A doctor not washing their hands at work is like a driver reversing into the road without checking their mirrors. At least that’s the point of view of Rachel Ben Salem, deputy director for infection prevention control and head of nursing at King’s College Hospital. “Without safety checks, you’re calling for a crash,” she says.

Reminders to wash your hands thoroughly and often became an unavoidable aspect of public health messaging during the pandemic, but that shouldn’t have been news to anyone. Hand hygiene has long been regarded as one of the main defences against the spread of infectious diseases. Our hands can be carriers for transmissible organisms, including the Covid-19 virus, which can be removed with thorough cleaning.

But hand hygiene compliance is not as simple as it seems, says infection prevention specialist and public health lecturer at Oxford Brookes University, Dr Mamdooh Alzyood. Healthcare staff may well be exposed to continual reminders to wash their hands, but whether they do it or not is impacted by a range of factors – from the culture within their workplace to what feels ‘normal’ to them.

For the levels of compliance seen during the pandemic to last, there needs to be a wider shift in norms surrounding hygiene. “Hand hygiene is not only a procedure; it is a culture,” says Alzyood. “We need to adopt a culture of hygiene. We are not there yet.”

Changed attitudes

Clinical guidance for when healthcare workers should wash their hands hasn’t changed on account of the pandemic. It’s simply being taken more seriously. Published by the WHO, the guidance outlines five points when healthcare professionals should clean their hands: before touching a patient; before a clean/ aseptic procedure; after any risk of being exposed to body fluid; after patient contact; and after touching a patient’s surroundings, such as their hospital bed.

Health professionals have certainly become more aware of these rules and increased their compliance, but both Ben Salem and Alzyood express concern that staff will revert to ‘normal’ once the pandemic is over. “[During] any health campaign, hospital accreditation or safety audit, hand hygiene compliance is perfect,” says Alzyood. “Especially during a hospital accreditation – [staff] know that infection control agents are coming. But after that, we go back to normal.”

This echoes Ben Salem’s experience monitoring and auditing levels of hand hygiene within her hospital as an infection control nurse. “If I come in to inspect the wards, everybody changes their behaviour. Everyone will clean their hands because they’ve seen that I’m watching them, and I’ve seen that happen time and time again,” she says.

Hypervigilance and anxiety about the pandemic have also caused some professionals to overwash their hands and to take excessive hygiene measures, says Dr Manjula Meda, consultant clinical microbiologist and infection control doctor at Frimley Park Hospital in Surrey. “This led to increased and often unnecessary use of gloves and practices such as double gloving, and the use of alcohol hand gel on gloved hands,” she says.

The WHO notes that gloves can help reduce the transmission of pathogens in healthcare settings when used appropriately, but they do not provide complete protection against hand contamination – and are not an excuse for not washing your hands.

Overwashing can carry risk if it causes the skin to become cracked and damaged, because this creates a potential mode of entry for a virus. However, as Alzyood stresses, it’s important to note that this is the only risk, and it can be managed by using moisturiser after you’ve washed your hands to maintain the skin’s normal flora and keep the surface healthy and intact.

Workplace culture

While an individual is responsible for washing their own hands, hand hygiene compliance requires buy-in across the entire workplace. Whether doctors and other senior staff advocate for hand hygiene can make a huge difference to how vigilant staff are about washing their hands, says Ben Salem. Not only does this communicate norms for professional conduct within a workplace, but it also makes it easier for senior figures to be held to account when they don’t comply. “Doctors will challenge other doctors,” she says.

Instilling a uniform culture is, however, complicated by the range of different people that work in hospitals, from cleaners employed by outside contractors to nonclinical staff such as couriers, who are not managed by hospital teams and not always aware of hand hygiene standards. “It’s very hard to manage,” says Ben Salem.

Add in the fatigue and stress caused by long and demanding shifts during the pandemic and managing all these moving parts becomes increasingly difficult.

To hold staff accountable for not washing their hands, appropriate monitoring measures must be in place. However, this poses a number of practical challenges, including resources – health services are already overstretched, and taking on dedicated staff to focus on hand hygiene isn’t realistic for many hospitals.

Self-reported hand hygiene is generally higher than actual levels of compliance, so to say with absolute certainty that a hospital unit has perfect hand hygiene, you would need an infection control agent to sit and watch staff around the clock, explains Alzyood. That isn’t feasible. Monitoring staff using CCTV isn’t an option, either, as this would be a threat to patient safety — plus, there would need to be someone on the payroll watching all those video feeds.

Alzyood recommends that hospitals address these challenges by establishing a workplace culture where it’s seen as the norm to wash your hands thoroughly and when recommended. However, this is easier said than done, and more research is needed into the motivations and behaviours that spur hand hygiene compliance, he adds.

Individual motivators

For the moment, it’s clear that there is an individual and psychological element to ongoing compliance, both in terms of the types of reminders that are most effective, and the motivations staff have for washing their hands well and often.

One of the main reasons both Alzyood and Ben Salem give for low hand hygiene compliance is how simple it is. As handwashing is perceived as basic compared to many of the processes in a hospital, it can be easily forgotten or dismissed.

Educating staff on its importance and then getting them to follow through has been extremely challenging, says Ben Salem. “It’s a war, really, to be honest with you, because people don’t realise the importance of hand hygiene. Even now, with all that we’ve gone through [during the pandemic], people are still laissez-faire, they’re reluctant.”

Research published in the journal PLOS ONE in 2020 identified a number of factors likely to impact handwashing behaviour among nurses, including the perceived ‘openness’ of hospital management, how their performance was perceived by their peers, and increased interactions with patients and staff members. As draining as they might be, it seems Ben Salem’s efforts are worthwhile. “Over half of participants indicated that receiving feedback from a patient or colleague would likely lead to an increase in future hand hygiene action,” the authors wrote.

Some research has been done into the efficacy of visual reminders, such as posters, and olfactory triggers, but Alzyood notes that more is needed – and that future research should broaden its focus beyond clinical environments. After all, healthcare workers are members of the public, too. “Everyone has a responsibility,” he says. “More research should really focus on handwashing in terms of schools and communities, and [what kind of] support we need to really embed this culture within our society.”

Any solution will need to emphasise the importance of having respect – both for hand hygiene and the people around us, adds Ben Salem.

The need for hand hygiene extends beyond this pandemic, and if healthcare workers can maintain their level of compliance, they will help prevent the spread of many infectious diseases, including hospital-acquired infections (HAI). According to NICE figures from 2017, it is estimated that 300,000 patients acquire an HAI in England every year, which costs the NHS around £1bn a year. “Covid-19 is not the only infectious disease,” says Meda. “Staff adherence to simple measures such as good hand hygiene can protect vulnerable and often immunosuppressed patients from acquiring nosocomial or hospital-acquired infections.”


Cost of hospital-acquired infections on the NHS per year.