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Hand-Washing Compliance Declines at the End of Hospital Workers’ Shift

PHILADELPHIA – Chances are that hospital staff packing up to go home after a shift are doing so with less-than-clean hands.

That’s according to new research that finds hospital workers who deal directly with patients wash their hands less frequently as their workday progresses, possibly because job demands deplete the mental reserves healthcare personnel need to continue to follow the rules.

The study, "The Impact of Time at Work and Time Off from Work on Rule Compliance: The Case of Hand Hygiene in Health Care," was published recently in the Journal of Applied Psychology.

Researchers led by Hengchen Dai, a PhD candidate at the University of Pennsylvania, looked at three years of hand-washing data from 4,157 caregivers in 35 hospitals in the United States. Data was provided by Proventix, which uses radio frequency identification (RFID) technology to monitor whether health care workers are washing their hands as recommended, essentially within a specified number of seconds of entering and leaving a patient's room. The workers’ RFID badges are read by communication units attached to hand soap and sanitizer dispensers.

With nurses being 65% of the health care providers in the sample, the remainder included patient care technicians (12%), therapists (7%), physicians (4%) and a small number of others.

Results show that "hand-washing compliance rates" dropped by an average of 8.7% from the beginning to the end of a typical 12-hour shift. Increased work intensity decreased compliance further, according to the report.

"Just as the repeated exercise of muscles leads to physical fatigue, repeated use of executive resources (cognitive resources that allow people to control their behaviors, desires and emotions) produces a decline in an individual's self-regulatory capacity," the authors write.

Workers who had more time off between shifts followed hand-washing protocols more carefully, however.

"Demanding jobs have the potential to energize employees, but the pressure may make them focus more on maintaining performance on their primary tasks (e.g., patient assessment, medication distribution), particularly when they are fatigued," Dai said in an American Psychological Association press release. "For hospital caregivers, hand-washing may be viewed as a lower-priority task and thus it appears compliance with hand hygiene guidelines suffers as the workday progresses."

Using past research – that a 1.0% increase in hand-washing compliance reduced the number of infections by 3.9 per 1,000 patients and that the cost per patient with a health care-acquired infection is $20,549 – the researchers calculated the potential impact of lower hand washing compliance at the end of shifts. Extrapolating their findings to all 5,723 registered hospitals in the United States, the study estimates the infection prevention lapses might cause an additional 600,000 infections per year at a cost of approximately $12.5 billion annually.

"We believe ours is the first study investigating whether accumulated work demands can affect rule compliance over the course of a single workday, as opposed to over weeks, months or years," said co-author Katherine L. Milkman, PhD. "We think this line of research could be applied to other types of workplace compliance, such as ethics standards in banking, safe driving behaviors in trucking and safety standards in manufacturing."