How visual reminders improved hospital handwashing by 43%

Intervention Health and Safety

Abstract

Hospital-acquired infections, which often occur due to improper hygiene practices, are a dangerous side effect to hospital stays. While reminders of handwashing are available and prominent, they are often ignored by healthcare workers. This behavior can result in infectious outbreaks, incapacitating whole hospital wards.

In 2016, Nyt Hospital Nordsjælland employed Danish behavioral science firm Kurkow to tackle this issue using visual design cues. The nudge would show the correct hygiene procedures before entering isolation rooms. By replacing text-based sanitation information with visual cues, the number of healthcare workers employing proper hygiene procedures jumped from 16% to 59%. 

Rating: 4/5 (Positive impact on participants, information published by private firm)

How visual signage improved hand-washing compliance in Nyt Hospital Nordsjælland
Condition Results
Text-based sanitation signage 16 %  of hygiene practices were correctly performed
Visual sanitation signage 59% of hygiene practices were correctly performed

Key Concepts

Nudges: Nudges are gentle suggestions towards the desired outcome which are created by subtly altering the context in which we make our decisions. They often occur below the level of our conscious awareness.

EAST Framework: The EAST Framework is a set of guidelines designed to make behavioral science interventions more effective. The four quadrants of the framework state that an effective intervention must be Easy, Attractive, Social, and Timely. Even if an intervention doesn’t include all four, its effectiveness drastically increases when any facet of the EAST Framework is used.

The Problem

Handwashing as a barrier to hospital infections

If the COVID-19 pandemic has taught us anything, it is the importance of washing our hands. Washing our hands helps us protect ourselves and others from dangerous pathogens. This is especially important for healthcare professionals who are in near-constant contact with various diseases. Unfortunately, healthcare professionals are often highly stressed or short on time, which can result in a lack of adherence to common hygiene practices. This lack of basic hygiene can result in dangerous side effects, such as hospital acquired infections which can result in increased mortality, morbidity, absenteeism, and treatment costs. 

Nyt Hospital Nordsjælland x Krukow

In 2016, Nyt Hospital Nordsjælland in Denmark was struggling with staff hygiene compliance. While they had not experienced an outbreak of hospital acquired infections, they were concerned that the lackluster hand-washing practices of their workers could likely lead to one in the future. Enlisting the help of Kurkow, a Danish behavioral design firm, the hospital got to work nudging their staff towards better hygiene practices. 

Design

Text to visual reminders

Kurkow observed that Nyt Hospital Nordsjælland’s hygiene reminders were largely in text format. While we can presumably read well, our brain has largely evolved to better understand visual cues. This is why we typically find it more cognitively difficult to understand a paragraph of instructions than to get the gist of an image that represents the same step-by-step process. Acknowledging this insight, Kurkow set out to transform all of the hospital’s text-based information into useful visual guidelines. 

Some methods used in making these visual cues effective included creating visual guidelines to show the physical position of the sanitation station in the room and breaking down the sanitation procedure into a tangible, step-by-step formula. 

The EAST Framework

When we examine frameworks that are used for applying behavioral science, it is clear why this nudge was so effective. In the Behavioural Insight Team’s EAST Framework, the first pillar for crafting an effective behavioral intervention is making your message cognitively easy, as simplifying is perhaps the most effective way to make your goal understood. In this example, this simplicity is represented in the replacement of thick blocks of written cues with simple images, which are far more likely to be observed and understood by busy healthcare workers.

This intervention also takes advantage of the second pillar of the EAST Framework, which involves making the message more attractive to the group you are targeting. Kurkow did this through the use of colorful, attention-grabbing images that would be highly attractive to our visual-oriented minds. 

Results and Application

43% increase in correct hand-washing procedures

Overall, the project has an array of positive effects, despite its simplicity. Measuring the amount of correctly performed hygiene procedures, Kurkow saw a 43% increase after implementing the visual design strategy. Before the experiment was set in place, the hospital’s healthcare workers only performed proper procedures 16% of the time, whereas after the procedure compliance to hygiene standards reached rates of nearly 60%. 

Less risk of infections

In addition to these short-term hygiene benefits, the resulting behavior change should lead to fewer hospital-acquired infections and hospitalization in general. Gentle nudges like this, despite their perceived simplicity and low costs, can surely minimize human pain and suffering in the long haul over a spectrum of applications. 

Industry

Application

Retail & Consumer Visual cues could be used for employees with other hygienic duties, such as restaurant or daycare employees
Health & Wellbeing Hygienic reminders could be used for individuals who need extra assistance in their homes, i.e. images of proper hygiene practice could aid young children or individuals with memory-disorders
Climate & Energy Public areas, such as museums or hotels, could provide signage to encourage environmentally-positive practices, such as not flushing foreign objects or turning off the tap while brushing your teeth

Ethics

  • The intervention improved outcomes for participants
  • More information on privacy and consent is needed, as well as knowledge on the effects across demographics

Yes

Room for improvement

Insufficient information/Not applicable

Welfare
Does the intervention demonstrably improve the lives of those affected by it? The rate of correctly performed hygienic practices nearly quadrupled, which most definitely improved the lives of physicians and most importantly, their patients.
Does the intervention respect the privacy (including the privacy of identity) of those it affects? Private information was not included in the study, but there was no mention of how participant privacy was protected.
Does the intervention have a plan to monitor the safety, effectiveness, and validity of the intervention? There is little information concerning the monitoring aspect of this intervention. While the success rate is promising, it does not come with a timeline or an evolution to ensure constant improvement.
Autonomy
Does the intervention abide by a reasonable degree of consent? There is not enough information given by Kurkow to suggest that participants consented to the observational aspect of this experiment.
Does the intervention respect the ability of those it affects to make their own decisions? The intervention relies on replacing written messages with visual clues. It doesn’t drastically interfere with the decision making process, but acts like a gentle nudge.
Does the intervention increase the number of choices available to those it affects? The intervention did not offer new and effective methods of hygiene regulation, it merely nudged physicians to abide by the pre-existing hygiene standards.
Equity
Does the intervention acknowledge the perspectives, interests, and preferences of everyone it affects, including traditionally marginalized groups? Not enough information is given to establish whether or not the intervention caters to marginalized groups.
Are the participants diverse? No information was given concerning the diversity of the participants.
Does the intervention help ensure a just, equitable distribution of welfare? By ensuring better hygiene standards, the intervention also increases the safety of patients entering the hospital and promotes their right to a high-quality health care service.

Related TDL Content

Evidence-Based Strategies for Washing Your Hands: If you are further interested in evidence-based ways to improve handwashing, look no further than Karine Lacroix’s article on the subject. Similar to this intervention, this article applies the EAST Framework to the issue of handwashing and gives many alternative strategies of how to apply these techniques to ensure ourselves a cleaner, safer future. 

Encouraging Social Compliance During COVID-19: During a global health crisis, compliance to things like handwashing and mask-wearing are essential for protecting ourselves and others. In this piece, TDL’s Siddharth Ramalingam examines how we can use similar techniques to the ones used in this intervention to help maintain public health safety standards during COVID-19. 

Sources

Krukow Behavioral Design. (2021). Nudging better hygienic practices. Retrieved from https://www.krukow.net/nyt-hospital-nordsjaelland