Introduction

Hospital-acquired infections contribute to an estimated 1.4 million deaths worldwide, including about 100 000 annually at a cost of $30B in North America alone.1 Inadequate hand hygiene remains a frequent and modifiable contributing factor, as established from hospital outbreaks of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and other hospital-acquired infections.2 Much attention has been devoted to promoting greater hand-washing through persuasion, education or admonishment.3 ,4 The purpose of this viewpoint is to highlight the countervailing behavioural factors that help explain the ongoing shortfalls of hand-washing among well-intentioned and hard-working healthcare providers.

Physicians are often singled-out as a group with low rates of hand hygiene compliance. A classical study, for example, found that physicians had about half the rate of compliance when compared with nurses (30% vs 52%, p<0.001).5 One interpretation is that physicians are arrogant, sloppy, recalcitrant, incorrigible, inept or oblivious. An alternate interpretation is that individual practitioners and the surrounding medical culture consider hand hygiene compliance unimportant. Here, we explore a different account for why the problem might not be solved by changing the personalities or motivations of physicians. Specifically, we suggest that the circumstances surrounding physicians in hospitals are rife with behavioural factors conducive to failures of hand hygiene.

Perhaps the most fundamental principle discovered by behavioural research …