HLTH 8247 Week 11 Observer Effect Applied Paper Example

Hub Scrubbing Looks Excellent When the Auditor Is in the Corridor: An Applied Social Psychology Paper Explaining a Gap Between Audited Compliance and Disinfecting Cap Use Through Observer Presence, Visible Norms and Managers' Attributions, and Where That Explanation Runs Out

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Walden University

HLTH 8247: Social Psychology

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Month Day, Year

Hub Scrubbing Looks Excellent When the Auditor Is in the Corridor: An Applied Social Psychology Paper Explaining a Gap Between Audited Compliance and Disinfecting Cap Use Through Observer Presence, Visible Norms and Managers' Attributions, and Where That Explanation Runs Out

The Pattern

On a 28-bed medical unit, a composite built for this paper, nurses are expected to disinfect the access hub of every central venous catheter before each use, either by scrubbing it with an alcohol pad or by placing a disinfecting cap that covers the hub between uses. National guidance recommends cleaning catheter access ports with an appropriate antiseptic before accessing them (O'Grady et al., 2011). The unit's infection prevention team audits the practice by direct observation: an auditor stands in the corridor for two-hour blocks, watches line access and records compliance. Audited compliance has run between 94% and 98% for a year. At the same time, the supply system tracks disinfecting caps issued to the unit. Cap use per central line day falls by almost half on days and shifts when no audit is scheduled, and is lowest on nights and weekends. The unit's line infection rate, while low, has not fallen.

This paper explains the gap with three ideas from social psychology: the effect of being observed, the norms that each setting makes visible, and the attributions managers make when they see the audit numbers. It then sets out where the explanation runs out.

Explanation 1: The Presence of an Observer

The simplest explanation is that nurses perform the practice more reliably when they know they are being watched. The term Hawthorne effect is often used for this, though a systematic review concluded that the evidence for a general Hawthorne effect is heterogeneous and that the term covers many different research participation effects (McCambridge et al., 2014). More specific evidence comes from a study that used an electronic location system to track hand hygiene events and auditors' movements over eight months. Dispensers within sight of an auditor were used about 3.75 times per hour, compared with 1.48 times per hour for dispensers out of the auditor's sight at the same time, and 1.07 times per hour for the same dispensers in the week before (Srigley et al., 2014). The behavior in that study was different, but the mechanism is the same: the auditor's presence raised the rate of a hygiene practice in the immediate area.

Zajonc (1965) proposed that the presence of others increases arousal, which strengthens well-learned responses. For a nurse who knows the hub protocol, an observer's presence may make the correct sequence more likely to run on time. When the observer leaves, competing demands, a call light, a late medication, a family question, return to the front of attention, and a step that takes fifteen seconds is easier to skip.

Explanation 2: The Norms Each Room Makes Visible

Observation does more than add pressure. It changes what the norm looks like. Cialdini et al. (1990) proposed a focus theory of normative conduct: people act in line with a norm when it is salient, and descriptive norms (what others do) and injunctive norms (what others approve) can point in different directions. During an audit, the injunctive norm is unmistakable, since the auditor's clipboard signals that hub scrubbing is required and noticed. The descriptive norm is also favorable, because every nurse in the corridor is scrubbing.

On a night shift without an audit, the injunctive norm is still written in policy, but it is not salient. The descriptive norm may be less favorable: if a nurse sees a colleague access a line without a cap and nothing happens, the visible norm becomes that skipping is common and tolerated. Each nurse who skips makes skipping a little more visible to the next. The focus theory predicts that behavior will follow whichever norm is in focus, and on nights it may be the descriptive one.

Explanation 3: Managers' Attributions

The third idea concerns how the unit's leaders read the numbers. Managers see audit results of 94% to 98% and conclude that the nurses are compliant and the practice is embedded. When cap use data or an infection suggests otherwise, the explanation offered tends to be about individuals: a few careless nurses, or agency staff who do not know the unit. Ross (1977) described the tendency to attribute behavior to people's dispositions while underestimating the situation. The managers' attribution leads them to remedies aimed at individuals, such as reminders to specific staff, rather than at the situation that produces the gap: an audit design that measures behavior only when it is observed, and a night shift with fewer staff and more interruptions.

Where the Explanation Runs Out

The three explanations fit the pattern, but each has limits, and together they cannot account for everything.

First, cap use is an indirect measure. Caps are issued to the unit, not to individual lines, and supply counts can be affected by stocking practices, waste and caps taken to other units. A fall in caps issued on unaudited days may partly reflect when stock is replenished rather than how often caps are used. Before relying on the gap, the unit should check whether supply delivery follows the audit schedule.

Second, the hand hygiene study measured a different behavior, with a different measurement system. Its finding supports the idea that observation raises compliance, but the size of the effect for hub disinfection may differ. Hub access is less frequent, more deliberate and often done inside patient rooms where corridor auditors cannot see.

Third, alcohol scrubbing is an alternative to caps. Nurses who scrub hubs with alcohol pads rather than placing caps would lower cap counts without lowering compliance. The supply data cannot distinguish a nurse who scrubbed correctly from one who did nothing.

Fourth, the explanations overlap. Observer presence, salient norms and staffing levels all change together between audited day shifts and unaudited nights, so this paper cannot say how much each contributes. A design that separated them, for example unannounced audits on nights, would be needed.

Fifth, the explanation says nothing about whether the gap matters clinically. The unit's infection rate is low, and other protections, such as chlorhexidine dressings and line removal when no longer needed, may compensate. The paper explains a measurement gap; it does not show harm.

What the Unit Could Do

The explanation suggests changes that target the situation rather than individuals. Audits could be unannounced and spread across all shifts, so that measured compliance reflects typical practice. Caps could be stocked at every bedside, attached to each line's tubing, so that the correct choice is also the easiest one. Feedback could report the descriptive norm truthfully, showing nurses the share of lines found capped on random checks across all shifts. And managers could treat the gap as a property of the unit's systems, not of particular nurses.

Conclusion

The gap between audited compliance and cap use is consistent with three established ideas: people act differently when observed, they follow the norms that are salient in the moment, and leaders tend to explain shortfalls by individuals rather than situations. Each idea points to a practical change. But the evidence is indirect, the explanations cannot be separated with the current data, and the clinical importance of the gap is unknown. The most useful next step is better measurement.

References

Cialdini, R. B., Reno, R. R., & Kallgren, C. A. (1990). A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places. Journal of Personality and Social Psychology, 58(6), 1015-1026. https://doi.org/10.1037/0022-3514.58.6.1015

McCambridge, J., Witton, J., & Elbourne, D. R. (2014). Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. Journal of Clinical Epidemiology, 67(3), 267-277. https://doi.org/10.1016/j.jclinepi.2013.08.015

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A., Pearson, M. L., Raad, I. I., Randolph, A. G., Rupp, M. E., Saint, S., & Healthcare Infection Control Practices Advisory Committee. (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52(9), e162-e193. https://doi.org/10.1093/cid/cir257

Ross, L. (1977). The intuitive psychologist and his shortcomings: Distortions in the attribution process. Advances in Experimental Social Psychology, 10, 173-220. https://doi.org/10.1016/S0065-2601(08)60357-3

Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Quality & Safety, 23(12), 974-980. https://doi.org/10.1136/bmjqs-2014-003080

Zajonc, R. B. (1965). Social facilitation. Science, 149(3681), 269-274. https://doi.org/10.1126/science.149.3681.269