By Lori Moore
Hand hygiene is an evidence-based best practice that spans across all hierarchies and disciplines,1 and every healthcare facility is faced with the challenging task of continually rolling out improvement efforts. Multimodal strategies are recommended to bring about changes in hand hygiene performance, among which is the task of determining healthcare workers’ barriers or reasons for noncompliance.2 Valuable time and resources are invested in identifying specific causes of noncompliance and developing and implementing countermeasures – an iterative process that cycles over and over in many facilities. If countermeasures do not result in improvement, healthcare workers’ cited barriers or reasons for noncompliance often end up in a basket labeled “resistance” with the implication that there is no legitimate reason for the noncompliance or that they are attempting to thwart the implementation of improvement initiatives.
Resistance has been broadly attributed as a constraint to performance improvement in healthcare and is quite often cited as the reason for failed change efforts.3-4 One study involving 700 hospitals across the United States found that resistance to change was a universal problem in healthcare, increased the difficulty of implementing new methods designed to improve performance and was a significant impediment to translating research into practice.4
There are many ways leaders talk about resistance to change such as “push-back,” “not buying in,” “criticism,” etc. In organizational change, the label of resistance is most frequently applied based on the subjective assessment or explanation ascribed to the actions, behaviors, and communications of change recipients that change leaders do not like, do not consider appropriate or are not seen as supportive of the change and which they also feel will increase the amount of work or time it will take to implement a change, thereby putting its very success at risk.5 This point of view, however, is predominantly a one-sided explanation offered by leaders for what they see as the absence of others wholeheartedly embracing a change and for any unsatisfactory progress or results.
The predominant approach to resistance is that it is detrimental and must be overcome, quashed, or eradicated.4,6 However, dismissing all resistance as negative or detrimental may rob leaders of a powerful tool for the implementation of change.7 Additionally, pushing the change through without better understanding the resistance or the lack of improvement may compromise critical relationships and may fritter away the opportunity to engage others in problem solving.7
So what do you do when you run into “resistance” in your attempts to improve hand hygiene? Jeff and Laurie Ford, experts in field of organizational change management, recommend first asking yourself two questions: “Why am I seeing this behavior as resistance?” and “If I viewed the resistance as feedback, what could I learn about how to refine the change effort?”7 Once those questions have been answered, you can then move forward with their five-step approach to effect change more productively.7
1. Explain what is changing: While it might be clear to hand hygiene leaders what “good hand hygiene” looks like, to healthcare workers in the context of their busy work day, this might not be so clear. Let them know exactly what needs to change and when, providing examples and real-world scenarios of your expectations for good hand hygiene.
2. Explain the why behind the change: By the time hand hygiene leaders are ready to roll out a change program, they have had ample opportunity to understand the reason behind the change and the necessary steps for implementation. It’s easy to forget that the reasons behind the change have not been similarly internalized by healthcare workers. They need to understand not only what needs to change but also the “why” behind the change.
3. Look for the pitfalls: Often it’s not the change itself that people are resisting but how it is being implemented. Those closest to the work are best positioned to recognize potential pitfalls. There may be aspects of the change that were not recognized by leaders in the planning stages. Encourage feedback, positive or negative, and be willing to listen to their perspective.
4. Seek their ideas: It’s important to build participation and engagement. Gaining “buy-in” can be as a simple as allowing them to be heard. Ask them for their ideas on how to improve hand hygiene. Remember, the function of a leader is to create an environment that encourages collaboration and generation of ideas and problem solving with those at the sharp end of change.
5. Uncover past failures: Many of the changes that make it through to implementation in healthcare quickly end up in the rear-view mirror evoking a “flavor-of-the-month” attitude toward subsequent changes. As healthcare workers listen to new change proposals, they remember past experiences and their future perspectives around change are shaped in that context. Leaders who bring closure to any past experiences, repair damaged relationships, and restore trust before and during a change initiative are less likely to encounter resistance than leaders who do not.
- Lori Moore, MPH, BSN, RN, CPPS CLINICAL EDUCATOR, HEALTHCARE GOJO Industries, Inc., Akron, OH
- Boyce JM, Pittet D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(RR-16):1-45.
- World Health Organization. WHO Guidelines for hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009.
- Austin T, Chreim S, Grudniewicz A. Examining health care providers’ and middle-level managers’ readiness for change: a qualitative study. BMC Health Serv Res 2020;20:1-14.
- Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. How active resisters and organizational constipators affect health care-acquired infection prevention efforts. Jt Comm J Qual Patient Saf 2009;:239-246.
- Ford JD, Ford LW. Stop blaming resistance to change and start using it. Organ Dyn 2009;39:24-36.
- Dent EB, Goldberg SG. Challenging “resistance to change. J Appl Behav Sci 1999;35:25-41.
- Ford JD, Ford LW. Decoding resistance to change. Harv Bus Rev, Winter 2014, 86-91.