Why do hospital staff neglect to wash their hands?

Compliance incentives need to target individual motivations

The low rates of hand-washing among people who work in hospitals are startling when you consider the dangers of infection to people whose health is already at risk.

According to World Health Organisation (WHO) figures, only 40% of doctors and nurses around the world follow the hygiene guidelines, despite all their years of training and experience,

An eight-year national Hand Hygiene Australia campaign to improve behaviour reported an improvement in hand-washing rates from 64% to 84.7%. However, the accuracy of this claim has been called into question by Mary-Louise McLaws, a professor in the faculty of medicine at UNSW, whose research shows many healthcare workers slip back into bad habits when they are not being watched.

Her study looked at a large Australian teaching hospital, which was trialling the use of electronic monitors and using human auditors for 20 minutes each day (the present standard). When the watchers left, compliance dropped dramatically to 30% in the medical ward and 55% in the surgical ward.

The national hand hygiene benchmark is 80% compliance, set by the Australian Health Ministers' Advisory Council.

McLaws' work indicates the initial positive behavioural change was only 'skin deep'.  This is an essential understanding because hospital-acquired infections are a major cause of patient mortality and hand hygiene is considered a primary preventative measure.

Hand-washing is regarded as the most critical action healthcare workers can take to prevent the spread of hospital-acquired  – and antibiotic-resistant – infections such as golden staph (Staphylococcus aureus).

'The underlying issue is that they are so busy. They have to make decisions in such a short time'

- CHUNG-LI TSENG

 'They care about different things'

Another study suggests hand-washing compliance programs that consider the different motivations of doctors and nurses may be more effective than programs that use the same strategies for everyone.

The top two motivations for complying with the hygiene standards are the same for doctors and nurses, according to Chung-Li Tseng, an associate professor of operations management at UNSW Business School, and his former PhD student Wenlin Chen, in their paper, 'Motivating Hand Hygiene Adherence of Healthcare Workers in Work Groups: A Discrete Choice Experiment'.

These two concerns are for personal safety (their own hands may become infected) and then the risk to patients. However, after that, the responses from doctors and nurses diverge.

"They care about different things," says Tseng.

According to the study, the third most important factor for compliance by doctors was task visibility – which means they were concerned about whether people could see what they did.

For nurses, the third most important factor was intergroup competition, which indicates a sense of rivalry with other teams.

Tseng and Chen say these differences could explain the varied effectiveness of management interventions, such as hygiene protocols. This could mean, for instance, a poster campaign warning that 'someone is watching' may not be effective for nurses, just as a 'be the cleanest team' approach for doctors may not change behaviours.

The WHO recommends a '5 Moments for Hand Hygiene' approach to cleaning hands: before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient; and after touching patient surroundings.

Data from Hand Hygiene Australia shows doctors have one of the lowest compliance rates compared with other hospital staff, with just 67.3% of medical staff washing their hands before touching a patient. The rates were even lower after they touched a patient's surroundings.

The '5 Moments' protocol is not without its critics, who complain it is too simplistic in its approach to a complex problem and that it does not tackle the transfer of germs from visitors or the patients' own hands.

'There is no one-size-fits-all approach to improve workers’ behavioural compliance effectively'

- CHUNG-LI TSENG

Routine of hospital life

Tseng says low compliance with hand hygiene standards is commonplace in most healthcare organisations, but that does not mean the health workers don't care about the issue.

"We have no doubt they are professional, they know the importance of hand-washing. The underlying issue is that they are so busy. They have to make decisions in such a short time," he says.

"To every patient, their hospital visit is a rare and unique experience but, for the healthcare workers, it is their routine life," says Tseng.

Tseng adds a doctor may finish seeing a patient and try to quickly recall in a split second whether they (the doctor) had touched anything – a bed, table or curtain –and may decide there was a low risk.

Some hospitals have been using electronic badges to monitor hand-washing. Using radio frequency identification technology (RFID), these badges record the use of sanitising dispensers.

Tseng says there have been observations that the benefits from electronic monitoring do not last long, peaking at 20 months and returning to original levels by the third year of operation.

"It may be that, over time, you care less and less. This is human," he says, pointing to the experience of dieters who can't maintain the discipline required to lose weight.

Other researchers have also noted the impact of the Hawthorn effect – a phenomenon where people change their behaviour if they know they are being observed.

Behind the thinking

Tseng and Chen's research is informed by a survey of 276 healthcare workers at a university teaching hospital in Taiwan. But in their main paper, they used a game theoretical model to look at how healthcare workers react to the compliance of their peers and it predicted several behaviours behind the non-compliance with hand-washing standards. They noted people use a combination of the following behaviours:

Free-riding: Staff don't wash their hands because they think it is enough that everyone else is doing it. Recommendation: the hospital can highlight the role of hand hygiene as a means of self-protection and can also increase the cost of being a free-rider, using monitoring to identify non-compliance and impose punishment.

Safe-playing: Staff wash because they want to protect themselves. Recommendation: the hospital should use education or training to enhance their confidence in hand hygiene guidelines.

Opportunistic: Staff switch between being free-riders and safe-players. They think other people's compliance is sufficient, but will wash if they observe others not doing it. Recommendation: make it harder to be a free-rider by imposing punishment and emphasise the benefits of hand hygiene to motivate the healthcare worker to be a safe-player.

Self-regarding: Their peers do not influence their behaviour; they will wash when they want to. Recommendation: the hospital should communicate with them more often and convince them of the importance and the necessity of maintaining high hand hygiene compliance all the time.

Tseng says relying on a standardised process to improve hand hygiene may miss the benefits that come from tackling the different motivations.

"If you ignore the differences, the intervention will not be effective," he says.

"To be effective, you have to understand what is behind their thinking. What is the message behind their behaviour? There is no one-size-fits-all approach to improve workers' behavioural compliance effectively."