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BMJ Qual Saf doi:10.1136/bmjqs-2015-004319
  • Viewpoint

Why even good physicians do not wash their hands

  1. Eldar Shafir2
  1. 1Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  2. 2Department of Public Policy, Princeton, Princeton, New Jersey, USA
  1. Correspondence to Dr Donald A Redelmeier, Sunnybrook Health Sciences Centre, G-wing Rm 151, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 1J5; dar{at}ices.on.ca
  • Received 21 April 2015
  • Revised 18 June 2015
  • Accepted 21 June 2015
  • Published Online First 9 July 2015

Summary

  • Lapses in hand hygiene are a persistent problem that has resisted a simple solution

  • Behavioural decision science provides a framework for understanding some of the lapses

  • Affective factors include a lack of positive reinforcement and a missing sense of certainty

  • Cognitive factors include recurrent monotony, divided attention and faulty memory

  • Social factors include insufficient prestige with inadequate enforcement of norms

  • An awareness of behavioural factors helps explain past failures to improve hand hygiene

  • Behavioural insights may lead to new technologies and to more effective solutions

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 …

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