Getting doctors to clean their hands: lead the followers.

Background: Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence.

Methods: Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physician's HH compliance.

Results: 718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physician's HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters.

Conclusions: If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physician's behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.