Abstract
BackgroundObservation and feedback are core strategies of hand hygiene (HH) improvement. Direct overt observation is currently the gold standard method. Observation bias, also known as the Hawthorne effect, is a major disadvantage of this method. Our aim was to examine the variation of the Hawthorne effect on HH observation in different healthcare groups and settings.MethodsA prospective cohort study was performed in a tertiary teaching hospital during a 15-month period. Up to 38 overt observers (82% nurses) and 93 covert observers (81% medical students) participated in HH observation. The HH events observed overtly were matched for occupation, department, observation time, and location with those observed covertly. The data of matched pairs were then analysed to detect possible Hawthorne effects on different variables.ResultsA total of 31,522 HH opportunities were observed (4581 overtly, 26,941 covertly). There were 3047 matched pairs after 1:1 matching of overt and covert observations. The overall HH compliance was higher with overt observation than with covert observation (78% vs. 55%, p < 0.001). The Hawthorne effect was nearly three times larger in nurses (30 percentage points) than in physicians (11 percentage points) and was significantly greater in outpatient clinics (41 percentage points) than in intensive care units (11 percentage points). The magnitude of the Hawthorne effect varied among healthcare worker occupations and observation locations (p values both < 0.001) but not among departments, observation times, or HH indications.ConclusionsHeterogeneity in the Hawthorne effect may influence the interpretation of overt observations and prevent the correct identification of target populations with poor HH compliance. Therefore, directly observed HH compliance may not be an adequate performance indicator for infection control.
Highlights
Observation and feedback are core strategies of hand hygiene (HH) improvement
The project was part of a campaign to improve HH in medical students after we found that doctors had the lowest HH compliance of all Healthcare worker (HCW)
The rate of overall HH compliance was higher by overt observation than by covert observation (78% vs. 55%, p < 0.001), with a difference of 24 Percentage point (PP)
Summary
Observation and feedback are core strategies of hand hygiene (HH) improvement. Direct overt observation is currently the gold standard method. Observation bias, known as the Hawthorne effect, is a major disadvantage of this method. Our aim was to examine the variation of the Hawthorne effect on HH observation in different healthcare groups and settings. Hand hygiene (HH) is an effective measure to prevent healthcare-associated infection [1–4]. Observation and feedback make up one of the five main strategies to improve HH [3]. Direct observation remains the gold standard method of evaluating HH compliance [3, 4]. Observation bias, known as the Hawthorne effect, plays a critical role in evaluating HH compliance. When the Hawthorne effect was estimated by the difference between direct overt and covert observation results, the magnitude of the effect on HH compliance ranged from
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