Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers

PLoS One. 2013;8(1):e53746. doi: 10.1371/journal.pone.0053746. Epub 2013 Jan 14.


Background: Evaluation and feedback of hand hygiene (HH) compliance are important elements of the WHO multimodal strategy for hospital infection control. Overt observation is recommended, but it may be confounded by Hawthorne effect. Covert observation offers the opportunity to decrease observer bias. In this study we conducted a one year hospital-wide HH promotion program that included medical students (MS) as covert observers.

Methods: HH compliance for the five WHO indications was determined by trained and validated observers. The overt observers consisted of eleven infection control nurses (ICNs) and two unit HH ambassadors (UAs) in each of 83 wards. The covert observers consisted of nine MS during their rotating clinical clerkships. Feedback was provided to department heads and staff each quarter.

Results: Of the 23,333 HH observations 76.0% were by MS, 5.3% by ICNs and 18.7% by UAs. The annual compliance rates were MS 44.1%, ICNs 74.4% and UAs 94.1%; P<0.001. The MS found significantly lower annual compliance rates for 4/5 HH indications compared to ICNs and UAs; P<0.05. The ICNs reported significantly improvement from the first to the fourth quarter; P<0.001. This was associated with feedback from the MS of very poor compliance by nurses during the first quarter.

Conclusions: Based on these findings we recommend a two-pronged approach to HH programs. The role of ICNs and UAs is to educate, serve as role models, establish, sustain good HH practices and provide direct feedback. The role of the covert observers is to measure compliance and provide independent feedback.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Clinical Clerkship
  • Data Collection
  • Education, Medical
  • Feedback
  • Guideline Adherence / statistics & numerical data*
  • Hand Hygiene / standards
  • Hand Hygiene / statistics & numerical data*
  • Health Personnel / statistics & numerical data*
  • Nurses
  • World Health Organization

Grant support

The authors are grateful to members of the NTUH Center for Infection Control and Center for Quality Control for their sustained support of the hand hygiene program and the hospital staff for their commitment to improve patient safety and reduce healthcare-associated infections. The authors are indebted to the Center for Diseases Control, Department of Health, Taiwan, for providing financial support for the Center for Excellence for Hand Hygiene (EU098040). Y. C. Chen also received a grant from Department of Health, Taiwan (DOH100-TD-B-111-001). The funding organizations were not involved in designing or conducting the study, the data collection, management, analysis, and interpretation, nor the preparation, and approval of the manuscript.