5 Studies Show How Direct Observation Inflates Hand Hygiene Compliance Rates Due to Hawthorne Effect

By Janel Nour-Omid, CEO and Cofounder

In today’s fast-paced, high-stress health care environment, it can be tempting to skip a hand wash if no one is looking.

A hand wash is required when entering and leaving patient rooms, after touching a patient or equipment, and after removing gloves and handling specimens. Because germs may reside on virtually anything you touch – including your phone, tablet or pager – hand washing in health care is a task that must be frequently repeated.

It’s also a task that is frequently skipped, unfortunately, especially when care providers are not being observed by a peer or supervisor. The tendency for individuals to change their behavior depending on whether or not they are being observed is known as the Hawthorne effect.

Studies present electronic monitoring as valid complement or alternative to direct observation

The Vitalacy team reviewed recent papers about the Hawthorne effect to see how it may be inflating hand hygiene compliance rates in organizations that use direct observation rather than electronic monitoring to measure compliance. This article updates a previously published Vitalacy blog article on the Hawthorne effect (Ihonor, 2019).

1. Our team first read “Validity of hand hygiene compliance measurement by observation: a systematic review” (Jeanes, et al., 2019). This review of 71 hospital-based studies that used direct observation to measure hand hygiene compliance found that the “results of monitoring hand hygiene compliance by direct observation may be biased.” For example, no night-time measurement was found in 65% of the studies and no data were collected on weekends in 86%. The conclusion? “Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality.”

2. Next, we reviewed Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events” (Vaisman, et al., 2020). This study observed compliance in 365,674 hand hygiene events out of a possible 911,791 opportunities. The presence of an auditor, or observer, increased hand hygiene compliance by 2.5-fold in the room closest to where the observer was standing. The conclusion? “These findings further challenge the validity and value of human auditing and support the need for alternative and complementary monitoring methods.”

3. The presence of the Hawthorne effect, as well as the accuracy of electronic monitoring, was noted in “Electronic hand hygiene monitoring: accuracy, impact on the Hawthorne effect and efficiency” (Gould, et al, 2020). Concordance on hand hygiene compliance assessed by direct observation and electronic monitoring occurred in 84% of the occasions. However, hand hygiene compliance increased from 24% to 76% during direct observation while remaining constant during electronic monitoring. The conclusion? “The 84% agreement between the electronic monitoring system and the manual observation suggest a high level of precision for the evaluated system. The Hawthorne effect was clearly seen in the increase by a factor of three in the manually observed adherence from session to session as the health workers became more aware of them being observed. The electronic monitoring system was able to avoid the Hawthorne effect when the observer was not present.”

4. “Assessing the Hawthorne effect on hand hygiene compliance in an intensive care unit” (Bruchez, et al., 2020) compared hand hygiene compliance rates as measured by overt (direct observation) and covert (electronic monitoring) methods both before and after a campaign to increase hand hygiene compliance. Both before and after the campaign, the compliance rate was heavily inflated during direct observation, with 68.10% compliance vs. 31.95% during electronic monitoring before, and 80.98% compliance vs. 56.11% during electronic monitoring after. The conclusion? “The Hawthorne effect and educational campaign markedly influenced compliance with hand hygiene recommendations. The results suggest that combining overt and covert observation methods, including regular feedback on hand hygiene compliance displayed on an electronic panel, may be a valid alternative to increase real hand hygiene compliance rates in hospital practice.”

5. Finally our team reviewed “Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study” (Leis, et al., 2020). The study noted a 29% increase in hand hygiene compliance within one month, followed by consecutive incremental increases up to 53% by 10 months. These compliance increases correlated with reduced healthcare-associated transmission of MRSA. The conclusion? “The introduction of a system for group electronic monitoring led to rapid, significant improvements in hand hygiene performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of hand hygiene.”

The evidence is quite clear

Direct observation inflates hand hygiene compliance rates. Electronic monitoring can improve these rates without inflating them and contribute to reduce infections.

Vitalacy’s automated hand hygiene compliance monitoring technology can help your organization improve hand hygiene compliance and reduce healthcare-acquired infections while meeting the Leapfrog Group’s new hygiene standard requiring the collection of compliance data on at least 200 opportunities each month (The Leapfrog Group, 2020). Contact Vitalacy today for a demo!


Bruchez SA, et al. Assessing the Hawthorne effect on hand hygiene compliance in an intensive care unit. Infection Prevention in Practice, June 2020;2(2).

Gould D, et al. Electronic hand hygiene monitoring: accuracy, impact on the Hawthorne effect and efficiency. Journal of Infection Prevention, May 28, 2020;21(4).

Ihonor L. How does the Hawthorne effect impact hand hygiene compliance in healthcare settings? Vitalacy Blog, April 11, 2019.

Jeanes A, et al. Validity of hand hygiene compliance measurement by observation: a systematic review. American Journal of Infection Control, March 2019;47(3):313-322.

Leis JA, et al. Introduction of group electronic monitoring of hand hygiene on inpatient units: a multicenter cluster randomized quality improvement study. Clinical Infectious Diseases, November 2020;71(10):e680-e685.

Vaisman A, et al. Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events. BMJ Quality & Safety, 2020;29(11).

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