Overcoming Patient Barriers to Discussing Physician Hand Hygiene

Do Patients Prefer Electronic Reminders to Other Methods?

Kaarin Michaelsen, PhD; Jason L. Sanders, PhD; Shanta M. Zimmer, MD; Gregory M. Bump, MD


Infect Control Hosp Epidemiol. 2013;34(9):929-934. 

In This Article

Abstract and Introduction


Background. Despite agreement that handwashing decreases hospital-acquired infections (HAIs), physician hand hygiene remains suboptimal. Interventions to empower patients to discuss handwashing have had variable success.

Objective. To understand patient perceived barriers to discussing physician hand hygiene and to determine whether patients prefer electronic alerts over printed information as an intervention to discuss physician handwashing.

Design. Cross-sectional study of 250 medical/surgical patients at an academic medical center.

Results. Ninety-six percent of patients had heard of HAIs. Ninety-six percent of patients thought it was important for physicians to clean their hands before touching anything in a patient's room. The majority of patients (78%) believed patients should remind physicians to clean their hands. Thirty-two percent of patients observed physician hand hygiene noncompliance. In multivariate analysis, predictors of not speaking up regarding physician hand hygiene included never having worked in health care (odds ratio [OR], 2.8 [95% confidence interval (CI), 1.5–5.1]), not observing a physician clean hands before touching the patient (OR, 2.4 [95% CI, 1.3–4.4]), and not thinking patients should have to remind physicians to clean hands (OR, 5.5 [95% CI, 2.4–12.7]). Ninety-three percent of patients favored electronic device reminders over printed information as an intervention to encourage patients to discuss hand hygiene with their doctors.

Conclusions. The strongest predictor of not challenging a doctor to clean their hands was not believing it was the patient's role to do so. Patients prefer electronic device reminders to printed information as an aid in overcoming barriers to discussing hand hygiene with physicians.


Despite widespread agreement that physician hand hygiene is important, compliance with handwashing remains suboptimal.[1–3] Educating physicians that handwashing prevents hospital-acquired infections (HAIs) has not led to sustained improvements.[4] Previous interventions targeted at healthcare providers to improve handwashing behavior have demonstrated variable success.[5–9] For example, introducing a 1:1 bed/sink ratio in intensive care units resulted in increased hand hygiene by nurses (63%) compared with physicians (19%).[8] The change to alcohol hand rubs increased overall healthcare worker compliance from 47.6% to 66.2%, but physician compliance remained low at 31.1%.[6] Using technology such as third-party remote video auditing of healthcare workers with continuous, near real-time feedback has been shown to increase hand hygiene rates from less than 10% to 81.6%, with a maintained increase through 75 weeks at 87.9%.[10] However, such technology is expensive and not always feasible for hospitals to implement.

Patient empowerment is recognized as 1 tool to increase handwashing compliance.[11–15] To encourage patients to discuss handwashing with healthcare workers, strategies rely on patient education regarding the importance of hand hygiene, coupled with the extension of explicit invitations to ask all healthcare workers if they had cleaned their hands. Similarly, the use of prompting visual aids—including posters, lapel pins, and small toy objects—have been tested. Despite this encouragement, barriers to patient participation in hand hygiene compliance clearly still exist.[11–19] Previous studies[12,16] have shown that even with encouragement, patients are more likely to challenge nurses and support staff regarding hand hygiene compared with physicians. To date, studies focusing exclusively on patients' reluctance to breach the "white coat barrier" and openly discuss hand hygiene with their physicians are lacking. Moreover, as new technologies to report and track hand hygiene become commercially available,[10,20–23] patient willingness to accept electronic alerts as prompts to improve physicians' compliance with hand hygiene has not been comprehensively studied. Thus, this study has 2 goals. First, it seeks to understand patients' perceptions of physician hand hygiene and their reasons for not discussing hand hygiene with physicians. Second, it aims to determine whether patients would accept and prefer electronic alerts versus traditional information packets on hand hygiene as prompts to increase physician hand hygiene compliance.