Medical practice

Health workers 'neglect hygiene late in their shifts'

“Visit hospital in the morning to be sure of a doctor with clean hands,” reports The Daily Telegraph.

The Telegraph cites a US study which found healthcare workers often fail to wash their hands and are more likely to wash their hands as advised at the beginning of their shift (not necessarily the morning) than at the end.

Researchers used electronic ID tags for healthcare workers with detectors placed on soap dispensers and hand gels in patients’ rooms to collect data on when the workers washed their hands.

They found that, at most, workers washed their hands on 42.6% of the occasions that they should have. This figure reduced to 34.8% of occasions by the end of a 12-hour shift. Workers were also more likely to wash their hands after longer time off between shifts.

Despite national and local instructions on hand hygiene and infection control, it’s clear from this study that healthcare workers will forget or not bother. And it seems that the more tired – or less rested a worker is – the more likely they are to forget or overlook handwashing rules.

If you’re in hospital or you’re visiting an inpatient, you also have a responsibility to wash your hands before entering areas where patients are and wherever prompted, as well as when leaving. And don’t be afraid to ask health professionals if they’ve washed their hands too.

Where did the story come from?

The study was carried out by researchers from the University of Pennsylvania and the University of North Carolina at Chapel Hill and was funded by the Wharton Dean’s Research Fund and the Wharton Risk Management and Decision Processes Center.

The study was published in the peer-reviewed Journal of Applied Psychology.

The media reported the story fairly accurately, although both the Mail Online and the Telegraph made the error of suggesting that professionals in hospitals have cleaner hands in the morning. In fact the research found that workers were more likely to clean their hands at the start of a shift. As hospitals are open round the clock with shifts overlapping, this could be at many different times of the day. If you’re in doubt,  ask your health professional if they’ve washed their hands – they shouldn’t mind you asking.

The Telegraph’s headline focussed just on doctors, when they had actually only made up 4% of the health workers studied. The Mail Online illustrated its story with a photo of a surgeon washing his hands in an operating theatre environment, but the study did not involve any preparation around surgery.

What kind of research was this?

This was an observational study which compared the number of times health workers complied with the expectation that they should wash their hands both on entering and exiting a patient’s room. As the study was only conducted using radiofrequency equipment, it is not able to provide any explanation for why hands were not washed on each of these occasions.

What did the research involve?

The researchers obtained data from a company that uses “radiofrequency devices” to monitor whether health workers use hand hygiene measures on entering and exiting patient’s rooms. Radiofrequency devices use wireless technology to detect and record devices that have electronic tags implanted in them.

56 units from 35 US hospitals were fitted with these devices to measure hand hygiene opportunities between 2010 and 2013. In this case the radiofrequency devices comprised a “communication unit” attached to soap dispensers and hand sanitisers in patients’ rooms, and radio-frequency badges worn by hospital workers to track their movement and use of the dispensers. From this data, the researchers were able to calculate the number of opportunities that should have led to hand hygiene (the “compliance”), such as every time the health worker entered and exited a patient’s room, and the number of actual episodes.

They collected data from 4,157 health workers, which included:

  • nurses (65%)
  • patient care technicians (12%)
  • therapists (7%)
  • doctors (4%)
  • clinical directors, infection prevention specialists, and others (12%)

The researchers assumed shift patterns and time off work by at least a seven hour gap between the last time they had exited a room and the next time they entered. They excluded any shifts of more than 12 hours.

What were the basic results?

The main results were:

  • hand washing “compliance” reduced from 42.6% of opportunities during the first hour of a shift to 34.8% in the last hour of a 12-hour shift
  • increasingly frequent interactions with patients and more time spent in patients’ rooms reduced hand washing compliance
  • hand washing frequency improved after more days off between shifts
  • taking an additional half day off (12 hours) was associated with a 1.3% increase in hand washing compliance
  • the more hours worked in the previous week, the faster the hand washing compliance reduced during a shift

Using the results of a Swiss study which found that a 1% increase in hand washing reduced the number of infections by 3.9 per 1,000 admitted patients, the researchers calculated that:

  • the decrease in hand washing compliance would cause 7,500 unnecessary infections per year across the 34 hospitals they studied
  • this would equate to 0.6 million infections across all US hospitals per year
  • if 5.82% of hospital acquired infections are fatal, this would mean there would be 35,000 unnecessary deaths per year in the US

How did the researchers interpret the results?

The researchers concluded that their findings suggest that immediate and continuous demanding work environments result in a gradual reduction in compliance with professional standards over the course of aday. They want future research to look at what changes can be made that might improve compliance with hand washing.


This study has found that the compliance with the expectation for health workers to use soap or hand sanitiser both on entering and exiting patients’ rooms was, at best, only 46%. They also found that this reduced over the course of a shift to just 34.8%.

This is even more surprising given that the health workers knew they were being monitored and were wearing the badges.

Reasons for this seemingly low overall compliance rate include that there may have been occasions where there was no direct patient contact (such as just talking to the patient). However, this does not account for why the compliance rate changed over the course of a shift, and is not a valid excuse under the protocol for washing hands. The researchers suggest that the reduced compliance, especially over the course of a shift is due to depleted “mental reserves”. However, the study did not look at how any interventions might improve the compliance.

This study highlights our natural human fallibility – especially when tired. Even with protocols, guidelines and diktats, we tend to forget or neglect to do very important things. In this case, health professionals forgot vital hand hygiene when dealing with patients.

However, it’s worth bearing in mind that this study was carried out in the US, where hospital set-ups are likely to be different (for instance, the patients are described as having their own rooms, which is less common in NHS hospitals).

In the UK, NICE recommends that all healthcare workers should always clean their hands thoroughly, immediately before and immediately after coming into contact with a patient or carrying out care, and even after wearing gloves.

When visiting someone in hospital, you should also be vigilant about washing your hands before and after entering a patient’s room and in other areas of the hospital.

If you are concerned about the hand hygiene of doctors, nurses or anyone else who comes into contact with you or the patient you are visiting, ask them whether they have cleaned their hands.

NHS Attribution