The mean age of the participants was 36.44 years, the majority of them were women (92%), the majority of them were married (88%) with a mean work experience of 11.32 years and 38.92% had overtime a month. Of 25 participants, 12% were anesthesiologists, 72% were nurses, 12% were anesthesiology experts and 4% were physiotherapists.
By analyzing the data, the main 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, 3- barriers related to equipment and facilities with subcategories of lack of equipment and poor quality equipment were extracted (Table 2).
Barriers related to healthcare workers
Hand hygiene practice is inevitably forgotten during high workload due to stress, lack of peace of mind and speeding up the assigned tasks. Participants considered the high workload in the intensive care unit as an important 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 in need of 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 intensive care unit and night shifts prevented them from complying with proper hand hygiene.
“Many times I did not have enough time to wash or disinfect my hands due to the high workload in the intensive care unit and the emergency situation of some procedures.” (A 37-year-old nurse with 12 years of work experience)
“When I have to take care of several patients at the same time especially in the night shift, I am less concerned about hand hygiene practice due to fatigue.” (A 48-year-old nurse with 24 years of work experience)
The knowledge of healthcare workers of nosocomial infections and direct and indirect transmission of infectious agents plays an important role in observing hand hygiene. The healthcare workers believed that 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.
“Sometimes we do not take hand hygiene seriously because we do not know enough about the complications of poor hand hygiene practice.” (A 35-year-old nurse with 18 years of work experience)
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. Strengthening a positive attitude towards hand hygiene practice and convincing them that their behaviors will have a great impact on the behavior of others, individuals can adhere to hand hygiene more.
“Many times we do not practice hand hygiene because we do not believe in the importance of hand hygiene and do not get used to it. We would practice hand hygiene more if they reported monthly statistics of nosocomial infections and their complications clearly.” (A 36-year-old nurse with 11 years of work experience)
Wrong behavioral patterns
A good pattern and positive norms are very important for people in social settings to play a role and observe the principles, rules and guidelines of that setting. The experiences of participants 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.
“Doctors, residents and head nurses, who can be good role models for us do not often pay enough attention to hand washing. Therefore, we underestimate the importance of hand hygiene practice and do not comply with it properly.” (A 35-year-old nurse with 18 years of work experience)
Barriers related to management
Improper planning and training
Managers can promote hand hygiene practice by proper planning and training, monitoring and positive feedback, provision of written policies, appropriate culture building and positive organizational support. Participants in the present study considered occasional water outage, insufficient control over the evening and night shifts, inappropriate culture, substitute of gloves for hand hygiene practice and no wounds or scratches on personnel hands as barriers to hand hygiene practice. Some participants also believed that hand hygiene was not practiced because of no obvious contamination on the skin of the hand during caregiving.
“When I use gloves, I feel that I no longer need to wash or disinfect my hands.” (A 48-year-old nurse with 24 years of work experience)
“I often forget hand hygiene practice while caring for patients, because I do not see obvious contamination on the skin of my hands.” (A 40-year-old nurse with 15 years of work experience)
“I easily neglect my hand hygiene because there is no positive culture for hand hygiene.” (A 29-year-old anesthesiology expert with 7 years of work experience)
Improper design of the physical space of the department
Workplace conditions are one of the most important factors in hand hygiene practice. For example, lack of access to the hand washing sinks for emergency use, especially for novice healthcare workers will prevent hand hygiene practice due to inconvenience and dissatisfaction. In this study, many participants acknowledged that the health system infrastructure was inefficient for hand hygiene practice and officials did not pay enough attention to the problems and barriers to the hand hygiene practice. Therefore, the availability of the hand washing sinks and the reduction of the distance between sinks and the patients' beds will facilitate access and increase hand hygiene practice.
“Many times there was no sink when I wanted to wash my hands.” (A 36-year-old anesthesiologist with 6 years of work experience) "
Barriers related to equipment and facilities
According to the participants, providing a sufficient amount of hand hygiene equipment in different and accessible areas, as well as providing quality equipment in different wards, especially in intensive care units, will increase hand hygiene practice, reduce nosocomial infections, their transmissions to the community and mortality. Participants frequently complained about barriers related to equipment and facilities in their workplace, which prevented them from proper hand hygiene.
Lack of equipment
Participants mentioned lack of enough sinks and smart faucets for hand washing, which can help control the infection better. The majority of them also could not dry their hands due to the limited tissue papers and the lack of a hand dryer, which plays an important role in controlling the infection. Some participants paid special attention to the quality of detergents and disinfectants, and the provision of hand moisturizers and considered lack of detergents or personal protective equipment, lack of skin moisturizers after hand washing and lack of resources for buying hand washing equipment as barriers to hand hygiene practice.
“I often could not practice hand hygiene due to lack of smart faucets and lack of time.” (A 26-year-old nurse with 2 years of work experience)
“Many times, I have neglected hand hygiene practice especially in the evening and night shifts due to the lack of tissue papers for drying my hands.” (A 30-year-old nurse with 5 years of work experience)
Poor quality equipment
Considering quality equipment to reduce skin damage will increase hand hygiene practice and control of nosocomial infections. In the present study, the poor quality of soap and disinfectants for hand hygiene, skin dryness and itching caused by disinfectants were among the factors that caused hand hygiene non-compliance.
“I have not done hand rub for a month and substituted gloves for it because of the poor quality of the disinfectants and the allergy I felt after using them.” (A 45-year-old nurse with 23 years of work experience)