Research for infection protection
  • germs
  • Adenovirus
  • Aspergillus niger
  • Bovine virus diarrhea
  • Clostridium difficile
  • Candida albicans
  • Candida albicans
  • Coronavirus
  • Corynebacterium
  • Escherichia coli
  • Helicobacter pylori

Author: Haessler et al. Source: BMJ Qual Saf 2012;21:499-502


Haessler et al.

Getting doctors to clean their hands: lead the followers

Hand hygiene is an important factor to reduce nosocomial infections. But nurses tend to be more compliant with hand hygiene than doctors, because the physician compliance still remains low. Their hand hygiene compliance might be influenced by workload, beliefs, access to hand hygiene products and the structure of medical training and education. This study hypothesized that hand hygiene behavior is affected by the peer pressure among internal medicine teams and the role modeling behavior of the attending physician.

This study was performed at a large urban academic medical centre with 659 beds and 320 trainees per year. Nine internal medicine teams were covertly observed by a research assistant. The teams were composed of one attending physician, one post-graduate year 3 resident, two post-graduate year 1 residents, one medical student and one pharmacy student. Team member entry and exit order as well as adherence to hand hygiene were recorded secretly within a 3-month period in autumn 2010. The mean hand hygiene percentage across patient encounters was estimated by the effect of the compliance of the first person entering and exiting an encounter and by the attending physician’s hand hygiene compliance.

718 opportunities prior to contact were observed during 123 patient encounters. Overall, the hand hygiene compliance prior to contact was 52% with a range from 47-67% depending on the training level. There were 133 patient encounters with 744 observed hand hygiene opportunities after contact. Overall, hand hygiene compliance was 70%. The hand hygiene compliance ranged from 64-87% depending on the training level.
Overall, hand hygiene compliance was highest among medical and pharmacy students independent of entering or exiting a room (60.2 % respectively 67.2 % when entering, and 71.2 % respectively 87.0 % when exiting).
If the first person, entering a patient encounter, performed hand hygiene, the mean compliance of the other team members was 64%, but was only 45%, if the first person failed to perform hand hygiene (p=0.002). Upon exiting a patient encounter, the behavior of the first person leaving the room did not appear to influence the others (p=0.33).
When the attending physician performed hand hygiene upon entering the patient encounter, the mean compliance was 66%, but only 42%, if he or she did not perform hand hygiene (p<0.001). Similar effects were observed, when the attending physician exits the room (p=0.013).

There is a strong follower effect for hand hygiene behavior when entering a patient’s room. Regardless the training level, if the first person, entering the room, performs hand hygiene, the others are more likely to perform it, too. This might be due to peer pressure. The attending physician behavior also has affects hand hygiene compliance of the other members after entering and exiting a room, regardless of whether the physician entered the room first or not. Obviously, role modeling impacts the behavior of learners. Senior clinicians should be aware of that and need to do more than just performing the task and expect others to follow. Overall, hand hygiene compliance was greater on exiting encounters, which might be a hint that self-protection is stronger than patient protection.

BMJ Qual Saf 2012;21:499-502

Please click here to download the complete study.