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'Hawthorne effect' sways hand hygiene compliance
Researchers from Germany observed a marked influence of the Hawthorne effect on hand hygiene compliance among health care workers in an ICU.
Direct human observation is considered the gold standard of monitoring hand hygiene compliance of health care workers (HCWs). However, few studies have examined the magnitude of the Hawthorne effect, which refers to the tendency of people to behave differently when they know they are being observed, the researchers wrote in Infection Control and Hospital Epidemiology.
Stefan Hagel, MD, of the Center for Infectious Diseases and Infection Control at Jena University Hospital, and colleagues sought to quantify the Hawthorne effect in hand hygiene performance among HCWs at a 24-bed ICU of a tertiary care hospital.
Seventy electronic dispensers of alcohol-based hand sanitizer were installed in the ICU, and each use of these dispensers was recorded in a database. A trained medical student conducted approximately 50 audits of HCW behavior, each lasting 2 hours. The observer counted all hand hygiene events, or HHEs, in accordance with WHO’s “Five Moments for Hand Hygiene” — the standard for most health care facilities.
Stefan Hagel
Hagel and colleagues compared the number of electronically recorded HHEs during periods of direct human observation with those recorded during the remaining 6 hours of the 8-hour shift.
According to the researchers, 3,978 opportunities for hand hygiene based on WHO’s recommendations were observed during the 96 hours of direct observation. The overall rate of observed hand hygiene compliance was 51% (95% CI, 49%-53%). They found a “good agreement” between the average number of HHEs recorded by the medical student and those registered by the electronic dispensers during the same 2-hour period, with a mean difference of two HHEs per 2 hours of observation (95% CI, –7 to 11).
The Hawthorne effect was evident, according to Hagel and colleagues, who observed an average increase from eight HHEs per hour during periods without direct observation to 21 HHEs per hour when a human observer was in the room. This translates to two HHEs per patient per hour in periods without observation and five HHEs per patient per hour when being observed.
“This result confirms the findings of the studies addressing the Hawthorne effect on hand hygiene performance that have been published so far,” they wrote.
The researchers acknowledged there are limitations to both approaches to monitoring hand hygiene compliance. For example, direct human observation can produce inflated estimates due to the Hawthorne effect, in addition to being “labor intensive and costly,” while automated hand hygiene monitoring technology makes it impossible to distinguish between product use by HCWs, patients and visitors.
“In our study, we observed a nearly three-fold increase of hand hygiene events under direct observation owing to the Hawthorne effect,” Hagel told Infectious Disease News. “Direct observation of HCWs may therefore result in spuriously high compliance rates, and the validity of these observations for benchmarking and public reporting is questionable.”
As a result, the researchers recommended a combined approach of direct human observation, which would give only performance feedback to HCWs on an individual basis, and using automated monitoring to provide an accurate estimate of hand hygiene compliance. – by John Schoen
Disclosure: Hagel reports that he received travel grants from Ophardt. The other researchers report no relevant financial disclosures.