Nurse Education in Practice (2006) 6, 156–162

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Using a motivational paradigm to improvehandwashing compliance

Mark Cole *

University of Nottingham, Grantham School of Nursing, Grantham Centre, 101Manthorpe Road, Grantham, Lincolnshire NG31 8FH, United Kingdom

Accepted 25 November 2005

Summary The education and training of staff is frequently cited as essential to thedevelopment and maintenance of hand hygiene compliance, which is often quotedas the single most effective measure to prevent Hospital Acquired Infection. Despitemuch time, effort and cost, there is a growing frustration within infection controlthat training programmes do not appear to have a lasting effect on behaviour or pro-duce consistently good hand hygiene compliers. This paper intends to encouragedebate by suggesting that handwashing needs to be considered within a wider edu-cational context and the motivational factors that impact upon performanceacknowledged and addressed. A critique of learning theories in relation to handhygiene will discuss why the use of traditional programmes in isolation may beunsuccessful, and how models and theories based in other disciplines could beadapted to help produce sustainable changes in practice. This paper recognisesthe contribution of contemporary training methods but argues that models suchas [Prochaska, J., DiClemente, C., 1984. The Transtheoretical Approach; CrossingTraditional Boundaries of Therapy. Dow Jones Irwin, Homewood] stages of changetranstheoretical model (TTM) and the interventionist paradigm of motivationalinterviewing could be borrowed and adapted from health promotion and appliedto hand hygiene as their function, to increase understanding and enhance motiva-tion in order to achieve sustainable behavioural change, are attributes which haveresonance for a challenging problem like hand hygiene compliance.

�c 2005 Elsevier Ltd. All rights reserved.

KEYWORDSHandwashing;Motivation;Learning theories

1d

471-5953/$ - see front matter �c 2005 Elsevier Ltd. All rights reseroi:10.1016/j.nepr.2005.11.006

* Tel.: +44 1476 565232x4309.E-mail address: mark.cole@nottingham.ac.uk.

Introduction

Hand hygiene remains the single most effectivemeasure to prevent Hospital Acquired Infection(Department of Health, 2003; Boyce and Pittet,2002; Pratt, 2001). Barbacombe (2004) suggests

ved.

Using a motivational paradigm to improve handwashing compliance 157

‘‘it’s so basic, so simple, almost insulting or embar-rassing even to mention, especially at an advancedpractice level’’. However, the importance of thisapparently simple procedure is not sufficientlyrecognised by health care workers (Pittet et al.,2004), and poor compliance has been documentedrepeatedly (Boyce and Pittet, 2002; Pittet et al.,2000; Reybrouk, 1983). Although some interven-tions to improve compliance have been successful,none has achieved lasting improvement (Boyce andPittet, 2002; Pittet et al., 2000). It would appearthat traditional educational approaches based onthe learning theories of behaviourism, cognitivismand humanism have not been associated withacceptable levels of compliance and behaviourchange. Therefore, educators of hand hygienemay have to revisit the term education, acknowl-edge the motivational aspects of complianceand consider using models outside the realmsof mainstream education within their existingprogrammes.

Learning theories and hand hygiene

Behaviourism

Watson and Rayner (1920), Thorndike (1931) andSkinner (1971) are behavioural writers who favoura reductionist approach to learning that deniesthe value of introspective methods and emphasisesthe importance of associations between a stimulusand response (Quinn, 2001). According to the HealthBelief Model ones action depends on the suscepti-bility of a health threat (Rosenstock, 1974). There-fore, it could be argued that highlighting the causallink between contaminated hands and the risk ofinfection to both the nurse and the patient mayact as a behavioural stimulus to comply. However,Rickard (2004) reminds us that micro-organismscannot be seen by the naked eye, and consequentlycontaminated hands, the transfer of bacteria to pa-tients and their multiplication on a vulnerable siteis difficult to pinpoint to a particular time, occa-sion or event. This may make the causal link be-tween contamination and infection a theoreticalconcept and the likelihood of a single omission ofhand hygiene by a single member of staff leadingto the spread of microbes that could cause infec-tion difficult to comprehend and difficult to quan-tify (Store and Clayton, 2004).

Behavioural teaching of hand hygiene techniquehas become popular in infection control followingthe work of Taylor (1978), who demonstrated thatcertain areas of the hands were regularly missedduring routine hand washing, moreover observa-

tional studies have demonstrated a wide variancein the time clinicians spend washing their hands(Taylor, 1978; Daschner, 1988; Gould and Ream,1993; Larson et al., 1998). The focus on techniqueis supported by Larson (1997) and Gould (2004) whofound in her study that good technique was rarelycompromised by pressure of work. However, highdemand for hand hygiene is associated with lowcompliance (Pittet et al., 1999; Gould, 2004), andalthough the behaviourist teacher may instil goodtechnical ability to perform the skill of handwash-ing, they may not prepare students for the realitiesof practice, the barriers to compliance or engagethem as active problem solvers.

Cognitivism

A major criticism of the behaviourist view is thathuman behaviour is too complex and exhibits suchoriginal pathways to the solution of problems asimple stimulus response theory cannot explainsophisticated learning and behavioural change(Child, 1997). Larson (1997) highlights the com-plexities of compliance and suggests interventionswill have to be a part of a programme that recog-nises the multivariate nature of behaviour andthe profound difficulties of behaviour change. Thiswould seem to support a cognitive approach thatrecognises learning as a complex internal processconcerned with thinking, perception, organisationand purpose. Major cognitive thinkers include Bru-ner (1966) and Ausubel (1968) who may supportwriters who argue that interventions to improveadherence to hand hygiene practice should focuson the educational, cognitive dimension (Pittetet al., 2004; O’Boyle et al., 2001; Larson, 1997).The underlying principle seems to be that if thecorrect information is possessed and understoodby the nurse the correct behaviour will follow.

Bruner’s theory of learning by discovery (1966)suggests the ultimate aim of teaching is to instil ageneral understanding of the structure of a sub-ject. He argues learning is an active process, stim-ulated by curiosity. Moreover, Bruner suggests thestudent adopts a hierarchical structure to theirlearning, constructing incoming information to apreviously acquired frame of reference. A studentmay learn handwashing technique (Behaviourism)but has not considered the barriers to compliance(Cognitivism), this results in poor performance assoon as they become busy (non-compliance.) Theliterature identifies recurring themes as to the rea-sons for poor compliance, these include; lack oftime, knowledge deficit, poor facilities and materi-als, drying of skin, forgetfulness and disagreement

158 M. Cole

with guidelines (Rickard, 2004; Boyce and Pittet,2002; Pittet et al., 2000; Harris, 2000; Voss andWidmer, 1997; Larson, 1995; Heenan, 1992). A cog-nitive perspective may argue that staff need tounderstand and explore the barriers to compliancein order to develop clinical problem solving strate-gies. However, in relation to hand hygiene Elliott(1992) appears to question the cognitive ability ofnurses by suggesting that they function at the levelof intuitive judgement, occasionally proceeding topeer aided judgement, and by implication do notposses appropriate levels of knowledge, under-standing or motivation that is required to improvetheir decision making skills.

Boyce and Pittet (2002) question whether an in-crease in knowledge will provide the motivation toimprove compliance. O’Boyle et al. (2001) found intheir study that intention to practice hand hygieneand reported compliance did not predict actual,observed behaviour. Indeed a common theme inthe literature is that estimates in self reporting,exceed observed performance (Rickard, 2004; BMJ,1999; Ronk and Girard, 1994). It would appear thatit is high activity levels rather than intention topractice that has greater impact on compliance(Pittet et al., 1999; Robert, 2000). Indeed O’Boyleet al. (2001) interpreting these findings argue anacknowledgement of the inadequate time to ad-here to infection control recommendations mayactually reflect a nurses cognitive awareness of ahierarchy of patient needs and a realisation ofthe priorities of clinical practice.

Decision theory informs us that people will actto ensure the best outcomes for themselves onthe basis of their personal perceptions of shortterm and long term consequences (Edwards,1954). Voss and Widmer (1997), Weeks (1999) andStone et al. (2001), all suggest that 100% compli-ance with handwashing guidelines is impracticaland unsustainable and would interfere with essen-tial care. Therefore, whether clinicians are unableto engage in cognitive learning (Elliott, 1992); havedone so and rejected handwashing guidance asimpractical (O’Boyle et al., 2001); or cognitiveteaching fails because it is difficult to deliver tolarge mixed ability groups (Myles, 1987); the evi-dence suggests cognitive approaches have failedto deliver long term sustainable change in hand-washing behaviour (Boyce and Pittet, 2002).

Role modelling

Bandura (1977) a neobehaviourist, outlines his so-cial learning theory or vicarious conditioning. Akey construct of this theory suggests if the conse-

quences of observed behaviour are seen as desir-able, the behaviour may be copied of modelled.The importance of role models in hand hygienebehaviour is well documented (Lankford et al.,2003; Salemi et al., 2002). Active involvementand encouragement from key staff members mayhelp to promote and sustain behavioural changein health care settings (Larson and McGeer, 1991;Leclair and Freeman, 1987). Moreover, awarenessof being observed is strongly associated with adher-ence, supporting the idea that social pressuresinfluence hand hygiene behaviour (Pittet et al.,2004). By contrast, negative role models can beinfluential, poor practice learnt and copied at thebedside (Stone et al., 2001; Lankford et al., 2003).Lankford et al. (2003), Feather et al. (2000) andLarson et al. (1986) argue that junior staff and stu-dents who have been taught to handwash abandontheir habit when senior colleagues are seen as poorcompliers. Indeed doctors have the worst reportedrates among any health care professionals, (Pittetet al., 2004), and is among the reasons given bynurses for the difficulty in ensuring sustainedadherence. In addition the importance of organisa-tional commitment to hand hygiene and thenegative impact which low commitment has oncompliance are cited by a number of authors(Boyce and Pittet, 2002; Pittet et al., 2000; Teareet al., 1999).

Humanism

Humanistic thinkers include Maslow (1971), Know-les (1978) and Rogers (1983) and put forward thetheory that learning is concerned with feelingsand experiences, leading to personal growth andindividual fulfilment. Rogers (1983) states thatthe student learns by feeding their curiosity, more-over Keegan and Lahey (2001) suggest studentslearn best when they discover solutions, not pre-sented with them. The theory of reasoned actionand the theory of planned behaviour are based onthe assumptions that human beings are rational,make systematic use of available information,and consider the implications of their actions be-fore engaging in behaviour. Jenner (2002), there-fore, suggests consideration must be given to theinternal factors that motivate staff to adhere tohand hygiene recommendations.

Accepting the notion that individuality and per-sonal motivation are key factors in hand cleansingwould explain why health workers sharing similarworking conditions differ in compliance rates be-tween 5% and 80% (Boyce and Pittet, 2002). Maslowmade a significant contribution to the humanistic

Using a motivational paradigm to improve handwashing compliance 159

learning theory, however, in witnessing the effectthat workload has on compliance it could be arguedthat hand hygiene is not well positioned in a busyclinicians hierarchy of needs. Nevertheless Knowles(1978) developing the theme of adult learning sug-gests adults in education bring with them a wealthof valuable life experience. Many skills do not haveto be taught and are already grounded in personalexperience. However, the view that students learneither by direct experience in the present or byreflecting on past experience may generate a neg-ative view towards hand hygiene, as one of the ma-jor criticisms is that theoretical learning isimpractical in the clinical area (Widmer, 2000).Moreover, it maybe suggested that personal experi-ence of the topic is often bad experience. Dran-kiewicz and Dundes (2003) found in their studythat only 63% of female college students washedthere hands after visiting the toilet and only 32%used soap. Two thirds of the sample took less than5 s. Guinnan and McGluckin (2002) demonstratedsimilar results, where in addition, they demon-strated that males were significantly poorer com-pliers than females (Widmer, 2000).

Motivational theory and hand hygiene

It would appear that in relation to hand hygiene, nosingle application of learning theory has been asso-ciated with an acceptable level of compliance andbehaviour change. Therefore, teachers of hand hy-giene may have to consider models outside therealms of traditional education. Fawcett (1989)recognises that many models and theories used bynurses have been borrowed from other disciplinesand states that ‘‘There is an increasing awarenessof the need to test borrowed theories to determineif they are credible in nursing situations’’ (Fawcett,1989, p. 23). Perhaps teachers should considerProchaska and DiClemente’s (1984) stages of changetranstheoretical model (TTM) which was originallydeveloped in the context of changing problembehaviours, and the interventionist paradigm ofmotivational interviewing as educational tools inrelation to hand hygiene.

While at an organisational level sustained behav-ioural change is elusive, at an individual level thereare many examples of excellent practice. This is inspite of the fact that all staff encounter the samebarriers to compliance vis-a-vis; poor facilities,too busy, impractical guidelines, sore hands andforgetfulness (Boyce and Pittet, 2002). This wouldsupport the argument that problems of non-compli-ance are at an individual and motivational level notan organisational one. It may require imagination

to see how the TTM model can be applied to clini-cal standards, as it is difficult to argue that handhygiene is not a good thing. However, the aims ofthe model to increases understanding and enhancemotivation in order to achieve sustainable behav-ioural change has resonance for the challenges thathave been identified and that are faced in relationto hand hygiene compliance.

The TTM describes a process whereby individualsmove from being unaware or unwilling to do any-thing about a behaviour (pre-contemplation), toconsider the possibility of change (contemplation)and finally to take action and sustaining or main-taining the change over time (maintenance). Orig-inally, it was assumed that there was a linearprogression through the sequential stages (Miller,1983; Rollnick et al., 1992), however, this waschallenged by Prochaska and DiClemente (1992)who argued self-changers rarely negotiate changein an orderly, progressive fashion. Moreover, indi-viduals may vary in where they are on the stagesof change continuum and that this may affecthow they will perceive information given to them(Kretzer and Larsen, 1998). It could be argued thatas ‘‘educated professionals’’ nurses should alwaysbe at the contemplation stage of behaviour changeif improvements to practice can be demonstrated,however, the evidence reviewed to date would sug-gest that this is not always the case. Indeed Houli-han (1999) appears to argue that action-orientatednursing interventions as described by (Larson, 1997),may be ineffective or detrimental to individualsat the pre-contemplation and contemplation stageas these stages are characterised by a great deal ofambivalence towards behavioural change. Perhapstrying to force change in practice when staffare not ready may explain the antagonism thatnurses often feel towards educators and infectioncontrol nurses who are seen to continually berateor manipulate them ‘‘to wash their hands moreeffectively’’.

Motivational interviewing (MI) is an intervention-ist paradigm sometimes used within the structureof TTM whose key goal is to assist the individualto work through their ambivalence about behaviourchange (Resnicow et al., 2002). The tone of the MIencounter is non-judgemental, empathetic andencouraging. Educators establish a non confronta-tional and supportive climate in which studentsfeel comfortable to express both positive and neg-ative aspects of their current behaviour. There isgenerally no direct attempt to dismantle denial,confront irrational or maladaptive beliefs, con-vince or persuade. Instead the goal is to help stu-dents think about and verbally express their ownreasons for and against change, how their current

160 M. Cole

behaviour (poor handwashing) may conflict withtheir professional goals (preventing hospital ac-quired infection) and impact upon their core valuesas a registered nurse (duty of care). The educatorrelies heavily on reflective listening and positiveaffirmations rather than direct questioning, per-suasion, or advice. Educators can address discrep-ancies in client knowledge, beliefs or behaviourswithout instilling defensiveness or attempting refu-tation. MI educators defer from providing informa-tion or advice until clients have first presentedtheir own understanding of the situation or theirown suggestion for overcoming obstacles tochange. Ideally it is the student rather than theteacher who makes the argument for change anddescribes the course of action. In the educationalparadigm of hand hygiene teachers or nurse spe-cialists provide proactive, planned, evidence basedpractice and expect a behavioural change from stu-dents. Using MI, the student would process infor-mation, find their own relevance, evaluate theirown risks and rewards, and convince themselvesthat change may be warranted.

MI is rooted in Rogers person centred approach toeducation with reflective listening and an emphasison understanding the student’s subjective reality,key components (Resnicow et al., 2002). Althoughhumanistic education accepts that learning out-comes are at the discretion of the student, MI canbe more directive and goal orientated (Rollnick,1995). Whereas in humanistic education a goalmay be to help a student accept and integrateincongruent behaviours or clinically unacceptablepractices, in MI greater emphasis may be placedon resolving these discrepancies and building moti-vation for change (Patterson, 1986). The educatorshould operate on the assumption that some indi-viduals are not ready to change, and the goal forsuch students may be simply to allow them to ex-press their ambivalence or disinterest, plant theseeds of discrepancy, and leave the door open forfuture intervention. When ambivalence has beenresolved and there is an expressed readiness tochange, behavioural strategies such as self monitor-ing, goal setting, shaping and reinforcement or cog-nitive strategies such as thought stopping orimagery can be incorporated in an educationalstrategy consistent with the principles of MI. Resni-cow et al. (2002) completed a comprehensive re-view of MI across a range of addictive and nonaddictive behaviours. Despite a number of practicalproblems including time, counsellor/educator com-petence and intervention fidelity, Resnicow et al.(2002) argued promising results have been achievedand the technique may have potential applicationacross diverse professional settings. Recognising

problems of time, competence and fidelity, Millerand Rollnick (1991) advocate the use of the briefmotivational interviewing (BMI), a technique foruse in time limited consultations. The BMI consistsof more concrete strategies providing structureand direction, yet retains the underpinning philoso-phy of MI. Arthur (1999) demonstrated its practicalapplication by testing the communication skills ofstudent nurses and argued competence can beachieved with 12 h of training (Arthur, 1999).Clearly the method has applications for use by spe-cialists and educators in complex settings.

Conclusion

Handwashing is the single most effective interven-tion to promote infection control in clinical set-tings with clear evidence of the effect that poorcompliance has on the morbidity and mortality ofpatients. While it is important to educate staff onthe theoretical and practical aspects of hand hy-giene, lack of education is not the sole barrier tocompliance. The learning theories and educationalinitiatives outlined in this paper can contribute toimproved compliance but must be underpinned byother strategies that address the lack of reinforce-ment of behaviour in clinical practice. Severalauthors have addressed the internal factors thatmotivate staff to adhere to hand hygiene recom-mendations (Jenner, 2002; O’Boyle et al., 2001).The theory of planned behaviour is a way ofexplaining why attempts to change behaviour byincreasing the knowledge of staff, through educa-tion and training alone have largely failed (O’Boyleet al., 2001).

Hand hygiene is a simple act, but is carried outwithin the context of a complex organisationalsystem and for this reason, any intervention toincrease compliance, must reflect these complexi-ties. Multi-modal handwashing campaigns includingeducation, role models, management support,activity levels, feedback and observation, publish-ing infection rates, patient involvement, postersand other marketing methods are suggested (Storeand Clayton, 2004). However, Jenner (2002) fo-cuses on the importance of attitudes which shesuggests are the key predictor of intention. Inter-estingly, the literature identifies that excellentpractice stands alongside negligent acts in thesame department, among health care workersexposed to the same multifaceted educationalapproaches. This would indeed suggest that indi-vidual motivation and behaviour are extremelysophisticated and cannot always be manipulated orenhanced by traditional approaches to education.

Using a motivational paradigm to improve handwashing compliance 161

It could be argued that multi-modal campaigns aresuccessful at reinforcing behaviour among staffwho already have an intention to comply. However,as a chain of infection is only as strong as its weak-est link, one poor handwashing technique wouldnegate the effectiveness of previous compliance.Perhaps, therefore, innovative strategies that tar-get the poor complier are as essential as traditionalapproaches that reinforce the good.

The goal of brief motivational interviewing is towork with the individuals need for autonomy byencouraging clients to explore their ambivalenceand move towards behaviour change. BMI has hada broad application to health promotion and behav-ioural medicine and although initial outcome stud-ies have produced mixed result, delivered withadequate fidelity, BMI appears to have potentialefficacy. However, numerous questions remain;can BMI be applied to an educational paradigm,can or should educators take on this ‘‘counselling’’role, what training is required, how will fidelity bemaintained, will it be cost effective, is it practical?Nevertheless in the words of Weinstein (2004)‘‘after 150 years of prodding, cajoling, educating,observing and surveying health care workers,adherence rates to hand hygiene remains poor’’.It is estimated that there are 5000 deaths each yearcaused by preventable hospital acquired infectionsin England and Wales, the problem is reachingepidemic proportions. As previous approaches toeducation have largely failed to deliver theimprovement required, unorthodox and imagina-tive educational initiatives should be examinedand explored.

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