From Belief to Behavior: An IP’s Step-by-step Approach to Changing Belief Systems

Soaking wet from my long walk in the icy cold rain, I entered Grandma’s house in the early spring of my 11th year.

“Goodness, child,” she exclaimed. “Now, just look at yourself. You’re gonna catch a cold lookin’ that way. You come over here right this instant and get yourself dried off somethin’ quick.”

I obliged, as I did every time my grandmother insisted that I would catch a cold if I didn’t do exactly as I was told. Over the years, my grandmother would provide me with multiple explanations for why I would be struck down by “those pesky germs.” And when I inevitably fell ill from the onslaught of typical seasonal respiratory viruses, it would be because I didn’t listen to Grandma and keep out of the rain. And so she’d park me directly in the sunlight because, she told me, “a good dose of the sun will take care of those pesky germs.”

Fast forward 11 years to nursing school when, to my surprise, I learned that respiratory viruses were not spread by the raindrops falling on my jacketless body. Much of what my grandmother had taught me about the spread of respiratory infections was grossly inaccurate. Still, despite my added knowledge as a nurse for 13 years and an infection preventionist for 8, I sometimes catch myself almost saying to my children: “Don’t you even think about leaving the house lookin’ that way. You might catch a cold.” Isn’t it funny how much our behavior and decisions are strongly influenced by what we’ve been taught or believe?

I remember speaking with an anesthesiologist about hand hygiene rates for the operating room. It struck me when he explained, “Honestly, I think we wash our hands too much in health care. It’s often unnecessary and much less important than we make it out to be.” It occurred to me that before adherence could be increased, I would need to persuade staff to believe hand hygiene is important.

To change behavior, we must change the core beliefs that drive the behavior. To do this, I suggest the following step-by-step approach to influencing or changing beliefs.

Gain trust

If a stranger walks uninvited into my home and announces that I should remodel my bathroom, I will probably call the police. I’m also not going to give a second thought to whether my bathroom needs to be renovated. However, if my close friend, whose opinion I respect and trust, suggests I remodel my bathroom, I’ll probably head to the nearest department store for paint. Similarly, you will be much more effective at influencing the beliefs of health care workers if you begin from a foundation of good relationships and trust. Building relationships and trust takes time, but those connections are essential to changing beliefs. Check out this article on making connections to learn more about how you can build relationships as an infection preventionist:
https://www.infectioncontroltoday.com/view/the-3-c-s-connection

Assess readiness

I know better than to ask my children to complete their chores when they wake up, before they’ve had their breakfast. They’re hungry and not in the mood to do the dishes before consuming their marshmallow cereal. So I wait for an appropriate moment before insisting they clean their room. Similarly, you cannot expect anyone to be receptive to belief change on a topic when they’re in a sour mood. You must first ensure that your audience is in a receptive emotional state before trying to influence their beliefs on a topic. I would not, for example, educate emergency department staff on the importance of cleaning and disinfection after they’ve cared for a particularly
traumatizing critical care case. Your message can wait for a more appropriate moment when staff will be emotionally receptive to your words.

Value their opinion

Teddy Roosevelt said, “People don’t care how much you know until they know how much you care.” Don’t expect anyone to change what they believe or their opinion on a topic until you’ve shown them how much you value them, their work, and their views. We are much more likely to listen to and consider someone else’s opinion or belief after being shown respect and consideration for our own beliefs and opinions. Simple conversations with your health care workers can open the door to showing your deep respect for them and their views.

Identify the beliefs driving behavior

You want staff to consistently wear surgical masks and wash their hands before accessing central lines. But before we can successfully change behavior, we must understand why the behavior we want to see has yet to occur. To do this, we must understand what health care workers believe about the critical infection prevention and control practices we’re trying to implement. Lead in with simple questions, such as: “What do you think might be driving the increase in central line–associated bloodstream infections (CLABSIs) on the unit?” Speaking with the health care team in this way will help you better understand any beliefs preventing practice change. When asking this question in an intensive care unit, a nurse responded, “CLABSIs can’t be prevented.” A belief, I realized, would need to be changed before we could effectively implement changes to improve CLABSI prevention.

Change their mind

As you seek to understand the beliefs driving behavior, think about what may be needed to change them. My surgeons needed to see the research and data. I spent hours conducting literature searches to provide them with evidence of why my suggestion could be the key to decreasing surgical site infections. Some beliefs or opinions, however, will have a strong emotional connection or be tied to a core belief. Staff may have had a negative experience with a family member in the hospital, or their religious, political, or sociological opinion could be influenced by their religious, political, or
sociological position. Beliefs tied to experiences, emotions, or core beliefs are among the hardest to influence. Positively influencing such beliefs will take persistence, patience, and empathy on the part of the influencer. Remember that experience is the greatest teacher, the strongest motivator, and often the gateway to changing someone’s beliefs and opinions. Physicians in a 19th-century maternity clinic refused to believe Dr Ignaz Semmelweis when he insisted that germs were being spread to patients by the hands of their physicians. It wasn’t until staff at the clinic experienced this truth for themselves, through handwashing and a subsequent decrease in infection, that they began to consider the possibility that Semmelweis was correct. To change someone’s beliefs or opinions, we must create or tell stories of experiences that cause a shift in a person’s perspective previously
influenced by core beliefs or past experiences.

History has shown time and time again that human behavior will change only once our beliefs do. Our beliefs influence behavior either positively or negatively. Therefore, to change behavior, we must first examine and change the beliefs driving that behavior. But changing someone’s mind takes time, persistence, patience, and empathy, primarily when the person is motivated by experience and core beliefs. We must develop a foundation of positive relationships and trust with the health care teams we seek to influence. We must sincerely value other people’s opinions and beliefs before seeking to influence them with any of our own. And we must seek to understand their beliefs, what they are, where they come from, and what it will take to change them.

Pioneers of medical science have successfully changed the beliefs of an entire society throughout history—pioneers such as physician and epidemiologist John Snow, who broke the handle off London’s Broad Street water pump to demonstrate his belief that the water was the cause of the cholera epidemic, not the noxious air that was believed to spread the disease.

As infection preventionists today, we are the pioneers of preventing and controlling infections. We are revolutionizing the approach to infection prevention and control, including recognizing that behavior change cannot occur until we have first begun to tackle the underlying beliefs and opinions that drive the health care behaviors we’re seeking to change.