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Nudging Hospital Visitors' Hand Hygiene Compliance
iNudgeyou © 2016
INTRODUCTION
Hospital-acquired-infections (HAI’s) are a costly
affair to patients and society as a whole. Acquiring
a hospital infection creates additional suffering
for the patient and it may at worst lead to death.1
Prolonged hospitalisation due to HAI’s also
represents a massive nancial burden to health
care systems around the world. Improving hand
hygiene behaviour in hospitals is among the most
promising ways of preventing such HAI’s.2 This
brief paper reports on a recent eld experiment
testing a simple nudge3 aimed at improving hand
hygiene amongst hospital visitors.
In Denmark, it has been estimated that 1 in every
10 hospitalised patients acquire an infection during
their hospitalisation.4 These incidents drive additional
health care costs and the Danish Health Care
System spends nearly 1 billion DKR on a yearly basis
accounting for the costs of prolonged hospitalisation.5
The hospital environment is rich on bacteria, even
one’s that only thrive within this specic environment.
These bacteria are a major threat to vulnerable and
weakened patients causing prolonged hospitalisation
and, at worst, death. Therefore it is of utmost
importance to try and eliminate the transmission
of bacteria and hand hygiene is the single most
important factor in reducing the transmission of
HAI’s.6,7
A lot of effort has been made to improve health care
workers’ hand hygiene compliance (HHC) and far
less has been done in order to maintain high levels of
HHC among visitors. To our knowledge there is only
one published investigation into this matter, which
in return yielded an increase in HHC from 0.52% to
11.67%.8
NUDGING HOSPITAL VISITORS'
HAND HYGIENE COMPLIANCE
Simon Carøe Aarestrup1, Frederik Moesgaard2, and Johannes Schuldt-Jensen3
1 Junior Researcher, iNudgeyou.
2 BSc, Business Administration & Psychology, CBS.
3 Junior Researcher, iNudgeyou.
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Nudging Hospital Visitors' Hand Hygiene Compliance
iNudgeyou © 2016
As the nudge approach dictates9, the authors of this
paper sat forth to develop a simple nudge and test
this in a eld experimental setting. The main objective
was to investigate how to further increase visitors’
use of hand disinfectant in a real-world setting.
THE INTERVENTION
The use of hand sanitizer is an active way of supporting
your relative in the recovery process. Throughout
all of the investigation it was assumed that hospital
visitors care about the well being of their hospitalised
loved ones and want to help setting them on their
feet again. Hence, what we were interested in was
to remove the obstacles that might possibly drive
the non-compliant hand hygiene behaviour causing
a gap between the visitors’ good intentions towards
their relatives and the visitors’ actual behaviour.
The nal intervention was made up of the three
nudge-functions, placement, colour and normative
message.
PLACEMENT
One of the rst things we noticed at Gentofte
Hospital was the placement of the hand sanitizers.
At the Medical Department all hand sanitizers were
primarily located above the sinks inside the hospital
wards (See Fig.1). The choice of using hand sanitizer
is thereby offered at a seemingly late point in time
competing against the choice of approaching one’s
hospitalized relative.
The rst part of the intervention included a new
placement of the hand sanitizer. We introduced a
freestanding hand dispenser at the very beginning of
the Medical Department to ensure the least amount
of competing stimuli in the environment.
COLOUR
The hand sanitizers had a low degree of salience
in the original setup. The hand sanitizer packaging
was transparent which made it blend in with the
surrounding environment (See Fig. 1). This visual
attribute made the hand sanitizer less likely to catch
the visitors’ attention when entering the ward.
In order to work around the transparency problem we
introduced a red sign right above the freestanding
hand sanitizer as the second part of the intervention
(See Fig. 2). In the natural world the colour red is the
most common signalling color.10 Consequently, the
colour red is a substantial visual stimulus better at
directing our attention compared to other colours.10
Another aspect of the colour red, is the different
associations the colour brings along with it. The
colour red is used in trafc to catch drivers’ attention.
In trafc red means that you have to stop as opposed
to the colour green that invites you to move on. We
wanted to integrate this association into the layout of
the sign (See Fig. 2).
NORMATIVE MESSAGE
The nal function of the intervention was a text
message printed onto the red sign. It stated “Here we
use HAND DISINFECTANT in order to protect your
relative”. The text message on the sign was made up
of two different elements:
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Fig. 1 Original placement of the hand sanitizers.
Fig. 2 The placement of the hand sanitizer during the
intervention period.
Nudging Hospital Visitors' Hand Hygiene Compliance
iNudgeyou © 2016
"Here, we use HAND DISINFECTANT"
The rst part of the text was constructed as a
normative message. Thus, we expected that it would
inform the visitors about the most accepted behaviour
in relation to hand hygiene at the hospital. People
who visit the hospital might nd it difcult to estimate
the right kind of behaviour in this particular context.
"… in order to protect your relative"
The second part of the text was used to make the
consequences of hand hygiene compliance more
tangible to visitors, by giving them a plausible reason
as to why they should engage in positive hand
hygiene behaviour.
EXPERIMENTAL DESIGN
Our eld experiment consisted of three different
conditions with 30 visitors observed in each condition
(N=90). First, the baseline condition was tested in
order to determine the general level of hand hygiene
compliance. Secondly, in our placement condition
we employed a freestanding hand dispenser at
the very beginning of the department. Thirdly, the
sign+placement condition made use of the new
placement as well as introducing the sign on top of
the hand dispenser. The data was gathered by direct
observation during ve concecutive days at Gentofte
Hospital.
THE RESULTS
In the wake of the eld experiment we ended up with
the following results. In the baseline condition only
3% of the visitors used hand disinfectant. Introducing
the new placement for the hand dispenser resulted
in 20% of the visitors using hand disinfectant. Finally,
with the combination of both the new placement and
the sign, hand hygiene compliance reached a level of
67% (See Fig. 3).
The groups showed an overall signicant difference
x2(df= 2, N = 90) = 14.45, p = .0007). Using a second
chi-square, we found that the “sign+placement”
group, were signicantly different from the other
two (x2(df= 1, N = 90) = 11.72, p = .0006). Using
a bonferroni correction for multiple comparisons on
both tests, they maintain signicance at p < 0.01.
The results from the eld experiment at Gentofte
Hospital clearly indicates that it is possible to increase
hand hygiene compliance among visitors by means
of changing the default placement and providing a
salient sign using a positively framed message. In
a broader perspective our results suggests that the
employment of behavioural insights is a valuable tool
to improve visitors' hand hygiene compliance.
SCA: corresponding author, simon@inudgeyou.com
SCA and FM: nudge development and eld experiment.
JSJ: data analysis.
1. WHO. (2009). On Hand Hygiene in Health Care First Global
Patient Safety Challenge Clean Care is Safer Care.
World Health, 30(1), 270. doi:10.1086/600379.
2. Boyce, J. M., & Pittet, D. (2002). Guideline for hand
hygiene in health-care settings: recommendations of
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Amount of visitors using hand sanitizer (%)
BASELINE PLACEMENT SIGN + PLACEMENT
3%
20%
67%
Fig. 3 Results from the eld experiment.
Nudging Hospital Visitors' Hand Hygiene Compliance
iNudgeyou © 2016
the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand
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