Clinician, wash thy hands: When the patient becomes the enforcer

As an intensive care physician at a hospital in Saskatoon, Dr. Susan Shaw is both comfortable and confident in the health care setting. But when she recently had to bring her daughter to the emergency room with a broken arm, “I couldn’t do it,” she blogged recently. “I couldn’t ask the nurses and doctor who looked after my daughter to wash their hands.”

If she was uncomfortable speaking up, what about the average patient and family?

Dr. Shaw’s experience illustrates an important and often overlooked issue in patient safety: the gap between what patients and families are told to do – “Remind providers to wash their hands” – and their willingness and/or ability to actually do so.

Hand washing is one of the key ways clinicians can avoid spreading germs to their patients and reduce the risk of infections acquired in the hospital setting. Yet health care workers often are inconsistent at washing their hands. In various studies that have attempted to measure hand washing compliance, the rate at some hospitals has been estimated at an abysmal 25 to 30 percent. Some studies have measured especially low rates among doctors and medical students.

No wonder, then, that patients and families have been enlisted in the campaign to help clinicians do better. But is the public any more successful in the role of enforcer than hospitals, medical clinics and nursing homes have been? It seems the answer is no.

A study that appears this month in the Infection Control and Hospital Epidemiology journal queried 200 patients about their awareness of the importance of hand washing and whether they would feel comfortable reminding nurses and doctors to wash their hands. The patients, all of whom were considered at higher risk for infections such as methicillin-resistant staph, were highly aware of the need for hand washing – but only 14 percent said they had ever spoken up and asked a health care worker to wash their hands. Moreover, only about half said they wouldn’t feel awkward asking a doctor to wash his or her hands.

Why such a gap between theory and practice? Based on her own experience, Dr. Shaw suggests some reasons:

I was worried about making the doctor and nurses feel uncomfortable. I knew my daughter’s care wouldn’t be compromised if I upset the doctor and nurses. I just didn’t want any awkward feelings.

Readers weighed in with similar stories of being too uncomfortable to ask – or of asking and being met with a grudging response. One person wrote, “When I did ask a nurse if she had washed her hands, I was greeted with a look that said to me I had been labeled a ‘difficult family member.’”

Indeed, more than a few health care professionals believe it’s not the patient’s or family’s place to remind them to wash their hands, as a study published a few months ago in the Archives of Internal Medicine concluded. Nearly one-third of the doctors and nurses who were surveyed said it was inappropriate for patients and families to have a role in this, and almost two out of five said they wouldn’t wear a button or sticker urging patients to ask them if they washed their hands. The reasons they gave: 43 percent said a reminder from a patient or family member would make them feel guilty, 27 percent said it would be humiliating and about 25 percent said having to stop and wash their hands in response to prompting by the patient would take too much time.

It all begs the question: Is it effective or even realistic to expect patients to help enforce hand washing compliance?

Patient and family participation is difficult to accomplish when the culture of a health care organization doesn’t openly encourage and support it, Dr. Shaw wrote. “I think it comes down to creating a new norm where healthcare workers clearly give permission to patients to expect and demand hand hygiene be part of care each and every time. This means focusing on the culture, behaviours ¬†and attitudes of us as healthcare providers.”

There’s an even larger issue here, though, and it’s this: Should hand hygiene be a shared responsibility between patients and clinicians, or does it rest first and foremost with the health care professionals?

Dr. Shaw reflects: “What I learned from my experience is that is the responsibility of the care provider and the healthcare system to do the right thing every time for every patient without expecting patients to be the inspectors of our work.”

Perhaps we shouldn’t be asking how to make it easier for patients and families to speak up and remind clinicians to wash their hands. Perhaps we should be asking instead how to get clinicians to wash their hands every time without needing to be reminded by patients.

2 thoughts on “Clinician, wash thy hands: When the patient becomes the enforcer

  1. Perhaps this is a problem in that particular Canadian Hospital , but not here in Fargo. My wife and I work in the local hospitals here in Fargo. I work at Essentia and my wife works at Sanford. Hand washing is very strictly enforced. We both wash our hands before and after each patient encounter. In fact we both put on gloves when examining patients. I work in the ER. She works in a clinic. Our hospital infection control department even monitors us on the cameras to see if we are being compliant. Your concerns about hand washing is valid . If you see a nurse or a doctor/ provider not using good hand hygeine , then you should absolutely speak up. Afraid of not being North Dakota nice is not worth the risk of a hospital aquired infection .But please be assured , in Fargo, we do a great job.

    • On behalf of patients everywhere, thank you for being so diligent about washing your hands.

      A lot of this seems to come down to organizational culture and a commitment to providing safe, quality care. Some organizations truly get this and have been successful in engaging their staff. Others seem to struggle with it for whatever reason.

      In an ideal world, patients and families wouldn’t have to speak up about hand washing because the doctor or nurse would already have washed their hands without needing to be reminded by the customer, their patient. Although patient participation is something that should be encouraged, I have to wonder whether it’s a good idea or even appropriate to expect them to be the backstops or the enforcers for safe practices that clinicians ought to be following, period. Hence my final question: Who has the ultimate responsibility here?

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