INTRODUCTION
Hand hygiene is among the most critical factors in preventing nosocomial infections in healthcare settings.[1] It is essential to consider the relationship between hand hygiene and the emergence of antibiotic resistance, which is a global threat to public health.[2] To promote hand hygiene practice and ensure the control and prevention of nosocomial infections, one of the key components in patient safety, the World Health Organization launched the first global challenge, “Clean Care is Safer Care,” in 2005.[3]
The reason is that close and frequent contact of healthcare workers with different patients has made their hands one of the primary sources of transmission of organisms and microorganisms.[4] Hands should be cleaned with soap and water or disinfectants after contact with patients or equipment. Eliminating colonized microorganisms in the skin of the hands is the most effective way to prevent the cross-transmission of pathogens. It is therefore recommended as the first step in preventing and controlling nosocomial infections.[5]
Nosocomial infections can occur 48–72 h after admission to a hospital or other healthcare facility where the infection and incubation were absent at admission.[6,7] According to the World Health Organization, 1.7 million nosocomial infections occur annually, and 1 in 29 people develop nosocomial infections.[8] Globally, the incidence of these infections varies from 3.5% to 12% in developed countries and from 7.5% to 19.1% in low-income and middle-income countries.[9] In India, studies reporting nosocomial infections in intensive care unit (ICU) have ranged from 11% to 60%.[10,11]
One of the departments with the highest rate of this infection is the ICU. Although the number of patients admitted to the ICU is less than that of other hospital wards, the incidence of nosocomial infections in the ICU is two to five times higher than in other wards.[12] Patients admitted to the ICU are at higher risk due to risk factors, such as multiple injuries, depressed levels of consciousness, and weak preventive mechanisms. These infections cause several problems in the treatment course of patients, including increasing the cost of laboratory procedures, increasing the use of drugs, increasing the length of hospital stay, and increasing antibiotic resistance.[13,14] They also kill 99,000 people and cost society $20 million annually.[8]
Hand hygiene practice significantly reduces the rate of healthcare-associated infections and has become an essential part of infection control programs as an easy and cost-effective method.[15] The effect of hand hygiene practice on reducing nosocomial infections is up to 50%.[16] Several studies have shown that hand hygiene compliance will improve the health and safety of patients and reduce complications, length of hospital stay, and mortality.[17,18] However, although hand hygiene techniques are simple, they are very challenging for individuals, and numerous studies have indicated low acceptance and poor performance of healthcare workers in this regard.[19,20] Surveys by the World Health Organization have shown that compliance with hand hygiene in healthcare workers is less than 50% and less than 10% in hospitals with a large workload.[4] Global hand hygiene compliance is about 40%.[21,22] Numerous reasons may prevent healthcare workers from hand hygiene practice, such as lack of proper equipment, high patient-to-nurse ratio, allergy to hand hygiene products, and insufficient knowledge.[23] Paying attention to individuals’ attitudes also plays a vital role because hand hygiene is influenced by individuals’ attitudes, beliefs, and opinions.[24,25] Lack of awareness and knowledge of individuals is also one of the factors affecting hand hygiene compliance, which can be increased by promoting knowledge and awareness.[26]
Since hand hygiene compliance in healthcare workers, especially those in the ICU plays a vital role in preventing and controlling nosocomial infections, the information and experiences of the healthcare workers in the barriers to non-compliance with hand hygiene seem very helpful. Qualitative research methods can be beneficial because they examine individuals’ beliefs, attitudes, experiences, and intentions.[27] Based on the literature review, no qualitative study investigated this issue, so we decided to analyze the experiences and views of healthcare workers qualitatively and discover the barriers to hand hygiene practice in the Barabanki district. Using a qualitative approach, we can examine the nature of the phenomenon in a natural context.
MATERIALS AND METHODS
Design
Qualitative research with a content analysis approach was used to collect and analyze data in 2022. Content analysis examines and explains concepts, words, and phrases within a text.[28]
Sample and setting
This qualitative study was conducted at the Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India, from late December 2022 to January 2023. The study population consisted of healthcare workers working in the ICUs of Mayo Institute of Medical Sciences, Gadia, Barabanki, Uttar Pradesh, including anesthesiologists (n = 7), infection control nurse (ICN) (n = 5), nurses (n = 26), physiotherapists (n = 4), attendants (n = 4), and safaikarmi (n = 4) who were selected by purposive sampling. Sampling was kept until saturation, meaning that no new data were added. Inclusion criteria included healthcare workers with at least 6 months of work experience in physical and mental health ICUs who were fluent in Persian. Participants were selected with various ages, work experience, and levels of education. The time and place of the interview were determined at the health center with the consent of the participants [Table 1].
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Table 1:: An example of the qualitative content analysis process
DATA COLLECTION PROCEDURE
A semi-structured individual interview was used in this study because participants could express their experiences and views more efficiently and purposefully; we could extract more in-depth information and ask more questions. Each interview took 30–45 min, during which the interviewer encouraged participants to participate in discussions and interactions and share their experiences. Some questions are as follows:
“What facilities are available for hand hygiene in your ward? Do you know the five moments of hand hygiene? Based on your experience, what barriers prevent you from observing the five moments while caring for the patient?” “What suggestions do you have for improving hand hygiene compliance? How effective is hand hygiene in controlling nosocomial infections?” Then, exploratory questions were asked proportionally to the answers. The researcher also noticed non-verbal communication, such as facial expressions and hand movements.
DATA ANALYSIS
The data analysis process was performed as guided by Lundman and Graneheim.[29] Qualitative studies aim to obtain a broad description and perception of phenomena.[30] In the first stage, each interview was transcribed verbatim and read several times for a general perception of the content. In the second stage, the text was divided into meaning units. Each meaning unit consisted of words and sentences with related content. In the third stage, meaning units were collected and recorded with initial codes. In the fourth stage, the initial codes were divided into subcategories based on similarities and differences. One category contained similar manifest codes. Finally, the latent concept and content in the data were extracted. During the data collection and analysis process, the researcher recorded any sparks related to the data and used them for subsequent interviews. An example of an analysis process is shown in Table 1.
The Guba and Lincoln criteria expressed by Streubert and Carpenter[31] were used to validate the study data. The participants reviewed the codes to achieve data reliability, and head nurses revised them. Good communication was established between the participants and the researcher. The researcher met the participants before the interview to build trust and provide an in-depth interview. Part of the text, along with the initial coding, was given to the participants to compare the degree of similarity between the ideas extracted by the researcher and their prominent opinions. To control the degree of appropriateness, qualitative research experts created concepts and categories until they reached a consensus. With an English translator, the corresponding author translated the categories and quotations from Persian to English, and professional editors edited the results.
RESULTS
By analyzing the data, the central theme of “barriers to hand hygiene practice” and three main categories, including (1) barriers related to healthcare workers with subcategories of workload, insufficient knowledge, improper attitude, and wrong behavioral patterns, (2) barriers related to management with subcategories of improper planning and training, improper design of physical space of the department, and (3) barriers related to equipment and facilities with subcategories of lack of equipment and poor quality equipment were extracted [Table 2].
Table 2:: Categories and subcategories related to barriers to hand hygiene practice in intensive care units
In the present study, we have included 50 healthcare workers; a maximum were nurses, that is, 26 followed by anesthesiologists, that is, 7, ICN, that is, 5, physiotherapists, attendants, and safaikarmi, that is, 4 each were selected by purposive sampling [Table 3].
Table 3:: Distribution of healthcare workers
BARRIERS RELATED TO HEALTHCARE WORKERS
High workload
Hand hygiene practice is inevitably forgotten during high workloads due to stress, lack of peace of mind, and speeding up the assigned tasks. Participants considered the high workload in the ICU as an essential barrier to hand hygiene practice. They also mentioned the large number of patients and the impossibility of keeping away from critically ill patients. Hand hygiene practice was also impossible for patients needing intensive care in emergencies and critical situations. They sometimes had to provide care to two patients at the same time, and on the other hand, fatigue due to overwork in the ICU and night shifts prevented them from complying with proper hand hygiene.
Insufficient knowledge
The knowledge of healthcare workers of nosocomial infections and direct and indirect transmission of infectious agents plays a vital role in observing hand hygiene. The healthcare workers believed that the lack of awareness of staff, especially novice ones, of the importance of hand hygiene in the incidence of nosocomial infections had an important role. Non-compliance with hand hygiene due to lack of awareness has led to increased antibiotic resistance, length of hospital stay, nosocomial infections, and even mortality.
Improper attitude
The majority of participants acknowledged that beliefs and attitudes toward hand hygiene practice were influential components in the behavior of individuals, and improving staff’s behavior would play a significant role in increasing hand hygiene practice. By strengthening a positive attitude toward hand hygiene practice and convincing them that their behaviors will significantly impact the behavior of others, individuals can adhere to hand hygiene more.
We often do not practice hand hygiene because we do not believe in the importance of hand hygiene and do not get used to it.
Wrong behavioral patterns
A good pattern and positive norms are significant for people in social settings to play a role and observe the principles, rules, and guidelines of that setting. The participants’ experiences show that individuals imitate senior managers, doctors, or residents in the workplace; therefore, if such people do not adhere to hand hygiene, it will directly affect the performance of other individuals.
Barriers related to management improper planning and training
Managers have the potential to encourage hand hygiene adherence by implementing effective planning and training strategies, providing monitoring and positive reinforcement, establishing written policies, fostering a suitable cultural environment, and offering positive organizational backing. According to participants in this study, identified barriers to hand hygiene practice included intermittent water supply disruptions, inadequate supervision during evening and night shifts, inappropriate cultural norms, instances of using gloves as a substitute for hand hygiene, and the absence of visible wounds or cuts on personnel hands. Additionally, some participants believed hand hygiene might not be prioritized due to the lack of apparent skin contamination during caregiving activities.
Improper design of the physical space of the department
The working environment significantly influences hand hygiene practices, exemplified by inadequate access to handwashing sinks in emergencies, particularly affecting new healthcare workers and impeding their adherence due to inconvenience and discontent. Within this study, numerous participants highlighted the inefficiency of the healthcare system’s infrastructure for hand hygiene practices, pointing out insufficient attention from officials toward these problems and barriers. Hence, enhancing the availability of handwashing sinks and minimizing the distance between sinks and patients’ beds are deemed crucial to facilitate access and encourage greater compliance with hand hygiene practices.
Barriers related to equipment and facilities
According to the participants, providing sufficient hand hygiene equipment in different accessible areas and quality equipment in different wards, especially in ICUs, will increase hand hygiene practices and reduce nosocomial infections, their transmissions to the community, and mortality. Participants frequently complained about barriers to equipment and facilities in their workplace, preventing them from proper hand hygiene.
Lack of equipment
Participants highlighted insufficient sinks and efficient faucets for handwashing as essential elements in infection control. Additionally, the majority faced challenges in drying their hands due to limited tissue paper availability or the absence of hand dryers, crucial factors in infection containment. Moreover, specific emphasis was placed on the importance of high-quality detergents, disinfectants, and the provision of hand moisturizers. Identified barriers to hand hygiene practice encompassed inadequate supplies of detergents or personal protective equipment, absence of hand moisturizers post-handwashing, and insufficient resources for acquiring handwashing equipment.
Poor quality equipment
Using high-quality equipment to minimize skin irritation can enhance hand hygiene adherence and the management of hospital-acquired infections. Within this study, factors contributing to non-compliance with hand hygiene included substandard quality of soap and disinfectants and instances of skin dryness and itching resulting from the use of disinfectants.
DISCUSSION
The results of this study suggest that healthcare workers in ICUs face several barriers to practicing hand hygiene. The main topic of “barriers to hand hygiene” includes three main categories, “barriers related to healthcare workers,” “barriers related to management,” and “barriers related to healthcare workers equipment and facilities,” each category has sub-categories.
In the present study, barriers related to healthcare workers were identified as one of the most critical barriers to hand hygiene practice. Many studies have identified workload as one of the barriers to hand hygiene compliance among healthcare workers.[32,33] Health workers lack time to practice hand hygiene due to the enormous workload and environmental and social issues, leading to burnout and lack of hand hygiene practices and cross-infection. Participants in this study also rated workload, fatigue, and large patient numbers as the main reasons for non-compliance with hand hygiene. Dai et al.[34] showed that health workers are less interested in performing hand hygiene at the end of a shift due to fatigue, and the longer the break between shifts, the more hand hygiene is performed.
Nicol et al.[35] also mentioned fatigue related to high workload as an obstacle to hand hygiene practice. In the present study, healthcare workers felt they did not have enough time to perform hand hygiene in an emergency, consistent with several studies’ results.[24,36] Therefore, it can be concluded that even if healthcare workers know how to wash their hands properly, they cannot perform hand hygiene due to their high workload, competent management system, and improved hand hygiene.
The results of this study indicate that some healthcare workers are unaware of the importance of hand hygiene and its role in hospital-acquired infection rates, increased costs, and problems caused by healthcare-associated infections. The results of several studies have supported the results of this study.[24,36] Continuing education of healthcare workers on proper hand washing methods by reminder posters plays a vital role in staff awareness and knowledge of hand hygiene.[1]
Oliveira et al.[37] argued that non-compliance with hand hygiene is not necessarily related to the knowledge of healthcare workers. Although employees were aware of the importance of hand washing, they did not practice it due to heavy workloads and insufficient motivation.[37] Joshi et al.[38] Therefore, provide the right equipment and facilities, hold regular training sessions to increase employee awareness and knowledge, and provide support and positive feedback that may be essential in implementing guidelines for hand hygiene and nosocomial infection prevention.[33]
In this study, some health workers had an attitude unsuitable for the practice of hand hygiene; some did not believe in hand hygiene, did not pay attention, and sometimes even forgot the practice—of hand hygiene. In several studies, positive attitudes of healthcare workers were associated with increased hand hygiene practices.[39,40] Nwaokenye et al.[41] believe that lack of knowledge, high workload, and high patient–nurse ratio make hand hygiene compliance easy or impossible to forget. Poor attitudes of healthcare workers toward hand hygiene practices increase the incidence of nosocomial infections. Therefore, the design of programs to increase health workers’ interest and positive attitudes toward hand hygiene practices and normalize health behaviors to enhance hand hygiene will be essential in reducing hospital-acquired infection rates and patient mortality.[42]
In the present study, poor behaviors also prevented the practice of hand hygiene. Models play an essential role in maintaining hand hygiene standards.[43] Ravaghi et al.[26] mentioned the compatibility of his behavior with others in the service. Participants believed that the behavior of physicians, especially the chief physician, played an essential role in their adherence to hand hygiene standards.[26] This issue highlights older adults’ influential role in promoting hand hygiene practices and improving patient safety. Therefore, it seems likely that the support and participation of the elderly, including physicians, in promoting hand hygiene practices and infection control standards could help remove barriers. Barriers to the practice of hand hygiene, at the same time, it is essential to highlight the fundamental principles of hand hygiene behavioral models, which are also used to change individual attitudes.[44] In the present study, inappropriate planning and management and inappropriate ward space design were mentioned as barriers to hand hygiene. Atif et al.[33] consider high workload, lack of obvious hand contamination, replacement of gloves for hand hygiene, limited hospital space, and absence of hand wash basins as barriers to good hygiene practices, consistent with our study. This study recommends organizing training sessions, positive feedback, management support, and a well-organized environment to promote hand hygiene practices.[33] Mclaws et al.[1] believe hospital authorities are responsible for practicing good hand hygiene and should control more barriers to removing them.
In this study, on the one hand, lack of equipment and, on the other hand, poor quality of equipment are also mentioned as important reasons leading to non-compliance with hand hygiene. Ravaghi et al.[26] also looked at the provision of appropriate hand sanitizers, tissues and tissues, the use of intelligent faucets, and the accessibility of sinks and water tanks. It eliminates contaminant barriers and enhances employee compliance with hand hygiene procedures.[26] Salmon and McLaws[45] believe the lack of suitable hand hygiene products, insufficient tissues, hand dryers, and skin damage from repeated washing are essential reasons for avoiding hand hygiene practices. Adequate, quality equipment will reduce skin damage, ensure compliance with hand hygiene, and prevent cross-contamination. As a result, management’s attention seems to help promote hand hygiene practices.
Qualitative design, small sample size, and conduct of the study in a trauma center are some of the limitations of the present study, so the results should be generalized with caution. It is also difficult to arrange interviews with some medical staff. Thus, a few participants in some groups can hinder distinctions between occupational groups.
CONCLUSION
The research findings indicate that multiple factors contribute to medical staff’s lack of adherence to hand hygiene protocols. Given the critical nature of ICUs, hospital infection control departments must focus on this issue. Various strategies should be devised to address barriers hindering hand hygiene practices. These strategies encompass training initiatives aimed at enhancing awareness and fostering positive attitudes regarding the significance of hand hygiene, offering support and encouraging feedback to staff, and ensuring the provision of high-quality and adequate equipment. This approach aims to minimize hospital-acquired infections, optimize patient health, and reduce maintenance costs.
Ethical consideration
Ethical approval was secured from the University of Hyderabad under Letter No. UH/IEC/2022/447, dated November 30, 2022. Following the participant selection process, the study’s objectives were communicated to them, and explicit written consent was acquired before the interviews for recording purposes. Participants were guaranteed data security and the freedom to participate or withdraw from the study. Each participant was assigned a unique identification number. Interviews were conducted at a designated time and location within the medical center, ensuring adherence to relevant guidelines and regulations governing all procedures.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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