1.1: Background
The first World Health Organization (WHO) Global Patient Safety Challenge, “Clean Care is Safer Care”, was launched in 2005-2006 to focus on improving hand hygiene compliance in healthcare facilities.[42] Hand hygiene was selected because it is a low-cost practice to prevent the transmission of multidrug-resistant microorganisms and to reduce healthcare-associated infections (HAIs).[43] However, hand hygiene improvement programmes often fail because top management for infection prevention and control (IPC) do not have sufficient implementation skills.[44] Hand hygiene is driven by behaviour in a socio-economical and organisational context.[45,46] Given that hand hygiene is a behaviour-driven action, promotion should be peer-centred and multimodal. This includes leadership engagement, peer pressure, and empowering role models, opinion leaders, and
champions.[44–46] Collaborative multimodal strategies fostering good team spirit and partnership among healthcare workers (HCWs) is an important implementation strategy to drive behaviour change.[45–52] Feedback of hand hygiene compliance, even if provided on a daily basis, only is effective in settings with strong social cohesion.[52]
A role model is a person who is esteemed by his or her peers, and whose excellent behaviour becomes an accepted reference.[53] Suitability of role modelling occurs when individuals are able to relate themselves to others of the same social role and interest.[54]
Their position and their qualities make it easy for others to identify with.[53,55,56] When HCWs are identified as having qualities others admire, they may become opinion leaders that are gatekeepers of the social system who diffuses information they received within their social system. Opinion leaders act as boundary spanners, using social communication skills
and informal social relationships; and (iii) are being perceived by others to be energetic, with insight and are innovative.[57] On the other hand, hand hygiene champions are usually well accepted, charismatic and influential leaders, or other authority figures holding a crucial component in effective infection control measures.[58,59]Champions are charismatically influential persons, perceived and accepted as authoritative leaders by their peers.[58] In an implementation, they shape organisational change through four functions: (i) protecting those involved in implementation from organisational rules and systems that may be barriers; (ii) building organisational support for new practices; (iii) facilitating the use of organisational resources for implementation; and (iv) facilitating the growth of organisational coalitions in support of the implementation.[59]
According to the Diffusion of Innovation (DOI) theory, readiness for implementation can be approximated by the duration between the exposure to the innovation and the decision to adopt it in a social system.[60] The innovation-decision period is the length of time required passing from the knowledge stage towards making a decision by the individual (or
organisation) to ‘accept or reject’ an idea. Innovators introduce the innovation or the new idea. They may or may not be part of the social system, but once peers start to adopt the innovation, implementation occurs. During implementation, four categories of adopters can be distinguished: early adopters, early majority adopters, late majority adopters, and laggards. Early adopters set the stage for subsequent adoption. They usually are well-respected peers and usually are better integrated into the social system than the innovators.
Later adopters check with the behaviour of early adopters for advice and information about the innovation in their process of considering adopting the new idea. Champions are early adopters, and, acting as positive role models and using their social network among peers, facilitate persuasion to adopt a favourable attitude towards hand hygiene by HCWs, and subsequently drive behaviour change. Early adopters are ‘role models’ because their
behaviour is not perceived as being too far ahead of the average. They decrease uncertainty
evaluation via their wide interpersonal communication network.[60] However, identifying diffusers can be labour-intensive as there is no reliable method to identify them,[59,61]while local cultures might interfere with the actions of champions.[46]
This projects’ implementation is addressed using a sociological approach, based on the DOI theory and applying social network analysis (SNA).[60,62] Organisations are not always democratic settings, where the principles of the DOI theory apply. Leadership is not always a natural process, delivered by well-respected role models but more often a top-down
managerial approach. Social network analysis allows us to describe structural
connectedness of team networks for hand hygiene promotion. In this study, networked structures consist of individual HCWs and are referred to as nodes. Networks are visualised through ties between nodes that represent inter-relationships illustrated in a sociogram.
Healthcare workers whose behaviour are considered excellent and are admired for their professionalism are not always change agents. By understanding the relationship and partnership among different networks of HCWs, this study identified change agents that acted as role models, who diffused positive hand hygiene behaviour to early and early majority adopters, which led to reciprocation of favourable hand hygiene behaviours among potential later adopters.
1.2: Rationale for this research
Why do we need hand hygiene compliance?
Healthcare-associated infections caused by the bacteria Staphylococcus aureus (S. aureus) is responsible for the majority of surgical site infections[63,64] and skin and soft tissue infections.[65,66] A proportion of S. aureus that has developed resistance to a marker
infections are of concern because these are more commonly associated with elderly hospitalised patients whose health may already be compromised.[65,66] Outbreaks of HAI due to HA-MRSA result in increased length of stay, and they are associated with both morbidity and mortality. [67] Successful efforts to reduce MRSA transmission in hospitalised patients included hand hygiene improvement. [47,68–71] The Geneva programme on hand hygiene linked hand hygiene compliance with a significant reduction in MRSA infection rates by 60%.[47] It included the availability of alcohol-based hand rub (ABHR) at the point of care, posters, and clinical leadership to facilitate compliance with hand hygiene. The WHO first Global Patient Safety Challenge “Clean Care is Safer Care” is based on this seminal Geneva programme.
How successful have the hand hygiene compliance interventions been?
Each year, hundreds of millions of patients are affected by HAIs, with a higher risk in developing countries.[72,73] Hand hygiene is one of the most cost-effective measures in reducing HAIs but compliance is generally low, even in high-income countries.[74]Although HCWs know about hand hygiene practices, many have not developed a favourable attitude towards it.[74]
Between 2000 and 2004, an Australian study reported before-patient contact hand hygiene compliance ranged from 25%-67% while after-patient contact ranged from 27%-70%.[75]
The wards were most commonly in the older-style Nightingale ward arrangement, where a single sink was located outside the entrance to a six-bedded ward with sinks up to 30 metres from the point of patient care.[75] HCWs were subsequently relocated to a new hospital where sinks were no more than five metres from the point of care with a sink located within a four-bedded ward and located outside each room. Yet, increased numbers and locations of sinks did not result in significant improvement hand hygiene compliance for either before-patient contacts (13% -47%) or after-before-patient contact (23%-72%) 10 months later, after
completion of relocation.[75] Larson (the ‘Washington programme’) utilised organisational cultural change as the focus for improving hand hygiene compliance (both soap and water washing and ABHR).[69] Pivotal to the Washington programme was HCWs’ active
involvement and clinical “buy-in” exemplified by staff leading the intervention through staff-led meetings, staff designed posters, and an overt involvement of senior administrative and senior clinical staff. The success of this programme over seven months was an increase in hand hygiene compliance with a concomitant decrease in transmission of other important HAIs, MRSA, and vancomycin-resistant enterococci.[69] To test these two international successful strategies, Washington[69] and the Geneva programmes[47] with a control study arm (consisting only of ABHR provision without leadership) a study was carried out in an Australian hospital that examined the effect of environmental changes on hand hygiene compliance.[76] The Washington programme[69] was launched by senior hospital executive and senior clinicians with ongoing reinforcement of the importance of the programme
through weekly ward tours, with the aim of providing visible support for the intervention.
The introduction of ABHR alone did not improve compliance (p=0.238).[76] However, the Washington programme that was staff-centred and supported by medical leadership achieved a 48% (p<0.001) improvement in compliance that was sustained over two years.[76] The Geneva programme failed to induce a significant increase in hand hygiene compliance in three wards without clinical leadership while the ward with strong clinical leadership achieved a 56% (p<0.001) improvement. [76]
Hand hygiene promotion needs leadership and should be peer-centred.[69,76] The trial of both Washington[69] and Geneva[47] programme has demonstrated that the introduction of the ABHR product alone is not effective without strong clinical leadership.[76] Senior
clinicians were used as leaders in the Washington study arm of the trial[76] while strong
undertake the practice but is not the most influential factor for compliance.[77] The most influential predictor of intention to comply for nursing staff was simply their perception that physicians and senior administration officers expected them to comply.[77]The facilitation of compliance is therefore not simply related to effort but is highly dependent on leadership to alter behaviour. The Washington programme[69] encourages staff at all levels to get involved while the Geneva programme[47] uses the influence of strong leadership. Yet, the common approach most often used when choosing a clinical leader for patient safety initiatives has been to select the most senior clinician. The weakness in this method is that not all senior and respected leaders exert influence.
Why sound intervention strategies have fallen short?
The DOI theory seeks to outline how and why new ideas and practices are adopted over time. Those who introduce new ideas and the readiness of those to adopt or not these new ideas are said to belong to one of five categories of adopters: innovators, early adopters, early majority adopters, late majority adopters, and laggards. Innovators are those first individuals who rapidly adopt the target behaviour.[60] They either develop new ideas or require a shorter innovation-decision period possibly because they have more favourable attitudes towards new ideas, embrace new ideas, utilise technically accurate sources about innovations, and place higher credibility in these sources than the average individual within their social, professional group or organisational ‘system’. Innovators may not be respected by other members of their system but they still play an important role in the diffusion process by launching new ideas.
Early adopters have a shorter innovation-decision period than later adopters and adopt early because they become aware of the new required behaviour or idea sooner than others within their system. This group has the highest number of opinion leaders in their system and also serve as ‘role models’. Potential adopters look towards early adopters as “the
individual to check with”, for advice and information about the innovation before adopting the new idea. They are respected and are considered the embodiment of successful and
discrete use of new ideas. In order to continue to be held in high esteem by their colleagues, early adopters decrease uncertainty about a new idea by adopting it and then convey a subjective evaluation of it to their peers via their interpersonal communication network. The early majority adopts the new idea just before the average member of the system but after the early adopters. This group interacts with their peers but does not hold the position of opinion leaders. This group usually consists of one third (34%) of the entire system. Their position between early adopters and late majority adopters provides an important
interconnectedness in the system’s interpersonal communication network. They may take some time until completely adopting the new idea, but once done, they implement the idea deliberately; however, they rarely lead the way within their system for any new idea or practice. The late majority adopters will eventually be influenced to adopt the innovation only after the average member of the system. Like the early majority adopters, these members make up one third (34%) of the five adopters categories. The late majority adopters approach innovations with scepticism and caution. This group observes the results of innovations and will not adopt the innovation until most members of their system have done so and emerging peer pressure is necessary to motivate adoption. The reason for their later adoption is that they may not have the conceptualisation of the earlier adopters and
uncertainty must be removed before this group feels safe to adopt the innovation. Laggards are the last to adopt (if ever) and are almost never opinion leaders. They are isolated in their system and their decision-making is based on previous practice, as their point of reference is the past. They are suspicious of change agents and view resistance as entirely rationale.
They require certainty that the new innovation will not fail before they can adopt it.
Models using clinical leadership to effect widespread change implicitly assumes that leaders also act as role models. Diffusion of Innovation can explain the differences in the success of the Washington[69] and the Geneva programmes[47] and the replicates of these protocols [71,76] that achieve significant but albeit small improvements. In accordance with the DOI, the designer and implementer of the Geneva programme [47] could be described as both innovators and early adopters. Hence, his/her influence reported in the seminal paper[47]
may have been in principle as a result of the early majority complying as this group accounts for a third of any system. The designer of the Washington programme [69]attempted to utilise all levels of staff including the innovator and the early adopters to develop and implement the programme and finally, the early majority as the programme design stresses the whole of system involvement. It is unlikely that the Washington programme succeeded in involving late majority adopters and laggards in the design and implementation stages. The identification of the appropriate clinical leaders in both of these protocols according to the DOI must be selected within the specific healthcare profession as HCWs cannot be considered a homogenous group for patient safety activities, rather medical staff look to each other for leadership.[78]For example, had the choice of leadership in the replicate studies [71,76] utilised the DOI approach of selecting and educating the well-liked early adopters in the system, who would then lead the behaviour change with an overt focus on the physician group to influence the nursing staff,[79] the percentage point improvement in hand hygiene may have been larger.
Why selecting leaders using Diffusers of Innovation method is superior?
Broadly, five methods are commonly used to select a leader: (i) leader selects him/herself as the role model; (ii) those who develop the innovation/intervention programme select the leader; (iii) the members in the system recruit participants (not leaders) who in turn each recruit new participants (namely, snowball method); (iv) identified members in the system select the leader; and (v) all the members of the system select the leader. The limitation of
the influence of leaders selected using approaches (i) and (ii) include potential for members of the system believing the leader may have a different (and perhaps harmful) agenda from the other members, the leader having limited knowledge of the members’ needs or that the leader has insufficient knowledge of the innovation. The snowballing effect of enrolling participants within the system avoids the selection bias of the first two methods. This is an excellent method for easily communicated messages. However, if the innovation is complex or the individuals cannot communicate the innovation effectively the flow-on effect of the correct message may be lost or damaged and the dynamics of the snowball method are temporary. The fourth method overcomes the disadvantages of methods (i) to (iii) and is the common method utilised in clinical leadership. The disadvantage of this method is that the effectiveness of the innovation is highly dependent on the selected leader who may not be well-liked or respected by his/her members of the system. Allowing all members of the system to select a leader is democratic, increases the likelihood of a well-liked adopter who is believed to be trustworthy being selected, and overcomes most of the disadvantages common to methods (i) to (iv). An additional advantage of method (v) is that a number of leaders can be selected for training and the members within e.g. healthcare professionals can select a leader from their own group or from other healthcare professional groups. The selected leader(s) instructed in the innovation can then communicate the intervention to the membership of the system. In accordance with the DOI, members of the system are asked to nominate those members whom they would go to for advice about an issue within the paradigm of the innovation (for example, medical/nursing practice or healthcare career advice). According to the Rogers and Cartano (1962) technique, leaders are chosen by the frequency of the members in their system nominating them.[80] The effect of the selected leader (or leaders) may simply work through their direct social network of communication or passive communication where the innovation is an overt behaviour (such as hand hygiene).
What is the relevance of social network concepts in hand hygiene promotion?
The focus of this thesis is the transmission of information within social networks for hand hygiene promotion. Social network analysis has been applied to similar fields.[81–85] A recent systematic review and meta-analysis demonstrated that many health behaviours are shaped by influences of social networks.[86] Social norms, key individuals, and the type of innovation shapes a person’s intention to adopt a behaviour within this social network. Social norms are the typical behaviour inside a social network, they characterize the scope of passable behaviour and set the standard for behaviour in the social network.[60]
Interpersonal communication channels are most influential in persuading other individuals in a social network to accept new practice behaviour.[60] However, for diffusers to perform as social communicators, they should not violate the norms within their social system.
Generally, SNA is based on the social network made up of individuals, organisations, or entities called ‘nodes’, which are tied or connected by one or more specific types of interdependency.[87] Nodes are the individual actors within the network and ties are the relationships between actors.[87,88] Identification and examination of key actors or nodes within healthcare networks are critical, they are defined by their position within the overall structure of the network and are important in the network function. Key actors and nodes are central individuals in a network who are the most connected or interact with the most other people, [89] they are described as ‘opinion leaders’ [80,90,91] Opinion leaders occupy key positions identified by their centrality score in SNA. Such influence is derived from their technical competence, social accessibility, and conformity to social norms.[60,80,92] When early adopters act as opinion leaders to translate an innovation for the remainder of the network, they become change agents for diffusion to accelerate.[60]
1.3: Thesis objectives
(i) To test two leadership principles in work teams on hand hygiene compliance: (a) influence of peer-identified change agents (PICAs) in which peers, acting as early adopters according to the DOI theory, facilitate hand hygiene improvement and sustainability by role modelling;
and (b) influence of management-selected change agents (MSCAs) who are expected to carry out top-down leadership where hand hygiene improvement is enforced by staff formally appointed by management.
(ii) To describe the perception of different change agents’ leadership styles by peers, their
(ii) To describe the perception of different change agents’ leadership styles by peers, their