How Does the Hawthorne Effect Impact Hand Hygiene Compliance in Healthcare Settings?

Updated: Sep 15

Children are better behaved when their parents are watching them, but social science suggests that this tendency to modify behavior when under observation does not disappear with age. It is known as the Hawthorne (or observer) Effect, and it can spell trouble for healthcare providers if they ignore the impact of this phenomenon on their facility’s performance.

Audits and appraisals provide an opportunity for healthcare providers to assess critical activities, such as staff compliance with hand hygiene protocols and patient satisfaction. However, if the Hawthorne Effect occurs every time these behaviors are assessed, could the majority of healthcare providers incorrectly believe that their hand hygiene levels are better than they actually are?

Are Hand Hygiene Compliance Rates Skewed by the Hawthorne Effect?

Research presented at the 43rd Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC) suggests that this is indeed the case. When researchers at Santa Clara Valley Medical Center in San Jose, California, measured hand-hygiene compliance rates among healthcare workers who knew they were being observed, or knew they were not, they found that healthcare workers were twice as likely to comply with hand hygiene when aware of being watched.

Other studies agree.

A German study by Hagel et al., in which hand hygiene compliance among healthcare workers was observed either directly or electronically, revealed that when healthcare workers were electronically monitored, they performed just eight hand-hygiene events per hour compared with 21 per hour when under direct observation.

Behavioral modification during observation is not surprising—it reflects the human tendency to seek acceptance through conforming and abiding by rules. However, the marked difference in hand-hygiene compliance rates in the presence and absence of observation is troubling.

Correct hand hygiene is integral to minimizing healthcare-associated infections and their serious consequences, yet many healthcare workers do not comply with guidelines.

So, what can healthcare providers do to ensure better compliance by all health workers?

Improving Hand Hygiene Rates

Studies have shown that simply telling healthcare workers that they aren’t cleaning their hands enough is not very effective at improving hand-hygiene compliance. Instead, the solution may lie in eliminating the current barriers to hand hygiene that have been outlined by the World Health Organization (WHO) in its Guidelines on Hand Hygiene in Healthcare report.

These barriers include limited access to hand-hygiene supplies, patient needs perceived as a higher priority than hand hygiene, wearing of gloves, forgetfulness, insufficient time for hand hygiene and high workload.

The inaccessibility barrier could be addressed by simply providing more hand-hygiene points throughout hospitals and clinics—from portable, alcohol-based rubs to wash basins.

The issue of poor compliance due to forgetfulness, high workloads and the prioritizing of patient needs over hand hygiene can be addressed by giving healthcare workers access to an automated prompting service that issues hand-hygiene reminders throughout their day. These alerts could be issued via an app or a wearable device.

By continuously alerting healthcare workers to hand-hygiene opportunities as they happen, these prompts could help to make hand hygiene an automatic response to external cues, rather than something that is done only when someone is watching.

Eliminating the Hawthorne Effect During Assessments

Recognizing that the Hawthorne Effect can lead to overestimation of a healthcare facility’s hand-hygiene compliance rates does not mean that performance assessments are redundant. Instead, this suggests a need to adopt alternative methods of assessment. Given the labor-intensive nature of in-person assessors, observer-free methods such as automated monitoring of electronic dispensers could prove useful. Such devices would allow a more accurate assessment of hand-hygiene rates by eliminating the Hawthorne Effect.

Lauretta Ihonor is a medical doctor and a freelance health journalist/writer. She is based in London, UK and specializes in writing about medical technology and general medicine. She has worked for CNN International, BBC and Sky News.


Association for Professionals in Infection Control and Epidemiology (APIC). Press release. Available at: Last accessed 5th March 2019.

Hagel S, Reischke J, Kesselmeier M, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring. Infect Control Hosp Epidemiol. 2015. Available at: Last accessed 5th March 2019.

Livorsi DJ, Goedken C, Sauder M, et al. Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance. JAMA Netw Open. 2018 Oct; 1(6): e183344. Available at: Last accessed 5th March 2019.

World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge: Clean Care is Safer Care. Geneva, Switzerland: WHO Patient Safety; 2009. Available at: 5th March 2019.

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