Variability in the Hawthorne Effect With Regard to Hand Hygiene Performance in High and

LowPerforming Inpatient Care Units

Author(s): ErolKohli, MPH; JudyPtak, MSN; RandallSmith, MS; EileenTaylor, BSN;
ElizabethA.Talbot, MD; KathrynB.Kirkland, MD
Reviewed work(s):
Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 3 (March 2009), pp. 222-225
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of
America
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 infection control and hospital epidemiology march 2009, vol. 30, no. 3

original article

Variability in the Hawthorne Effect With Regard to Hand Hygiene

Performance in High- and Low-Performing Inpatient Care Units

Erol Kohli, MPH; Judy Ptak, MSN; Randall Smith, MS; Eileen Taylor, BSN; Elizabeth A. Talbot, MD;
Kathryn B. Kirkland, MD

objective. To determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline
levels of hand hygiene compliance.
design. Observational study.
setting. Three inpatient care units, selected on the basis of past hand hygiene performance, in a hospital where hand hygiene observation
and feedback are routine.
participants. Three infection control practitioners (ICPs) and a student intern observed hospital staff.
methods. Beginning in late 2005, the 3 ICPs, who were well known to the hospital staff, performed frequent, regular observations of
hand hygiene in all 3 inpatient care units of the hospital, as part of routine surveillance. During the study period (JanuaryMay 2007), a
student intern who was unknown to the hospital staff also performed observations of hand hygiene in the 3 inpatient care units. The rates
of hand hygiene compliance observed by the 3 ICPs were compared with those observed by the student intern.
results. The 3 ICPs observed 332 opportunities for hand hygiene during 15 observation periods, and the student intern observed 355
opportunities during 19 observation periods. The overall rate of hand hygiene compliance observed by the ICPs was 65% (ie, in 215 of
the 332 opportunities, the performance of proper hand hygiene by hospital staff was observed), and the overall rate of hand hygiene
compliance observed by the student intern was 58% (ie, in 207 of the 355 opportunities, the performance of proper hand hygiene by
hospital staff was observed) (P p .1 ). Both the ICPs and the student intern were able to distinguish between inpatient care units with a
high rate of hand hygiene compliance (hereafter referred to as high-performing units) and those with a low rate (hereafter referred to as
low-performing units). However, in the 2 high-performing units, the ICPs observed significantly higher compliance rates than did the
student intern, whereas in the low-performing unit, both the ICPs and the student intern measured similarly low rates of hand hygiene
compliance.
conclusions. Recognized observers are associated with higher rates of hand hygiene compliance, even in a healthcare setting where
such observations have become routine. This effect (ie, the Hawthorne effect) is more pronounced in high-performing units and insignificant
in low-performing units. The use of unrecognized observers may be important for verifying high performance but is probably unnecessary
for documenting poor performance. Moreover, the Hawthorne effect may be a useful tool for sustaining and improving hand hygiene
compliance.
Infect Control Hosp Epidemiol 2009; 30:222-225

The Hawthorne effect, first described by Elton Mayo during
studies of worker productivity at the General Electric Haw-
thorne Works near Chicago during the period 1927 through
1932, refers to the tendency of subjects who know they are
being observed to temporarily change their behavior.1 Several
studies have reported evidence of the Hawthorne effect during
observations of hand hygiene performance.2-4 Some authors
caution that this effect should be accounted for when mea-
suring the effects of interventions designed to improve hand
hygiene compliance,3 and others propose that it be harnessed
as a tool to improve hand hygiene compliance in healthcare
settings.5 Several studies suggest that the improvement in
hand hygiene compliance induced by observation may be
short lived: Bittner et al.6 showed that there was a reduction
in the rate of hand hygiene compliance when the observations
ceased, and Harbarth et al.7 showed that there was a reduction
in the rate of hand hygiene compliance within 2 weeks after
the initiation of formal observation.
Our medical centers hand hygiene policy is based on the
Centers for Disease Control and Prevention guideline.8 Be-

From Dartmouth Medical School, Hanover (E.A.T., K.B.K.), and the Dartmouth Institute for Health Policy and Clinical Practice (E.K., K.B.K.) and the
Dartmouth-Hitchcock Medical Center, Lebanon (J.P., R.S., E.T., E.A.T., K.B.K.), New Hampshire.
Received July 7, 2008; accepted October 4, 2008; electronically published January 27, 2009.
2009 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2009/3003-0003$15.00. DOI: 10.1086/595692

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All use subject to JSTOR Terms and Conditions
 variability in the hawthorne effect with regard to hand hygiene
ginning in late 2005, as part of the routine infection preven-
tion program activities, 3 infection control practitioners
(ICPs) who were well known to the hospital staff regularly
conducted 3060-minute hand hygiene audits in assigned
units throughout the hospital, recording potential opportu-
nities for hand hygiene and noting opportunities taken and
not taken on a standard observation form. During these au-
dits, these ICPs counted only hand hygiene opportunities
before and after direct contact with a patient or the patients
environment. Unit-specific and organization-wide hand hy-
giene performance data are posted monthly on the hospital
intranet.
During 2006, the 3 ICPs observed 2,592 opportunities for
hand hygiene and documented an overall compliance rate of
46% (ie, in 1,367 of the 2,956 opportunities, the performance
of proper hand hygiene by hospital staff was observed). No-
tably, the rate of hand hygiene compliance increased from
35% (472 of 1,335 opportunities) in the first 3 quarters of
2006 (JanuarySeptember) to 55% (895 of 1,621 opportu-
nities) during the fourth quarter (OctoberDecember).
We sought to determine the degree to which the Hawthorne
effect was evident in our hospital, where regular observations
of hand hygiene by ICPs have been a part of routine sur-
veillance for more than a year, and to identify variations in
the magnitude of this effect in inpatient care units with dif-
ferent baseline levels of hand hygiene compliance.
methods
Our study was conducted during the period January through
May 2007 in 3 inpatient care units of a 396-bed tertiary care
medical center. These inpatient care units were chosen be-
cause they represented 3 patterns of rates of baseline hand
hygiene compliance during 2006: unit A was a pediatric crit-
ical care unit that had consistently high rates of hand hygiene
compliance (mean rate, greater than 90%); unit B was an
adult critical care unit that had been recently improving its
rates of hand hygiene compliance (mean rate, 40%60%);
and unit C was a medical unit that had consistently low rates
of hand hygiene compliance (mean rate, less than 50%). Unit
A was regularly assigned to one particular ICP, and units B
and C were regularly assigned to another particular ICP. The
third ICP did not perform hand hygiene audits in the units
selected for our study.
During the study period, the ICPs continued to conduct
routine hand hygiene audits of their assigned units, counting
only opportunities that occurred before and after contact with
the patient or the patients environment; no attempt to mea-
sure opportunities during patient care (eg, moving from dirty
to clean areas) was made. Opportunities for which an ICP
was unable to determine with certainty whether hand hygiene
was done were excluded from both numerator and denom-
inator. Unit-specific rates of hand hygiene compliance were
calculated as the number of observed opportunities taken
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223
divided by the total number of opportunities observed, and
they were expressed as a percentage.
During the winter of 2007, a volunteer student intern was
trained by the ICPs in hand hygiene observation. Concor-
dance of hand hygiene observations between the student in-
tern and each of the 3 ICPs was established in inpatient care
units that were not a part of our study, by having the student
intern and the ICPs observe hand hygiene performance in
the same unit, at the same time, and by comparing their
measured rates of compliance. Then the student intern was
given a hospital-issued identification badge and a white coat
and was directed to perform 30-minute hand hygiene ob-
servations in the study units during times when the ICPs
were not present. If questioned by staff, the student intern
presented unit floor plans and indicated that he was observing
hospital staff flow and space efficiency for a quality improve-
ment project. To our knowledge, the student interns true
identity and activity were never discovered.
Because of the student interns class schedule, most of his
observations were conducted in April and May, whereas the
ICPs observations occurred throughout the 5-month study
period. Unit B was identified as a transitioning unit, be-
cause of an observed improvement in hand hygiene perfor-
mance during the first quarter of 2007, and it was not until
that time that the student intern was directed to perform
observations there. For this reason, none of the student in-
terns observations for unit B were available before April, and
only observations by both the ICPs and the student intern
that took place in April and May were included. The health-
care workers in units A and C were consistently observed for
hand hygiene performance, as measured by regular audits by
the ICPs, before and throughout the study period, so the
observations from January through May were included. All
healthcare workers who provided care in the unit were in-
cluded in the hand hygiene observations. All observations
took place between 8:00 am and 6:00 pm. The x2 test was
used to determine whether differences between the student
interns observations and the ICPs observations were statis-
tically significant across the units.
results
During the study period, a total of 687 opportunities for hand
hygiene were observed in the 3 study units: 498 opportunities
for nurses, 95 opportunities for physicians, and 94 oppor-
tunities for other staff (which included respiratory, physical,
and occupational therapists, radiology technicians, phlebot-
omists, and others). The ICPs observed 332 opportunities
during 15 observation periods, and the student intern ob-
served 355 opportunities during 19 observation periods. The
student intern observed more opportunities for nurses than
for physicians (85% vs 9%). The ICPs also observed more
opportunities for nurses than for physicians (59% vs 19%).
The overall rate of hand hygiene compliance observed by
the ICPs was 65% (ie, in 216 of the 332 opportunities, the
224 infection control and hospital epidemiology march 2009, vol. 30, no. 3
performance of proper hand hygiene by hospital staff was
observed), and the overall rate of hand hygiene compliance
observed by the student intern was 58% (ie, in 206 of the
355 opportunities, the performance of proper hand hygiene
by hospital staff was observed) (P p .1). Both the ICPs and
the student intern were able to document which inpatient
care unit had a high rate (unit A, which was previously, and
is hereafter referred to as, a high-performing unit), a low rate
(unit C, which was previously, and is hereafter referred to as,
a low-performing unit), or an intermediate rate of hand hy-
giene compliance (unit B, which was considered in transi-
tion). For both the ICPs and the student intern, compliance
rates were significantly different between units A and B, be-
tween units B and C, and between units A and C.
If stratified by inpatient care unit, the rate of hand hygiene
compliance measured by the student intern was significantly
lower than the rate of compliance measured by the ICPs in
both unit A and unit B, whereas the rate measured by the
student intern and the rate measured by the ICP were not
significantly different in unit C (Table). The greatest differ-
ence between the rates of compliance observed by the ICP
and the student intern was observed in the high-performing
unit (ie, unit A): the student intern reported a compliance
rate of 79% (89 of 112 opportunities), and the ICP reported
a compliance rate of 98% (53 of 54 opportunities) (P p
.003). In the low-performing unit (ie, unit C), both the ICP
and the student intern reported similarly low rates of hand
hygiene compliance (47% [72 of 152 opportunities] and 40%
[44 of 111 opportunities], respectively; P p .3 ). The ICP and
the student intern documented similar hand hygiene com-
pliance rates for physicians (70% [44 of 63 opportunities]
and 72% [23 of 32 opportunities], respectively), but the ICP
documented a higher rate of hand hygiene compliance for
nurses than did the student intern (65% [127 of 197 oppor-
tunities] vs 59% [177 of 301 opportunities]; P p .03).
discussion
Our study adds to others that have demonstrated the impact
of known observers on hand hygiene performance in a health-
care setting (ie, the Hawthorne effect)2,3,6,7; it also adds new
information on the extent of this effect in a healthcare setting
in which hand hygiene observation is a part of routine sur-
veillance and in which interventions designed to improve
hand hygiene compliance are underway. We document that,
in our healthcare setting, the Hawthorne effect was most
evident in the high-performing unit and remained evident
even after approximately 2 years of routine observations. Be-
cause many healthcare facilities use ICPs as observers of hand
hygiene performance, it is important to recognize that, as
hand hygiene performance improves, this practice may lead
to an overestimation of the true rate of hand hygiene com-
pliance. Moreover, our study may add useful insights into
how the Hawthorne effect could be used to help sustain im-
proved performance.
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With regard to hand hygiene performance, the studies that
have suggested that the Hawthorne effect is a short-lived
phenomenon were studies that were done under different
circumstances than ours.6,7 These studies introduced obser-
vation for a limited time, to study its effect or to measure
the effect of another intervention designed to improve hand
hygiene, and were carried out in healthcare settings in which
baseline levels of hand hygiene compliance were lower than
those in our study units. Our study was done more than a
year after routine hand hygiene observation was made a part
of our infection prevention program and regular feedback on
performance was established. Our baseline data demonstrated
that the overall rate of hand hygiene compliance was im-
proving. For this reason, our finding of a sustained Haw-
thorne effect in inpatient care units with a history of high
rates of compliance is relevant in healthcare settings in which
improvement is underway and in which the tools for sus-
taining the improvement are sought.
Proposed explanations for the Hawthorne effect include
the psychological effect of being singled out, noticed, or made
to feel important.1 In our study, the Hawthorne effect was
limited to inpatient care units with higher rates of hand hy-
giene compliance. We speculate that the staff in these units
take pride in their work and wish to show it off to official,
recognized observers. (Ironically, because of the consistently
high level of compliance in these units, the ICPs assigned to
audit them actually performed fewer observations there than
in other units, as illustrated in the Table.) For the staff in the
low-performing unit, the fact that they knew that they were
being observed had a negligible effect on observed perfor-
mance. Staff whose supervisor tolerated poor performance in
the past may not fear the negative consequences of the ob-
servation of a poor performance or may not yet have given
a high priority to hand hygiene performance.
Even without student intern observations during the first
3 months of 2007, the data from unit B may be instructive,
table. Levels of Hand Hygiene Compliance Observed by Rec-
ognized Infection Control Practioners (ICPs) and an Unrecognized
Student Intern in 3 Inpatient Care Units at a Medical Center, Jan-
uaryMay 2007
Inpatient
Rate of compliance observeda
care Difference,
unit By ICPs By student intern % P
Unit A 53/54 (98) 89/112 (79) 19 .003
Unit B 90/126 (71) 74/132 (56) 15 .01
Unit C 72/152 (47) 44/111 (40) 7 .3
note. Comparing the ICPs observations of unit A with unit B, of unit
B with unit C, and of unit A with unit C, we get a P value of less than
.001. Comparing the student interns observations of unit A with unit B
and of unit A with unit C, we get a P value of less than .001; comparing
the student interns observations of unit B with unit C, we get a P value
of .02.
a
The unit-specific rates of hand hygiene compliance were calculated as the
number of observed opportunities taken, divided by the total number of
opportunities observed, and expressed as a percentage.
 variability in the hawthorne effect with regard to hand hygiene
because it was an inpatient care unit in which the rate of
hand hygiene compliance was in transition during the study
period. During the first 3 months of 2007, unit Bs perfor-
mance was quite similar to unit Cs: ICP observations doc-
umented a hand hygiene compliance rate of 46%. In April
and May, both the ICPs and the student intern documented
rates of hand hygiene compliance that were higher than this
baseline rate, which suggests a real improvement, but the
ICPs documented rates were significantly higher than the
student interns, which suggests that along with the improve-
ment came a desire to perform for the official observer. If
our theory is correct, continued covert observations in unit
B would demonstrate increasing rates of hand hygiene com-
pliance that lag behind those observed by recognized ICPs.
Other differences between the study units, besides their
past levels of hand hygiene compliance, might explain our
findings. The 2 higher performing units were both critical
care units. Perhaps critical care staff respond differently to
being observed than do other types of staff. The physical
layout of those units, the scope of their work, or the pace of
their activity may also make ICP observers more noticeable.
Differences between pediatric staff (in one unit) and those
who care for adults may also play a role. It is also possible,
but unlikely, that the student intern was recognized in unit
C but not in units A and B.
It is interesting to note that both the student interns and
the ICPs documented rates of hand hygiene compliance
among physicians were quite similar and that they were much
higher than the overall rate of compliance observed among
physicians during the period January through May 2007
(which was 53%). Several factors may explain this finding.
First, a presentation made to a physician leadership group in
April highlighted the traditionally lower rates of hand hygiene
compliance among physicians, compared with other staff, and
specifically featured graphs of trends in hand hygiene com-
pliance in both units B and C. This presentation may have
influenced the behavior of the physicians who worked in these
units during the following weeks. Alternatively, physicians
may be exquisitely sensitive to being observed and may be
responsive to even the presence of an unrecognized person
carrying a clipboard in a patient care unit, which might ac-
count for their higher than expected level of compliance.
Because the observations of physicians made up a minority
of the observations in our study, we do not think our other
conclusions were affected by this unexpected finding.
Because our study was limited to 3 inpatient care units in
a single healthcare facility, the generalizability of our findings
is not known. Further study in other healthcare settings
should also include observations of staff who work during
the evening and those who work the night shift.
If our findings are validated, they suggest that hospitals
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225
that embark on hand hygiene improvement initiatives may
not need to invest resources in undercover observers during
the early phases of their campaigns. The finding in other
studies that the Hawthorne effect is only temporary in these
healthcare settings is not refuted by our study, and it appears
that, in a healthcare setting of regular hand hygiene obser-
vation, the presence of recognized observers has little influ-
ence on low-performing staff. However, as healthcare facilities
achieve higher levels of hand hygiene performance, it may
be necessary to deploy covert observers who are unrecog-
nizable to staff, to verify ongoing good performance. Most
importantly, we believe that establishing an ongoing hand
hygiene observation and feedback program may create a cli-
mate in which the Hawthorne effect becomes an effective tool
for sustaining improvement, at least in high-performing
units.
acknowledgments
Potential conflicts of interest. All authors report no conflicts of interest rel-
evant to this article.
Address reprint requests to Kathryn B. Kirkland, MD, Section of Infectious
Disease and International Health, Dartmouth-Hitchcock Medical Center, 1
Medical Center Drive, Lebanon, NH 03756 (Kathryn.Kirkland@dartmouth
.edu).
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