Leadership in Health and Social Care: The challenge of promoting effective teamwork on hand hygiene compliance in an inter-disciplinary environment for team leaders in Hong Kong authority hospitals
Part I
Introduction:
Hand hygiene is the single most effective and cost efficient method for preventing and reducing the transmission of hospital acquired infections. Adherence to hand hygiene practices is the most important method of reducing infections in healthcare facilities. Because hands of healthcare workers frequently serve as vectors for the transmission of organisms between patients, and are also a major reservoir for pathogens with antimicrobial resistance, the simple act of washing ones hands can greatly reduce the risk of transmitting an infection to another patient. While this may not be enough to disinfect a healthcare worker’s hands completely, it does greatly decrease the odds of such an event (transferring one patient’s sickness to another) from happening.
As Duffin states, improper hand hygiene techniques and poor hand hygiene compliance can predispose immune-compromised patients to develop potentially life-threatening infections and increase the patients' length of stay in hospital, cost per patient day, and cost per episode of care needed. As suggested by Maskerine and Loeb, a multidisciplinary approach, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase a healthcare worker’s adherence to hand-hygiene recommendations. In a multidisciplinary approach, committed nursing leadership and strong communication with team members is essential.
Modern healthcare is a very complex business; nurses hope to provide high quality of healthcare to their clients. Thus, they must have strong leadership skills to lead the nursing team and their followers if they are to be successful in their endeavors. Good leadership skill can rebuild and heighten the team spirit and morale; it can also benefit patients, staffs, hospitals, and the organization. This essay will discuss the uses of different strategies, theories, challenges and personal reflection in tackling barriers and leadership problems in my working area.
Context:
According to WHO guideline, hundreds of millions of patients around the world are affected by health care-associated infections (HCAIs). Although HCAI is the most frequent adverse event in health care, its true global burden remains unknown because of the difficulty in gathering reliable data. Most health care-associated infections are preventable through good hand hygiene by cleaning hands at the right times and in the right way.
However, as stated by a journal study of the Infection Control and Hospital Epidemiology that compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance of said instructions have been successful, none have achieved lasting improvement; and in the Hong Kong situation, Hong Kong Special Administrative Region (HKSAR) has always been a keen supporter of the WHO The First Global Patient Safety Challenge: Clean Care is Safer Care initiative. It has even come to the point that the Department of Health and Hospital Authority have jointly organized the major Hand Hygiene Awareness Day on the 5th of May 2010 and it has had hand hygiene campaign promotions every year.
The aim is to arouse and emphasize the basic, yet very important practice in prevention of cross infection of disease by hands and hope to pass along the message from the hospital setting to the public as well.
As a newly promoted advanced practicing nurse, the leadership role in enhanced patient safety is one of the main core components in competence consideration. Yearly hand hygiene audit is basically implemented in the hospital. Education tools with guidelines and free access to alcohol hand rub facilities are supplied among the working sites. Despite this however, the improper use of gloves and poor compliance of hand hygiene procedures are still sometimes found during spot checks or when in a rush to deliver patient care.
Thus, infections such as urinary tract infection, respiratory influenza viral infection, MRSA, MDRA come into alert almost periodically. One of the ways to solve this harmful situation is to strengthen leadership skills and management style to solve or at the very least, improve the situation when it comes to poor compliance on hand hygiene. According to the Institute of Medicine report , the development of strong leadership skills can enable nurses to change the health setting, and empower nurse leaders who wish to be a leader in this change.
As Kendrick’s puts it, transformational leadership can cause a change in the individual and social system. The leader/s can make a valuable and positive change or challenge their followers’ vision in order to empower them to gain higher achievements.
Analysis:
The theories of leadership are numerous; and they are as follows: the Trait theory, Style theories, Path-goal theory, Situational and contingency theory, the transactional and the transformational theory of leadership. Brakes (2002) in turn classify leadership styles into a democratic leader, collaborative leader, autocratic leader or paternalistic leader.
Putting them in a nutshell, the trait theory talks about a leader having characteristics that can cause people from different organizations to follow him/her. The style theory in turn focuses on what a leader should do. Lastly, the Path-goal theory centres on leaders guiding followers down the “right” path that will lead to their mutual goals.
Apart from the above classifications by Brakes, most people usually classify leadership into “transactional’ and “transformational’ styles. This paper however will focus on applying the Transformational style to apply the change is hoped to be attained. Transformation leaders concern themselves with the vision of creating and developing change for the future. The transformational leader helps his/her followers in creating and developing a vision for the good of the organization as a whole. This vision is then used to give followers a sense of purpose and gives them a goal to work towards together. A transformational leader dislikes having to control their followers; instead they concern themselves with motivating and inspiring them to achieve the group’s goals. They emphasize on mutual trust, value and agreement.
When problems occur, a transformational leader encourages their followers to face and solve these problems together . Hence, many leaders believe that using transformational leadership methods is the best way to fulfil a leadership role in achieving their expectations of job descriptions and goals.
Discussion:
The most essential organisational component for effecting change is leadership. There are many stages of change such as recognising the pressures of change, evaluate external and internal environments and/or factors, establish goals for the implementation of the change, plan appropriate change strategies, implementing according to the plan and evaluating the change and its impact, this is in accordance to Kotter’s 8-Step Change Model.
But before the implementation of change and how transformational leadership can help implement this, we must first analyze the problem. As stated in the introduction, the main problem is the fact that, while implemented, healthcare institutions do not implement effective hand hygiene strictly enough. This problem is not contained in one location alone however, but is in fact a widespread problem that exists everywhere in the world. This paper will however, focus on the Hong Kong healthcare implementation of hand hygiene.
- Helping doctors in keeping with the hand hygiene guideline where nurses accompanying doctors would squirt rubbing alcohol onto their hands as they did their ward rounds.
- Starting up a competition where nurses made their own reminder posters because it was shown that self-designed posters had a better effect in the implementation drive,
- Placing point-of-care hand rub facilities in strategic locations.
- Implementing a hand hygiene class and a daily checklist for all healthcare workers.
The paper above shows that there is a way to implement hand hygiene effectively in the healthcare setting of Hong Kong. However, knowing how the method works and knowing how to apply it are two different things; this is where change implementation and transformational leadership comes in.
Transformational leadership is usually compared to transactional leadership as, in the long years since both theories were first conceptualized, it was shown that a leader could be both transactional and transformational. To be clearer (and to try and put it simply), transactional leadership works on a concept of a “give and take” take relationship while transformational leadership focuses on the leader’s personal traits and his/her ability to implement the change he/she wants .
While a leader can be both transformational and transactional at the same time (despite them being polar opposites of each other) because of the same underlying psychological mechanisms involved, this paper will cover transformational more because of the wide range of possible problems and solutions it can resolve. This is because transformational leadership has four elements that are quite general in nature.
More importantly, because of the general and wideness of these factors, they can be applied easily in dealing with the problem of hand hygiene. These four factors are as follows:
- Inspirational motivation
- Individual consideration
- Intellectual stimulation
- Idealized influence
Inspirational motivation is basically how well a leader can explain his vision to his/her followers where the end result is the group aiming to attain the vision of the leader. Individual consideration is the leaders skill at making sure that his/her followers are happy. This includes knowing each of their strengths and weaknesses and understating how to put them into good use (strengths) and compensating for them (weaknesses).
Intellectual stimulation Is the ability of the leader to encourage his group to come up with creative and innovative solutions to a problem or to getting to the group’s vision. This factor includes focusing on a problem and not finding a person to blame for said problem. Finally, idealized influence is how much of a role model the transformational leader is. For example, if the leader wishes for his subordinates to be respectful, he/she must question him/herself first on whether or not he is portraying the traits of a respectful person.
In relation to the problem of hand hygiene, transformational leadership is perfect for this as the revitalization program started by the Hong Kong Baptist Hospital revolves around implementation by enforcement through being a role model. While this may seem absurd, the results of Cheung’s and her team’s work prove that their method works and all that is required is proper implementation.
Recommendation
It is truly recommended that the transformational leadership theory be used for the implementation of effective hand hygiene practices. While the other forms of leadership theories have their pros and cons (and this paper is not trying to devalue them), for hand hygiene practices to be truly effective, there must be a change in the habit of healthcare workers in their respective facilities.
This change of habit cannot be forced upon the healthcare professionals as it has been shown that the best way to apply a change is by positive reinforcement and not through negative means . Furthermore, this change must be lasting, as deviation from hand hygiene will result in a long list of complications for all the parties involved: the patients, the healthcare workers and the healthcare institution in which they work.
Out of the different leadership theories, transformation leadership is best suited for this task as positive reinforcement for a change in behaviour requires the application of the four factors of transformation change, especially the factor of idealized influence. Also, transformational leadership has been proven to work well in interdisciplinary environments as it takes the individual into account.
Part II
Reflective summary
Looking at everything in perspective, hand hygiene is one of the most basic ways of keeping healthy and protecting oneself from infection. This is doubly true for healthcare workers, not only for themselves, but also for the patients that they handle. Washing of hands and applying of alcohol based had rubs are some of the cheapest ways to avoid passing on pathogens from one patient to another. Quite possibly, because of how basic this practice is, it is also one that is either easily forgotten, or dismissed when in a rush.
This problem of healthcare workers not applying the practices of hand hygiene properly is a problem that is drastically widespread that the World Health Organization even has to start Hand Hygiene Awareness day all over the world with the 5th of May being Hong Kong’s Hand Hygiene Awareness day. Taking the fact that HCAI is an easy problem to take care of if one simply practices efficient hand hygiene, a change in the attitude towards hand hygiene is required.
For this change to be implemented, the right form of leadership is required. As the problem is behavioral in nature, the form of leadership needs to be behavioral as well, something that the application of transformational leadership is quite capable of handling. Additionally, if transformational leadership methods are to be used, then a transformational leader is also needed for the challenge of promoting effective hand hygiene practices to be surmounted.
Of course, merely talking about the problem and the best solution for it is not enough to actually overcome the problem; one must also have a strategy to tackle it. With that in mind, this paper took a look into Nurse Cheung and her companion’s work at the Hong Kong Baptist Hospital. Their implementation steps were easy and simple, yet the results of their work was staggering, with them breaking the mould in raising the compliance rate in hand hygiene practices over 50% since the time it was started.
Given that there is evidence to prove that complying to hand hygiene practices can be implemented all that is needed now is a strategy to apply the desired effects in a different workplace.
As an example to explain the previous paragraph (using Cheung’s implementations as an example), the workplace needs to find out if there are already point-of-care hand rubs in strategic locations throughout the workplace? If there are, then are there enough to adequately supply the healthcare facility’s staff? If not, what can be done to change this? This step needs to be taken so that a framework can be created or at the very least, it will give the team assigned to this a way to quantify both the problem, the steps being taken to fix it and the progress of the implementation.
Additionally, this step will also allow the team that will tackle the problem to find and/or create realistic solutions to the problem on hand. Taking Cheung’s work again as an example, are there already self-made reminders in the healthcare facility? If yes, then are they working? If so then is it smart to create more or is the supply of posters already enough? As shown, this is how important data gathering is in creating a strategy as only when the problem has been measured can realistic solutions be made.
This in turn will lead to choosing the right people. The importance of this step can be seen in the phrase “hire the right people for the job”. What is meant her is that if the wrong person is assigned to the task, then no amount of thinking will result in any change. Assigning the right person is critical as it will determine how reliable the date they gather and how realistic their solutions are. Just as much as one would not hire a janitor to design a building as that is an architects job, it is strongly recommended by this paper that the people assigned to this implementation are nurses as they are well versed in the problem and its possible solutions.
Lastly, the strategy created must be time-bound. To be quite frank, changes such as this needs to be funded, and the awful truth is that funds are not unlimited. More importantly, when it comes to healthcare, results must arrive as soon as they have been confirmed to be effective as it is people’s lives that are being gambled. The word “gambled” is not used here lightly. As stated in the introduction, HCAIs have been known to cause life-threatening complications. Thus, the implementation of more efficient ways to promote hand hygiene should be finished in the shortest time possible. However, this sense of time constraint should take into account that positive results tend to take a bit of time to emerge.
Therefore, this paper concludes that the best way tackle the challenge of promoting hand hygiene compliance in an inter-disciplinary healthcare facility lies in assigning it to nurses where the primary objective is to raise the compliance level to at least 15% of it’s current level in the shortest amount of time possible with the most realistic (and possibly creative) solutions in mind. While this statement may not be a truly specific objective (being rather general in its nature), it is good enough for the moment since there are already proven frameworks that can be used as a basis.
References
(2006). Infection Control and Hospital Epidemiology , 21 (6), 381-386.
Bass, B. (2008). The Bass Handbook of Leadership: Theory, REsearch, and Management Applications (4th ed.). Bass and Bass.
Brymer, E., & Gray, T. (2006). Effective leadership: trasformational or transactional? Australian Journal of Outdoor Education , 10 (2).
Cheung, C., Luk, S., Wong, Y., Lau, S., Li, K., Ching, P., et al. (2013, June 20). O041: Overcoming hand hygiene campaign fatigue by an effective innovation involving the infection control link nurses. Retrieved January 23, 2014, from US National Library of Medicine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687951/
Duffin, C. (2008). Leadership and Workload Key to Infection Control. Nursing Standard , 22 (47), p. 7.
Kendricks, J. (2011). Transformationa leadership, cnaging individuals & social system: Professional Study. 56 (11) , 14.
Maskerine, C., & Loeb, M. (2006). Improbing Adherence to Hand Hygiene Among Health Care WOrkers. Journal of Continuing Education in the HealthP Professions , 26 (3), 244-251.
Millward, L., & Bryan, K. (2005). Clinical Leadership in healthcare: a position statement. International Journal of Health Care Quality Assurance , 18 (6), 13-25.
Mind Tools. (n.d.). Kotter's 8-Step Change Model. Retrieved January 23, 2014, from Mind Tools: http://www.mindtools.com/pages/article/newPPM_82.htm
World Health Organization. (2009). WHO guidelines on Hand Hygiene In Health Care. Retrieved January 23, 2014, from World Health Organization: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
