System To Encourage Better Hygiene Behaviour

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Systems to encourage better hygiene behaviour - A user-centred OPI project © 2012 By CONCEPTMAKING

1. PREFACE // 9 2. THE BACKGROUND FOR THE PROJECT // 15 2.1 Background // 16 2.2 About Conceptmaking // 16 2.3 Challenges // 18 2.4 OPI cooperation // 20 3. THE HYGIENE BEHAVIOUR SUPPORT SYSTEM // 23 3.1 The general principles of the system // 24 4. PROCESS, APPROACH AND METHOD // 27 4.1 Pilot project // 29 4.2 Test og research locations // 30 4.3 The user-centred innovation process // 30 4.4 Anthropological studies // 30 4.5 Technical measurements of hygiene behaviour // 32

6. USER INVOLVEMENT // 53 6.1 Workshop I // 54 6.2 Workshop II // 61 6.3 Challenges // 62 6.4 Findings among the groups’ concepts // 64 7. FROM CONCEPT TO PROTOTYPE // 67 7.1 Mock-up // 68 7.2 Prototype // 72 7.3 Continual user involvement // 72 7.4 Ethical considerations // 74 8. PROJECT RESULTS // 77 8.1 Impact measurement - quantitative // 78 8.2 Impact measurement - qualitative // 80 8.3 Occasions to talk about hygiene // 83 9. THE WIDER PERSPECTIVE // 85

5. ANTHROPOLOGICAL FINDINGS // 35 5.1 Barriers to good hand hygiene // 36 5.2 Low levels of physical and psychological energy // 38 5.3 Hands and environment // 38 5.4 Furnishings, design and accessibility // 40 5.5 The role of the patient // 44 5.6 The hygiene taboo // 47 5.7 Communication // 50


As a result of poor hygiene, close to ten per cent of all Danish patients get hospital-acquired infections, over 3,000 Danes lose their lives each year, and over a million sick days are necessary. The total cost to society is almost four billion kroner per year.� - The Danish Council for Better Hygiene



// 1.0 PREFACE

// THE GENTLE LITTLE NUDGE The realisation that far too many people skip good hand hygiene after toilet visits gave us the courage to forge a new path. The hygiene behaviour support system was created through a combination of gentle nudging and hardcore behaviour modification. A door that opens with a light movement of the hand opens and shuts automatically. A toilet that flushes itself after use. Lights that blink and draw the patient to the hand basin, where lights also encourage the use of soap, water and paper, followed by the grand finale, where using the hand disinfectant opens the door, and the patient leaves the toilet with perfectly clean hands. Nudging is a gentle little push in the right direction. A method that can help encourage the behaviour we would like to see more of. Nudging is about affecting people’s actions and behaviour without using traditional methods such as rules, penalties and prohibition.

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The nudging principle is not about reducing people’s options, but rather influencing them to make the choice we would like them to make. The new hygiene behaviour support system, where light attracts patients and draws their attention to certain elements in the toilet facility, is an example of how users are still free to choose their hygiene behaviour while at the same time they are being nudged to choose good hand hygiene by the lighting. However, the system does more than just nudge. The new door/disinfectant combination, whereby the user must use disinfectant to open the door, represents a direct regulation of user behaviour. This is a radical total system motivated by the courage and will to better hand hygiene. The system includes a red emergency button that allows users to override the door/disinfectant combination, for example if a patient is allergic to disinfectant or other reasons.

“Systems to encourage better hygiene behaviour” is an OPI project (Private-Public Innovation) funded by Central Jutland Region’s Growth Forum. The goal of the project is to create innovative hygiene behaviour support solutions that can help reduce the massive cost to society connected with the high frequency of hospital-acquired infections (approx. 1 in 10 patients). With a focus on patients’ hand hygiene in connection with toilet visits, the project is centred on concrete user needs, user-centred development and the identification of the barriers to good hand hygiene. Our vision with this project has been to develop solutions that contribute to reducing the number of hospital-acquired infections - and thereby also reducing the human and economic costs connected with them. Thanks to our many findings, the scope of the project has grown to include a desire to draw attention to the taboos associated with talking about hygiene.

This report presents the preliminary results of the research phase, the project’s creative processes in the context of developing, testing and evaluating concepts, mock-ups and prototypes, as well as the final project results. Our hope is that other sectors and industries will be inspired by the project to work with their own hygiene challenges and to improve hygiene behaviour. Our intention is to make it possible to integrate a hygiene behaviour support perspective into existing buildings as well as the planning of future schools, day care facilities, hospitals and private businesses.

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WHO estimates that in Europe alone, hospital-acquired infections are responsible for 16 million extra days of hospital stays, 37,000 deaths and a cost of about 7 billion Euro.�

- The Danish Council for Better Hygiene




2.1 // BACKGROUND In order to reduce the many human costs associated with poor hygiene, it is crucial that efforts be made to reduce the spread of infection. Many agents are represented at a hospital - patients, personnel and relatives. The interactions among these agents are complex, as there are many different procedures connected to the treatment and care of patients. This complexity means many sources and paths of infection. In addition, resistant micro-organisms that cause infections we cannot treat are becoming more and more common. Many of these micro-organisms are resistant to hand disinfectants, which means that both hand washing and hand disinfection are necessary. Even though the hygiene challenge has many aspects, it is widely recognised that good hand hygiene is the best documented method to prevent the spread of infections between personnel and patient, patient and personnel.1

It is estimated that approx. 25-50 per cent of the many hospital-acquired infections can be prevented.2 The background for the project is thus the enormous potential that lies in improving the hand hygiene of Danish patients. This has demanded that we gain knowledge and understanding of why patients behave as they do - in other words, of what values, norms and practices are connected with hand hygiene, as well as what the barriers to good hand hygiene are. 2.2 // ABOUT CONCEPTMAKING CONCEPTMAKING TM is an interdisciplinary design and consultancy firm specialising in radical innovation and concept development (new services, products, organisations, etc.), as well as organisational development. We work with user involvement in a consistent and focussed manner, including designing user involvement strategies, as well as designing, planning and facilitating user-centred development processes/projects.

Today, knowledge of the importance of good hand hygiene has reached many people, but the challenge still lies in translating this knowledge into changed behaviour.”

- The Danish Council for Better Hygiene

1: Statens Serum Institut (SSI) 2: Hans Jørgen Kolmos, Professor, Chief Consultant, MD Odense University Hospital, 2008

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2.3 // CHALLENGES Campaigns seldom have long-term effects. Studies show that the effects of campaigns often cease when the campaigns themselves end. Thus, there is a need for more consistent efforts that ensure that hand hygiene is practised when it is necessary. Efforts to improve hand hygiene at hospitals have primarily been aimed at the hand hygiene of personnel, and studies show that doctors and nurses only perform correct hand hygiene in half of the situations where it is recommended.3 There has been only limited focus on patient hand hygiene. At many hospitals, the personnel distribute a folder to patients about the importance of good hand hygiene in connections with toilet visits and meals.

But patients often don’t read the folder, ostensibly because they are unwell and have many other things on their minds. There is widespread agreement that patient hand hygiene is important, but methods and approaches to translate this knowledge into practice have not yet been developed. This lack of knowledge is the central focus of the OPI (Public-Private Innovation) project: “Hygiene behaviour support systems“. The projects ambition has thus been to develop a system that not only communicates more of the existing knowledge about hand hygiene, but that actively supports users in good hand hygiene in connection with toilet visits.

There is really no documentation for the correlation between improvements in hand hygiene among patients and the frequency of infection. However, it is important to emphasise here that the absence of documentation is simply an expression of the fact that the area is underresearched, not the absence of any such correlation. When we look at results from outside the healthcare sector, we find research from daycare facilities that shows a connection between improved hand hygiene and lower rates of absenteeism among children.” - Kjeld Møller Pedersen, Professor of Health Economics, the University of Southern Denmark

3: Statens Serum Institut (SSI)

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2.4 // OPI COOPERATION In the fall of 2009, Randers Regional Hospital (RRH) and Conceptmaking began a dialogue to explore the possibility of a public/private innovation partnership (OPI) to improve hygiene in hospital toilets.

These partnerships are a dynamic process where the end results cannot be predicted. Therefore, they cannot be described and commissioned within the framework of traditional public tenders.

OPI projects are a new form of collaboration where private and public partners collaborate on interdisciplinary innovation processes in order to develop innovative products that can create better service for the public sector and better products for the private sector.

In May 2010, RRH and Conceptmaking initiated their collaboration on the research and innovation project “Hygiene behaviour support systems”. The project was concluded in autumn 2012.

Naturally, it’s important for hospital personnel to practice good hand hygiene. But patients touch many of the same things, and can therefore easily infect one another. This area has been overshadowed by the message that personnel must wash their hands, but I definitely think it’s time to involve patients as well. The project is very interesting on those grounds alone.”

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- Hans Jørgen Kolmos, Professor, Chief Consultant, MD Odense University Hospital

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3.1 THE GENERAL PRINCIPLES OF THE SYSTEM The Hygiene Behaviour Support System has been designed and developed in order to guide users to correct hand hygiene in connection with toilet visits and thereby reduce the risk of the spread of infection. The general principle behind the system is that no handles, fixtures or components are to be touched by humans. Everything is operated touch-free, and to open the door, the hand disinfectant dispenser must be activated. In other words, hands are clean and disinfected when the patient leaves the toilet. Users are guided through the steps of correct hand hygiene by following a light sequence on the soap dispenser, the faucet, the paper towel dispenser and the disinfectant dispenser (opens the door). The individual dispensers can be used independently regardless of whether the lighting sequence is followed. The system includes an emergency button that ensures that patients can always exit the room if this is activated.

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Personnel are always able to access the toilet by means of a special external personnel button. In addition to the direct interaction with users of the hospital toilet, the system gives personnel (technical and service personnel as well as care personnel) the possibility of monitoring soap, paper, disinfectant and battery levels, which allows them to ensure that the toilet is functional at all times.



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PHASE 1: MAY-OCT // 2010

PHASE 2: NOV-APR // 2011

PHASE 3: MAY // 2011




1. Monitoring group 2. Project group 3. Information meeting 4. Casting

1. Desktop 2. Analogue - input 3. Pre-tests 4. Interview 5. Focus groups 6. Processing

1. Pattern recognition 2. Focus areas

PHASE 4: JUN-OCT // 2011

PHASE 5: NOV-OCT // 2012

PHASE 6: NOV // 2012




1. Workshop I 2. Idea generation 3. Fast prototyping 4. Workshop II 5. Summary 6. Processing 7. Involvement of private suppliers

1. Involvement of private suppliers 2. Mock-up and prototype 3. Implementation 4. Tests and adjustments 5. User involvement

1. Post-tests 2. Reporting 3. Final meetings 4. Knowledge-sharing 5. Film 6. Theme day

To define the focus of the project as sharply as possible, it has been crucial to investigate the hygiene challenge as it is experienced by users, in other words patients and personnel. This has given the project a solid foundation on which to create a good solution.”

- Marlene Møller, Anthropologist, Conceptmaking

4.1 // PILOTPROJECT Before the project was launched, a pilot study was performed at the gastro-intestinal unit at Randers Regional Hospital. The goal of the pilot study was to map concrete needs as experienced by personnel and patients in connection with hygiene. It became clear quite quickly that the hygiene challenge is complex, and that it therefore requires a holistic approach and new ways of thinking about hygiene. The gastro-intestinal patients in the unit had all recently been operated. Many experienced a great deal of worry and frustration about their diagnoses in addition to postoperative pain.

For many of these patients, hygiene becomes a secondary concern and can seem irrelevant. However, these patients are at high risk of infection, for example in connection with surgical incisions, which means that good hand hygiene is extremely relevant for them. It may therefore seem paradoxically that many such patients fail to translate their knowledge of the importance of hand hygiene to practice.

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4.2 // TEST AND RESEARCH LOCATIONS The gastro-intestinal and liver unit at RRH was the primary test location for the project. Staff members also participated in project and working groups as well as in creative concept development processes. In addition, the orthopaedic surgery unit at RRH and two divisions of the haematology unit at Aarhus University Hospital (AUH) participated as research locations. Staff members from these units also participated in project and monitoring groups as well as workshops. 4.3 // THE USER-CENTRED INNOVATION PROCESS The hygiene project has thus developed on the background of concrete user needs which have been expressed and investigated at the two participating hospitals. From the beginning of the project, our ambition has been to approach the processing with user-centred methods, drawing on anthropological research, user

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workshops and concept development processes that involve users. The decision to base development on anthropological studies was made to ensure that the hygiene solutions developed, address real needs and concerns formulated by the agents facing the challenges: patients and personnel. 4.4 // ANTHROPOLOGICAL STUDIES The values and perspectives that underlies the users’ hygiene behaviour were investigated through interviews, focus groups and participant observations. Articulating these perspectives was crucial. It is necessary to understand users’ motivations for behaving as they do, in order to tailor interventions to individual users and thereby change their behaviour.

To reach this sustainable solution, we have involved healthcare personnel and patients in the innovation process. It is important to understand what motivates patients’ hygiene behaviour so that the solution developed is not just technology for technology’s sake. The solution must fulfil the practical needs of users and at the same time take into account the social and cultural factors that lie behind a given behaviour, for example hand hygiene.”

- Jarl Christensen, CEO and Partner, Conceptmaking

4.5 // TECHNICAL MEASUREMENTS OF HYGIENE BEHAVIOUR A prototype of a data collection system to collect data on users’ hygiene behaviour after toilet visits was developed by Conceptmaking while the anthropological studies were being carried out. The behaviour of patients in the toilet facility was monitored using sensors in the ceiling as well as measurements of dispensers, water consumption, etc.

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The results of these measurements corroborated the results of the anthropological surveys: that many patients perform poor or no hand hygiene after toilet visits. Sensor measurements also showed that optimal hand hygiene was only performed in three per cent of visits (water, soap, paper and disinfectant). Over half of the patients performed no hand hygiene at all.




5.1 // BARRIERS TO GOOD HAND HYGIENE In the experience of the healthcare personnel we interviewed, patients generally neglect hand hygiene, both men and women. This negligence is experienced both in the case of patients who receive assistance during toilet visits and patients who visit the toilet alone. In addition, personnel named lack of knowledge of the possibility of getting help with hand hygiene as well as a wish not to inconvenience personnel as possible contributing factors.

People must not have a chance to be lazy, to be sloppy.”

Through focus groups with personnel and conversations with patients, we attempted to get behind the measurements of patients’ hygiene behaviour. A wide range of factors contributes to patients’ poor hand hygiene which are linked to the following areas:

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- Cancer patient, Aarhus University Hospital

• • • • • •

Low levels of physical and psychological energy Hands and environment Furnishings, design and accessibility The role of the patient The hygiene taboo Communication

When you have a 40-degree fever, washing your hands isn’t what you’re thinking about.”

5.2 // LOW LEVELS OF PHYSICAL AND PSYCHOLOGICAL ENERGY The importance of good hygiene behaviour can seem irrelevant for people who are very ill. Despite the fact that the very ill are particularly vulnerable to infections because of weakened immune systems, for people in this type of crisis situation, there are more important questions and frustrations to be dealt with. As both personnel and patients explain, when you are ill and in pain, your energy levels are low, and you just don’t bother washing your hands.

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- Cancer patient, Aarhus University Hospital

5.3 // HANDS AND ENVIRONMENT Conditions for performing good hand hygiene in hospital toilets are not always optimal, as patients must often touch many different surfaces (the flush mechanism, the wash basin fixtures, soap and disinfectant dispensers, doorknobs, etc.) Studies have shown that these points of contact are potential sources of infection. Touching them should therefore be avoided. For a variety reasons to do with their conditions, some patients have accidents when visiting the toilet, which contributes to further pollution of the space. Patients aren’t always capable of “cleaning up” after themselves, and as a consequence, they end up exposing other patients to the risk of infection unintentionally. When the environment presents a risk of infection, good hand hygiene is particularly important.

I understand why some of them give up in advance.”

- Nurse, RRH


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To a high degree, behaviour is affected by the surroundings it takes place in. The furnishings of the toilet facility can make the path from toilet to hand basin difficult, if equipment and aids are in the way. Several staff members referred to patients’ movements around the toilet facility as an “obstacle race”.

In addition, our studies showed that soap and disinfectant dispensers often don’t resemble objects intended for patients, because the healthcare-related packaging signals that the products are for professional use. For this reason, we must assume that some patients don’t “dare” to use them.

If you are feeling ill to begin with, it seems likely that your motivation to “fight” your way to the hand basin will fall even further, when the path is not clear. Likewise, the placement of soap and disinfectant dispensers is crucial. If the dispensers are placed too high up, too far from the hand basin, or if the hand basin is too deep, it can be difficult to reach them, especially for the many patients who have difficulty walking, experience dizziness, use a walker or are confined to a wheelchair. It mustn’t be “easy” to “cheat” on hand hygiene - that’s why accessibility is important.

It was clear, therefore, that the project must include motivational design. In a patient focus group, the idea emerged that the symbols for soap and disinfectant should be accompanied by writing describing the contents of the dispenser. The symbols for touch-free areas should also include clear pictograms describing how to dispense soap and disinfectant. Patients in the focus group also agreed that colour contrast should be employed in order to increase legibility.

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When we carry our research in the healthcare sector, we often encounter products and solutions that patients and personnel do not use as intended or to the degree intended. Normally, we discover that this is because motivational design principles have not been applied, and it appears as if the designers have neglected to involve users in the product development process.� - Jarl Christensen, CEO and Partner, Conceptmaking

5.5 // THE ROLE OF THE PATIENT There is a specific “patient role” that many people assume when they are admitted to hospital. This role colours the way many patients experience their own role, responsibility and integrity. They become more passive, and taking responsibility for their own and others’ safety and health becomes less relevant, which may help to explain why their hygiene behaviour is inadequate.

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Patients leave their identities at the door when they are admitted: they no longer take responsibility for themselves. They become indifferent to their own integrity and other people’s sense of modesty; their inhibitions fall away. They become identical. They bring their (bad) habits with them from home... In other words, they don’t show extra consideration of hygiene when they are hospitalzed. They pee with the door open - “It doesn’t bother me”....and many of them don’t wash their hands. You can tell because the wash basin is dry.” - Nurse, Aarhus University Hospital // 45

This also applies to people you see around town dressed to the nines. They take off their jewels when they’re admitted.” - Nurse, Aarhus University Hospital 5.6 // THE HYGIENE TABOO

Many healthcare personnel say that they are partially responsible for patients taking on this role, as personnel participate in stripping them of their identities and hospitalising them. This takes place when they are admitted, dressed in identical clothes, and nursed. They become patients - bodies to be treated and healed - rather than independent, responsible individuals. Their health is in others’ hands. By the same token, behaviours that normally belong to the private sphere (personal hygiene, sleep, meals, etc.) are moved into the public sphere at a hospital. “Something happens when people are admitted to hospital,” said a nurse. “Patients become indifferent about their own dignity and others’ modesty.”

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The patient role contributes to depriving patients of a sense of responsibility, which may have an indirect effect on the ability and will to perform hand hygiene after toilet visits, as well as the perception of the necessity of doing so. Patients who were surveyed all perceive the hospital as a clean place, and thus do not connect the hospital with the risk of becoming ill, which may constitute a risk factor in itself, as it may mean that patients are less careful of themselves and others.

“Even though you may feel like you’re being labelled a pig, so be it - you have to wash and disinfect your hands,” said a nurse’s assistant in a focus group. Most healthcare personnel share her opinion in principal. However, in practice it is much more difficult to motivate patients to good hand hygiene, and much more difficult to insist when patients try to avoid hand hygiene. The intimate nature of the toilet visit makes it difficult to “help” patients demonstrate good hand hygiene. For many healthcare personnel, it feels uncomfortable to remind a patient to remember to wash his hands.

“....The problem is how to phrase it, especially if they reply ‘I don’t need to do that right now’. Then just what are you going to say?” - Nurse, RRH

Hygiene, particularly personal hygiene, is associated with certain taboos linked to moral norms and values about the clean and the unclean. Taboos regarding cleanliness are ingrained norms for good and bad behaviour that we don’t think of consciously or particularly concretely in our daily lives, but that we attempt to live up to. When a nurse says “You can cover it up in terms of ‘we’re at a hospital, you’re sick, it’s important’...cover it up in terms of professionalism, so you don’t feel like you’re stepping on anyone’s toes,” this expresses precisely how difficult it can be for individuals to criticise another person’s unhygienic behaviour. It becomes easier if the criticism is covered up as an impersonal, professional communication about hygiene on behalf of a hospital you share with others.

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This dimension of transgressing a taboo is also true for patients. Two patients explained that they would find it embarrassing and unpleasant to be confronted by healthcare personnel about poor hand hygiene. The problematic issue of the hygiene taboo is exemplified in the following quotes from interviews:

I feel that I’m going too far in some way when I have to tell them (patients) that they have to wash their hands.”

It’s hard to correct a patient when it (the unhygienic behaviour) is unintentional and caused by illness, whereas it’s easier if a patient consciously chooses not to.”

You have to be careful not to make the patient feel exposed.”

You’re intervening in the behaviour of adults as if they were children you’re raising.”

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As an extra bonus, the innovative toilet gives us a good occasion to talk about hygiene with the patients, because of course we have to introduce them to the advanced toilet. Otherwise talking about personal hygiene can be very embarrassing, because it’s a very private thing.”

- Henriette Lund Larsen, Staff Nurse, RRH

Our research thus reveals that hygiene is a taboo area, and that this leads to insufficient communication about and guidance of patients in relation to hand hygiene, which must be considered a considerable barrier to raising the general standard of hygiene. The hygiene system dissolves some of the barriers associated with the hand hygiene taboo in addition to quantitatively increasing the amount of hand washing and disinfection performed. The system functions as a tool to facilitate dialogue between patients and healthcare personnel: it depersonalises the situation.

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5.7 // COMMUNICATION Despite standard guidelines on hand hygiene for personnel, as well as information for patients in the form of written material handed out on admission, communication about hand hygiene is constantly being negotiated, and is affected by the specific context to a high degree. ” Some people can handle a certain tone, others need to have the message delivered less directly. Assess the situation. It’s about getting the message across, giving instructions in a good way.” - Nurses’ aid, AUH There is also variation from unit to unit with regard to how focussed personnel are on the importance of hand hygiene. Even though it is the responsibility of personnel to talk to patients about hygiene, this is not a guarantee that this actually happens:

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” You’ve probably been told to do that, but who does... after all, you don’ t have to do it just because you’ve been told to....” - Healthcare personnel, RRH This pragmatic approach is evident when healthcare personnel point out that explaining hygiene guidelines to certain groups of patients has no effect, as these patients are neither physically or mentally able to process this kind of information. There are several reasons for this. For example, some patients on medical wards are comatose when admitted to hospital, just as others are substance abusers who consume hand disinfectant to take the edge off their withdrawal symptoms. In other cases, personnel experience that patients simply don’t follow these kinds of guidelines.

As personnel, we are very focussed on our own hand hygiene, and we give our patients general information on the importance of hygiene. But with the new toilet system, we are able to support patients in good hygiene after toilet visits much more effectively, a situation we know presents a major risk of infection from patient to patient.” - Henriette Lund Larsen, Staff Nurse, RRH

The healthcare personnel we interviewed all say that patients are bombarded with information when they are admitted, and that they don’t read the material. In some case, the material is read by relatives, however. Conversations with patients have made it clear that being admitted to hospital can be overwhelming, which means that information about hygiene easily recede into the background. For this reason, it is crucial that written materials and oral communication are given to patients in contexts they experience as relevant, not as “optional” written material to be hidden in the bedside table, but in the form of recurring dialogue.

There is a need for new ways of communicating hand hygiene: patients don’t read the materials they are given on admission, verbal communication between personnel and patients can be experienced as embarrassing and inappropriate, and is furthermore dependent on the individual staff member’s assessment of the situation and willingness to confront the patient.

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6.1 // WORKSHOP I On the background of the results of the project’s research phase, Workshop I was held in June 2011. Healthcare personnel and service assistants from AUH and RRH participated, along with service managers from RRH and Conceptmaking’s consultants. The goal of the workshop was both to share the results of the research phase with participants and to draw on their professional knowledge and experience, in order to illuminate concrete issues related to hygiene. The participants’ contribution would become part of the process of creating concepts for new hygiene behaviour systems.

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On the conviction that reducing hospital-acquired infections requires a new approach, both in relation to users’ hygiene behaviour and their physical surroundings, participants with different backgrounds and functions worked together in a creative and forward-looking way. There were two focus areas for this work: 1) The hygiene behaviour of hospital toilet facility users and their knowledge about hygiene 2) The hygiene behaviour support toilet facility of the future

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FOCUS AREA I: Using a two-by-two coordinate system, the groups mapped users’ knowledge and behaviour in relation to hygiene. On the knowledge axis of the coordinate system, the groups mapped the different users according to how much or how little knowledge about hygiene they have. On the behaviour axis, users were ranked according to how good or poor their hygiene behaviour is.

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This overview formed the basis for a discussion of the challenges associated with influencing and changing the knowledge and behaviour of individual user groups. The goal of the exercise was to gain insight into what user groups the system should target.

FOCUS AREA II: The groups used Lego bricks to visualise the hygiene behaviour support toilet facility of the future. Participants used the Lego bricks to describe and model the toilet components, technologies and systems that should be incorporated into the system. At the end of the exercise, the groups described how collaboration among different groups of hospital staff should be organised to support the effects of the hygiene behaviour support toilet facility.

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6.2 // WORKSHOP II Workshop II was held in September 2011. Participants included healthcare professionals, private sector suppliers and consultants from Conceptmaking. The goal of the workshop was to crate creative, concrete ideas for hygiene behaviour support concepts. A precondition for all creative processes at the workshop was that all components in the system must be touch-free sensor solutions, on account of the high risk of infection associated with toilet facilities. This requirement was intended to minimise the number of critical points of contact/sources of infection in the toilet facility, as well as to enable the components to be integrated into a total system.

The stations challenged participants to develop and test their ideas on three different scales:

Participants were assigned to groups, all of which performed three exercises (Stations). Each station was designed to get participants to engage the central challenge: How do we make sure that patients come out with clean hands after a toilet visit?

- A Lego model that did not limit participants to actual measurements, standards or budgetary constraints. The goal of these stations was to illustrate the groups’ ideas, professional reflections and discussions and to develop alternatives to existing hospital toilet facilities.

- A 1:10 model of the test toilet facility in Randers. Participants had an opportunity to develop, challenge, test and adapt their ideas using a miniature kit that included fixtures and components included in the toilet facility (toilet, hand basin, soap and disinfectant dispensers, etc.) - A 1:1 model of the test toilet in Randers allowed participants to work in a context that corresponded to reality.

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6.3 // CHALLENGES The groups were introduced to three different challenges in their work that they were to engage during the creative process. A challenge in this sense can be understood as a tool that can be drawn on in the creative process, thus challenging participants to look for solutions and ideas in directions they would not have explored otherwise.



A persona is a fictive description of a user based on anthropological studies of real users and their needs. The function of these personas is to challenge participants to engage with a broad sample of users and specific needs, resources and limitations to ensure that the concept is appropriate to the real needs of users. The groups were given five personas to incorporate in the development of their concepts.

A presentation on ethics gave participants the challenge of incorporating ethical considerations into their preliminary prototypes. Three questions were posed:

CHALLENGE II: BEHAVIOUR AND DESIGN Two shorter presentations on behaviour and design theory were made to the groups. The groups were also given postcards with central concepts (social collaboration, community, participation, feelings, meaning etc.). The groups were challenged to include these in the development of their concepts/ solutions.

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- Discuss what you think about the idea of collecting information about the behaviour of toilet users and influencing them to act in a way that promotes health in a space that is considered private? - Discuss whether and in what situations it’s OK to intervene in a way that limits the individual’s autonomy in order to ensure the safety of the group? - Evaluate your own concept from an ethical perspective, including whether the concept might place users in inappropriate situations. Adapt your concept if you find that there are ethical problems with it.

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6.4 // FINDINGS AMONG THE GROUPS’ CONCEPTS The concepts developed by the three working groups had clear points of resemblance as well as complementary ideas. For example, all three groups proposed a simple introduction for users to guide them though the different elements in good hand hygiene (soap, water, paper, disinfectant). All three groups also worked with lighting as an important way of attracting and focussing attention. Feed back on users’ (good/poor) performance was also a central element in all three concepts. All three proposed placing a monitor across from the toilet to provide information as well as guide users through good hand hygiene, as well as providing feedback - for example, in the form of happy/sad smileys. All three groups also agreed that sound should not be incorporated into the design.

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On the background of the idea generation processes and the development of concept prototypes in Workshop II, Conceptmaking continued to work on system development. In collaboration with other project participants, a concept was selected - in other words, through the synthesis and further development of different elements generated in the workshop.




7.1 // MOCK-UP From April to July 2012, a mock-up of the toilet facility was constructed at Conceptmaking’s Conceptlab facility. The mock-up was furnished in accordance with the guidelines and proposals that had been developed in the two workshops. In close collaboration with the suppliers KONE, ORAS and Berendsen, the facility was furnished with a new type of magnetic sliding door, a new water fixture and new models of soap, disinfectant and paper dispensers, as well as a toilet with an automatic flush function. All of these features were controlled by a new hygiene behaviour support system designed by Conceptmaking.

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A digital application was developed which allows information to be displayed on monitors, along with statistics on the hygiene status of the use of the toilet facility. The digital application has a variety of functions and potentials. For healthcare personnel, it can function as a tool to present key data, which allows them to intervene if the hand hygiene levels are too poor, thus ensuring a higher level of patient safety.

For patients and relatives, the digital application might function as a source of feedback that involves them and informs them on the hand hygiene status of the unit. This could contribute to highlighting the importance of good hand hygiene, which could in turn have a motivating effect.


Studies show that doctors and nurses become more aware of the problem of hospital-acquired infections when they are given this type of feedback, and that this leads them to change their behaviour. This goes to show that when people are given feedback on their behaviour, and especially its consequences, there are obvious benefits, as they change their behaviour.â€? - Kjeld Møller Pedersen, Professor of Health Economics, the University of Southern Denmark

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A prototype was installed in unit CD9, room 6, at Randers Regional Hospital in August after making some adjustments and adaptation at Conceptlab. After installation, key personnel at CD9 were trained and provided with a user’s guide to en able them to train colleagues and patients in using the new prototype.

A patient focus group interview was held in connection with the development of the hygiene behaviour support system. The aim of the interview was to involve patients in the design of soap and disinfectant dispenser in accordance with the principle of motivational design.

The decision was made not to use the digital application in the test period, as only the four patients in room 6 would be involved in the study. It would not have been ethically defensible to display statistics on such a small sample, as we would have been unable to guarantee patient anonymity. The prototype was tested from mid-August until late November 2012.

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During the hygiene support system test period, there was a running dialogue between personnel at CD9 and Conceptmaking on adaptations to the system. Interviews with patients and personnel were also performed in order to gather feedback on the experienced use and effect of the system. This qualitative knowledge is the foundation for the quantitative system measurements and effects produced by the system’s software.

7.4 // ETHICAL CONSIDERATIONS Ethics were at the top of the agenda throughout the project. Toilet visits are personal and intimate. Therefore, we strove to ensure users’ full anonymity in connection with both data collection (sensor monitoring of actual behaviour) and anthropological research. Introducing radical changes like the new hygiene behaviour support system in a public setting such as a hospital where users (patients) are vulnerable, and where many are elderly, confused and in pain, means that ethical considerations must be of paramount concern. There was particular focus on the new door/ disinfectant solution, which had the potential to provoke confusion and panic in some patients.

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Therefore, the project decided that the installation of the system should be accompanied both by a thorough introduction for personnel and - even more importantly- by a thorough introduction of the system for each patient performed by personnel on admittance to hospital. In this way, every effort was made to ensure that patients felt comfortable using the new system.



// 8.0 PROJECT RESULTS 100 % 90 80

8.1 // IMPACT MEASUREMENT - QUANTITATIVE Thanks to the technical measurements of users’ actual hygiene behaviour that were performed early in the project (pre-tests), it was possible to measure the effect of the prototype on the hygiene behaviour support system. The pre-test of patient hand hygiene showed that less than half of patients washed their hands with soap after toilet visits. Fifty-five per cent of users walked out of the door after using the toilet without performing any hand hygiene at all. Twenty-five per cent washed their hands with water only after toilet visits. Only ten per cent of patients used hand disinfectant. Optimal hand hygiene, where the toilet visit is followed by the use of water, soap, paper4 and disinfectant, occurred in just three per cent of cases.

The results of the after-tests on the hygiene behaviour support system show a marked improvement in hand hygiene: optimal hand hygiene was practised in over sixty per cent of toilet visits, and ninety-five per cent of toilet visits were followed by the use of hand disinfectant.5


A statistical analysis of the results was performed after the first four weeks of the test period. The objective of the analysis was to draw and comment on the conclusions indicated by the data from the project. The statistical analysis was intended to verify and quantify the effects of the behaviour-supportive solutions that were tested in the project.


” The conclusion of the analysis is thus clear with regard to measurable behaviours: the results are convincing.”


- A statistical analysis and evaluation of the project Hygiene Behaviour Support Systems and Interventions, 2012, p. 10

60 50

30 20 10





Excellent practice**

Traditional patient toilet After installation of the hygiene behaviour support system

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4: The use of paper was not monitored in the pre-tests. Paper is integrated into the hygiene support system, as the aim is to prevent patients from drying their hands on their clothes, which are often dirty, and from applying disinfectant to wet hands, as this reduces the effectiveness of the disinfectant. 5: In the hygiene behaviour support system, it is not possible to exit the toilet facility without using hand disinfectant unless the patient activates the emergency exit, or unless the door is opened from the outside by activation of the personnel access button.

*Paper consumption before installation unknown ** Excellent practice: water, soap, paper and disinfectant

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8.2 // IMPACT MEASUREMENT - QUALITATIVE In addition to the measurable effects of the hygiene behaviour support system, a number of interviews with patients and personnel in the unit were performed. The goal of these conversations was to generate knowledge about users’ lived experiences with the system. Users were asked about such issues as the overall functionality of the system, how easy/difficult the system was to use, how they behave in the facility, and how they experienced the door/disinfectant combination. The interviews provided insight into the possibilities and limitations for the optimal use of the system from the perspectives of different users. Throughout the project, the great knowledge and experience of healthcare personnel about their patients has proven to be crucial. Their close contact with many different patients means that they have a deep understanding of the challenges patients experience, and they are able to provide general profiles of patients.

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For these reasons, the healthcare personnel’s evaluation of the system has been particularly important. For both practical and ethical reasons, personnel introduced patients who were expected to handle toilet visits on their own to the system. Bedridden patients were not introduced to the system, as they do not use the toilet facility. Those patients who are able to do so were taken to the toilet facility and shown the procedure. A healthcare professional stated that it only takes three or four minutes to demonstrate the system, and that lack of time is a bad excuse.

Generally speaking, both patients and personnel are satisfied with the system. Generally, personnel experience that patients who normally perform toilet visits independently understand how to use the system, and that they are pleased that they don’t have to touch anything and that they don’t have to “remember” everything - for example, to flush. Some healthcare personnel found that confused and demented patients did not understand the system. These patients are typically assisted with toilet visits because of their conditions, however. When describing assisted toilet visits, several healthcare personnel stated that they required patients to activate the disinfectant by the door themselves.

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Not everyone remembers to flush...the elderly just leave. Now the toilet flushes automatically, so the toilet bowl is always clean.”

“ “ “ “

- Nurse’s aid, CD9, RRH

The fact that it blinks has an effect on the elderly, I believe.”

Normally I tend to forget to use soap at home.”

- Nurse’s aid, CD9, RRH

- Younger patient

It’s nice that you don’t have to touch anything...and practical, with the lights that guide you through the steps and show you the way.”

- Younger patient

They think it’s clever. I introduced a woman to it yesterday, and she said, ‘It’s clever, this way I don’t even have to think about it,’ because it’s just a procedure.”

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- Nurse’s aid, CD9, RRH

8.3 // OCCASIONS TO TALK ABOUT HYGIENE The system has given personnel new opportunities to talk with patients about the importance of good hand hygiene. Whereas it could be embarrassing for individual staff members to confront and “convince” patients to perform hand hygiene after toilet visits before, it has now become much easier, as personnel can simply refer to the system and no longer appear as the “senders” of the message. The hygiene message is made collective, which means that it will be more clearly communicated at the hospital. The system has also provided occasions for conversations about hygiene between patients who have introduced each other to its use. In these conversations, patients have also focussed on potential improvements which will be included in the further development of the system.

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On the basis of the deep knowledge and practical experience with hygiene behaviour we have gained from the project, we see great potential for applying hygiene support solutions in other sectors and industries outside healthcare. Hygiene plays an important role for all of us, and good hygiene behaviour can contribute to reducing infectious disease - and reduce the costs caused by them.

Infections are normally associated with longer hospital stays - from three to five days depending on the infection. We can express that in monetary terms: in this connection a day in hospital costs close to DKK 7,000 on average. There’s money in reducing these stays.” - Kjeld Møller Pedersen, Professor of Health Economics, the University of Southern Denmark

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Hygiene behaviour - or the lack of it - has to do with learned behavioural patterns which are manifested as habits early in a person’s life. Therefore, there is particularly great potential in working with hygiene at schools and daycare facilities, where rooms and furnishings might encourage learning and competency development in relation to taking care of oneself and others through appropriate hygiene behaviour.

“This would be a natural place to intervene in order to learn children and young people about the importance of good hand hygiene from a young age,” - according to Professor Hans Jørn Kolmos. A healthy learning environment requires a health internal climate with the right temperature and noise levels - and to a high degree also good hygiene.

We also know from studies done at daycare facilities in Odense Municipality that teaching children and personnel to wash their hands often and properly reduced the number of sick days by a third. Those are numbers that are really worth taking seriously.” - Hans Jørn Kolmos, Professor, Chief Consultant, MD Odense University Hospital // 87


With our concept, we have demonstrated that it is possible to guide patients to better hand hygiene using simple measures.� - Jarl Christensen, CEO and Partner, Conceptmaking

In the nursing sector, institutions often function as private homes for individual residents, and many routines and principles are transferred from private homes. This creates a complex intersection between public and private space that personnel must manoeuvre in on a daily basis. A correct approach to hygiene is vital to avoid the spread of infection among residents and personnel in these institutions. A hygiene support system would support personnel in their daily work and help residents and relatives perform correct hand hygiene, thus reducing the risk of infection. As the system collects data on disinfectant, soap, paper and battery levels, personnel would also be able to ensure that residents always have access to a functional system that doesn’t run out of soap, paper and disinfectant.

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The industry also has stringent requirements regarding hygiene in connection with many forms of production. This applies to the food industry, the medical industry, the restaurant industry, etc. In a variety of areas, policies and guidelines for these forms of production have been developed. However, they often turn out to be difficult to follow in practice, and it can be expensive for a business if a product must be altered or if production comes to a standstill because of errors and defects associated with bad hygiene. For these reasons, it would be relevant to investigate how a hygiene behaviour support system might help integrate considerations of hygiene into production.

Our intention is for the hygiene behaviour support perspective to be integrated into existing structures and integrated into the planning of new facilities not only in the hospital sector, but also in schools, daycare facilities, food production facilities and other businesses and sectors where the spread of infection can have major human and economic costs.

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