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'Development and Application of a Behavioural Science Paradigm For Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2018 Development and application of a behavioural science paradigm for infection prevention Clack, Lauren Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-152756 Dissertation Published Version Originally published at: Clack, Lauren. Development and application of a behavioural science paradigm for infection prevention. 2018, University of Zurich, Faculty of Arts. DEVELOPMENT AND APPLICATION OF A BEHAVIOURAL SCIENCE PARADIGM FOR INFECTION PREVENTION Cumulative thesis presented to the Faculty of Arts and Social Sciences of the University of Zurich for the degree of Doctor of Philosophy By Lauren Clack Accepted in the spring semester 2018 on the recommendation of the doctoral committee: Prof Dr Urte Scholz, Main Supervisor Prof Dr Hugo Sax Zurich, 2018 SUMMARY (EN) Healthcare provider (HCP) behaviours play a critical role in preventing negative patient outcomes, such as healthcare associated infections (HAIs). Yet, HCP compliance with basic infection prevention practices to prevent transmission of infectious organisms remains low. Further, current guidelines may not consider the full range of behaviours involved in pathogen transmission. A thorough understanding of healthcare provider behaviours relevant for infection prevention, as well as the mechanisms that drive these behaviours is paramount to designing effective behaviour change interventions. This thesis thus develops and applies a behavioural science paradigm to address these limitations and to guide infection prevention efforts. This thesis is comprised of eight studies and is presented in two parts. Part 1 employs exploratory and structured observations, video- based observations, and Delphi expert consensus to identify, classify, quantify, and assess the clinical relevance of HCP behaviours related to transmission of microorganisms that play a role in patient infection. Part 2 employs multiple behavioural analytical methods (e.g. concept-mapping, video-reflexive ethnography, and systematic literature review) to understand the range of factors that influence HCP infectious risk behaviours. The findings of this thesis lay the framework for designing theoretically coherent interventions to support safe HCP behaviours and thereby reduce infectious patient risks. ii ZUSAMMENFASSUNG (DE) Das Verhalten von Mitarbeitenden des Gesundheitswesens spielt eine entscheidende Rolle bei der Verhinderung von spitalerworbenen Infektionen. Die Umsetzung von infektionspräventiven Massnahmen, wie z.B. der Händehygiene, bleibt jedoch weltweit weiterhin mangelhaft. Um dieses Verhalten positiv zu beeinflussen, braucht es ein differenziertes Verständnis des infektionsauslösenden Risikoverhaltens von Mitarbeitenden als auch der Determinanten dieses Verhaltens. In zwei Teilen und acht Studien wird ein verhaltenswissenschaftliches Paradigma entworfen und angewandt, um die Mängel in der Umsetzung von präventiven Massnahmen zu identifizieren und damit der Infektionsprävention neue Ansätze zu eröffnen. Teil 1 verwendet verschiedene Methoden wie unstrukturierte und strukturierte Beobachtungen, indirekte, videobasierte Beobachtungen und eine Delphi-Expertenbefragung zur Identifizierung, Klassifizierung und Quantifizierung des genannten Risikoverhaltens. Teil 2 nutzt verhaltensanalytische Methoden wie Konzept-Mapping, Video-reflexive Ethnographie und eine systematische Literaturübersicht, um die ausschlaggebenden Determinanten für dieses Verhalten zu identifizieren. Die Ergebnisse dieser Arbeit bilden die Grundlage für theoretisch fundierte Interventionen zur Förderung eines infektionspräventiven Verhaltens von Mitarbeitenden des Gesundheitswesens im Sinne einer erhöhten Patientensicherheit. iii ACKNOWLEDGMENTS I would like to begin by acknowledging that I was partially funded by the Swiss National Science Foundation (32003B_149474) while working on this thesis. The work presented in this thesis would not have been possible without the academic, professional, and emotional support of several people. I would like to take the opportunity to begin to thank them here, though my words can hardly do justice to describing how grateful I truly am for their love and support. I would like to thank Professor Urte Scholz, the primary advisor of the thesis, for welcoming me into her group and for her thoughtful feedback throughout this work. I would also like to thank Professor Hugo Sax, the co-advisor of this thesis. Thank you, Hugo, for being a wonderful advisor, mentor, and friend. Thank you for all that you have taught me, well beyond the scope of this thesis. It has been a lot of fun! I am also ever grateful to my previous advisors at the University Hospitals of Geneva, Dr. Walter Zingg and Professor Didier Pittet, who sparked my initial interest in the field of hospital infection prevention and control. A special thank you to my HUG colleagues, Walter, Hugo, Sylvie, and Fabricio, with whom I learned so much about qualitative research, central venous catheter-related bloodstream infection prevention, and how to travel Europe! I keep very fond memories of our work together. I am especially grateful for the support of all my wonderful colleagues from the Infection Prevention Team at the University Hospital of Zurich. Thank you Carlo, Mesida, Daniela, Mirjam, Bettina, Heidi, Sabine, Anne, Stefan, Pia, Marie-Theres, Julia, Dirk, Peter, and Aline for being such a great team, for your expert advice and also for being such willing Guinea pigs! I have thoroughly enjoyed working with such a fun and inspiring team and look forward to continuing our work together. In particular, a very special thank you to Simone Passerini and Jasmina Bogdanovic. All this work would not have been possible and would not have been nearly as much fun without the two of you! Thank you both for your passion, your stamina, and for the great times inside and outside of the office. I would like to thank all the brilliant individuals outside of the hospital I had the opportunity to collaborate with professionally throughout the different stages of this project and from whom I could learn so much. Special thanks to Tanja Manser, Jan Schmutz, and Fabiana Lorencatto. Finally, I would like to express my deep gratitude to my family and friends for their unwavering love and support. Thank you mom, dad, and Andrea for the wonderful foundation you’ve provided me. With your unending love and compassion, you taught me to dream big and you’ve supported me every step of the way. None of this would have been possible without you. And finally, thank you Gustavo for being a great partner, inspiring me with your endless curiosity and challenging me to be better on a daily basis. iv TABLE OF CONTENTS SUMMARY (EN) ....................................................................................................................... II ZUSAMMENFASSUNG (DE) ..................................................................................................... III ACKNOWLEDGMENTS ............................................................................................................. IV TABLE OF CONTENTS ............................................................................................................... V LIST OF FIGURES .................................................................................................................... VII LIST OF TABLES ................................................................................................................... VIII 1. CHAPTER 1: INTRODUCTION AND MOTIVATION ............................................................ 1 1.1. General introduction ................................................................................................. 2 1.2. Theoretical Background ............................................................................................ 5 1.2.1. Hospital Infection Prevention ............................................................................. 5 1.2.2. Health psychology applied to infection prevention .......................................... 10 1.3. Infectious risk moments approach .......................................................................... 18 1.4. Research questions and studies ............................................................................... 21 2. CHAPTER 2: PROOF OF CONCEPT, PILOT STUDY .......................................................... 26 2.1. Study 1: Infectious Risk Moments: a novel, Human Factors-informed approach to infection prevention. ............................................................................................... 27 3. CHAPTER 3: METHODS FOR OBSERVING INFECTIOUS RISK BEHAVIOURS ................... 38 3.1. Study 2: Frequency and nature of Infectious Risk Moments during acute care based on the INFORM Structured Classification Taxonomy ........................................... 39 3.2. Study 3: "First-person view" of pathogen transmission and hand hygiene - use of a new head-mounted video capture and coding tool. ................................................ 59 4. CHAPTER 4: ASSESSING THE CLINICAL RELEVANCE OF IDENTIFIED INFECTIOUS RISK MOMENTS ....................................................................................................................... 76 4.1. Study 4: Likelihood of infectious outcomes following Infectious Risk Moments during patient care - an international expert consensus study
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