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The Hawthorne effect in measurements of hand hygiene compliance: a definite problem, but also an opportunity
  1. Sarah Haessler
  1. Correspondence to Dr Sarah Haessler, Tufts University School of Medicine, Baystate Medical Center, Baystate Infectious Diseases Division, 759 Chestnut Street, Springfield, MA 01199, USA; Sarah.Haessler{at}

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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.1 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,2 ,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.3 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.4 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.5 Unlike the placebo effect,6 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.7

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. …

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