The 'wicked problem' of hospital handwashing

It sounds like a simple task: how do you make sure that health care workers in hospitals wash their hands?

Handwashing has been identified as the single-most important action in preventing the spread of hospital-acquired (and antibiotic-resistant) infections such as golden staph. The World Health Organisation estimates that these infections contribute to 80,000 deaths each year. The issue is pressing – but despite their training and good intentions, hospital staff don’t always follow handwashing protocols.

Watch the latest episode of A Different Lens: Beating the Superbugs 

For the past year, practice professors Mark Armstrong and Daphne Flynn, the director of Monash Art, Design and Architecture’s Health Collab, have been working with leading clinicians on a strategy to improve hospital handwashing rates. The designers describe the brief as a “wicked problem” that becomes curlier the more they look into it.

Professor Armstrong explains the issue this way: “Somebody goes in for a minor procedure and three weeks later they re-present with golden staph. No one really knows what happens. There is no accountability, as such, and it's damaging all sorts of things ... It damages the hospital’s reputation. It undermines our confidence in the hospital system.”

Read more: Sleepwalking towards an antibiotic apocalypse 

The Health Collab uses design strategies to improve health outcomes – the lab is applying design expertise to a wide range of projects, from bionic implants to air cabin interiors. The hand hygiene brief involves what Professor Armstrong calls “experiential design”, which seeks to change behaviour.  As part of its research, the design team conducted in-depth “empathy interviews” with hospital patients and workers. “By observing what's going on, you can understand the why,” Professor Flynn explains.

Professor Armstrong provides an example of how a doctor might forget to wash his hands: “You’ve got a clinician attending to a patient in one bed, and there’s another patient there – an elderly patient, Mr Johnstone, who is not supposed to be mobile, and who has his drip connected. He starts to march off down the hall. So the clinician, rightly so, stops what he's doing and turns around and steadies Mr Johnstone and calls for the nurse.

“And then the doctor turns back to his own patient and touches her – that's a breach of hand hygiene …”

According to the WHO, the five moments of hand hygiene are: before patient contact; before an aseptic task (such as surgery); after bodily fluid exposure; after patient contact; and after contact with patient surroundings.

If all health care workers followed these protocols, they would wash their hands dozens of times each day – with either soap and water or with an alcohol-based antiseptic gel.

The Health Collab team has been investigating multiple approaches to the wicked problem to improve compliance. Can the design of taps and basins be changed to make handwashing easier? How do you stop sensitive skin from becoming irritated? Can an electronic barrier surround patients that emits a sound when breached, reminding staff to wash their hands?

"Somebody goes in for a minor procedure and three weeks later they re-present with golden staph. No one really knows what happens."

The empathy interviews made it clear that doctors and nurses “are under a great deal of time pressure”, says Professor Armstrong. They forget to wash their hands because other tasks arise that appear more important. He says a successful design solution “has to be usable, easy and reliable and memorable”.

The constant parade of visitors in hospitals is another complication, says Professor Flynn. “How do we raise awareness among them? In hospitals they have gel stations. But there is so much going on, a cacophony of communications and people and stuff everywhere. Half the time you can’t even see these points, where you wash your hands. And it’s voluntary …”

A communications strategy is part of the Health Collab’s hand hygiene work in progress, including messaging that reminds hospital staff of the consequences of not washing their hands. Health care workers don’t tend to catch hospital-acquired infections themselves, and that has been identified as one of the reasons handwashing can be overlooked.

The Health Collab team will set up an initial trial to test its interventions in a live setting before conducting a clinical trial.

“We're hoping that in five years’ time the incidence of hospital-borne infection as a result of poor hand hygiene will be significantly reduced,” says Professor Armstrong. “And this will save millions of dollars and lots of suffering.”