Hand hygiene is a critical infection prevention task, but it is frequently performed inadequately. Hand hygiene training via an annual classroom session is the traditional approach, but multiple studies have shown it is ineffective at changing practice. As Albert Einstein once said, “Insanity is doing the same thing over and over again and expecting different results”. We examined the academic literature on education and training and identified the theories relevant to hand hygiene training. We then applied these theories to designing a hand hygiene training app and how best to use it in practice. The result is more effective training that takes less time for learners.
“Insanity is doing the same thing over and over again and expecting different results”
Education theories for hand hygiene training
In collaboration with Glasgow Caledonian University (GCU), we examined the underlying theories of learning. We found that there are two types of learning: declarative and procedural. Declarative learning is concerned with facts, information and concepts. Procedural learning is concerned with physical skills and habits. The teacher imparts facts and figures in declarative education, and the student absorbs these. However, in procedural education, students learn by doing and need repeated short burst training over several weeks to retain the learning. Hand hygiene is a physical skill and thus requires a procedural learning approach.
Traditional annual classroom-based hand hygiene training mainly uses “declarative” techniques to impart facts and knowledge. But, it lacks the “procedural” methods of repeated training needed to build and maintain physical skills. Multiple studies have shown that traditional approaches to hand hygiene training result in poor retention by learners. This therefore leads to poorer outcomes for the transmission of infections. It’s important to note that student motivation has little impact on their inability to retain hand hygiene skills. The fundamental issue is the mismatch between the training objective and the mode of delivery.
How to teach the skill of hand hygiene
So how should we train a procedural skill like hand hygiene? Famous educationalists such as Eriksson, Driscoll and Bloom have considered these issues and identified some efficient approaches such as:
- “Deliberate practice”, i.e. repeated practice with feedback
- “Overlearning”, i.e. training beyond proficiency to improve retention
- “Mastery learning”, i.e. matching the speed of instruction to each learner’s progress
These techniques are also used to train musicians, artists and surgeons. However, we might be mistaken for believing that this approach is not “practical” for hand hygiene training.
We examined the educational theories of Eriksson, Driscoll, Bloom and others to identify the critical components of a hand hygiene training program. We used these findings to design a hand hygiene training app and associated educational program and evaluated the approach with students in GCU. The training program delivered better learning outcomes in less learner time by using an innovative mobile app to support the learners “deliberate practice”. It also used “mastery learning” to match the pace of training to each individual’s progress. The key to success was weekly testing sessions over four weeks to validate that the learners acquired the skills. We published our findings in the Journal of Education and Information Technologies.
During the evaluation, 47 participants used SureWash’s Hand Hygiene APP to practice the WHO 6-step technique. The app was used over four weeks, and training required approximately 1 minute at any time of the day. At the end of each week, the SureWash ELITE training kiosk was used to assess the participant’s proficiency along with visual observation. Participants passed the assessment by correctly performing all six steps of the WHO hand rubbing technique in the correct order in 20–30 seconds. The anonymised training data was then stored on a cloud learning management system and was provided to the GCU research team at the end of the 4-weeks.
Of 47 participants, 38 (81%) took approximately 24 training sessions over four weeks to achieve proficiency. This result shows that repeated training with feedback is necessary to build the skill of hand hygiene. These findings also support our previous study with Yale University where students achieved proficiency after approximately 32 hand hygiene training sessions over one week.
Assessment is the key to engagement
It is difficult to generate enthusiasm for hand hygiene classes with PowerPoint presentations, videos, and demonstrations. This method can result in healthcare workers disengaging from training. The analysis of the app usage during the study shows that daily practice was low due to the voluntary nature of the training. However, usage increased immediately before an assessment. As any teacher knows, testing is crucial for promoting student engagement. Therefore, the use of formative assessment helps motivate students and build their skill levels.
The study found that self-directed learning combined with regular assessments motivated learners to develop hand hygiene proficiency. Also, replacing the 1-hour classroom session with use of the app plus testing reduced the learners’ time spent on hand hygiene training by 50%. Consequently, this new approach to hand hygiene training can empower learners to independently develop their hand hygiene skills, at times convenient to them.
What did we learn?
This study clarifies that as hand hygiene is a psychomotor skill, it should be taught using procedural learning methods. To develop hand hygiene proficiency in students, they need repeated training sessions with real-time feedback, combined with regular assessments. We can also see that a hand hygiene training app that measures skills allows healthcare workers, patients, and visitors to learn effective hand hygiene independently.
The paper is available to read in full in the ‘Education and Information Technologies’ here:
The SureWash Hand Hygiene app is also available for download to all: