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  Table of Contents  
Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 280-282

Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital

1 Judge Business School, Darwin College, University of Cambridge, United Kingdom
2 Centre of Development Studies, University of Cambridge, United Kingdom
3 Department of Microbiology, Tata Medical Center, Kolkatta, West Bengal, India
4 Department of Palliative Care and Psycho Oncology, Tata Medical Center, Kolkatta, West Bengal, India

Date of Submission11-Dec-2012
Date of Acceptance11-May-2013
Date of Web Publication25-Jul-2013

Correspondence Address:
S Bhattacharya
Department of Microbiology, Tata Medical Center, Kolkatta, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.115639

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 ~ Abstract 

Poor hand-hygiene (HH) is the primary cause of health-care related infections, yet compliance has proven to be challenging. This multi-method study into HH in a state-of-the-art cancer hospital demonstrates that the presence of resources and prioritisation of HH alone is not sufficient for HH compliance. A large gap was found between perceived (87%) and actual (52%) HH compliance and knowledge. Similarly, although 82% of the respondents knew proper HH moments, they did not act on it. These gaps between perception and reality suggest that resources, knowledge and training might not be sufficient for improving HH: Psychological barriers need to be addressed too.

Keywords: Attitude, compliance, hand-hygiene, perception, psychological barriers

How to cite this article:
Dalen R v, Gombert K, Bhattacharya S, Datta S S. Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital. Indian J Med Microbiol 2013;31:280-2

How to cite this URL:
Dalen R v, Gombert K, Bhattacharya S, Datta S S. Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital. Indian J Med Microbiol [serial online] 2013 [cited 2021 Feb 26];31:280-2. Available from:

 ~ Introduction Top

Hand-hygiene (HH) practices remain a salient issue across the world. Poor HH is the primary cause of health-care related infections, in particular those caused by multi-drug resistant organisms. [1],[2] Infections prolong hospital stays, increase costs of treatment and increase the risk of adverse outcomes for the patient. [3]

The current study investigates actual and perceived HH compliance in a 14 month old modern oncology hospital, the Tata Medical Center (TMC), Kolkata.

 ~ Materials and Methods Top

The study was carried out in the month of August 2012 and consisted of three parts. First, an observational study investigated HH compliance (World Health Organisation [WHO's] 5 opportunities for HH and quality of hand-cleaning) in the general wards, intensive care unit, high dependency unit and surgical bays. In total 470 min of observations were completed. The observed population consisted of doctors (13%), nurses (70%), housekeeping staffs (9%) and visitors of patients (9%). The other two parts of the research entailed a HH knowledge questionnaire and a HH-attitude survey. The latter two were conducted among 35 nurses and 34 doctors. For all three parts standardised observation charts and questionnaires of the WHO and the Centres for Disease Control and Prevention were used. [4],[5]

 ~ Results Top

Observational study

Of all the moments, which required HH actions, in only 14% was proper HH performed. In 58% of cases, HH was omitted and in the remaining 28%, HH was performed, but done poorly. The wrist was missed in 16% of cases and 11% of cases both wrists and web between the fingers were missed. The opportunities most frequently missed [Figure 1] and [Figure 2] were before and after touching the patient (29% and 18% respectively) and patient surroundings (43%). Nurses and doctors claimed HH compliance to be 88% and 85% respectively for themselves while actual compliance was 47% for nurses and 51% for doctors [Table 1]. Nearly, 82% knew the right moments of HH in theory, yet in practice most staff did not comply. Housekeeping and visitors with compliance rates of 18% and 21% respectively performed the worse. Lastly, during ward rounds 90.5% of the doctors were found to wear infection carriers such as rings, watches, bracelets and stethoscopes.
Figure 1: Hand-hygiene practices and missed opportunities

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Figure 2: Profile of missed opportunities in hand-hygiene

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Table 1: Perceived and actual hand-hygiene performance

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Attitude study

The survey results paint a picture of HH compliance at TMC that strongly diverges from reality. Respondents found that HH receives a priority among all issues at TMC and they all acknowledge the importance of HH in preventing health-care associated infections. On a scale of 0-4, with 0 is "not important at all" and 4 "very important", both items scored above 3.5 on average. Most significantly, everyone was very positive about both their own and others performance in HH: The average estimation is close to 90%; although, the doctors have less confidence in others: They estimated the compliance of their colleagues to be 65%.

Knowledge study

The questionnaire, which tested respondents' knowledge of HH, showed that 82% could identify the proper HH moments. However, there were also some gaps, mainly in the clinical knowledge: To questions on the survival of pathogens and hand-rub effectiveness over half of the respondents answered wrong.

 ~ Discussion Top

The 5Fs (food, fomites, flies, feces, finger) through which enteric infections are transmitted are applicable to the transmission of nosocomial infections. [5] The factor that is most difficult to control in a hospital setting is the 'finger factor'. Lack of proper HH facilities such as availability of rubs and HH points has been often quoted as a leading cause of high infection rates. [6] However, the present hospital is a state-of-the-art advanced oncology hospital, which complies with all WHO standards.

Despite state-of-the-art facilities, plenty resources and perceived prioritisation of HH among hospital staff, HH compliance was poor. Our results hint that underlying mechanisms causing this outcome are psychological by nature. Three key findings that stood out were discrepancies between perceived and actual HH compliance, lack of HH adherence in spite of knowledge and perception of one's own professional group to be more adherent than others.

Psychology research has shed some light on these results. Human behaviour has two components (a) intrapersonal factors, e.g., belief, attitude, knowledge etc., (b) interpersonal factors that include interpersonal processes and peers that provide social identity. [7],[8] In our study, the divergence of perception of one's own compliance with actual observed compliance rate can be explained by multiple psychological factors as lack of insight into one's own practices in the absence of robust feedback mechanism, psychological defensiveness, social desirability bias towards the study researchers, classic attribution error of 'bad things being perceived to be carried out by others' and taking 'personal credit for good things happening' in any situation. [9],[10],[11]

Therefore, the various psychological barriers to implementation of good HH practices could be those related to staff work related (increased work load), cultural (relative importance given to high tech skill acquisition rather than simple routines), attitudinal (views towards HH), administrative (relative importance given to infection control strategies) and motivational (no added incentive in practicing good HH).

Lack of knowledge could be tackled with training and education. However, psychological factors such as motivation, commitment, discipline, group dynamics and culture are more difficult to tackle. These require behaviour modification techniques and appropriate rewards for good behaviour.

The findings of the current study are not significantly different from other studies in India and the developed world in essence: Resources alone do not ensure sound HH practices. [6],[7],[8] However, in this study in contrast to others, we emphasise the point that to change practices of staff - assuming sufficient resources - we need to work with specialists in (group) psychology.

 ~ Conclusion Top

Despite vast resources, prioritisation of HH and high perceived HH standards of the modern hospital in which the research took place, poor HH compliance was found. Results suggest that psychological factors such as motivational and group dynamics are a key underlying cause. Our findings highlight that by focussing on resources and training only, the high infection rates associated with poor HH compliance might not be solved. An increased focus on psychological aspects, which influence decision making in HH campaigns might therefore be important.

 ~ References Top

1.Chakrabarti A, Singh K, Narang A, Singhi S, Batra R, Rao KL, et al. Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India. J Clin Microbiol 2001;39:1702-6.  Back to cited text no. 1
2.Paul R, Das NK, Dutta R, Bandyopadhyay R, Banerjee AK. Bacterial contamination of the hands of doctors: A study in the medicine and dermatology wards. Indian J Dermatol Venereol Leprol 2011;77:307-13.  Back to cited text no. 2
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3.Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285-92.  Back to cited text no. 3
4.Measuring hand hygiene adherence: Overcoming the challenges. The Joint Commission. Available from: [Accessed on 2013 Feb 4].  Back to cited text no. 4
5.World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Available from: may/tools/9789241597906/en/index.html. [Accessed on 2013 Feb 4].  Back to cited text no. 5
6.Devnani M, Kumar R, Sharma RK, Gupta AK. A survey of hand-washing facilities in the outpatient department of a tertiary care teaching hospital in India. J Infect Dev Ctries 2011;5:114-8.  Back to cited text no. 6
7.Pittet D. The Lowbury lecture: Behaviour in infection control. J Hosp Infect 2004;58:1-13.  Back to cited text no. 7
8.Iñiguez G, Tagüeña-Martínez J, Kaski KK, Barrio RA. Are opinions based on science: Modelling social response to scientific facts. PLoS One 2012;7:e42122.  Back to cited text no. 8
9.Aunger R, Schmidt WP, Ranpura A, Coombes Y, Maina PM, Matiko CN, et al. Three kinds of psychological determinants for hand-washing behaviour in Kenya. Soc Sci Med 2010;70:383-91.  Back to cited text no. 9
10.Judah G, Aunger R, Schmidt WP, Michie S, Granger S, Curtis V. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health 2009;99 Suppl 2:S405-11.  Back to cited text no. 10
11.Zhong CB, Liljenquist K. Washing away your sins: Threatened morality and physical cleansing. Science 2006;313:1451-2.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]

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