Closing the Gap Between Hand Hygiene Perception & Reality

Healthcare workers commonly estimate their hand hygiene compliance before touching a patient to be nearly 80%. In actuality, compliance is often as low as 12%, according to a 2022 study published in the Journal of Infection Prevention.

Providers simply don’t wash or sanitize their hands as often as they think they do. The 2022 Journal of Infection Prevention study found that both doctors and nurses overestimate hand hygiene compliance, estimating an average compliance rate of almost 70% after touching patient surroundings, though actual compliance in those circumstances was only 18%. A 2019 study found that hand hygiene compliance rates before gloving were just 42%, even though nearly every healthcare worker surveyed said they always perform hand hygiene before donning gloves. 

The gap between providers’ perception of hand hygiene practices and actual practice is large – and stubbornly persistent. Researchers and infection control preventionists have known about this gap for years, but it remains despite efforts to improve hand hygiene. Finding a way to close the gap between hand hygiene perception and reality may be key to improving patient outcomes and decreasing healthcare associated infections (HAIs).

Cognitive biases cause healthcare providers to overestimate hand hygiene

Scientists now know that our physical bodies affect our perception. Researchers have found, for instance, that people who are physically tired overestimate the amount of work a task may take. Humans are also more likely to perceive simple, easy-to-read messages as true than complicated or difficult-to-read messages, even if both messages contain the exact same words.

Psychologists have also discovered that cognitive biases – subconscious errors in thinking caused by the human brain’s innate tendency to simplify information and filter it through personal experience – skew judgment. According to an article shared by the Association for Psychological Science, hospital workers are prone to “an ‘illusion of invulnerability’,” which means that they’re likely to overestimate their personal immunity to germs. This cognitive bias may be one reason healthcare workers don’t perform hand hygiene as often as they should; after all, they subconsciously believe that they’re already quite well protected from germs.

Overconfidence, or “confidence greater than reality justifies,” is another cognitive bias that’s prevalent among healthcare workers. A 2020 research study examining medical students’ perception of hand hygiene is revealing: each of the 1042 surveyed students rated their capabilities in hand hygiene “higher than those of fellow students, nurses, and physicians.” 

Overconfidence can be a good thing – after all, a healthcare provider who doubts his ability to act effectively is unlikely to quickly respond to a Code Blue – but it can also interfere with quality improvement efforts. Healthcare workers who believe that they’re performing hand hygiene almost every time it’s required are unlikely to devote any time to changing their practice. 

These providers may also resent interventions designed to increase hand hygiene compliance. As stated by the authors of the 2020 study looking at medical students’ relationship to hand hygiene, “The condition to unintentionally rate one-self’s hygiene and communication abilities to be better than the competencies of other persons is likely to lower the intrinsic motivation to attend infection control trainings.”

Objective measures of reality can stimulate action

Sometimes, simply pointing out the gap between perception and reality is enough to motivate behavior change. When researchers recorded a gap between physicians’ perceived prescribing patterns and actual prescriptions, “significant changes in prescribing behavior occurred,” according to a small 1983 study. 

It’s not clear if reviewing the prescription data was sufficient to permanently alter the physicians’ prescribing patterns or if additional interventions were needed. However, this study points to the need to measure objective data, compare it to providers’ perceptions, and then discuss the findings.

A more recent 2022 study that looked specifically at doctors’ and nurses’ hand hygiene compliance recommends behavior change techniques to address overconfidence and overestimation biases. Accurate, objective hand hygiene data collected by electronic systems can be invaluable as it allows leaders to draw “attention to discrepancies between current behavior and relevant self-images to create cognitive dissonance.”

 A hospital that can’t document healthcare providers’ actual hand hygiene has little chance of effectively improving hand hygiene rates and, in turn, decreasing HAIs. In contrast, healthcare facilities that track hand hygiene with technology can share objective data with employees, which may motivate them to make the changes needed to align their practice with their perception.