Hand Washing goes Viral! Beating the odds together
Read Full Essay
Be honest, did you wash your hands after every bathroom visit and before every meal in the past? Perhaps you were not in the habit (guilty at times). Perhaps on some occasions you were in a hurry or didn’t like the fact that your only option for hand drying were those blowers that leave your hands damp requiring an extra wipe on your pants to complete the task.
What would it take to get 100% compliance around hand washing?
A number of years ago my students and I did some *discrete* observations of hand washing behavior on campus. I’ve continued this practice of observing handwashing in my travels. Our observations suggested that folks washed their hands around 40% of bathroom visits with no difference across genders.
OK, so now are you ready to be honest about your hand washing?
Do you think those signs at restaurants requiring all employees to wash their hands before returning to work are effective 100% of the time? Restaurant employees should be keenly aware of how their bathroom behavior(s) can impact their customers through protecting our food, utensils and the rest of the restaurant from pathogens. But if you have a young person in your life that has worked the food industry (like I do), go ahead and ask them if hand washing occurs all the time. You will probably not like the answer.
What about our health care providers? Seems like the same hand washing diligence would be in order. Health care providers must disinfect their hands prior to working with patients. They come in contact with multiple bacteria, viruses, and other pathogens that could easily be passed on to vulnerable patients. Unfortunately, the worst place to go to be exposed to infection by a random pathogen is a hospital or doctor’s office.
One of my favorite authors (and Appalachian State graduate!) Steven Dubner of Freakonomics fame (check out his podcast) loves to cite a 1996 study from a pediatric hospital in Australia. When asked to self-report their hand sanitizing practices, doctors said they performed the act 73% of the time. However, nurses were spying on them and claimed Doctors’ actually sanitized their hands only 9% of the time!
My student Sara Stephens had our lab observe Certified Nurse Anesthetists (CNAs) during intravenous line procedures (Stephens & Ludwig, 2005). We found that CNAs sanitized only 24% of the critical times after their hands could come in contact with a pathogen. Even when we met with the CNAs and established a goal setting and feedback intervention we only got hand sanitizing up to 65%. We also noticed that doctors who performed intravenous line procedures on their own prior to surgery were much worse.
OK, even health care professionals struggle to attend to their hands 100% of the time.
NOW will you admit you don’t wash your hands all the time after conducting your business in the bathroom?
Life Critical Compliance
Now that we’ve finally got most of you to admit that you are not 100% compliant in your own safe hand washing behaviors let’s turn the conversation to the types of life-critical behaviors we ask our employees to do to protect their safety. We provide harnesses to wear, detailed procedures, and policies like “stop work” to follow. We get quite frustrated when incidents occur and discover the worker was not following these rules. We get a sobering reminder of reality when we do a walk-about and see that our folks are not close to 100% compliant (that is if they didn’t see you coming).
All of those antecedents you put in place such as training, operating procedures, posted rules, and safety meetings don’t assure compliance to their targeted behaviors. Certainly, they have an impact for some of your workers (the same ones who go the speed limit all the time while driving their personal vehicles). But antecedents like these only direct the behavior, they don’t motivate. They have to be associated with a consequence to adequately discriminate the right behavior to do in the circumstance. For antecedents such as rules, the only associated consequence is punishment – but we all know that punishment in the workplace is improbable (see my previous blogs).
What is probable is that complying with these rules require effort, cumbersomeness, and extra time. They are work’s version of hand washing where you still have to use your pants to dry completely. It is much easier to slip out the bathroom door without going through the process of soaping and washing down your hands, standing by a loud blower (which should require PPE) and wiping your hands on your pants.
Can we get to 100% Compliance?
I am writing this in the midst of the Coronavirus outbreak across the world. I cancelled a work trip to Africa, my University cancelled at least one week of school and is considering going online for the rest of the semester. I got really worried as my wife worked through flu-like symptoms after coming off work-related travel last week and….
I wash my hands all the freaking time now!
My own history of hand washing started when my nephew Stephen underwent a bone marrow transplant for childhood leukemia. His brother Jacob was an exact match and now, some 15 years later, Stephen announced to the family not to worry during the Coronavirus outbreak because his immune system is fully functioning (after all he has his brother Jacob’s system now). However, back when Stevo was going through the year-long multiple chemo procedures, my whole family religiously washed our hands prior to our visits. His immune system after the bone marrow transplant was non-existent…
We all washed our hands all the freaking time!
And you know what? It WORKS! In my job at the University I come in contact with hundreds of students a day in my classes and meetings. They are a cesspool of germs and nastiness (with a large dose of awesomeness mixed in). It is easy to suffer the latest flu or cold by being in such constant and close contact with young folks from all over the region (and globe). After Stephen taught me to wash my hands more habitually I rarely, if ever, get sick!
Yeah… do that thing!
I would be curious after this current viral crisis that captured the attention (and anxiety) of the world, if handwashing after visiting the bathroom is far above our 40% baseline.
Are you washing your hands all the time now too?
What does our global attention to hand washing during pandemics teach us about worker compliance around life-critical and other behaviors required for safety? The probability of getting this Coronavirus, according to experts is somewhere between 40-60% and the probability of fatality if you get it is arguably around 3% (probably lower). If the odds of getting disciplined for an unsafe act were 40-60% and the odds of death were 3% do you think we would have something closer to 100% compliance in the workplace? Yes -- negative reinforcement works when the odds are good.
The odds don’t line up that way in the workplace. This is good because we don’t want the likelihood of serious injury and death being anywhere close to 3%. But also, the very low likelihood of punishment and injury put our safety rules at a disadvantage as the likelihood of ease, comfort, and timeliness wins nearly every time with shortcuts.
So, what are we left with?
In his podcast, Stephen Dubner cites a comment by Jeff Starke, a physician at the Texas Children’s Hospital in Houston who also had a hand sanitizing problem. Consistent with Sara and my research, he couldn’t get hand sanitizing above 70% using various interventions. Then they made hand hygiene part of their pooled bonus plan. Everyone in the hospital had to maintain a 96% compliance rate to earn their bonus. They only made it above this goal when hospital executives added it as part of their bonus. So yeah, if you want near 100% compliance on life critical behaviors, make your executives financially accountable for worker behavior (not just injuries). Good luck.
The Power of People
One thing I am certain of is when I am teaching a safety workshop, 100% of workshop participants (at least the men) wash their hands going to the bathroom during a break! That’s because we are all together in the bathroom and need to hang out next to each other for the rest of the afternoon! Similarly, I bet hand washing at work is much higher when a colleague is in the bathroom with you. Why is this? Simple, you don’t what the reputation as being that dude (or dudette) with pathogen hands (especially nowadays).
Fortunately, in many occupations you do have colleagues working around you who can direct your behavior toward actions that keep yourself and others safer. Does the reputation threat of bathroom non-handwashing shame translate to our workplaces as well?
Do workers protect their reputations? You bet… reputation as a professional is the most rigorously protected thing at work. Then ask yourself about your workplace… when someone takes an obvious short cut or takes off PPE to make work easier is their reputation harmed? Alternatively, when a worker alerts another worker about the risks being taken and suggests a safer alternative, is that caring workers’ reputation harmed because he is being the safety fairy or is actually calling out the reputation of another worker (a big big no-no out there)?
It comes down to culture.
What is your cultural norm? When a worker is doing something risky, are other workers willing to step in and coach their peer? Would doing so be a risk to the reputation of either worker involved? What would be said behind someone’s back?
I’ve argued in my books and blogs that “culture” is not some complicated feel-good construct that, frankly, no one really understands. Culture can be broken down into a behavior, and therefore, can be improved. My definition: “Culture is people talking to each other”.
What talking is going on now that hurts reputations when someone tries to intervene to promote safe behaviors? Alternatively, what talking can you promote through your safety programs (like behavioral safety) that turns the tables in such a way that coaching fellow workers on safe behaviors is actually reputation building?
Talking to promote safety can happen, I’ve seen it many times. It takes time as does any process of shaping behavior across a workforce (and management force) but it is the most valuable protective means available. It takes people depending on each other and valuing those discussions to build the safety culture that will sustain safety at your worksite.
What’s going to protect me from this and future versions of pandemic viruses? Certainly, decisions made to curtail conferences, classes, and basketball games may help as will travel restrictions (and general paranoia keeping people off the streets). The constant emails, texts, and other reminders to wash my hands helps too.
But, by far the biggest thing that will protect me and you and everyone we love is — Other people washing their hands.
We’ve always been in this together folks. Let’s beat the odds.
Citation
Stephens, S.D., & Ludwig, T.D. (2005). Improving anesthesia nurse compliance with Universal Precautions using group goals and public feedback. Journal of Organizational Behavior Management, 25 (2), 37-71.
(Sara Stephens went on to work at the University of Michigan Medical School (Safety Management Services. I hope she is on the front line of our hand sanitizing solution during this pandemic!)