Managing Cognitive Biases that Compromise Infection Prevention and Control

You're listening to the Phil Klein Dental Podcast. Cognitive bias is a mental shortcut that influences our thinking and decision-making, leading us to process information in a selective and subjective manner. In some instances, it can result in inaccurate or irrational judgments. So why are we talking about this on a dental podcast? Well, if this kind of shortcut thinking happens too often in the dental setting, it's likely that our infection prevention and control protocol will become compromised. So to address the different kinds of cognitive biases we experience and ways in which we can manage them on a personal level and as an entire dental team is our guest, Michelle Strange. Michelle has over 20 years of experience in the dental field, transitioning from a dental assistant to earning advanced degrees in health science and dental hygiene education. She owns Level Up Infection Prevention and Michelle Strange RDH, where she continues to practice dental hygiene while sharing her expertise through various platforms. Michelle, it's a pleasure to have you on the show. Oh, thank you for having me on. So there's no doubt, Michelle, as dental professionals, we know how important infection prevention and control is. We certainly learned a lot in COVID about how critical it is to be compliant. have the right PPE and have protocol in place to know how to use the PPE and so forth. But there are some obstacles to compliance that have to do with human behavior. And that's what we're going to be talking about in today's podcast. So how did you, Michelle, personally get interested in understanding at a greater depth the human behavior factor and how it relates to infection prevention and control compliance? It was just realizing my own behaviors and recognizing that some of my choices as a health care provider weren't always prioritizing the safety of my patients or even myself. I mean, that was honestly a real turning point for me when I started. I took on the role of the infection control coordinator or like your OSHA officer, your patient or patient safety officer. You know, you're supposed to have one of those in your offices. And I was assigned that. And I began. training some new team members in various offices that I worked. I was also a teacher in a dental hygiene program. And I just quickly saw how human behaviors like forgetfulness, fatigue, and just even our own personal beliefs could significantly influence how we adhere to guidelines. And that's all guidelines. That's, you know, how you wipe rooms down, how you go through the flow of sterilization. ones that I see often is how people wear or if they choose to wear PPE. And I've definitely witnessed, you know, firsthand how minor slips in infection control can lead to more serious consequences. And this really sparked my curiosity and the why behind these behaviors. I'm like that toddler that never grew up. I'm always asking why, like, why, why are we doing this? Why are we doing that? And so. Back in the day, one of my prerequisites in school before entering dental hygiene courses was psychology and sociology. And I often find myself wishing I had paid more attention to those courses because after 20 years in the industry, I'm learning how deeply psychology influences our daily actions and the critical role it plays in ensuring safety. as providers. And so I do believe that the more that we understand psychology, our human behaviors, our cognitive biases, and just overall human psychology, I think we can all be better equipped at managing our own emotions and thoughts around things like infection prevention, but how do we help? kindly, gently, without shame, help our colleagues. Because at the end of the day, it's all about safety. It's keeping us safe. It's keeping our families safe. It's keeping our patients safe. Yeah. So that's certainly one of the advantages of robots. Robots will do things very, very well. And there's absolutely no cognitive bias involved. They're not sentient. So being sentient is great, but it's also a disadvantage when it comes to adhering or complying to rules. So when you say that In your experience, and you were the ICC in your practice, and you're like an expert in infection control for sure, did you have these vacillations on a day -to-day basis where you weren't focused and maybe not complying as well as you should have? Or was this a rare thing, which just happened once in a while? I think very early in my career, like never. And then as I have definitely grown in the last 24 years as a clinician and... understood my own cognitive biases. I think I am probably doing it on a definitely a weekly basis. I love a self audit. I love to be like, why do I do it like this? Why? Why did I just have that visceral reaction to a correction or new knowledge? I'm like, wow, that one stung. Or, you know, like, you know, I had to double down. Like, I like I said, I'm that why like, I want to ask a lot of questions. And, you know, we could talk about a few of the biases because I I've seen quite a few, but, you know, I've suffered from the confirmation bias. I have suffered from avoidance. I have suffered from delegitimizing some concerns. And so now I like to check in on myself. But I'm also, I encourage my colleagues to check me too. Like, I think a great example that I often talk about is I was in a practice, I was temping, there was a new dental assistant there. And she was, you know, just kind of feeling her way through like, who are the personalities in this office? And I'm coming in, I'm dropping all my stuff, I'm talking, and I kind of get distracted because I also have a little ADHD, which I think if you're a really... in dentistry, you have a little ADA because we just multitask with the best of them. Right. And I dropped my instruments. I put them in the ultrasonic. I'm talking blah, blah, blah. And I go to walk off and she's like, Oh, do you, and like, like so coyly, like, do you mind starting that ultrasonic? And I was like, Oh, absolutely. I do like, no, please. Have you seen me doing anything where I'm not following through with a task that is going to directly affect patient safety? If I am walking out of this, room with some hygiene after taking off my gloves. If you see me touching my mask a whole bunch throughout the day, correct me because these are behaviors that I'm probably not even aware of. My brain has skipped to the next 30 steps in whatever thought process I have right now. Call me out, but with kindness. I don't want to be like, oh my God, Michelle is always like forgetting to do these things. Like call me out kindly, like, because my ultimate goal is to do right by y'all, do right by me, do right by my patients. But yeah, I have suffered from some biases. When you temp for another office, do you look at these? other employees more critically because you're attempting in a new office and saying and because you're curious to know how everybody else does things compare that to if you worked in the same practice for 10 years you know everybody you know their habits i'm just curious to know as a temp are you constantly judging other people's ppe habits talk about that for a second Well, I think I start with judging the PPE in general because sometimes it's not all that great. Sometimes I'll look at the boxes of masks. There's not even ASTM ratings on there. Sometimes I'll look at the gloves and you can just tell like they're just for everyone. Just any hand goes into this, whereas I might like ones that are, I don't know, just a little more compatible to my hand size. I am a petite human, so I wear small gloves and they're just like mediums work for everyone. like, no, not, no. So I think I do start by judging PPE because there is a very much a difference in quality. And then it's very interesting. I always like to observe. Like I said, I'm really trying not to be, you know, super judgmental, unkind in any way, you know, but I, you know, one time of not doing hand hygiene, like it's going to be the, you know, the. transmission of disease in that particular moment? Probably not. But if I'm just constantly watching somebody maybe not perform hand hygiene or touch their mask a whole lot or put their other PPE on with gloved hands, gosh, that is one I see quite a bit, not understanding the rhythm and the sequence of donning and doffing your PPE. Those are ones that I see quite a bit. And so sometimes I will say, can I, may I? give you some thoughts on some observations I saw today or that I keep seeing. And I do walk in and tell people like I do infection control. Like I own a company with infection control. I do these things on a regular basis, not in a way to like scare them, but also just kind of set the stage because I'm most likely going to bring something up, but hopefully in a way that's very kind. And like I said, I always give them permission to tell me. Humble me. I'm very, I'm open to change. I'm open to explaining why I might do something. So I like to really set the stage for that first before I start throwing out my thoughts and opinions. No, and the quality of PPE is very important. I know we talked offline, you love the cranberry brand for a lot of reasons, but the gloves have to fit. Number one, they have to be comfortable because if the dentist or anybody on the dental team is working every day, eight, nine hours a day in the office, however long it is, and they're constantly fidgeting with their gloves because they don't fit, they can't handle instruments well, they can't get tactile feel with their instruments. And also a lot of these PPE products come from other countries where they don't have the quality assurance. and you don't know what's in the box, the box may be the same, but the stuff that's in it may be different from the last time you ordered. Whereas these top companies like Cranberry and other companies that make really good PPE is really important. So when you go to a different office, you probably look at like, what are they buying? It tells you something about the practice too. It does say something about the practice. But getting back to the crux of this podcast, how do cognitive biases or individual attitudes impact adherence to PPE guidelines? Well, let me start with giving the listeners a little idea of what I'm saying when I'm talking about a cognitive bias. So these are essentially just these like mental shortcuts that can often lead to errors in judgment, especially in critical contexts like PPE. So like you said, we're not robots, we're humans and we are going to cut corners and we are going to have errors in judgment. So if it happens, it's more about like identifying it, being emotionally. am mature enough to see it, recognize it, be open to it and make adjustments. I wanted to kind of give you a few that I can say that I have suffered from. And then also ones that I see pretty commonly if you're open to that. So one of them is being like overconfident. So it's called overconfidence bias. And this occurs when someone believes that they do not need to be as diligent with PPE because they've never contracted an illness in the past. Right. So they kind of it leads them to underestimate these real risks. And I see that more commonly with the veterans in the industry. Like I don't have to wear like gloves. I've been sticking my hand in like God knows what for 20 years and I'm fine. And it's like, oh, gosh, but like maybe you're not the susceptible patient in that chain of infection. So they have this overconfidence that nothing's going to happen to them. I also see a lot of normalcy biases. So this is a tendency to believe that a disaster, like a disease outbreak, is unlikely to happen because it hasn't occurred in their experience, right? So they just kind of brush it off because it's not their normal. I think confirmation bias, that's the one that I know that I have had to work on the most, especially around reading research and stuff. And this is a bias that involves acknowledging information that supports like pre -existing beliefs. So I'm only looking for the things to confirm the things that I believe and not being open to anything else. So like when I tell you your mask needs to be up around your nose and kind of like really sealed. And fitting around the chin or turning the loops on the ear loops, twisting those. Like, that's not a proper way to wear a mask. And here are the reasons why. And then they confirm their biases by going to look for things that say, like, look, these people have never, like. had an issue with that. I think that's also when that like overconfidence bias comes in compliments confirmation bias as well. And then, you know, I think just good old cognitive dissonance, which is just experiencing a true discomfort from like holding to conflicting beliefs. So maybe knowing there's an importance of PPE, but also feeling like it's too cumbersome. You're always getting hot. You're always fogging up your thing, your loops. your goggles. So you hold these two conflicting beliefs like this. I believe that I'm uncomfortable and I believe that these PPE or that PPE is super important and is a painful effect. Actually, I've read in a lot of studies, it's like you feel like you were just slapped in the face, like the equivalent of learning a new belief. gives you pain sometimes. And then I think the last one that I see quite often is this belief bias. And that's when you evaluate the strength of an argument based on the believability of its conclusion. So for instance, if someone believes that PPE isn't necessary for protection, they might just disregard evidence showing that PPE actually does reduce the risk of infection. Again, I have suffered from a lot of these. I was not somebody very early on that, you know, I wore my gloves, I wore my mask, I wore eyewear, but I didn't wear a good type of mask. I did not know my ASTM rating. And I was doing aerosol generating procedures all day, every day. And I was sick. all of the time and i just did not believe to make this connection between what i was doing as a clinician and the type of ppe i was wearing the quality of it and changing it on a frequent basis and then like how sick i was getting all the time and now i still suffer from like chronic upper respiratory infections because of stuff like that so so we all have it i've experienced it yeah no those are all good points so in a way there's a rationalization behind some of these biases in other words this is a very basic one these gloves cost three times more per box than these gloves now what you want to believe is that the cheaper gloves do basically the same thing right because you want to buy the cheaper gloves I'm already figuring how much I'm going to save in a year by buying a whole case of these every two months versus a case of this other brand. So that's a cognitive bias, right? You're trying to believe something or rationalize based on the result that you're looking to eventually get, which is to say, we're all good with these cheaper gloves. And again, we're talking about PPE now. So there's a real difference between cheap stuff, when I say cheap, poorly made. and less expensive than things that are much better made. And with that comes a higher expense. But then what is the trade-off? You know, where's the compromise? Is it your health of your staff? Is it the health of your patients? Let me ask you this question. How can dental practices address the patient's concern or their misconception about PPE without compromising trust or rapport. So like to piggyback on your point there, like, okay, let's say that you are. Like on board, I want to put some money and I want to give a little bit more budget to the PPE because I believe in the quality. I believe how the quality assurance from the company. I believe that this is going to help people have better ergonomics, less hand fatigue. They're not going to drop things as much. My patients are going to see people wearing masks. properly when they enter our practice. But then you got to like deal with a whole team that may not see the value in that as well. And so I do believe that it's all about training and communication and open communication and thorough training are just really crucial components in fostering. a culture of safety. This is something that I think you really have to do from top down. Leadership plays a pivotal role in setting that tone, showing that everyone's health and safety are top priority, that we are putting money into quality products because X, Y, and Z. I think you also have to be very transparent. So be clear about why. PPE is necessary, why you're putting this expense into it, why you're being thoughtful about the products that you are using. You know, explain the science and the real life statistics behind its use in a very straightforward way. And when people typically, not always, but when people typically understand the why behind actions, they're more likely to commit to them. I also think you have to emphasize safety. So you want to always highlight that PPE is not just a policy, but a practical tool. to protect everyone, patients and team members, even your family. It's about creating that safe environment for every single person that walks in and out of that door. And then again, like I said, training, you have to have education. Like you have to provide training sessions and updates on the correct use. If you are going to make a change in PPE, have a conversation with your team. explain, like I said before, explain the whys, explain your decisions because they might, I don't know, be in love with like the cheapest gloves. I don't know why, but they might. And then you have to explain to them, like, we're not only concerned about like where these are manufactured, the cleanliness of the facility. I worry about your hand fatigue, but also even things like how the gloves, for instance, are packaged in a box. Which is something that I never thought about until probably like five years ago. I think when Cranberry showed me their box where the gloves are just pulled out by the cuffs. So like we're gently pulling these gloves out in a way that it has a good aseptic technique. That we aren't accidentally pulling 12 out of the box. You know, like we're being very strategic with the gloves that we're going to be using. So really discuss that. Like don't just throw it at them and say like. okay, this is what's happening. You know, people want to have like, feel like they have autonomy in their day to day. And then I also encourage people to show empathy, you know, recognize that wearing PPE can sometimes be uncomfortable or inconvenient that people. It's just important to acknowledge that these feelings very openly, like show empathy that they might struggle with a glove change. They've been practicing with a very specific type of glove for 10 years and now we're making a change and they're going to need to be coddled a little bit. Understand their frustrations, understand their pain points, and then be able to, again, Have training, have transparency, offer, you know, maybe some solutions, but show them empathy. Don't let it just be like, well, this is what we're doing. Shut up or get out, you know, kind of thing, like have some empathy. And I think when we approach it with like some patience, some, you know, providing clear information, really showing understanding and creating an environment of trust. This not only helps to in maintaining strong rapport, but also ensuring that everyone is on board with the. these essential infection control practices. Like wearing your PPE is pretty important and choosing what's going to work for the team is just as important. You just got to be transparent about it. Yeah. And it seems to me as an employer, from the dental practice owner's point of view, you want to hold on to a good staff. You want to hire good quality people. And if the employees see that the practice is buying and I don't mean to say this in a bad way, but budget PPE. And they may have come from another office where they used really high quality PPE. And now they're seeing a practice that decided to save money and buy in bulk this new PPE that's not as comfortable, doesn't fit as well, awkward to don the gloves, whatever the... is, they're now comparing it to what they had before. And it's much better to be moving in the up direction as far as quality from one practice to another than going in the down direction, because that's going to stand out in that employee's mind. And it's a statement about the practice. So let's pivot a bit here, Michelle, and talk about legacy errors. These are important because they're kind of errors that are passed on from one employee to another, and they could survive for a long time between one generation of employees and move even to an entire new generation of employees. So it's important to kind of understand what a legacy error is and how it affects specifically compliance with PPE guidelines. Legacy errors are one of my favorite things to talk about because again, I do them. I experienced them. I've had to correct myself. So a legacy error is a mistake or some kind of misconception that continues to be repeated because it's been, you know, quote unquote, the way we've always done it. So maybe like, so I started in dentistry at 17. I was just a baby. I was the assistant's assistant in an ortho office. And then I was an on the job trained. ortho assistant. And let's say I took all the things that I learned as an on-the-job trained young child, learning how to wear my PPE, which was zero to none. Like, I don't even know if we had masks back then. And let's say that I just kind of kept that, you know, I just never wore it. And I just, and then I trained somebody else and then they trained somebody else. And then we just have these bad behaviors that no one ever stopped the audit. And I've talked about this at the top of the podcast, like that self audit, like, am I wearing my broccoli? Like, do I take off my gloves in the proper way? Do I wear my mask with the ear loops crossed? And then some new trainee come through and they see me wearing my lips or my mask with the loops, you know, crossed. And then they start doing it. That's a legacy error. And I see so many legacy errors around mask wearing specifically. I think a lot of them came from the pandemic. and were exacerbated because of us wearing masks out into the world because we stopped treating them like medical waste because that's what they are. That mask, your gloves, your gowns, these are medical waste, your PPE. And so some examples of a legacy error would be like touching the outside of a mask, pulling it down around your chin. I swear if I could get on social media for one day and not see a dental professional make a reel with their mask around their chin, like I would feel like. I won the lottery. That is a legacy error. Wearing it incorrectly. Wearing it on the wrist. It gets put on the wrist and walking through the office. Also not changing it between patients. Using the same one all day long. Maybe even wearing it below the nose because you fog your loops or fog your goggles or whatever. I also see a lot of legacy errors around other PPE too, just like I mentioned earlier. not donning and doffing them in the correct order that would reduce cross-contamination and so when we think about legacy errors i i know that they're a challenge because they become ingrained in our routines and so we really have to think about like again calling each other out kindly gently we're like do you realize that um you twist your loops do you know that you even do that do you know that you're walking around the office with your mask around your chin um I literally saw somebody walking through the parking lot from a dental office with their mask around their chin. I was like, Oh my God, medical waste. We keep it in the office. And so. Being, I think training is a way to rid our offices and our team of some of these legacy errors, like make it fun, make it interesting, do almost like a team huddle where we're like, all right, we're going to have like two people go back to back and see who can don't end off their PPE correctly, but the quickest, you know, something silly and fun at a prize, at every reward. I think we can talk about legacy errors in a way that's kind and gentle. but make it fun. Like it doesn't have to be like, you guys are not, you know, like you're not have to be the sheriff there, but we are all guilty. of legacy errors. And I think when we start doing these self audits and these kind call outs, we can start ridding ourselves of those. I'm sure, Michelle, there are some really great videos that show how to put PPE on, take it off, how to handle PPE during the day, what not to do. These videos, I guess, can be watched during the morning huddle as a group or individually at home, I assume. And I think you've made some really good videos that you've shown on Viva Learning. Yeah, I have a lot of videos in my webinars that you can find with Viva Learning. to of donating and doffing. The CDC also has a great like breakdown chart and also a great video that you should all check out is if saliva were red from OSAP. We did that because when I looked at it, it was from like the 90s. So I think videos like that are also important because even though you're donating and doffing PPE, finding quality PPE is about like, what are you touching and where are you going with that PPE? That also matters too. And I think that's a great video for that. The main thing. this podcast, the focal point of what we tried to accomplish here was to bring to light that there are behavioral patterns, human behaviors that are just typical to the human being where they stick within their echo chamber. They just stay there and they do everything they can to rationalize why it's okay. It's really important that we break out of that echo chamber and listen to the things like what you were saying, Michelle. Revisiting our habits really will help with our ultimate goal of keeping the team members and our patients safe. So I really do think you had a lot to bring to the table here. We thank you very much. Any last words for our audience before we wrap it up? I think just like you said at the beginning, we're not robots. We are humans. Our habits are things that happen small little increments over time. And we have no clue often, most of the time that we're even doing those things. Many of my habits have been, I've been humbled by students on a regular basis when I was teaching. Like, Ms. Strange, do you know you're doing this, Ms. Strange? And I'm like, oh my dad, no idea I was doing these little things. And so I... much as um we're going to kind of do our own self-audit um i think just being aware of like your body your mind your emotions when people are like Michelle do you know that um you haven't done hand hygiene one time in this like appointment and i go you know and my brain is gonna go No, I've done it. Like, I'm going to go on the defensive, right? And then I'm going to, again, circle through some of these biases because they often piggyback off each other. And so just be kind that people don't always understand these. As you're taking in the information, give yourself some grace. Realize that you have habits. You just do. We all do. Because we're not robots, we're humans. And it's those human behaviors, those human errors that are inevitable. We just have to get a hold of them. Thank you so much, Michelle. Really appreciate your input and been a great contributor to our CE organization. And we love having you on. Thank you so much. Thank you.