Exploring the Barriers and Levers to Hand Hygiene of Nursing and Medical Staff in Emergency Departments: A Mixed Methods Study

Background: Emergency Departments (ED) frequently host patients with undiagnosed infectious conditions and patients who are vulnerable to infection. Minimising the risk of exposure to infectious diseases is a priority in healthcare and is managed using a variety of strategies. Hand hygiene (HH) underpins these strategies, but ED have lagged behind improvement in HH compared to other units in New Zealand public hospitals. Given the consequences of healthcare associated infections (HAI), further investigation is warranted to identify barriers and levers to HH in the challenging environment of ED.  The aim of this explanatory sequential mixed methods study was to identify barriers and levers to HH practice in two ED in New Zealand.  Design: The mixed methods study was conducted in two phases. In Phase One, a questionnaire was used to survey nurses and doctors in the two ED sites. In Phase Two, follow-on focus groups were used to explore in-depth, specific aspects of the survey results.  Methods: In Phase One, doctors and nurses in the ED sites were surveyed to identify perceived barriers and levers of HH. A previously validated questionnaire from the United Kingdom was used. Following piloting, the questionnaire was circulated via email to all doctors and registered nurses. Results were analysed descriptively. Areas identified as strong barriers and levers to HH practice were identified, and used to inform development of a focus group interview guide.  In Phase Two, focus group participants were identified from a self-selected convenience sample of survey respondents. Focus groups were audio-recorded and data transcribed verbatim into NVivo Pro 11 before undergoing thematic analysis.  Results: The survey was distributed to doctors (n= 81) and nurses (n= 214). The response rate was low (11% for nurses, 12% for doctors). Two focus groups (n=6 & n=2) and one face to face interview (n=1) was held with nurses participating in each session. No medical staff participated in this phase of data collection. All respondents had worked in healthcare more than three years. Healthcare workers identified that professional role was the strongest lever for HH (93.1%, n=95), closely followed by knowledge and skills (84.3%, n=86). Healthcare workers demonstrated an awareness of benefits of HH including improving patient confidence and avoidance on infection for the patient and themselves (65.9%, n= 89). 45.6% (n=62) of responses identified a lack of encouragement or role modelling in this area of practice.  The physical environment in the ED was a major barrier (53.7%, n=73) although shorter stays in ED were not perceived as a barrier to HH (73.5%, n= 25). High patient turnover and acuity were also perceived as barriers to HH. HH initiatives were perceived to have a marginal effect (55.3%, n=57). Social influences and communication were further barriers to HH, with healthcare workers identifying discomfort when challenging others about HH.  Conclusion: Current barriers to HH including the environmental challenges, and social and cultural barriers to HH need to be addressed. Hand hygiene education that targets known challenges in, and misunderstandings about practice, need to be developed. Organisations must clearly articulate expectations of HH through policy and procedure, including a commitment to address non-compliance. Doctors and nurses should be supported in developing strategies to effectively communicate about, and challenge HH practices. With organisational support and a harnessing of the professional responsibilities that doctors and nurses hold, there is opportunity to strengthen barriers and mitigate barriers to HH.