I’m always interested in why people don’t do what they know that they should or why things don’t happen as we think they will. Interventions that are demonstrably effective, evidenced in the literature and incorporated into guidelines are not implemented even though ‘it’s in the policy’. We have to remember that implementation often has many sides. We can spend a lot of time designing an effective intervention based on the most robust evidence and then it just doesn’t happen on the shop floor. Sometimes this is failure to engage the staff that will actually implement the measure, but what about the involvement of those to whom the deed is done? A simple two-letter word can stop healthcare provision in it’s tracks. That word is ‘No’.

In a very nice short report in the August edition of ICHE, Hines and colleagues decided to investigate why, despite it being policy to use Chlorhexidine (CHG) on patients in critical care areas, compliance with this evidence-based measure was only 63%. Importantly, they sought to discover why this was so.

Using a short, 11 question survey on SurveyMonkey™ (free for up to 10 questions, so always worth considering) to collect information on knowledge, beliefs, practices and potential barriers. They also importantly asked respondents what would increase their compliance. The respondents were grouped into two categories; Nurses and Patient Care Technicians (PCTs). Coming from the UK, I’m not familiar with the role of a PCT however it seems to be a developing role that may have been called an orderly, aide etc. In the UK we may call them a Health Care Assistant I would guess. More information on this role can be found here.

Anyway, I digress. The findings of the study are interesting. 88% identified that CHG was in the organisation’s policy and so it appears that the knowledge level of the staff was high. The attitude results were interesting however in that 85% felt that bathing was beneficial to patient care (quite interesting that 15% felt that a wash wasn’t beneficial..) however only 63% felt that CHG bathing was a benefit. Interestingly, the PCT’s attitude to CHG bathing was more positive than the nurses (possibly because they were the ones doing it). 80% of PCTs felt that CHG bathing was a priority whereas only 50% of nurses thought it was. The authors suggest that this may be related to the task-oriented role of the PCTs.

The reported barriers are also interesting. The PCTs most commonly cited patient refusal, probably again because of their more direct involvement and there was also a suggestion from the authors that there may be an artefact of the level of authority that these staff members hold. Should the PCTs, who deliver a lot of the ‘hands-on’ care be equipped with negotiation and education skills that would enable them to engage with reluctant patients I wonder? The nurses also agreed with this, but to a lesser extent. Were nurses better equipped to explain the benefits of the intervention?

The question as to what would increase the use of Chlorhexidine baths yielded a view that more education for patients and their families and more assistance from support staff would be beneficial. This question was a pick list of possible measures. I think I might have left this totally blank and allowed a free text answer. Although there was an ‘other’ box at the end, personally if I think I have completed enough possibles I’m unlikely to bother with the ‘other’ box. Leaving it blank may have thrown up some interesting possibilities that those implementing an intervention themselves may find beneficial and that they had not thought of themselves.

I’d really like to see this sort of work taken a stage further with some qualitative interviews of nurses, PCTs and patients to really tease out what the barriers are and how they could be overcome. The patient refusal is an interesting one and merits further study. We can find the most effective treatments, write a policy that says ‘this is what we do’ but if the patient says ‘no thanks’ it doesn’t really matter. We need to understand why patients say no and use techniques to tease out the real reasons. May years ago I sold cars for a living. We were thought to use a simple technique to tease out a real objection to purchase if the person was reluctant that could be dealt with. It’s easy. Ask what the problem is. Listen to the answer carefully and then use “If I could….. would you…” to counteract the issue raised. If the answer is ‘No’ than that wasn’t the real objection. Careful probing nearly always gets you to the root issue. Only then can you attempt deal with it.