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Use hand cleaning to prompt mindfulness in clinic

BMJ 2016; 352 doi: (Published 04 January 2016) Cite this as: BMJ 2016;352:i13
  1. Heather M Gilmartin, post-doctoral nurse fellow, Denver-Seattle Center of Innovation, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, CO, USA
  1. heather.gilmartin{at}

A regular prompt for reflection could reduce distraction

In the frenzied environment of clinical practice, we often don’t notice what we’re doing until a problem arises. Shuttling between patients and tasks may feel overwhelming. When we’re hurried it’s easy to lose focus on the task at hand and to become distracted. When we’re not fully engaged in the experience of each step in our day, we may blindly react to events instead of noticing what is occurring and then responding with a focused approach.

The act of cleaning hands, a simple yet important task practiced throughout the day, could serve to prompt a time of mindfulness to bring a clinician’s awareness back to the present and allow for moments of clarity, insight, and reflection during a work day.

The practice of mindfulness

The modern practice of mindfulness has been described as a process of paying attention on purpose, in the present moment, and non-judgmentally.1 The practice is grounded in philosophical-religious tradition and is meant to help move a person from simply reacting to an event to intentionally suspending judgment of reactions, observing the moment, and responding thoughtfully.1

Formal mindfulness training includes interventions such as daily meditation, whole body awareness practice, and hatha yoga, taught in two to eight week sessions by trained instructors. Informal mindfulness practice requires little instruction beyond recommending a focus on breath, the body, and what is happening in the present moment, and it can be practiced during ordinary activities.2

Hand hygiene is a habitual procedure before and after patient contact. The automatic nature of the intervention can allow it to be missed or incorrectly performed, as attention is not focused on the process and the reason for it. The cleansing of one’s hands should be reframed as an act of self care that provides a moment of mindfulness to increase presence and awareness, as well as an act of infection prevention for each other.

If a connection can be made between the hands and the mind, we may transform this fundamental tool of infection prevention from an act of passive compliance to one of self care.1 To realize the practice, the process should be broken down into steps so that each moment is fully experienced (box).

The skill of switching

In a state of mindfulness, thoughts and feelings are observed, acknowledged, and accepted as is. This dispassionate state of self observation is thought to introduce a space between perception and response, allowing for a switch from automatic pilot to a state of cognitive awareness.3

This skill of switching, which involves the flexibility of attention so that people can shift their focus from one subject to another, is imbedded in the practice of healthcare.4 We move from moments of diagnosis and treatment to responding to queries and to interacting with patients and colleagues. The act of focusing attention on breath during a time of scattered thinking allows us to acknowledge the present state, and it’s a skill that can be developed by busy clinicians through practice.

Other benefits

Another potential benefit of mindful practice is the reduction of cognitive errors, through attention to the thought processes that drive clinical decisions.4 During a routine day most of our decisions are processed through our subconscious mind.5 The training and experience accumulated through years of practice allow us to operate on intuition and habit, with little sense of effort. Though effective, this automatic routine is now considered a source of cognitive failure.4

A mindful approach to clinical decision making has been proposed as a method to bring awareness to the automatic response and to recruit the logical and rational thought processes that are driven by our analytic mind. By doing so we may tackle cognitive errors such as the inappropriate use of urinary catheters through habit.6

One limitation to formal mindfulness practice has been finding the time to implement it. Shapiro and colleagues,7 in a randomly controlled trial of mindfulness based stress reduction in healthcare professionals, reported that participants experienced decreased perceived stress and greater self compassion than controls, but their study had a high drop-out rate, probably because of the time commitment involved. They postulated that the addition of the two hour intervention, plus daily home practice, to an already demanding schedule might not be feasible for many clinicians.

Although formal training and daily meditative practice provides the greatest opportunity for an awakened existence, the act of “mini meditations” during hand hygiene processes may represent a simple method for providers to experience the benefits of mindfulness.

A moment of mindfulness

Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

Set an intention—be it listening with intent, choosing your words mindfully, or acting with compassion in your next encounter.

Smile to acknowledge this act of kindness to yourself and to your patient.

Alcohol based hand rub

Pause, take a breath, and notice the sound and feel of hand rub being delivered to your palm.

Be present in the moment and experience the sensation of rubbing the foam/gel into your wrists, hands, and fingers until the product evaporates and leaves you clean.

Soap and water

Pause, take a breath, notice that you are turning on the faucet, and regard the feeling of water flowing from your wrists to your fingers.

Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, and then washing it all down the drain.


Cite this as: BMJ 2016;352:i13


  • I thank Sanjay Saint: George Dock professor of internal medicine, University of Michigan Health System; chief of medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

  • Editorial Does mindfulness work? (BMJ 2015;351:h6919, doi:10.1136/bmj.h6919)


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