LAUSR

We thank Asundani for sharing his experience and commend him for his commitment to social cohesion that makes his medical team feel safe to nudge him to comply. Our findings1 that social cohesion is a pivotal factor in providing a safe environment to build confidence to adopt our nudging initiative, or Asundani’s 100% or 100 bucks, is unsurprising really yet undervalued. As professionals we have focused on theory to understand and cajole clinicians to adopt hand hygiene.2-5 However, by overlooking the importance of the social cohesion of the ward, we have discounted the positive impact that a friendly atmosphere has on a team to feel safe while being placed under pressure to adopt new patient safety challenges.6 Asundani has reminded us of the additional benefits the physician’s ward round has over the nurse clinician’s working environment; a physician undertaking a ward round with a team can passively provide the Hawthorne effect that increases the team’s compliance or actively provide shout outs or nudges contemporaneously to team members as hand hygiene opportunities (HHOs) arise, have a committed complier such as Asundani who has intuitive social cohesiveness, and has fewer HHOs than nurses.7 In contrast, most nursing care with a HHO will be undertaken in the absence of a peer, and each nurse has 3 times the number of HHOs per weekday shift in a medical or surgical ward than a physician on the same ward (27 vs 8 HHOs, respectively).7 This burden of HHOs is generalizable to U.S. hospitals.8 Even with this heavier burden of hand hygiene, we found compliance was 1.5 times higher in nurses than physicians.6,7 However, this effect was in the presence of a human auditor, and compliance for all clinicians was overestimated by the presence of human auditors.9 In an attempt to support efforts to improve compliance, we prepared all clinicians to shout out a nudge with take a moment when they observed any clinician walking toward a patient’s room and provided accurate daily compliance rates. Our automated monitoring9 did not lighten the nurses’ HHO burdens, who contribute approximately 65% of all HHOs8; however, a large improvement in compliance did occur in the socially cohesive ward but could not be sustained past the trial. Asundani’s efforts to provide a socially cohesive group and a continuous ever-present intervention may not easily be transferable to nursing staff. We both agree that social cohesion is important but the question now remains how to effectively implement social cohesion in the unique nurse clinician working condition.