Issue 23 / 24 June 2013

HAND hygiene is the simplest, most effective method for reducing hospital-associated infections in patients.

Yet hand hygiene (HH) programs in Australia and around the world consistently report doctors have the lowest compliance of all professional groups.

This is nothing new — in 1840, Ignaz Semmelweiss provided evidence that HH reduced maternal mortality, yet he failed to convince his colleagues of the benefits of HH or to adopt the practice.

Why are doctors resistant to HH? Studies have shown that being male, being a doctor and working in a high workload area often means they are less likely to clean their hands. Doctors have been quoted as saying they are too busy to perform the task, which may be required hundreds of times a day for a worker with significant patient contact.

We sent an online survey to the hospital email addresses of doctors within our health service in Melbourne. Questions included willingness to remind other doctors to perform HH, reasons for not speaking up, perceived reaction of doctors to being reminded, the doctors’ own perceived reaction to being asked, and doctors’ beliefs about the importance of HH and their role in preventing hospital-acquired infection (HAI).

We found that 98% regarded HH as important or very important and 79% believed they had a large or very large role to play in preventing HAI.

However, willingness to ask another doctor to perform HH decreased as the seniority of the doctor being asked increased — 89% were willing to ask an intern but only 40% were willing to ask a consultant.

The main reason for not challenging interns and residents was the desire not to interrupt them (47% and 35% respectively), but the main reason for not challenging registrars and consultants was an unwillingness to question a senior figure (56% and 64% respectively).

The main anticipated reaction of the doctor being asked to perform HH also differed according to the seniority of the doctor. For registrars and consultants, the anticipated reaction of irritation was 28% and 40% respectively, yet when these doctors commented on what their own reaction would be only 2% of registrars and 5% of consultants said they would be irritated while 55% and 52% said they would be surprised or thankful.

Our study highlights the steep medical hierarchy that exists among medical staff and a reluctance to challenge behaviour.

The aviation industry has identified communication breakdown as paramount in error. Analysis of black box recordings demonstrated most plane crashes were not the result of a single pilot error but a series of miscommunications.

As a consequence, Crew Resource Management (CRM) training is mandatory and has resulted in widespread culture change. The principle behind CRM is that any member of the team — regardless of seniority — can speak up if they notice an irregularity occurring.

CRM training has been adopted by other industries with a strong hierarchical structure (firefighters, defence forces) but is not widely applied in medicine.

In our study, doctors indicated they were embarrassed to question colleagues.

Social power” is defined as the power that a person has in society and among peers and it is recognised as an important determinant of compliance in infection control.

Within hospitals, social power commonly lies with senior staff and the “power” they hold over junior staff engenders emotions such as embarrassment in the face of challenge.

In order to transform behaviour we need to improve communication skills. Empowerment to challenge may involve teaching strategies for delivering sensitive information.

HH represents a platform for future research to examine techniques to empower medical staff to speak up and to encourage each other to facilitate open communication.

Dr Rhonda Stuart and Dr Claire Dendle are infectious diseases physicians with Monash Infectious Diseases, Monash Health, and at the department of medicine, Monash University.


Are you willing to tell senior doctors to wash their hands?
  • Yes - definitely (44%, 74 Votes)
  • Yes - a gentle reminder (32%, 54 Votes)
  • No - not my place (25%, 42 Votes)

Total Voters: 170

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9 thoughts on “Rhonda Stuart

  1. joe Moloney says:

    One of the problems about effecting change, is that one has to strike the right note in communicating with persons at different levels of seniority in the medical team.  One of the pervasive irritations of the current health system is that protocols of clinical management are often officiously presented without a careful respect for those to whom they are addressed.  There is a particualr skill required of some members of the nursing staff for example, if they want to suggest corrections to medical practice.  It doesn’t help that rules seem to differ from hospital to hospital.  In my current position doing locums to different hospitals, I’ve been in the almost comic situation of fulfilling the requirements of two hospitals, but not another one, by exactly the same process, simply because of minor differences perceived as problematic in that one place.  (To do with for example, choosing to use sterile gauze instead of a sterile pack for cannula insertion, and having the temerity to insert a cannula carefully kept sterile, back into a washed area of skin before adminitering broad spectum antibiotics).  Compounding the difficulty is a tendence of nursing staff increasingly to fire off “incident” reports, before having a sensible discussion with those they are wishing to correct.  Personally I find this akin to cowardice, and trouble-making.  (Simply because the trail of paperwork created then becomes seriously intrusive to work committments)

  2. Kyla says:

    It’s hard when working in a high contact area like Emergency.  I am allergic to most of the hand sanitisers, and my hands get so dry and even eczematous with frequent hand washing it’s sometimes very hard to be hand hygeine compliant.  Yes, I carry hand cream and yes I even sometimes carry my own supply of hand sanitiser, but generally my hand skin is a mess and when my skin has broken down it certainly increases my own risk of infection. And yes, I try to wear gloves a lot too.  Sigh. It’s hard.  I’m not trying to trivialise hand hygeine or make excuses, just give some of the daily barriers to gold standard practice in this area.

  3. Meredith Hinds says:

    I agree with anonymous. As a senior doctor, I am also often carrying stuff and sometimes have to put it on the floor to wash my hands. In general in our local base hospital there is a severe lack of desk/bench space and write up room, rooms are very cramped and every inch is being used for something. There is a general feeling of chaos and I think this affects people’s capacity or inclination to follow protocols.

  4. Sue Ieraci says:

    In general, doctors respond better to evidence than to authority I have three suggestions: 1. Bedside videos that capture patient contact, and show evidence of contact without handwash. 2. Prioritise the most important ”moments” – ie touching infected patients with bare hands should be prioritised over washing before and after gloving – get strongest compliance on the most important steps; and 3. Swab hands and surfaces and show us evidence that we are carrying pathogens on our hands. Personally, what works best for me is those bottles of alcohol cleanser everywhere – quick and easy.

  5. Natalia Bovell says:

    As a junior doctor I find the biggest challenge to handwashing is finding somewhere to put all the medical files we need to carry so I can wash my hands.  I often carry around 10 files, a pen and patient medication charts.  Something as simple as a small table beside the basins or beside the antibacterial hand gel would be greatly appreciated by the junior staff.  There is also a LOT of time pressure as we zoom from patient to patient (files, pens, charts in hand) with the often limited time we have face to face with consultants. 

  6. ann says:

    Washing hands is just common sense and theres no excuse for neglecting it in Australia.
    Junior doctors are willing to jeopardise patients health by not reminding more senior staff to wash their hands out of fear of repercussions or avoidance of conflict.
    There’s clearly an even greater issue then hygiene which needs addressing,the issue being of the hierarchical system which is still in play in hospitals.
    This system is outdated and encourages egos,can jeopardise patients treatment,etc

  7. patricia goggin says:

    The 5 moments of Hand Hygiene are part of Infection control policies in each state and frankly there is no excuse for non compliance with any health professional.When will medical staff be accountable & take ownership of poor practice,?There is no doubt why Semmelweiss went mad!

  8. elizabeth merrilees says:

    Many hospitals have hand santitation stations everywhere and at the door or foot of patient beds, yet cleaners, orderlies and nurses seem much more likely to use them than doctors.

  9. Dr Richard Shiell says:

    Whenever a nurse or doctor physically touches a patient he/she must be followed by a mobile wash bowl and conditioned to hand wash.  This would be quite easy to organise on Ward-Rounds but more difficult with less formal contact from  Nurses, Residents and Medical students.

    As with seat-belt wearing it will be hard for a start but within a year we will wonder at our past negligence.

    Dr Richard

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