Allow me to set the scene: I was visiting an elderly relative in an NHS hospital recently (they would deny being elderly – but I’m afraid it is now true). I witnessed a healthcare worker moving efficiently from bed to bed examining each patient (including direct patient contact) to take observations without any hand hygiene between patients and without decontamination of the reusable blood-pressure cuff. I explained to my relative the need to challenge this behaviour. My relative asked – almost pleaded with me – not to intervene saying “you’ll clear off and they’ll be left caring for me overnight”. So, did I have the courage to defy my relative and challenge this behaviour?
I’ll tell you later. But before I do, let me turn your attention to a recent study in AJIC. A survey of healthcare workers, patients, and relatives examined attitudes towards patients challenging healthcare workers about poor hand hygiene practice. Of the 196 healthcare workers surveyed, only 32% supported patients challenging hand hygiene practice (42% of doctors and 25% of nurses). The main reasons that doctors took this view was a perceived lack of patient expertise to make a useful challenge (aka “patients don’t know what they’re on about”), and concerns about how it would damage the patient-doctor relationship (aka “this would erode my sense of power”). Depressingly, the main reason for nurses not supporting patient participation what that it is unnecessary (aka “inconvenient”).
From a patient viewpoint, among the 337 patients and relatives surveyed, the main reason for not challenging healthcare workers about hand hygiene was a fear of either causing annoyance of being treated differently (76%) – the same concern held by my relative. The authors found that being female, younger than 55, having a higher level of education, and observing hand hygiene practice were significantly associated with an intention to challenge staff about hand hygiene.
My own view is that we should embrace patients and their relatives as a useful source of ‘nudge’ reminders about hand hygiene. Healthcare workers came into this business to do the right thing, not to harm patients, and most will respond well to being challenged about hand hygiene practice. But perhaps we need a less combative language for the dialogue (“ask me about hand hygiene” vs. “challenge poor practice when you see it”), and perhaps we need to give patients and visitors express permission to remind staff about hand hygiene. It’s not right to make patients accountable for ensuring that staff perform hand hygiene when caring for them: that responsibility rests with the healthcare worker. But the more nudge reminders we can introduce into the clinical setting, the better.
So…did I challenge the healthcare worker who was going from bed to bed without performing hand hygiene? In the end, I did not. But I wish that I had. In hindsight, I should have found a way to gently remind the healthcare worker about hand hygiene without creating tension. I guess that I didn’t think quickly enough. Fortunately, my mum was discharged without any signs of infection. But others are not so lucky. So, let’s all find ways to productively include our patients and their relatives in our efforts to get hand hygiene right.
Image: Pixabay.
Reflections on Infection Prevention and Control 
This same thing happened to me when my daughter was admitted for a cardiac ablation. I witness numerous missed opportunities for hand hygiene as well as other infection control practices. I said nothing. Why? because I was terrified at what their reaction may be and I didn’t want my daughter to be in an even more vulnerable situation than she already was. So incredibly disappointing that I couldn’t trust my own profession to do the right thing and act with integrity.
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Pleased to hear I’m not alone (and hope your daughter is ok)
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I have experienced that missed opportunity for hands washing. It’s devastated and very shocking. Some health care professionals should think very carefully about the fact that no washing hand after providing care to a patient could lead to serious complication or consequences.
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Thank you for being open about this tricky subject, Jon. It’s an entirely relatable situation and you’re almost certainly not at all alone in this regard.
To what extent is the hand hygiene non-compliance caused by staff being tired/over-worked, or demoralised by management practices and funding cutbacks?
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I’m sure it’s a factor – but not the only driver
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Interesting dilemma Jon. Many years ago patients going into hospital could buy Patientpak , a personal antimicrobial kit that contained a sign to display at the patient’s bedside that said “Please wash your hands before treating me”.
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I know this is a problem. I was in a holding bay overnight in the ED, with an out of control fever. There were 9 of us patients lined up along a wall in guerneys. The man next to me had an MRSA alert hanging over his bed. The nurse attended to him, then came to me with same gloves on and no hand hygiene, and said ‘is it OK if I give you your IV antibiotic now’. I replied, ‘yes if you wash your hands first’. She became very angry with me, stomped over to the sink, then switched on the tap. Then switched off the tap and squirted some solution on to her gloved hands but did not remove her gloves and did not wash her hands. Hence, I had to refuse the medication for fear I would get some sort of infection through the cannula. Very upsetting experience.
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I had a similar interaction as an IPC nurse-
an elderly (90’s) relative was in hospital with leg ulcers and type 1 diabetes
the medic came to put in a CVC line
blue tray not cleaned as i observed where he took it from
No hand hygiene
rings on fingers long sleeves and watch on wrist.
he was about to commence the insertion of the CVC
I asked him to hold on and explain what he was about to do – he explained
my reply was:
Does this trust not employ a BBE policy and I would be vary happy if he cleaned his hands prior to the procedure.
he immediately left the patient bay and complained to the ward sister who informed him I was a nurse.
he came back -apologised – and did the right thing rolled up sleeves removed jewellery and washed his hands with soap & water
then started the procedure at the bedside, as he left I thanked him for’ doing the right thing’ No worries he replied
MY WORRY was ……what if I had not been in the room at the time?
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Today a patient who I met in the hospital corridor told me: No, I am not going to shake your hand because I am “ESBL+”.
That was a very welcome “nudge” and wish we could encourage patients to be more assertive on this matter.
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