HandWashing Compliance amongst HealthCare Workers: a socio-cognitive contribution

Transcription

1 Presentation University of Aberdeen: Doctoral Programme 19th November 2007 HandWashing Compliance amongst HealthCare Workers: a socio-cognitive contribution Magda Sofia Roberto magda_roberto@sapo.pt Social and Organizational Psychologist Ph.d Student ISCTE, Lisbon Supervised by: Professor Silvia Silva (ISCTE) Professor Kathryn Mearns (University of Aberdeen)

2 HealthCare Sector: Problem Infectious Pathology Hospitalized patients Increases hospitalization time Increases mortality Two-way way hazard noxious to both: HealthCare Workers Patients Bacteria transmission occur: Cross-Infections (transmitted from patient to healthcare worker) Nosocomial Infections (result of treatment in a hospital, but secondary to patients original condition) e.g. CDC, 2003; Dorsey, Cydulka & Emerman (1996); Fay (1996) February 08 HandWashing amongst HealthCare Workers 2

3 HealthCare Sector: Statistics HealthCare Workers and Patients are daily exposed to: 3 types of pathogens (blood-borne, air-borne borne,, facial/ oral-borne borne) Most frequent cross- infections Hepatitis B (66 thousand HealthCare Workers infected per year) Hepatitis C (16 thousand HealthCare Workers infected per year) HIV (1000 HealthCare Workers infected per year) Most frequent nosocomial infections Urinary tract Pneumonias Annual Incidence 2 million cases per year 3 cases per minute Predicted mortality HealthCare Workers may die every year Predicted Mortality 80,000 deaths per year 9 deaths per hour Pruss-Uskin, Rapiti & Hutin, 2005; Sekpowitz, 1996; CDC, 1995 Patient Safety in American Hospitals, Health Grades 2004; Starfield, 2000; February 08 HandWashing amongst HealthCare Workers 3

4 HealthCare Sector: Prevention How to prevent hospital infections? To comply with safety procedures, namely Universal Precautions Universal Precautions Definition? Safety rules that aim to reduce the transmission of viruses amongst patients and HealthCare Workers (e.g. use of gloves, masks, washing hands properly) Compliance to Universal Precautions? Suboptimal adherence amongst HealthCare Workers with data indicating compliance rates lesser than 50% Health & Safety Executive, 2006; CDC, 2003 February 08 HandWashing amongst HealthCare Workers 4

5 Universal Precautions: HandWashing HandWashing Definition? Action that decreases the colonization of transient flora found on the skin Is HandWashing the most important Universal Precaution? 1. Since 19th century: hand hygiene is an effective way to decrease hospital infections (e.g. Nogueras, Marinsalta, Roussell, Notario, 2001); 2. Wearing gloves does not provide complete protection against acquisition of infections (e.g. Reingold, Kane, Hightower, 1989); HandWashing Compliance? Compliance rates continue to be less than 50% (e.g. Pittet, 2006; CDC, 2002) February 08 HandWashing amongst HealthCare Workers 5

6 Universal Precautions & HandWashing: findings (I) Within the HealthCare Sector, studies focusing compliance to Universal Precautions or HandWashing have explored the role of: 1. Isolated Variables HealthCare Workers Beliefs and Attitudes (e.g. Wissen,, 1993); HealthCare Workers Behaviours (e.g. Ferguson et al., 2004); 2. Theoretical Models Theory of Planned Behaviour (Ajzen, 1988); PRECEDE-PROCEED PROCEED Model (Green & Kreuter,, 1974; 1991); Organizational Models of Safety Climate (Zohar,, 1980); February 08 HandWashing amongst HealthCare Workers 6

7 Universal Precautions & HandWashing: findings (II) Theory of Planned Behaviour (Ajzen, 1988) Limbert & Lamb (2002) Intention Predictors may change due to HealthCare Workers work experience; Model explains from 52% to 58% of the variance in intention; Watson & Myers (2001) Attitudes are the best intention predictor for nurses; Model explains 45% of the variance in intention; February 08 HandWashing amongst HealthCare Workers 7

8 Universal Precautions & HandWashing: findings (III) Precede Proceed Model (Green & Kreuter, 1974; 1991) Creedon (2006) Interventional Program based upon Predisposing, Enabling and Reinforcing Factors; Increased hand hygiene amongst HealthCare Workers; Significant changes found in HealthCare Workers Attitudes, Beliefs and Knowledge; Dejoy, Gershon & Schaffer (2004) Direct effect of Predisposing Factors on behavioural compliance; Indirect effect of Enabling and Reinforcing Factors on behavioural compliance; February 08 HandWashing amongst HealthCare Workers 8

9 Universal Precautions & HandWashing: findings (IV) Organizational Models of Safety Climate (Zohar 1980) Dejoy, Gershon & Schaffer (2004) Safety Climate may mediate the relationship amongst Work Environment and Compliance; Zohar, McGovern, Vesley, Kochevar, Gershon, Rhame et al., (2000) Safety Climate as main predictor of compliance, despite the relevance of work experience, knowledge and conservative attitudes towards risk; February 08 HandWashing amongst HealthCare Workers 9

10 HandWashing Compliance: Why to Study It? 1. Lack of studies developed using theoretical models; 2. Need to explore the role that some psychosocial variables may have on compliance to HandWashing, namely Vulnerability Perception and Social Influence; 3. To clarify the role of Safety Climate as a relevant variable for compliance to HandWashing; February 08 HandWashing amongst HealthCare Workers 10

11 Main Goal: Socio-Cognitive Contribution To develop a socio-cognitive cognitive perspective that embraces three theoretical contributions: 1. Theory of Planned Behaviour (Azjen,, 1988); 2. Organizational Models of Safety Climate (Zohar, 1980); 3. Protection Motivation Theory (Rogers,, 1975; 1983); February 08 HandWashing amongst HealthCare Workers 11

12 Socio-Cognitive Model Attitudes Individual Antecedents HealthCare Workers Experience of Work Behaviour Beliefs Normative Beliefs Subjective Norm Social Antecedents HealthCare Workers Professional Education Control Beliefs Perceived Moral Norm Intention Hw Organizational Antecedents Safety Culture HealthCare Organization Department Safety Climate Team Safety Climate Perceived Behavioural Control Vunerability Perception February 08 HandWashing amongst HealthCare Workers 12

13 Perceived Moral Norm (I) Moral Concern Concern for other s welfare in people s judgements and choices 2002); choices (Sparks & Sheperd, Within the Theory of Planned Behaviour (Ajzen, 1988) Increasing evidence of a role for perceived moral obligation indicates the importance of moral-normative influences in social behavior; Studies of moral norm in the context of the TPB were reviewed by Conner and Armitage (1998) who estimated that across studies moral norms predicted an additional 4% of the variance in intentions after controlling for TPB predictors Literature Evidences Committing driving violations (Parker et al., 1995); Milk consumption (Raats, Shepherd,, & Sparks,, 1995); Consuming food produced by the use of, genetic engineering techniques (Sparks, Shepherd,, & Frewer,, 1995); February 08 HandWashing amongst HealthCare Workers 13

14 Perceived Moral Norm (II) Attitudes The degree to which performance of the behaviour is positively or o negatively valued (Azjen,2006, pp.1 ) Subjective Norm The perceived social pressure to engage or not to engage in a behaviour (Azjen,, 2006, pp.1 ) Perceived Moral Norm People s perceptions of their own rules of moral conduct towards a given behaviour (Godin, Conner & Sheeran,, 2005, pp.500) Perceived Behavioural Control People's perceptions of their ability to perform a given behaviour (Ajzen, 2006, pp.1) February 08 HandWashing amongst HealthCare Workers 14

15 Perceived Moral Norm (III) Research Question: Patient needs will take priority above HealthCare Workers needs? Self-reported factor for poor adherence with HandWashing (e.g. Lymer, Richt, Isaksson,, 2003; Pittet,, 2000) February 08 HandWashing amongst HealthCare Workers 15

16 Study One: : Main Goals I. Obtain indicators that may contribute to define a bottom-up perspective that could clarify the factors that HealthCare Workers consider that Predispose, Enable and Reinforce their behaviour of compliance to HandWashing; II. Contribute to overcome the lack of qualitative studies done on HealthCare Sector; February 08 HandWashing amongst HealthCare Workers 16

17 Participants 19 HealthCare Workers from several health instituitions Age Mean: : (23-56) Sort of HealthCare Workers: : 36.8% Nurses,, 31.6% Doctors,, 26.3%, Others 31.6% February 08 HandWashing amongst HealthCare Workers 17

18 Data Collection Semi- Structured Interviews (1 hour in average) Open-Content Analysis Questions framework based upon Precede-Proceed Proceed Model (Green & Kreuter,, 1974; 1991) by analyzing: I. Predisposing Factors (e.g. HealthCare Workers Beliefs) II. Enabling Factors (e.g. Risk Perception) III. Reinforcing Factors (e.g. Social Influence) February 08 HandWashing amongst HealthCare Workers 18

19 Data Collection Examples of questions : Can you define Universal Precautions/ HandWash? Which factors do you consider that may hinder compliance to HandWash? How can you describe the role of your supervisor as safety suppporter? Who do you think that may influence you in order to increase your compliance to HandWash? Content Analysis Reliability: : Cohen Kappa.79 February 08 HandWashing amongst HealthCare Workers 19

20 Categories Definitions Super-Ordinate Category Compliance to HandWashing Categories Definition Sub-Categories Definition Enabling Factors Allow the motivation to be realized Predisposing Factors Provide the motivation to the behaviour Antecedent Factors Factors that influence the compliance behaviour Reinforcing Factors HealthCare Workers Moral Norm Incentive the persistence of the behaviour To give primacy to patients security and treatment, as a moral imperative, by neglecting their personal safety Vulnerability Perception To underestimate the presence of objective risks on their daily routine Safety Climate Perception that HealthCare Workers have about safety practices amongst their organization Unit Role Team Role Safety Equipment Safety practices implemented by supervisors in their unit Safety practices implemented by colleagues in their teams Adequacy between personal safety needs and the type of safety equipment Significant Others Professionals viewed by HealthCare Workers as important to promote compliance HealthCare Workers Other Professionals Only HealthCare Workers are relevant to promote compliance Compliance could be promoted by other sort of professionals, not only by HealthCare Workers February 08 HandWashing amongst HealthCare Workers 20

21 Categories, frequencies and percentages Categories Sub-Categories Example Absolute Frequency % [1 Antedecent Factors Enabling Factors Recycling 14 73,7 Predisposing Factors Medical Emergencies,, Stress, Lack of time 18 94,7 Reinforcing Factors Risk Information 14 73,7 HealthCare Workers Moral Norm To put patients health and safety always on 1st place 18 94,7 Vulnerability Perception Underestimate objective risk 16 84,2 Safety Climate Unit Role Unit Supervisors promote safety 14 73,7 Team Role Colleagues / Team promote safety 17 89,5 Safety Equipment Adequate safety equipment 14 73,7 Significant Others HealthCare Workers Nurses 14 73,7 Professionals from other sectors Safety Experts 7 36,8 [1] The percentage was calculated upon the Absolute Frequency of the Sub-Categories (e.g. 18*100/19 = 94.7) February 08 HandWashing amongst HealthCare Workers 21

22 Socio-Cognitive Model Attitudes Individual Antecedents HealthCare Workers Experience of Work Behaviour Beliefs Normative Beliefs Subjective Norm Social Antecedents HealthCare Workers Professional Education Control Beliefs Perceived Moral Norm Intention Hw Organizational Antecedents Safety Culture HealthCare Organization Department Safety Climate Team Safety Climate Perceived Behavioural Control Vunerability Perception February 08 HandWashing amongst HealthCare Workers 22

23 Safety Climate (I) To perceive a positive safety climate may enable workers motivation to comply with safety procedures (e.g. Gonçalves, Silva, Meliá, Lima, 2005) Multi-level level interpretation of Safety Climate amongst HealthCare Sector is required: Unit/ Department Level responsible for establishment of safety policies and procedures; Team responsible for aplying that procedures; Sources of climate perceptions will be related to two levels of analysis Measures Safety Climate Measures developed by Zohar (2004; 2003; 2002; 1980); February 08 HandWashing amongst HealthCare Workers 23

24 Safety Climate (II) Can Safety Climate have an impact on Attitudes, Subjective Norm and Perceived Behavioural Control? Less progress has been made in understanding the mechanisms by which w safety climate affect safety behaviour, and the relationship between these constructs and other variables (Neal & Griffin, 2002); Safety climate may be seen as a social-cognitive cognitive construct, opposed to passive observation of formal procedures and isolated practices (Zohar & Luria,, 2004, pp.323); A practice will become a source of (low( low) climate perceptions if it remains unequivocal and stable, contributing for the workers to make inferences about safety (Zohar & Luria, 2004, pp.323); The more positive the Safety Climate becames, the more positive will be the attitude towards the behaviour, the more relevance will have the subjective norm and the more control will be perceived towards the behaviour? February 08 HandWashing amongst HealthCare Workers 24

25 Socio-Cognitive Model Attitudes Individual Antecedents HealthCare Workers Experience of Work Behaviour Beliefs Normative Beliefs Subjective Norm Social Antecedents HealthCare Workers Professional Education Control Beliefs Perceived Moral Norm Intention Hw Organizational Antecedents Safety Culture HealthCare Organization Department Safety Climate Team Safety Climate Perceived Behavioural Control Vunerability Perception February 08 HandWashing amongst HealthCare Workers 25

26 Vulnerability Perception According to the Protection Motivation Theory: it is expected that the higher the perceived vulnerability to a negative event, the higher the intention to follow the recommendations The way how the non-specialists think about risk developing the subjective risk or their vulnerability perception (Lima, 2005) Relationship amongst Vulnerability Perception and Safety Behaviours Congruency amongst objective and subjective risk may increase the tendency to comply with safety rules (e.g. Brewer, Weinstein, Cuite & Herrington,, 2004) A subjective evaluation of the risk, oposed to the objective risk, may influence the workers to dont comply with safety procedures (e.g. Rundmo, 1997) Measures: To apply the measures proposed by Lima (2005; 1999; 1998) focusing the specific main infection risks (blood-borneborne pathogens and air-borne pathogens) February 08 HandWashing amongst HealthCare Workers 26

27 Study three: Main Goal To identify and explore the relationship between Safety Climate, Vulnerability Perception and Safety Behaviour of compliance to HandWash; February 08 HandWashing amongst HealthCare Workers 27

28 Safety Climate Theoretical model HandWash Vulnerability Perception February 08 HandWashing amongst HealthCare Workers 28

29 Participants One Public Portuguese Hospital from Lisbon Workers: 100 nurses from Pediatric Emergencies Age Mean: years (22-56) Workers Gender: 55% female and 45% male February 08 HandWashing amongst HealthCare Workers 29

30 Data Collection - Variables Self-report questionnaire 5 point-likert type scales Measures Safety Climate (organizational, supervisor and colleagues) 9 items (3 items each) (adapted from Zohar, 2000) Vulnerability Perception 3 items (inverted scale) (adapted from Lima, 1998) Safety Behaviour 5 items (adapted from CDC, 2003) Good Reliability range: Alphas from.72 to.89 February 08 HandWashing amongst HealthCare Workers 30

31 Statistical Results Mean SD Organizational Safety Climate 2, Supervisors Safety Climate 2, *** Colleagues Safety Climate 2, ***.76*** Vulnerability Perception 2,8*** * -.41*** -.39*** 1-5 Safety Behaviour 3, ***.58***.59*** -.14*** 1 1 Standard Deviation 2 Correlations amongst variables February 08 HandWashing amongst HealthCare Workers 31

32 Results: Theoretical model Safety Climate β =.25* r = -.35*** Safety Behaviour R 2 =.43*** β = -.16 Vulnerability Perception February 08 HandWashing amongst HealthCare Workers 32

33 Theoretical model Vulnerability Perception Safety Climate Safety Behaviour February 08 HandWashing amongst HealthCare Workers 33

34 Moderator Model The role of safety climate amongst the relation between Fear Arousal and Risk Perception Safety Climate Vulnerability Perception 0.76* 0.59*** 0.68*** Safety Behaviour 0.71** Safety Climate X Vulnerability Perception 0.23** ***p < 0.001; ** p < 0.05 February 08 HandWashing amongst HealthCare Workers 34

35 Socio-Cognitive Model Attitudes Individual Antecedents HealthCare Workers Experience of Work Behaviour Beliefs Normative Beliefs Subjective Norm Social Antecedents HealthCare Workers Professional Education Control Beliefs Perceived Moral Norm Intention Hw Organizational Antecedents Safety Culture HealthCare Organization Department Safety Climate Team Safety Climate Perceived Behavioural Control Vunerability Perception February 08 HandWashing amongst HealthCare Workers 35

36 HandWashing Will be decomposed in several parts: What should be done (soap, alcohol-rubs rubs); When should be done (before and after seing a patient, after using gloves); Easy to measure Easy to HealthCare Workers understand it February 08 HandWashing amongst HealthCare Workers 36

37 Future Directions To pre-test the questionnaire within the sector Apply the model to one unit within a Hospital Replicate the results on a different unit from a different hospital; Apply the model to HandWash Safety Procedure Replicate the results with a different Universal Precaution, namely the Use of Gloves February 08 HandWashing amongst HealthCare Workers 37

38 Presentation University of Aberdeen: Doctoral Programme 19th November 2007 Thank you for your attention Questions are Welcome Magda Sofia Roberto Social and Organizational Psychologist Ph.d Student ISCTE, Lisbon Supervised by: Professor Silvia Silva (ISCTE) Professor Kathryn Mearns (University of Aberdeen)