The Hawthorne effect in measurements of hand hygiene compliance: a definite problem, but also an opportunity.

To cite: Haessler S. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs2014-003507 The Hawthorne effect was first described in the 1950s, based on an analysis of experiments conducted three decades earlier at the Hawthorne works of the Western Electric Company in Illinois. These investigations of ways to improve productivity show that regardless of the intervention—changes in factory illumination, changes in the structure of breaks or even changes back to the original working conditions—worker productivity increased. While many have debated the meaning of these results, 3 a common, basic interpretation has been that the attention received by participants in an experiment can itself alter the outcomes of the study. The concept that subjects behave differently in experimental settings has had an enduring impact in social sciences research. In medical research, the Hawthorne effect is seen as a type of bias, as patients seem to fare better by simply participating in a clinical trial, presumably due to the increased attention paid to participants, and the benefits of being watched. The effect has been most convincingly demonstrated in a study of intense versus minimal follow-up among patients with dementia receiving Gingko supplements, showing that the act of frequent follow-up visits rather than the administration of a medication led to improved patient outcomes. Unlike the placebo effect, where patients in a placebo arm experience a real change in symptoms while taking an inert substance, the Hawthorne effect represents a social phenomenon driven by a desire to please and meet the expectations of the researcher. In healthcare epidemiology, direct observation has long been the gold standard for monitoring hand hygiene compliance rates. Yet, many are worried that the Hawthorne effect inflates rates of hand hygiene compliance generated by direct observation. Healthcare workers will be more likely to perform hand hygiene when they know that a monitor is observing them. Data collected by unit-based hand hygiene auditors have especially been suspected because the auditor is easily recognisable and their mere presence on the unit could trigger a temporary increase in hand hygiene activity, which artificially inflates the compliance rate. Although no study has convincingly demonstrated the Hawthorne effect in measuring hand hygiene compliance, the plausibility of such an effect has stimulated various creative methods to avoid it and obtain more accurate measures. For instance, ‘secret shoppers’ not suspected of auditing hand hygiene, such as medical students, research assistants and hospital administrators, have been used at some hospitals. High tech methods of monitoring compliance while avoiding biased measurement have included radio frequency identification systems, wireless radio systems, video-monitored observation systems and electronic counters mounted on hand hygiene dispensers. However, these systems are expensive and carry the risk of eroding employee trust by generating the sense of ‘Big Brother watching’. Thus, the question of whether or not the Hawthorne effect inflates rates of hand hygiene compliance obtained by standard observation remains an important one for most hospitals. Srigley et al used a real-time location system (RTLS) to track the usage of hand hygiene products and the location of EDITORIAL