Appleyard B. The Brain is Wider than the Sky: Why simple solutions don't work in a complex world.London: Weidenfeld & Nicolson; 2011

Dobelli R. The Art of Thinking Clearly.London: Sceptre; 2013

Hoang D, Khawar N, George M Video didactic at the point of care impacts hand hygiene compliance in the neonatal intensive care unit (NICU). J Healthc Risk Manag. 2018;

Ibrahim MAB, Chow C, Poh BF Differences in psychosocial determinants of hand hygiene between health care professional groups: Insights from a mixed-methods analysis. Am J Infect Control. 2018; 46:253-60

Mahida N, Boswell T, Vaughan N. Re: In defence of high hand-hygiene compliance rates. J Hosp Infect. 2017; 97:30-4

Ooi R, Griffiths A. Obstetric competence and compliance with surgical hand antisepsis prior to elective and emergency surgical procedures: A closed-loop audit. J Hosp Infect. 2018;

Saito H, Borzykowski T, Kilpatrick C ‘It's in your hands–prevent sepsis in health care': 5th May 2018, World Health Organization (WHO) SAVE LIVES: Clean Your Hands campaign. J Hosp Infect. 2018;

Sedgwick P. Understanding the Hawthorne effect. BMJ. 2015; 351

Handwashing and psychology

02 April 2018
Volume 26 · Issue 4


That health professionals should wash their hands seems obvious, but why are compliance rates so low? As George Winter explains, simple doesn't always mean easy

The acronym KISS (Keep It Simple, Stupid) is attributed to the American aeronautical engineer Kelly Johnson.

On the face of it, simplicity makes sense, but it can be complicated. As Appleyard (2011) argues, ‘simple solutions don't work in a complex world’.

Few things are more complex (or should that be ‘complicated’?) than the way we think. We are prone to deviating from logical, reasonable thought and behaviour: we overestimate our knowledge, worrying more about the prospect of losing something than making a similar gain, and ‘[i]n the presence of other people we tend to adjust our behaviour to theirs, not the opposite’ (Dobelli, 2013:2).

Let us consider handwashing. It is clear that handwashing can prevent infections, yet the median compliance rate among health professionals is around 40% (Ibrahim et al, 2018). Even placing cameras to monitor handwashing protocols does not boost compliance rates to anywhere near 100%, as demonstrated by Ooi and Griffiths (2018). Before camera installation, the handwashing technique of obstetric surgeons conducting elective and emergency operations was recorded as 50% unsatisfactory, 20% satisfactory and 30% excellent. Post-intervention rates were 27.5% unsatisfactory, 30% satisfactory and 42.5% excellent (Ooi and Griffiths, 2018). Although the authors tried to mitigate the Hawthorne effect—when behaviour changes in response to observation and assessment (Sedgwick, 2015)—the participants still knew they were being monitored, yet 27.5% recorded unsatisfactory scores.

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