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How to Leverage Positive Peer Pressure to Improve Hand Hygiene

Hand hygiene has always been a primary focus of infection prevention, but due to the COVID-19 pandemic, it is under intense scrutiny. Even though the skill of hand hygiene is straightforward and easy to learn, consistent compliance has been difficult to achieve in healthcare settings, including post-acute long-term care (PALTC). One way to improve hand hygiene compliance is to create a group culture where hand hygiene is the norm, so that members are more motivated to conform. Below are ideas to help instill that expectation:

Belonging to a group that prioritizes hand hygiene

We are social beings, and as such, we have an inherent emotional need to identify with a group and be accepted into that group. Fostering a sense of belonging is key when leveraging social norms to influence behavior. While the need to belong to a group may seem obvious, nurse leaders should not underestimate the power of belonging to improve compliance with hand hygiene. Some ways the nurse leader can foster a sense of belonging to the facility team are to:

  • Encourage staff members to be allies to each other. When they feel others care about them and “have their back,” people usually respond in kind. One way nurse leaders can facilitate this is to not only explain how to perform hand hygiene, but to emphasize the why. It could sound something like “Our team performs hand hygiene because we care about keeping each other, our families, and our residents safe from infection.”
  • Acknowledge the individual contributions staff make to the team and remind them how these contributions make a difference to resident outcomes, as well as how they help their teammates. For example, when you see a new certified nurse aide practicing hand hygiene, acknowledge them and emphasize how what they just did protects not only the resident they are going to take care of next, but also the teammate they’re working with.
  • Acknowledge teams and praise their efforts, reminding them how their team actions are making a difference for the residents. For example, when members of the team perform hand hygiene or remind each other to do so, a nurse leader reinforcing a team mentality might say, “I appreciate how this team sticks together and fights against the spread of infection to keep not only residents safe, but also each other.”
  • Have fun reinforcing group identity. Matching t-shirts, group contests or activities, and participation in fun campaigns help people form relationships and attachments to each other and within their group. For example, a fun campaign centered on infection prevention could ask staff and residents to create a catchy slogan for hand hygiene, design a t-shirt, or design games and contests that can be played during the course of the campaign.

Motivation from peers to perform hand hygiene

Each group has social norms—behaviors that are accepted and expected of the people that belong to that group. People are usually motivated to conform so they can remain in the group. Thus, they behave in the ways that are socially acceptable and expected. This is not really a surprise, since most of us can share examples of experiencing what is commonly referred to as peer pressure. Yet the desire to conform and be accepted by peers has also been studied related to healthy behaviors. Studies of the hand hygiene performance of subjects ranging from physicians to childcare workers find the following three things:

  • When individuals believe that hand hygiene is important to others in their group, they perform hand hygiene more often because they want to conform and remain part of the group.
  • When individuals believe that failure to perform hand hygiene will result in a sanction against them by their peers, hand hygiene compliance increases.
  • When individuals believe that performing hand hygiene results in a positive outcome, hand hygiene compliance increases. For nursing facility staff, positive outcomes could include keeping themselves, their families, the residents, and their teammates safe from infection.

A word of caution is in order when discussing social norms and peer pressure; the workplace should remain supportive and foster teamwork, not hostility, which encourages the development of cliques. The nurse leader must emphasize the positive outcomes of hand hygiene and the potential negative consequences of failing to perform hand hygiene, such as spreading infection to residents or to their team. By doing so, the nurse leader creates the desire to comply, which is far more effective than a reminder of the facility’s policy or the regulation.

Another approach is to select peers as champions for hand hygiene, as well as for adherence to other infection prevention and control protocols. Champions can do a multitude of things, such as:

  • Measure hand hygiene compliance through observations. For more information on how to do this, read the article “Safer Care: Improving Hand Hygiene Compliance” and consider using the AAPACN Hand Hygiene Competency tool.
  • Educate new staff members on how to perform hand hygiene and why hand hygiene is performed.
  • Be intentional about praising others when they notice hand hygiene compliance is increasing.
  • Be part of planning and implementing infection prevention and control campaigns.
  • Help team members learn to use the communication technique CUS.

Learn to CUS

A critical component of safety culture is staff holding each other accountable for the expected behaviors and practices that should be performed. Staff need to know what to do when they witness a peer not performing hand hygiene when it should be done. Some staff will feel comfortable giving others a gentle reminder, which could be as simple as “Don’t forget to wash your hands” or “Let’s use the hand sanitizer before we see the next resident.” In many situations, gentle reminders will work, but do not assume everyone knows how to be diplomatic and supportive. It can be difficult to essentially call out a peer or even their superior for not doing something they should be doing; diplomatic prodding becomes more challenging when a peer or superior doesn’t listen to the gentle reminder. In these situations, a proven communication technique known as CUS can help.

TeamSTEPPS® 2.0 for Long-Term Care is a program from the Agency for Healthcare Research and Quality (AHRQ) that provides comprehensive, free training on a system of teamwork, specific to long-term care, to improve resident safety. CUS is one of the many communication strategies taught in this evidence-based program. It consists of three assertive statements:

I am Concerned

I am Uncomfortable

This is a Safety issue

A staff member practicing the CUS communication technique may sound something like “I’m concerned. I’m uncomfortable when I don’t see hand hygiene being done that it will spread infection. This is a safety issue.” It must be clear that all staff can use CUS, and in fact, are expected to for the good of each other and the residents.

Additional Resources

Compliance with infection prevention and control is of paramount importance. For more information on this topic, AAPACN offers a number of free tools to members and podcasts available to all. AAPACN also offers a variety of articles on this topic, including “PPE: How to Improve Facility Competency and Compliance,” and recorded webinars, including “How to Use QAPI to Improve the Infection Prevention and Control Program.”

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