Hand hygiene remains the single most important measure that can be undertaken by healthcare workers to prevent nosocomial infections. It has been 167 years since the pioneering study by Semmelweiss proved it effective¹1. Semmelweis IP. The etiology, concept, and prophylaxis of childbed fever, translated by K. Codell Carter. Madison: The University of Wisconsin Press; 1983., and with the recent spread of multidrug-resistant bacteria in hospitals, hand hygiene is now more important than ever²2. Rabelo MA, Bezerra Neto AM, Loibman SO, Lima JLC, Ferreira EL, Leal NC, et al. The occurrence and dissemination of methicillin and vancomycin-resistant Staphylococcus in samples from patients and health professionals of a university hospital in Recife, State of Pernambuco. Rev Soc Bras Med Trop 2014; 47:437-446.. Despite being simple, effective, safe, and cheap, the worldwide compliance of healthcare workers to proper hand hygiene is typically below 50%, and it is estimated that 50-70% of nosocomial infections are transmitted on the hands of healthcare workers³3. World Health Organization (WHO). WHO guidelines on hand hygiene in health care, 2009. [Cited 2014 June 14]. Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/.
http://www.who.int/gpsc/5may/tools/97892... .

In the literature, innumerable reasons have been proposed to explain this fact, with a consensus that causes in the clinical setting are lack of resources, training, or supervision. However, even when dealing with highly skilled healthcare workers working in high-resource hospitals, full compliance with hand hygiene procedures has never been achieved³3. World Health Organization (WHO). WHO guidelines on hand hygiene in health care, 2009. [Cited 2014 June 14]. Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/.
http://www.who.int/gpsc/5may/tools/97892... . Thus, we believe that, besides lack of resources and training, a low level of commitment to patient wellbeing is a major cause of low compliance.

When considering this hypothesis, it is important to analyze individual compliance with each of the 5 moments proposed by the World Health Organization (WHO) as critical points in hand hygiene protocols³3. World Health Organization (WHO). WHO guidelines on hand hygiene in health care, 2009. [Cited 2014 June 14]. Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/.
http://www.who.int/gpsc/5may/tools/97892... . These moments are: 1) before touching a patient, 2) before aseptic/clean procedure, 3) after body fluid exposure, 4) after touching a patient, and 5) after touching the patient's surroundings. When the references cited by WHO Guidelines on Hand Hygiene in Health Care are considered, and compliance analyzed at the pre- and post-care points, compliance at the post-care points is greater than compliance at the pre-care in 10 (83.3%) of the 12 studies cited³3. World Health Organization (WHO). WHO guidelines on hand hygiene in health care, 2009. [Cited 2014 June 14]. Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/.
http://www.who.int/gpsc/5may/tools/97892... .

As well, the general lack of commitment to patient wellbeing commonly observed in hospitals is supported by the compliance with different isolation precautions recommended by the Centers for Disease Control and Prevention (CDC)⁴4. Centers for Disease Control and Prevention (CDC). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. [Cited 2014 June 14]. Available at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.
http://www.cdc.gov/hicpac/pdf/isolation/... . While compliance with contact precautions usually falls below 30%⁵5. Dhar S, Marchaim D, Tansek R, Chopra T, Yousuf A, Bhargava A, et al. Contact precautions: More is not necessarily better. Infect Control Hosp Epidemiol 2014; 35:213-221., compliance with respiratory precautions in our hospital is almost 100% (data not published). We believe that the main explanation for this observation is the perception among healthcare workers that tuberculosis and meningococcal meningitis pose a real risk to themselves⁶6. Pazin-Filho A, Soares CS, Ferrais AS, Oliveira e Castro PT, Bellissimo-Rodrigues F, Nogueira JA, et al. Tuberculosis among health care workers in a Brazilian tertiary hospital emergency unit. Am J Emerg Med 2008; 26:796-798., while infections caused by multidrug-resistant pathogens, such as Klebsiella pneumoniae, Pseudomonas aeruginosa, or Acinetobacter baummanni, typically spread to only the hospitalized patients⁷7. Bellissimo-Rodrigues F, Gomes AC, Passos AD, Achcar JA, Perdoná GS, Martinez R. Clinical outcome and risk factors related to extended-spectrum beta-lactamase-producing Klebsiella spp. infection among hospitalized patients. Mem Inst Oswaldo Cruz 2006; 101:415-421..

If we are correct, infection control in hospitals must include efforts to motivate a strong commitment from all healthcare workers to the main objective of their work: promoting the patient's health. In the past, this has been partially accomplished by multimodal hand hygiene campaigns, which have tried to improve compliance through behavioral science methods, including motivational lectures and posters³3. World Health Organization (WHO). WHO guidelines on hand hygiene in health care, 2009. [Cited 2014 June 14]. Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/.
http://www.who.int/gpsc/5may/tools/97892... ,⁸8. Allegranzi B, Gayet-Ageron A, Damani N. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013; 13:843-851.. In our hospital, we have used a technique of motivating healthcare workers by asking them to put themselves in the place of the patient, and consider how they would like to be cared for if they were the patient. This technique may be easily used during clinical rounds and lectures, or as a wall reminder, as shown in Figure 1. When this technique is successful, a marked change in behavior is observed among the target healthcare workers, as they realize that someday it may be their turn to be the patient. Thus, we should all ask ourselves: am I caring for my patients as I would want to be cared for?

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

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