I had been in infection prevention and control (IPC) for close to a decade before I heard and recognized that health care personnel are not out to break our IPC rules. Sadly, this was my working assumption for years! A health care worker who misses a hand hygiene opportunity is not trying to hurt their patient or make trouble for the IPC department. It is either an honest oversight, they had something more pressing to attend to, or our process and set up is not conducive to them doing the right thing. I exaggerated on this epiphany in my new employee orientation by asking, "How many of you have ever woken up thinking, 'I really want to harm patients when I get to work'?" I would jokingly say that if anyone raised their hand, I would report them to Human Resources for being a Disney villain. We all laughed because that was a poor assumption.

Most health care workers cite a desire to help people as their reason for choosing this line of work.¹ When I learned this, I was forced to take a second look at drivers of adherence. For a long time and in many facilities, infection preventionists have been dubbed hand-washing enforcers. We are greeted with phrases like, “What have we done this time?” Some staff go as far as hiding because of our well-earned reputation of auditing and chastising.

As behavioral science has progressed and we all recognize the need for psychological safety in our facilities, a growing body of evidence suggests that our methods do not drive long-term behavior change. A new paradigm is emerging—one that emphasizes psychological safety, peer coaching, and behavioral science to foster a culture of accountability and continuous improvement. As the adage goes, how we got here will not get us there. I want to go there, where staff do not hide from me when I come into their department, where I am greeted with the joy befitting a good partner and colleague, where frontline staff are equipped with the tools and reasons for them to follow their calling and take good care of people. Let us go there, shall we?

Problems with Policing Adherence

For decades, hand hygiene and other patient safety monitoring programs have followed this pattern: observing health care workers from a distance, recording, reporting, and correcting nonadherence. We rely on unfamiliar observers who are perceived as intruders within the department. This creates a culture of fear, mistrust, and eventually resistance. Staff feel scrutinized rather than supported. This leads to:

• Underreporting of nonadherence and safety events to save face. “We did not tell you because we did not want to get in trouble.”
• Adherence only while under surveillance (Hawthorne effect): “Everyone wash your hands; IPC is here!”
• Gaming the system: “We recorded hand hygiene every time a team member left the bathroom.”
• Disengagement from infection prevention efforts: “They will come and tell us when we do something wrong.”

Such methods yield short-lived gains. IPC staff know the frustration of returning to the same departments and addressing the same issues week after week, month after month, and year after year. We spend so much effort relaunching hand hygiene programs, injecting excitement and engagement into a practice as basic as wearing a seatbelt. As IPC staff review these results against our efforts, we may erroneously conclude that our teammates do not care about patient and staff safety.

Research has shown that such approaches are not sustainable. A systematic review by Erasmus et al. found that despite extensive monitoring, the median hand hygiene adherence rate in 96 empirical studies was 40%, and lower in intensive care units.² Despite all this work, there is little evidence of sustained improvement over time.^2,3There are also very few studies that look at behavioral determinants.^2,3

Psychological Safety as a Foundation for Change

Psychological safety, defined as the belief that one can speak up, ask questions, and admit mistakes without fear of punishment, is a cornerstone of high-performing health care teams. When staff feel safe, they are more likely to engage in open dialogue, seek feedback, and adopt new behaviors.⁴ Edmondson’s seminal work on psychological safety highlights its role in fostering learning and innovation in complex environments like health care.⁵ In the context of hand hygiene, psychological safety enables frontline workers to discuss errors and barriers without fear. This leads to sharing observations, cocreating solutions with other departments, and actual, intentional teamwork.

Coaching as a Behavior Change Strategy

Moore and colleagues describe coaching as a method to “plant the seeds of change” by addressing the underlying reasons for nonadherence, such as workflow disruptions, forgetfulness, or unclear expectations.⁶ This approach aligns with behavioral science principles, including habit formation, social reinforcement, and intrinsic motivation.

Coaching offers a powerful alternative to traditional adherence enforcement. Rather than punishing nonadherence, coaching focuses on real-time, face-to-face, empathetic feedback that helps individuals reflect on their behavior and adjust. Peer-to-peer coaching leverages the influence of trusted colleagues to reinforce norms and build accountability.

Coaching works best when there is familiarity within and across teams. Familiarity builds trust and fosters psychological safety.⁴ In the field, this looks like auditors and observers being transparent about their tasks, being inquisitive about the processes they are observing, and providing positive and negative feedback.

Hawthorne effect

The Hawthorne effect is the enemy of transparency in observations. We are concerned about behavioral changes when staff perceive they are being observed. This is important in study design, but in practice, most patient safety monitoring programs focus on improving patient outcomes rather than on study design. If leveraging the Hawthorne effect improves health care safety outcomes, then why not?

The Hawthorne effect is often cited, but I fear it is not well understood. When considering the Hawthorne effect, keep these characteristics in mind:

• The size and type of behavioral change depend on how long the subject notices the observer.
• Behavior change occurs only when individuals are aware of being observed.
• Behavior change has a performance ceiling; even when observed, errors will still occur.
• Behavior changes wane with time as subjects become accustomed to observers (habituation).⁷

Evidence from the Field

Several health care organizations have successfully implemented coaching-based hand hygiene interventions:

• At UNC Medical Center, Sickbert-Bennett et al. piloted a peer observation program using a mobile app that allowed staff to provide real-time feedback on hand hygiene practices. Over 3 years, the program led to significant improvements in adherence and fostered a culture of mutual accountability.⁸ The strength of this approach is familiarity and its emphasis on providing positive feedback.
• A London, England National Health Service Trust codesigned a behavioral intervention with frontline staff, emphasizing shared ownership of hand hygiene goals. The initiative resulted in improved adherence and greater staff engagement.⁹ The strength of this approach is intentional teamwork.

These case studies demonstrate that psychological safety can affect hand hygiene behavior, enhance team dynamics, and improve patient safety culture.

Many facilities are transitioning to electronic hand hygiene monitoring. Choose platforms with the closest-to-real-time feedback, eg, badge or dispenser alerts and messages, to impact behavior change. They provide the most opportunities for coaching. Platforms with aggregated or no feedback work best when the goal is data gathering and research. However, they can be integrated into a coaching program.

Implementation Considerations

Transitioning to a coaching model requires planning and interdisciplinary leadership support. The approach hinges on psychological safety as an organizational and departmental characteristic. At the organizational level, safety and continuous improvement, as elements of organizational culture, are key drivers of psychological safety. At the team level, leadership integrity, status inclusiveness, change orientation, and leader and peer support are required.⁴ In the absence of these elements, the interventions will have limited effectiveness.

Key operational steps include:

• Aligning leadership messaging with the values of trust, learning, and shared responsibility.
• Leveraging tools that facilitate data collection and real-time coaching.
• Creating safe spaces for feedback and reflection, free from judgment or hierarchy.
• Training peer coaches in effective communication, motivational interviewing, and feedback delivery.
• Be transparent with the team about their process and outcome measures.

Challenges and Limitations

Cultural resistance, time constraints, and lack of resources will affect program success. Moreover, it requires a shift from measuring simple adherence metrics to more nuanced indicators of behavior change and team engagement. As mentioned earlier, all this hinges on psychological safety as a foundation for organizational change.

Conclusion

The future of hand hygiene lies not in surveillance tools but in programs that support team members. By focusing on behavioral change and psychological safety, health care organizations can move beyond burdensome programs and adherence metrics to a place where hand hygiene is a shared, valued, and sustained commitment.

References

• Rosa WE, Roberts KE, Schlak AE, et al. The critical need for a meaning-centered team-level intervention to address health care provider distress now. Int J Environ Res Public Health. 2022;19(13):7801. doi:10.3390/ijerph19137801
• Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on adherence with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283-294. doi:10.1086/650451
• Gould DJ, Chudleigh JH, Moralejo D, Drey N. Interventions to improve hand hygiene adherence in patient care. Cochrane Database Syst Rev. 2007;(2):CD005186. doi:10.1002/14651858.CD005186.pub2
• O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020;32(4):240-250. doi:10.1093/intqhc/mzaa025
• Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
• Moore D. Plant the seeds of change with just-in-time coaching. Infection Control Today. Published 2021. Accessed January 2026. https://www.infectioncontroltoday.com/view/plant-the-seeds-of-change-with-just-in-time-coaching
• Chen LF, Vander Weg MW, Hofmann DA, Reisinger HS. The Hawthorne effect in infection prevention and epidemiology. Infect Control Hosp Epidemiol. 2015;36(12):1444-1450. doi:10.1017/ice.2015.216
• Sickbert-Bennett EE, DiBiase LM, Willis TM, et al. The holy grail of hand hygiene adherence: Just-in-time coaching. Am J Infect Control. 2019;47(5):531-536. doi:10.1016/j.ajic.2018.10.005
• Price L, MacDonald J, Gozdzielewska L, et al. A helping hand: Co-designing hand hygiene interventions with healthcare workers. PLoS One. 2024;19(1):e0287654. doi:10.1371/journal.pone.0287654