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Why Don’t Doctors and Nurses Wash Their Hands?

The lack of adequate hand washing by our healthcare providers continues to be the primary cause of infection in our country’s healthcare facilities. Nosocomial, or hospital acquired, infections are the most common and pervasive of all preventable adverse events and result in substantial direct and indirect costs to our nation, not to mention the substantial pain and suffering for the unfortunate patients that are affected. 1

For almost 150 years, healthcare workers have been taught that cross-infections are transmissible but not contagious and that the most effective way to prevent these cross-infections is to wash their hands before and after every patient contact. As one physician-investigator observed, “[b]ut they don’t do it. They don’t merely not do it every time, they don’t do it most of the time and sometimes not even when it might be most expected, as when caring for an intensive care unit (ICU) or emergency room patient.” 2

In U.S. hospitals today, hand washing is still the exception rather than the rule. Most studies agree that between 40 to 60% of all doctors and nurses fail to wash their hands between patients. 3 Low-level compliance with hand hygiene is particularly poor in ICUs, where studies show that compliance does not exceed 40%. 4

Why do healthcare workers continually fail to adequately wash their hands? The answer, unfortunately, remains elusive. Some of the reasons that have been suggested for such a low level of compliance include the lack of priority over other required procedures, insufficient time, inconvenient placement of hand washing facilities, allergy or intolerance to hand hygiene solutions, and lack of leadership from senior medical staff. 5

There is little doubt, however, that economic considerations also play a role. In an infection control journal article entitled Why Don’t Doctors and Nurses Wash Their Hands?, Dr. Peter Heseltine sadly observes, “[a]s healthcare costs more and budgets contract, there has emerged a philosophy of the reversed Field of Dreams. If we don’t build it, they won’t come.” 6

Additionally, The American Journal of Infection Control has warned that if we only consider the direct economic consequences of preventing infections, an institution’s infection control program could conceivably result in an apparent decrease in net revenue, 7 a serious problem indeed for any healthcare administrator today.

These potential economic consequences were wisely foreseen by Dr. Robert Haley more than seventeen years ago when he cautioned that if “hospitals receive substantial extra payment for each infectious complication, administrators may be tempted to reduce resources allocated to infection control programs.” 8 It seems that nobody listened. (See, Understanding the Cost of Errors).

If hospitals were not reimbursed for their patient’s hospital acquired infections, facility administrators would surely demand diligent adherence to its hand washing protocol, and would do so very quickly! If physicians were not paid for their treatment of these infections, it would be a safe bet that hand washing rates would soar while the occurrence of healthcare acquired infections would drop precipitously!


Nevertheless, new research suggests that having a busy workload, being in a technical specialty and performing activities with a high risk of cross-transmission are all factors that increase the odds that a physician will not follow hospital handwashing guidelines. 9


Some studies show that the failure to properly wash ones hands is inversely related to status: Doctors are less likely to wash than nurses' aides. 10

In their recent book entitled Internal Bleeding, The Truth Behind America’s Terrifying Epidemic Of Medical Mistakes, Drs. Robert Wachter and Kaveh Shojania boldly state, “[s]ome of us can’t be bothered to wash our hands before examining patients.” 11

 

Last update on: 10/02/06


  1. Dunagan WC, Murphy DM, Hollenbeak CS, Miller SB. Making the Business Case for Infection Control: Pitfalls and Opportunities. Am J Infect Control, 2002; 30:86.
  2. Heseltine P. Why Don’t Doctors and Nurses Wash Their Hands? Infect Control Hosp Epidemiology, 2001; 22:4.
  3. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Ann Intern Med, July 6, 2004; 141:1; Heseltine P. Why Don’t Doctors and Nurses Wash Their Hands? Infect Control Hosp Epidemiology, 2001; 22:4; Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital: Infection Control Program. Ann Intern Med, 1999; 130:126; Larson E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Infect Dis, 1999; 29:1287.
  4. Sproat LJ, Inglis TJ. A multicentre survey of hand hygiene practice in intensive care units. J Hosp Infect, 1994; 26:137; Thompson BL, Dwyer DM, Ussery XT, et al. Handwashing and glove use in a long-term-care facility. Infect Control Hosp Epidemiol, 1997; 18:97; Maury E, Alzieu M, Baudel JL, et al. Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med, 2000; 162:324.
  5. Boyce JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med, 1999; 130:153;Thompson BL, Dwyer DM, Ussery XT, et al. Hand washing and glove use in a long-term-care facility. Infect Control Hosp Epidemiol. 1997; 18:97; Gould D. Nurses' hand decontamination practice: results of a local study. J Hosp Infect, 1994; 28:15; Larson E, Killien M. Factors influencing hand washing behavior of patient care personnel. Am J Infect Control, 1982, 10:93.
  6. Heseltine P. Why Don’t Doctors and Nurses Wash Their Hands? Infect Control Hosp Epidemiology, 2001; 22:4.
  7. Dunagan WC, Murphy DM, Hollenbeak CS, et al. Making the business case for infection control: Pitfalls and opportunities. Am J Infect Control, 2002; 30:86.
  8. Haley RW,White JW, Culver DH Hughes JM. The Financial Incentive for Hospitals to Prevent Nosocomial Infections Under the Prospective Payment System. JAMA,1987; 257:1611.
  9. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Ann Intern Med, July 6, 2004; 141:1.
  10. Berens, M. Tribune Investigation: Unhealthy Hospitals. Chicago Tribune. July 21, 2002; Boodman SG. No End to Errors Three Years After a Landmark Report Found Pervasive Medical Mistakes in American Hospitals, Little Has Been Done to Reduce Death and Injury. Washington Post, Dec.3, 2002; Gaynes RP. Surveillance of Nosocomial Infections. Infect Control Hosp Epidemiol. 1997; 8:7; Tibballs J. Teaching hospital medical staff to handwash. Med J Aust. 1996; 164: 395.
  11. Watchter RM, Shojania KG. Internal Bleeding – The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. Rugged Land. 2004
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