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Titus L. Daniels, Reconsidering Hand Hygiene Monitoring, The Journal of Infectious Diseases, Volume 206, Issue 10, 15 November 2012, Pages 1488–1490, https://doi.org/10.1093/infdis/jis549
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(See the major article by Hornbeck et al, on pages 1549–57.)
Hand hygiene (HH) is a fundamental component of any successful infection prevention and control program. Healthcare professionals and the public now accept the performance of HH before and after patient contact as an essential and expected behavior. Despite this broad acceptance of the importance of performing HH, compliance rates among healthcare professionals remain unacceptably low [1, 2]. Some might argue that these publicized rates are artificially low because of the small sampling of actual opportunities. Others may contend that the publicized rates are artificially high because of imperfect observation methodologies. Both are probably correct.
Direct observation of healthcare workers (HCW) interacting with patients and the environment continues to be considered the gold standard for assessing HH compliance [3]. Multiple challenges exist with this methodology. First, the investment in human capital all but ensures that undersampling will occur. As shown by Fries and colleagues, a 60-minute observation period captured only 0.5%–1.7% of the average total number of opportunities per day [4]. Observations are also generally limited to work shifts when a full complement of personnel is available for administrative tasks (ie, daytime). Further, the direct observation strategy for measuring HH compliance has long been limited by the “Hawthorne effect,” which refers to a change in behavior that results from the direct visualization of activities. Anecdotally, virtually every healthcare epidemiologist can almost certainly retell a conversation in which an HCW recounted performing HH only when observers were present and conducting compliance audits. Though many organizations attempt to mitigate this effect by using unknown, nonstaff, volunteer, or other types of “secret” observers, over time most individuals working in patient care units will be able to determine the purpose of any person not usually identified as being part of the patient care environment.
