A new study has a message for doctors and nurses who fail to wash their hands: Don't think about yourself. Think about your patients.
Getting health care professionals to comply with notices to wash their hands before and after dealing with patients has been something of a thorn in the side of many hospitals. Although this simple measure limits the spread of sickness — and could potentially reduce the nation's hospital health care bill by billions of dollars — many doctors and nurses simply ignore it. Compliance rates for hand washing in American hospitals are only around 40 percent,and years of awareness programs urging doctors to wash up or use disinfectant gels have had little effect.
Part of the problem, according to a forthcoming study in the journal Psychological Science, are the actual signs posted in hospital washrooms urging health care workers to wash up. Changing the message from "Wash Your Hands to Protect Yourself" to "Wash Your Hands to Protect Your Patients," the study found, could motivate some doctors and nurses to wash their hands more frequently.
"There's this perception among some health care providers that 'I'm around sick people all the time and I don't get sick very often, so my immune system is extra strong,'" said David Hofmann, an author of the study and a professor of organizational behavior at the University of North Carolina at Chapel Hill. "But if you go back to the Hippocratic oath that all doctors adhere to, it's 'First do no harm.' So if you have a sign that says 'Hey, look, here's a really vulnerable person you're about to walk in and see,' then maybe a sign focused on that person will cue this larger core value in the physician to protect the patient."
To find out, Dr. Hofmann and his co-author, Adam Grant, took baseline measurements of the amount of soap and disinfectant caregivers used in a large North Carolina hospital. Then they measured the change in soap use when they put up different signs by the dispensers. One sign read "Hand Hygiene Prevents You from Catching Diseases." Another read "Hand Hygiene Prevents Patients from Catching Diseases." And a third sign, which served as a control, had a generic message: "Gel In, Wash Out."
The patient-focused sign produced a 33 percent increase in the amount of soap and disinfectant used per dispenser over a two-week period, compared with the other signs.
In a second phase of the study, trained observers recorded how often doctors and nurses physically washed or disinfected their hands. The sign urging doctors to think about patients produced a roughly 10 percent spike in hand washing compliance, a jump that was small but statistically significant.
"We think it's proof that this identifies a vulnerable person and therefore cues more responsibility on the health care worker to protect that patient," Dr. Hofmann said. "We think that signs focused on vulnerable patients seem to have a stronger effect, and we would encourage hospitals to adopt that kind of approach."
Some experts caution that while any increase in hand washing rates can go a long way, the causes of low compliance are complex and varied. A 2009 report from the Joint Commission, a group that accredits more than 19,000 hospitals, nursing homes and other health care providers, found that the reasons for skipping soap varied from hospital to hospital, and even from unit to unit on a single floor. Some doctors said their hands were usually too full when they walked into a patient's room. Others complained that too much soap dried out their hands or said the placement of sinks and gel dispensers was inconvenient.
Still, the data also showed that when hand hygiene compliance in a hospital went up, patient infection rates went down, and that discussing this specific source of patient harm with doctors was an effective way to persuade caregivers to wash up more frequently, said Anne Marie Benedicto, the chief of staff for the Joint Commission and the Center for Transforming Healthcare. She said that simply changing the messages of signs urging hand washing was unlikely to eradicate the problem, but she called it a step in the right direction.
"I would say that if these issues could be solved by a poster, we would have solved them a long time ago," she said. "But the whole idea of creating an environment that's focused on patient safety is a good way of thinking about it."