Why training may not always be the right course of action – part 5

Why training may not always be the right course of action

In Part 4 we gave a little thought to the matter of memory. Now we’ll ask why health professionals in hospitals still fail to observe simple rules of hygiene to avoid infection and cross-contamination. We’ll look at performance in hospitals in Britain and the USA. We’ll begin with a profile of three behaviour patterns: skill-based behaviour, knowledge-based behaviour and rule-based behaviour.

Behaviour patterns

Skill-based behaviour

Formal published research often refers to particular behaviour patterns. One such is skill-based behaviour. This is inadequate performance due to our brains storing instructions. We don’t stop to consider how to tie a tie or shoelaces, for example; we are pre-programmed to do it. We become so familiar with aspects of our daily work routines that they become second nature. That’s fine as long as nothing changes, but when we become this comfortable with our environment, we open ourselves up to errors from overconfidence— the “I’ve done this a thousand times” mentality.

Knowledge-based behaviour

This is inadequate human performance governed by analytical processes and stored knowledge. It occurs when we face a situation that we have never faced before (or infrequently faced) and no stored rules exist for it that would provide us guidance. In such cases, we must depend on our knowledge and expertise to solve the situation. For example, much of the chaos associated with the first responders’ response to the 9/11 attacks was due to the fact that their disaster preparedness plans did not anticipate that type of attack. Therefore, first responders had to rely on their individual experience and expertise in how to effectively respond.

Rule-based behaviour

This is inadequate human performance governed by stored rules accumulated via experience and training. For example, we are typically governed by policies and procedures within our work environments. Some hospital workers are lax about hand-washing hygiene because they have never personally suffered an infection and so feel the risk is overstated. In other circumstances, for example in the case of CPR, campaigns recognise that some people are reluctant to do it because they don’t believe they can or because they would “feel stupid” doing it in public. Like the Massachusetts cartoons on delaing with strokes, the British Heart Foundation video It’s Not Hard  featuring Vinnie Jones makes use of all the appropriate media – and a good deal of humour.


Matters might have improved a little over the past 5 years but unwashed hands in the UK’s hospitals still contribute to the spread of MRSA. Ensuring health professionals follow simple rules of hygiene like hand washing is key to stopping bacteria spreading. But observed practice shows very poor rates of adherence to guidelines and reveals that staff fail to take account of risk, even with patients with MRSA. The Journal of Hospital Infection reported that 38 per cent of a research sample of health professionals failed to wash their hands after contact with MRSA patients, while 25 per cent failed to wash their hands after contact with faeces and 38 per cent failed to wash their hands after contact with blood. This was despite the knowledge that they were being observed. The Professor of Psychology heading the research said, ‘What is most worrying here is that healthcare professionals say one thing and they do another. There is no link between what they say and what they do. If we adopt a culture where we urge healthcare workers to treat everyone as if they are infected, then they stop risk assessing. They can’t wash their hands all the time, so we need to teach them how to risk assess.” 2006 research from the University of Hertfordshire and the Institute for Employment Studies (IES)

Figures from a spot check in South Wales showed that 42 per cent of doctors and consultants were failing to clean their hands properly according to guidelines. When challenged over whether they had washed their hands, some asked “why?” A director of nursing said: “We have had a lot of discussions at executive board. We instigate disciplinary action if they have been told to wash their hands and they don’t do it again.” The culture of not washing hands was affirmed to be completely unacceptable, and yet it was still, “a custom more honour’d in the breach than the observance” (Shakespeare, Hamlet).

The North Carolina approach

The same problem exists further afield, in North Carolina, where years of awareness programs have had little effect. Part of the problem, according to a study in the journal Psychological Science, are the actual signs posted in hospital washrooms urging health care workers to wash up. Changing the message from “Wash Your Hands to Protect Yourself” to “Wash Your Hands to Protect Your Patients,” the study found, could motivate some doctors and nurses to wash their hands more frequently. The patient-focused sign produced a 33 percent increase in the amount of soap and disinfectant used per dispenser over a two-week period, compared with the other signs. In a second phase of the study, trained observers recorded how often doctors and nurses physically washed or disinfected their hands. The sign urging doctors to think about patients produced a roughly 10 percent spike in hand washing compliance, a jump that was small but statistically significant.

That is the end of Part 5. In Part 6 we’ll consider the need for physical and mental supports, see what the US Coast Guard knows, and draw lessons from Rudyard Kipling.

About Phil Green

Phil Green has written 84 post in this blog.

Phil identifies himself as a perfomance consultant and teacher who helps people and organisations to do the best they can at work. He has strong skills in designing learning materials and workflow support, and draws from a wide spectrum of methods and technology. Co-designer of a certificated qualification in blended learning, he has trained hundreds of others from many industry sectors in how to create effective learning solutions, both online and offline.

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  1. Phil Green says

    Since I wrote this piece, my local NHS hospital, the very excellent Chesterfield Royal Hospital, closed its doors to all visitors to adult in-patient wards. They explained, “”This is to try and resolve the outbreak of norovirus currently affecting eight of our wards – with many patients and staff succumbing to the illness.”
    Source BBC: http://www.bbc.co.uk/news/uk-england-derbyshire-17055414

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