1. Thompson, Elizabeth M. RN, CNOR, MSN

Article Content

Recently, reports on hand-washing compliance and a Joint Commission alert discussing disruptive behavior caught my attention. While healthcare institutions, and specifically the perioperative setting, are focused on new technology and complex organizational quality improvement processes to increase efficiency and promote better patient outcomes, we might do well to return our focus to the basics.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Old issues still need attention

The Joint Commission notes that disruptive behavior contributes to medical errors, poor patient satisfaction, adverse outcomes, increased cost of care, and loss of staff.1 As a result, The Joint Commission recommends that institutions develop codes of conduct and a process for dealing with inappropriate behavior.


Hand washing is a continuous focus in healthcare, especially in the surgical suite, and with good reason. (See SSIs: What are the host factors? on page 10.) Hospital-acquired infections affect approximately 2 million people in the United States and kill about 90,000 people.2 These are staggering statistics. The CDC and the World Health Organization (WHO) have specific, detailed guidelines on how and when to wash your hands and the use of alcohol-based hand sanitizers.


These issues are't new. Semmelweiss identified hand washing as a method of preventing infection transmittal in 1848 and codes of conduct are as old as civilization. While the effects of lateral violence and poor hand washing techniques are well documented and have demanded attention for many years, great strides haven't been forthcoming. Human behavior is difficult to manage and, judging from the history of these two issues, very difficult to change.


Learning from our youth

While others are affected by these issues, changes in behavior need to be internalized and valued by the individual healthcare worker. I am always a little uncomfortable as a professional and as an educator to have to instruct or reinforce the importance of hand washing after using the restroom and before returning to work after lunch. If this behavior isn't ingrained into our consciousness as children, our nursing curriculum reinforces and educates us on the effects of poor hand washing on our patients. It's equally disconcerting to have discussions on "nurses eating their young" and verbal abuse from other clinicians.


In an area so focused on aseptic technique and teamwork, it would seem surgery should be the last place where these types of reinforcement are needed. Maybe we should take our guidance on behavior and conduct from Robert Fulgrum's short essay, All I Really Need to Know I Learned in Kindergarten.3 The lessons learned early in our childhood, some of which are (in part) cited here from his essay, seem especially applicable:


Share everything. Play fair. Don't hit people. Put things back where you found them. Clean up your own mess. Don't take things that aren't yours. Say you're sorry when you hurt somebody. Wash your hands before you eat. Flush.3


It would seem that adhering to the golden rule and basic hygiene has as much an effect on patient outcomes as new technology or organizational quality-improvement processes.


Elizabeth M. Thompson, RN, CNOR, MSN


Editor-in-Chief, Nursing Education Specialist, Mayo Clinic, Rochester, Minn.




1. Advisory Board Daily Briefing, Joint Commission alert warns bad behavior undermines care quality. Available at: Accessed July 10, 2008. [Context Link]


2. Quoc V, Nguyen MD. Hospital-acquired infections. Available at: Article Last Updated: Aug 21, 2007. Accessed July 23, 2008. [Context Link]


3. Fulgrum R. All I really need to know I learned in kindergarten. Available at: Accessed July 23, 2008. [Context Link]