction.
(%)
the
same
(a) and row
with
(b)
are significant different
superscript
USA
House-keeping (%) staff n = 140 (b)
l(O.01)” 8 (5.6) 10 (7.0)
between in
nurses n=142 (4
Kong*
11 12 42 30 12 33 (P
will
most
likely
(SENIC)’
Staff
nurses
n=7069 %
(7.9)b (8.6) (30)b (21.4) (8.6)* (23.6)
0.3 0.1 2.1 56.1 4.4 36.9
x*=53). significantly
(PiO.05)
by
x2 with
Yates’
areas of infection control are workers in the Study on the Efficacy of Nosocomial Infection Control (SENIC) project. The SENIC workers investigated the role of social power, defined as the potential ability of an influencing agent to change the cognitions, attitudes or behaviour of another person (the target), in infection control.3 There are six bases for social power and they were first described by the social psychologists, French and Raven.4 The SENIC definitions for these bases of power are: 1. Coercive power-stems from the ability of the influencing agent to mediate punishment for the target. 2. Reward power-stems from the ability to mediate rewards. 3. Legitimate power-stems from the target’s acceptance of a role relationship with the agent that obligates the target to comply with the agent’s request. 4. Expert power-stems from the target’s attribution of superior knowledge or ability to the agent. 5. Referent power-stems from the target’s utilization of others as a ‘frame of reference’ to evaluate his/her behaviour. 6. Informational power-stems from the persuasiveness of the information communicated by the agent to the target. In the SENIC project, 7046 nurses were surveyed to discover the base of power most likely to secure the compliance of the subjects.3 A similar survey was conducted in Hong Kong among nurses and house-keeping staff’ and the results of the two surveys are shown in Table I. Strict comparison between the results of the two surveys is not possible because there is no evidence that the two samples of nurses are comparable.
Staff compliance
to policies
109
Nevertheless, both studies do show that for nurses, the best responses are for informational and expert power. Therefore, infection control nurses (ICNs) should exercise these powers to enhance compliance with infection control policies. As suggested by Haley et al. this should include the provision of ‘relevant references and convincing information’ including local surveillance data.’ A significant finding in the Hong Kong study are the differences in response between house-keeping staff (HKS) and nurses. This is not altogether unexpected, because the two groups differ in many aspects, especially educational background and working culture. It is important for ICNs to appreciate that HKS are more responsive to legimitate and coercive power; and less to informational power. Therefore to influence the HKS, it would be better to present the request as coming from a legitimate superior and evidence of their supervisor’s endorsement should always be shown. Utilizing
the results
of behavioural
science
research
The study on social power by the SENIC workers is a possible model for future development. The results of behavioural science research in other fields could also be adopted for the purpose of infection control. However, it is important to be selective because the spectrum of behavioural science research is rather broad. There are three fields of studies in the behavioural sciences which may be relevant for infection control. These are the fields of social psychology, organizational behaviour and consumer behaviour. Social psychology is defined as the scientific study of how people think about, influence, and relate to one another.6 In the field of social psychology, topics like attitude change, social influence and social compliance have been thoroughly investigated and many of these data may be relevant for the alterations of PCPs. Organizational behaviour is the study and application of knowledge about how people act within organizations7 and is considered an integral part of management science. The hospital is a large and complex organization and obviously, there will be ideas and concepts in organization behaviour which will be relevant for infection control. Consumer behaviour is the study of how and why consumers buy and consume.’ In this field of study, much is done to understand human behaviour in the context of marketing a product. New policies are often introduced in infection control, and various methods and ideas, identified in consumer behaviour could be used to persuade hospital staff to comply with a policy. In the remaining portion of this chapter, a classical theory from each of the three specialties will be presented. Three studies will be described in which these theories were evaluated for achieving staff compliance of infection control policies in the hospital.
110 Table
W. H. Seto II.
Discontinuation
of recapping
in 208 nurses
5 weeks Nurses
Groupings
after
introduction
with
of sharps
no recapping
All nurses (% of n)
Agreeables (% of n,)
Non-agreeables (% of nz)
A Simple announcement n=62 Agreeables (n,) = 23 Non-agreeables (nz) = 39
13 (21)
7 (30)
6 (15)*
B Passive method n=79 Agreeables (n,) = 55 Non-agreeables (n2) = 24
52 (66)
47 (85)”
5 (21)*
C Active and passive method n=67 Agreeables (nl) = 27 Non-agreeables (nz) = 40
57 (85)
24 (89)’
33 (83)
*Differences
between
The
rows
reasoned
are
all
significant
action
(P~0.05)
except
model-predicting
for
numbers
boxes
with
asterisk.
staff compliance
When a new policy is implemented, it would be an advantage if the infection control team could identify ahead of time those staff who will comply, and predict what is required in the in-service education programme. A classical theory in social psychology is the theory of reasoned action by Azjen and Fishbein.’ This theory assumes that people behave rationally and that generally, the intention to act is the result of considerable mental deliberation. The theory states that this behavioural intent is a good predictor of actual behaviour. A study was conducted to assesswhether this is true in the hospital, and the impact of in-service education on those with or without behavioural intent.” A policy was introduced to stop the recapping of needles and nine randomly selected wards were divided into three groups (A, B and C) of three wards each. From an initial survey, the recapping practices of nurses were ascertained, and they were divided into those with the behavioural intent to discontinue with the practice (the ‘agreeables’), and those without (the ‘non-agreeables’). Methods utilized to introduce the policy included simple announcement through the nursing hierarchy in group A (control), passive method (posters and pamphlets) were added in group B and both passive and active method (in-service lectures) in group C. Five weeks later, behavioural change was assessed by another survey and the result is shown in Table II. As shown, 59% (122) of the nurses had discontinued the recapping practice and the largest proportion occurred in group C (active and passive
Staff compliance
to policies
111
method) with 85%, followed by 66% in group B (passive method) and finally the 21% in group A (simple announcement). Change in the recapping practice of the ‘agreeables’ and ‘non-agreeables’ was also analysed and for the ‘agreeables’, group B (posters and pamphlets) with 85% change, was superior to that of group A (simple announcement) with only 30% change (RO.001, Z=4.80). The addition of the active method (in-service lecture) in group C showed no significant improvement (P=O*67, Z=O*43) over the passive method (group B). In contrast, for the ‘non-agreeables’, the 21% change observed for group B (posters and pamphlets) was not significantly higher (P=O*58, Z=O.55) than the 15% change observed for simple announcement (group A). However when an in-service lecture (group C) was included, the change of 83% was significantly higher (RO.001, Z= 0.86) than the 21% in group B. The results of group A show that communication through the nursing hierarchy is rather ineffective. for those with the behavioural intent (the agreeables), it is a matter of getting the message to them, which is the function of the poster and pamphlets. Further persuasion by the in-service lectures showed no additional effects. However, for those without the intent (the non-agreeables), active persuasion by the in-service lecture is needed. Before the introduction of a new policy, it may be worthwhile conducting a survey to assess the proportion of staff already with the behavioural intent. If these are the majority, then an in-service lecture is probably not needed, and the passive method would be sufficient. Participatory
decision-making
A topic under intense study in organization behaviour since the 1930s” is participatory decision-making (PDM), which is defined by Vroom and Jago as ‘exerting influence resulting from the employee’s assuming an active role in a decision-making process’.” Vroom and Yetton” described five types of PDMs, a classification that is widely used in the organizational behaviour13 and these are: 1. Autocratic I-no participation. The decision is made solely by the administrator, and no attempt is made to request information or consult the opinion of subordinates. 2. Autocratic II-requesting information. The decision is made solely by the administrator, but the necessary information was collected by specific requests to the subordinates. 3. Consultative I-individual opinion. The decision is finally made by the administrator after consultation with subordinates who are approached individually for their opinions and suggestions. 4. Consultative II-group opinion. The decision is finally made by the administrator after consultation with subordinates who are invited to contribute their opinions and suggestions in a group discussion.
112 Table
Types 1. 2. 3. 4. 5.
W. H. Seto III.
(a) Nurses’
(b)
(PDM)
currently
Frequency n=251 I-no participation II-requesting information I-individual opinions II-group discussion participation
Compliance
score of nurses
of PDM
Personal opinion Group discussion Full PDM Representatives
80 100 38 32 1
to the type
of PDM
when
implementing
(%)
(32) (40) (15) (13)
a new policy
Compliance
1. No participation 2. Request information 3. 4. 5. 6.
of the type of participatory decision-making practised in Queen Mary Hospital
of PDM
Autocratic Autocratic Consultative Consultative Group-full
Types
description
score
;:za 3.1” ;:; full
PDM
6.1
Differences in response to the types of PDM was significant by Friedman’s statistics (P
5. Group-full participation. Subordinates are invited to contribute their opinions and suggestions in a group discussion, and the decision is made according to the consensus of the entire group. Numerous studies in various organizations have documented that PDM can enhance the satisfaction and productivity of employees13 and it is reasonable to believe that PDM can also be effective in influencing nurses for infection control. A survey by personal interview was conducted in Queen Mary Hospital, involving a random sample of 251 nurses, on the response to PDM for the implementation of infection control policies. In the first question, respondents were presented with the five types of PDM as described above (except that ‘nurses in the wards’ were substituted for ‘subordinates’), and were requested to indicate the type of PDM ‘which best describes the current practice in the hospital when new policies involving patient-care practices are introduced’. Table III(a) shows the responses to question 1, which indicate that most respondents (72%) felt that autocratic types of PDM best described the current practice in the hospital while only 1% indicated that full PDM was practised. The second question had the following statement: ‘A new infection control policy is now being implemented in your ward. How will the following types of PDM affect your compliance to the new policy?’ Nurses
Staff compliance
to policies
113
were requested to indicate their response in a 7-point ordered scale. For question 2, a new type of PDM was added to the list. Ward representatives are often invited to join a central decision-making group in the hospital and it is useful to assess the effectiveness of PDM when only these representatives are allowed to vote. This type of PDM was designated representative full PDM. Table III(b) sh ows the responses to the second question. The greatest response was to full PDM and the least to ‘no participation’. There was however two interesting observations. The responses to type B, C and D showed no significant difference, but there was a drastic increase in response to full PDM. It seems that nurses were not overly impressed if the infection control unit just consulted them without giving them the power to vote. The second was that representative full PDM had a very positive response which is even higher than full PDM. This is important because the infection control unit cannot conduct a hospital-wide referendum for every new policy, but it is possible to request ward representatives to vote on behalf of their colleagues. There is potential for the use of PDM to enhance staff compliance. It is an avenue that deserves further research in infection control.
The
use of ward
opinion
leaders
Consumer behaviour research has shown that within social groups, there are individuals who exert a significant amount of social influence over others. These individuals are known as opinion leaders14 and in the process of communication, new information must often be accepted by these opinion leaders (OLs) before it can be effectively transmitted to the entire group. Although this concept is now widely recognized in management and marketing research, it has never been applied in the context of infection control. Perhaps the impact of in-service education by the infection control team could be enhanced by involving these opinion leaders in the wards. A study was conducted in Hong Kong in which OLs in the wards were identified and then enlisted to assist in the in-service educational programme for infection control.” A guideline on urinary catheter-care was introduced in two groups (A and B) of three randomly allocated wards. Two OLs per ward were identified by nurses in group A, using a sociometric method, a scoring system where nurses in the wards are used for identifying them. For education, in-service lectures were conducted in both groups A and B, and the OLs’ where requested to conduct demonstration tutorials for all nurses (in small groups of 6-8) in group A. Before the education program, training sessions were conducted for the OLs, in which the new guideline and a standard format for the demonstration tutorial were presented and discussed. Before and after the education programme, the guideline’s frequency of
114
W. H. Seto Table
IV. Results
Group A opinion leader Group C lecture only Statistical comparison n =total
number
of practices
of the education
and
lecture
programme
involving
Direct
observation
Before
education
opinion for
62% (n = 90) 69% (n=90) P=O.34, x2=0+39
leaders
incorrect After
practices education
42% (n=151) 62% (n=253) PCO.01, x2=15.8
assessed.
practice was assessed by direct observation of incorrect patient-care practices. Three practices which could be evaluated unobtrusively were selected: improper securing of catheters, kinking in the catheters or collection tubes, and the use of urine bags without a drainage spigot. Before the new guidelines, urine bags with no draining spigot were routinely used. These were changed daily, which was incorrect because the closed drainage system was broken. The result of the study is shown in Table IV. As shown the percentage of incorrect patient-care practices in the two groups, before the education programme, were comparable (P=O*34, x2=0.89). After the education programme, the percentage in group A involving the OLs was 42%, which was significantly lower (P~0.01, x2 = 15.8) than the 62% in group B. This indicates that the OLs were probably effective in enhancing the impact of the education programme in group A. The efficacy of the OLs is predictable. Infection control procedures are often an integral part of the patient-care practices in the ward and it is an advantage to involve the ward staff as instructors in the education process. They are already familiar with their colleagues in the wards and after the education programme they can continue to motivate the nurses to comply with the new policy. The involvement of the ward staff as active participants of the infection control programme is a growing trend in infection control. In the same category is the proposal of the ‘liaison nurse’ in every ward16 and the setting up of satellite infection control committees.” Behavioural
sciences-a
new
frontier
in infection
control
The study of the behavioural sciences in infection control is still in its infancy. A wealth of information has already been accumulated in psychological research which can be applied in infection control. In such investigation, the individuality of the hospital staff must be respected. They must not be manipulated simply to achieve compliance. The intent is rather to coach them in the right direction so that ultimately the patient will benefit.
Staff
compliance
to policies
115
References 1
2. 3.
4. 5.
10 11. 12. 13. 14. 15.
16. 17.
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