Why healthcare workers don't wash their hands: a behavioural explanation

Hand-washing compliance was examined by thematic analysis of focus group discussions in nurses, mothers and children. Perceptions in these groups were identical, with the purpose of hand-cleansing seen as self-protection from infection. This assessment is not grounded in microbiology, but is strongly driven by emotion.Two types of hand-cleansing (“hand-hygiene”) behaviour were identified: (a) “inherent” hand-washing. This behaviour is taught by mothers to their children early in life. The behaviour occurs when hands have been visibly or “emotionally” soiled or feel sticky, and drives most hand-hygiene undertaken in the community; and(b) “elective” hand-hygiene, which occurs in the absence of perceived threat. As patient contact by healthcare workers is frequently assessed by healthcare workers as not posing risk, healthcare workers omit much elective hand-hygiene, leading to potential cross-infection. Modelling responses of 754 nurses on the Theory of Planned Behaviour for these two hand-hygiene behaviours in the healthcare setting explained 64% of elective hand-hygiene and 76% of inherent hand-washing intention.Translation of hand-washing behaviour patterns of the community into the healthcare setting is the predominant driver of all hand-hygiene in healthcare workers. In-hospital elective hand-hygiene behaviour is further significantly predicted by belief in the benefit from the activity, peer pressure and role modelling of senior physicians and administrators. For inherent hand-washing intent, only attitudes and peer behaviour are predictive. Time constraints, commonly implicated to explain poor compliance, are important mostly to elective hand-hygiene. Reduction in necessary effort by introducing an alcohol-based hand rub without a concomitant behavioural modification program will therefore have only minimal impact. Further components essential to hand-hygiene programs have been identified. These accord with the outcomes of the modelling and include the need for institutional recognition of hand-hygiene as a priority, overt clinician leadership support, and reinforcement of purpose by both education and performance feedback. In the long-term, society would be best served by altering the entire paradigm of hand-hygiene behaviour with nationwide campaigns based on principles of social marketing. Ideally, hand-hygiene should be taught by mothers and reinforced in early education programs as behaviour that is self-protective but with the defining theme: ����clean your hands, and protect others, not just yourself.&#148