Scientists at the Amsterdam University Medical Center (UMC) investigated a behavioural approach to improve compliance. Right in the middle: the OPHARDT Hygiene Monitoring System.
Hospital-acquired infections are an undesirable and increasingly frequent side effect experienced by patients during a hospital stay. In most cases, harmful pathogens are transmitted to patients by the hands of hospital staff during care. These germs are then able to multiply rapidly, causing patients to become ill.
The simplest, most effective and economical way to prevent harmful hospital infections is through careful hand hygiene. According to expert estimates, simple hand disinfection can reduce nosocomial infections by up to 30 percent. In practice, however, large gaps exist in the quantitative and qualitative implementation of hygienic hand disinfection. Compliance rates in medical facilities often amounts to less than 50 percent. 
This alarming statistic highlights the importance of research focused on understanding why hand hygiene opportunities are missed, and what can be done to improve compliance. In addition to personnel and infrastructural factors, the behavioural approach is increasingly coming into focus and is regarded as an important component to foster improved hand hygiene behaviour.
A friendly push in the right direction
Using behavioural approach, we are able to investigate the many ways in which we can influence people’s behaviour. Studies on the effect of reward and punishment are continuing to be published, even how it applies within the framework of hand hygiene. “Nudging” is a technique that has been explored and proven successful in other areas of discipline, such as helping people quit smoking, whose effect is now being explored with regard to hand hygiene behaviour. The concept behind nudging involves attempting to change people’s behaviour by convincing them of the desired action in a gentle and subtle way. [2,3]
“We investigated several cognitive biases that could have a negative impact on hand hygiene behavior and used these to develop nudges.”Martine Caris, Resident in internal medicine, clinical epidemiologist in training at Amsterdam University Medical Centre.
A research team led by Martine Caris at the Amsterdam UMC examined the effect of nudging on hand hygiene behaviour. The study was conducted over six weeks and focused on two wards of the clinic (Ward A and Ward B). Ward A and Ward B were similar in terms of patient clientele, bed equipment and area of medical focus.
To establish baseline data, three Wi-Fi-capable ingo-man® plus Weco disinfectant dispensers were installed to measure hand disinfection behaviour in each ward over a two-week period –and six weeks in total. Researchers then distributed a questionnaire to hospital staff and students, and based on the results, developed two posters, each consisting of a hygiene-relevant graphic and a catchy slogan. The posters were placed next to dispensers near the entrance of the two hospital wards to serve as nudges to staff, visitors and patients to remind them to disinfect their hands. In order to identify which poster had a stronger effect on hand hygiene, these were separated and placed in the appropriate areas for two weeks at a time.
Nudges show effect
Throughout the study, the OPHARDT Hygiene Monitoring System collected data on each hand hygiene event in both wards. Based on this, researchers were able to evaluate and compare the results from Ward A and Ward B, taking into account patient days for more directly comparable results.
Both posters had a positive effect on the frequency of use of the ingo-man® dispensers. Hand disinfection behaviour of hospital staff, patients and visitors was significantly improved in Ward B and during doctor’s rounds on both wards.
“The use of nudges offers a decisive advantage: they can be easily integrated into everyday clinical practice with relatively little effort.”Mireille Dekker, Infection control practitioner, clinical epidemiologist at Department of Medical Microbiology and Infection Control at Amsterdam University Medical Center
All in all
As exemplified in this study, the use of nudges can be a particularly cost-efficient and effective tool in reminding individuals to disinfect their hands and prevent the spread of infection. In addition to hospital staff, visitors and mobile patients will also use the dispensers when entering or leaving the ward.
Examples of nudges can include more than just posters. Using a varied approach and changing the type of nudges can help keep things fresh and hand disinfection on the mind. Involving hospital staff in the design of slogans and designs can also increase awareness of hand disinfection and support a positive effect on hygiene compliance.
In this context, Wi-Fi-based disinfectant dispensers, such as the ingo-man® plus Weco, can help healthcare professionals in measuring and improving hand hygiene compliance.
The research team from Amsterdam UMC intends to continue their research on nudging techniques in an effort to promote infection prevention.
 Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283–294
 Sunstein CR. Nudging smokers. N Engl J Med 2015; 372: 2150-1.
 Bucher T, Collins C, Rollo ME, McCaffrey TA, De Vlieger N, Van der Bend D, et al. Nudging consumers towards healthier choices: a systematic review of positional influences on food choice. Br J Nutr 2016; 115: 2252-63.