‘We do not wash hands’: Barriers to the maintenance of five moments of hand hygiene among learner nurses at a university in Limpopo province, South Africa

Hand hygiene forms a key interventive strategy in infection prevention control among nurses in healthcare institutions and forms a widely accepted cornerstone for preventing hospital-acquired infections (Vermeil et al. 2019). Furthermore, the use of alcohol-based hand scrub is taken as a world standard for hand hygiene; however, there are still notable barriers that still exist resulting in health-associated infections continuing to affect hundreds of millions of individuals around the globe. According to the World Health Organization [WHO] (2020), hand hygiene assists with controlling and preventing healthcare-associated infections (HCAIs), which are transmitted among patients and healthcare workers. In most cases, these infections are generated by the hands of healthcare workers as they provide care to patients (Khodadadi 2019).

Hand hygiene is a practical intervention in low- and middle-income settings since it is a cheap and effective strategy to avoid HCAIs (Kuti et al. 2019; Sands & Aunger 2020; Alwatifi & Hattab 2022). The WHO established an evidence-based approach called the five moments of hand hygiene, which focuses on handwashing before touching a patient, before carrying out an aseptic or clean technique, after contact with body fluids, after touching a patient, and after touching patient's environments (WHO 2009). According to Shobowale et al. (2016), hand hygiene is recognized as the treatment intervention plan to reduce the cross-transmission of pathogens in the healthcare milieu and has shown great results in reducing HCAIs. This positions hand hygiene as one of the most essential ways to prevent the spread of multi-resistant microorganisms and HCAIs (Popovich et al. 2021). This can be facilitated through adhering to the five moments of hand hygiene in many cases (WHO 2009). Al-Dorzi & Arabi (2017) argue that the most effective way to control the spread of infection is compliance with infection control methods such as effective handwashing, especially following five moments of hand hygiene, which is a core in preventing infection outbreaks in healthcare institutions. However, Potgieter et al. (2021) highlighted that South Africa has distinct and varied social and economic elements that affect everything from the availability of basic water to the use of hand hygiene in healthcare facilities. Nonetheless, the WHO has introduced the five-moments protocol, hand hygiene watching and performance response and this appears to have improved compliance with hand hygiene (Luangasanatip et al. 2015; Storr et al. 2017).

Hand hygiene inspection is generally regarded as the golden standard for assessing hand hygiene execution in healthcare institutions. Apart from that there are other strategies to improve hand hygiene, which is recommended by WHO (2009) where there is a hand hygiene observation tool used to assess a healthcare facility's infection prevention and control practices and guide quality improvement activities. Despite the easy process of practicing hand hygiene for infection control, hospital healthcare staff, especially nurses, often adhere to hand hygiene instructions only to a limited extent. The study that investigated the effect of behavioral interventions targeting hand hygiene practices among nurses in high-income hospital settings revealed that hand hygiene is a complex behavior with a myriad of motivators and barriers (Sands et al. 2020). Some studies show that adherence to hand hygiene remains poor due to a variety of factors in the healthcare environment (Luangasanatip et al. 2015; Vermeil et al. 2019). Despite, extensive research on hand hygiene, there are still gaps in the literature covering healthcare professional learners, including learner nurses' practices. The findings of a study conducted by Loyland et al. (2020) recommend that the improvement in the learner's actions around hygiene and infection prevention in clinical settings may also increase their awareness and reduce HCAIs. This highlights the necessity to study five moments of hand hygiene practices among learner nurses. Learner nurses are among the healthcare workers who operate on the frontlines of healthcare; thus, they are constantly exposed to sick people and dirty surfaces, increasing their risk of getting sick and spreading disease. Learner nurses interact with patients more than any other learners in the health professions during their clinical practice. As a result, their compliance with the rules on handwashing seems to be more crucial in preventing the spread of infections.

The university is situated along the R71 road to Tzaneen in the semi-urban area of Mankweng in Polokwane, Limpopo province, South Africa. Learner nurses in this university are allocated for clinical practicals in the nearby accredited hospitals and clinics to gain the necessary skills and competence prior to the completion of the nursing program.

The study was qualitative in nature. An explorative and descriptive research design was used to explore and describe the barriers to the maintenance of five moments of hand hygiene among learner nurses at a University in Limpopo province, South Africa. The design enabled the researchers to gain in-depth information. The population included for this study comprised 189 learner nurses registered in the Department of Nursing Science at a university in Limpopo province for the 2020 academic year. The nursing department has learner nurses from level one up to level four who were registered for the R425 program as per the South African Nursing Council. A non-probability homogenous purposive sampling was used to obtain 15 participants who voluntarily signed an informed consent form.

Data were collected through individual interviews in 2020 until data saturation was achieved at 15 participants, 10 females and 5 males. The posed question was ‘What are the barriers you experienced when maintaining the five moments of hand hygiene in the wards?’ Probing and paraphrasing were used to ensure a thorough understanding of what the participants were saying. All the interviews were audio recorded and field notes were taken. The interviews lasted between 30 and 45 min. The researchers employed Tesch's eight-step coding method to analyze the transcribed data as outlined by Creswell & Creswell (2017), and field notes were incorporated into the transcriptions.

Trustworthiness was ensured by applying the criteria of credibility, transferability, dependability, and confirmability (Creswell & Creswell 2017). Credibility was ensured through engaging with the participants for 30–45 min and an audit trail. A clear and detailed research methodology was used to ensure confirmability of the study. Dependability is ensured by involving an independent coder who is an expert in qualitative data analysis. Transferability was ensured by providing adequate details of the research methodology.

Ethical clearance was obtained from the University of Limpopo's Turfloop Research Ethics Committee (TREC), number: TREC/373/2017/PG. Permission was obtained from the School of Health Care Sciences. The participants gave written informed consent to participate in the study. Issues of confidentiality, privacy, anonymity, and avoidance of harm were all ensured.

The study findings show that there are barriers that block the learner nurses from implementing and maintaining the five moments of hand hygiene. The identified barriers were limited resources in the allocated clinical facilities and insufficient time to implement and maintain five moments of hand hygiene. See Table 1.

Limited resources in the allocated clinical facilities were the most common barrier identified by the learner nurses. All the learner nurses who participated in the study indicated that the available resources in the clinical area do not allow them to practice five moments of hand hygiene. Limited resources were related to the shortage of water supply, inadequate equipment and supplies for hand hygiene, as well as the shortage of human resources.

The water shortage was reported as one of the limited resources contributing to the failure of learner nurses not to implement and maintain the five moments of hand hygiene as required when allocated in the clinical facilities. The shortage of water issues was outlined by Participant 3 who said, ‘in some instances you might find that there is a washing facility but there is no water’.

Participant 6 said: ‘Sometimes you find out that there is no water at the hospital, for example, if there is no water at the hospital, we do not wash hands’.

Participant 8 echoed: ‘We fail to implement proper hand hygiene when there is no water at the hospitals’.

Participant 10 indicated that the water supply includes warm and cold water. He felt that washing hands with cold water contributes to the failure to implement and maintain hand hygiene. He also said another problem with water is ‘some of the basins have only cold water and at that time the weather it's not suitable for you to use the cold water. Obviously you will not wash your hands or do a proper washing’.

Apart from the shortage of water supply, it was discovered that learner nurses experience challenges with inadequate equipment and supplies to maintain five moments of hand hygiene. The absence or faulty sinks and taps, soap, and drying paper or towels were reported as the cause of not washing hands as required by the five moments of hand hygiene. This was clear from Participant 1, who echoed that: ‘With the implementation of five moments of hand hygiene you might find that there's no soap in the ward and you're just forced to use water only and in some instances you might find that there's no drying paper or towel and you have to dry your hand with air while going to the patient. Therefore, we don't have resources required so that we can implement and maintain correctly’.

Participant 14 said: ‘You may find that the drainage system is not working or the basins in the hospitals are blocked’.

The quotation from Participant 3 was found to be elaborating on the challenges of inadequate equipment and supplies: ‘or sometimes the washing facility is dysfunctional, and you might find that there are no paper or towel to wipe our hands after washing hands’.

Participant 10 is of the same opinion: ‘Most of the healthcare facilities that I was exposed to lack resources. Sometimes in the unit you may find out that there is no anti-scrub solution. You may find out that the basin is not working’.

Some of the participants indicated that if there is running water in the facility, they will implement and maintain five moments of hand hygiene. However, most of the time, there will be other challenges related to the resources like equipment and supplies that impact the practice negatively, which was reported as follows: Participant 8: ‘Sometimes you find that taps in other cubicles are not functional, and you have to travel to another cubicle to wash hands’. Participant 11 said: ‘I think it can be the taps that are not functioning. You may find that in maybe 2 or 3 cubicles there are taps which are not working or have no taps so one has to go to the last cubicle to wash hands’.

Participant 12 echoed: ‘With hand washing facilities you may find that there's only one that's working or in a good condition, so you find that nurse has to run from wound dressing room to other room just to wash hands’.

The shortage of human resources was identified as the other challenge that learner nurses experience in implementing and maintaining five moments of hand hygiene. Participants 5, 11, 12, and 13 mentioned that there are not enough staff members to carry out activities and care for the patients. Therefore, they try to work as fast as they can, resulting in not washing hands as required. Participant 14 echoed: ‘Nurses are short-staffed to be taking care of the patients in the ward, so they have to do everything quickly and omit hand washing’.

Participant 6 with a similar opinion said ‘I would say the challenge is, if there is a shortage of staff, we are unable to follow that procedure of doing the 5 momentsbecause you find that you are doing something, and you have to go and do something else’.

Drawing from the quotations it was apparent that in most cases there is no running water in the clinical facilities that they are allocated, and if there is water you may find that there is inadequate equipment and supplies for hand hygiene or a shortage of staff that impede the practice of five moments of hand hygiene. The above-mentioned quotes confirm that limited resources in clinical facilities are barriers to the implementation and maintenance of five moments of hand hygiene.

A high and heavy workload was also reported as another reason for not adequately implementing and maintaining the five moments of hand hygiene. The participants indicated that high and heavy workloads result in poor or no implementation of five moments of hand hygiene. Participant 4 said: ‘Sometimes it is just that you have to run and attend to the other patient, so you just rush to the other patient without washing your hands’.

Participant 8 mentioned that: ‘The challenges include the issue of busy days at the hospital, during the busy days, we normally become so busy that we fail to implement or maintain proper hand hygiene’.

In particular, workload and busy days force them to push routine work to finish on time. Therefore, a high and heavy workload is associated with a shortage of staff and a lack of time to implement and maintain five moments of hand hygiene. They indicated that the reasons for them not to wash their hands when the unit is too busy is because they are overwhelmed by the activities and doing five moments of hand hygiene is going to take them time. Participant 6 said: ‘I would say the challenges are, if the ward is busy or if there's a shortage of staff, we are not able to follow that procedure of doing the 5 moments because you find that you are doing something, and you have to go and do something else’.

Participant 2: ‘There is a lack of time, you might find that there are a lot of patients, and you have to do aseptic procedures so there won't be time to wash hands after every patient’.

Participant 5: ‘It is sometimes difficult to perform the procedure because at other times the hospital will be very busy and there won't be enough time for an individual to perform the correct and full 5 hand hygienic moments’.

Participant 7: ‘Sometimes you find that the ward is too busy, and you don't get time to do the 5 moments of hand hygiene, you just wash quickly’.

Participant 13: ‘I have realized that in the clinical area, we don't perform five moments of hand hygiene accordingly, and maybe because sometimes we lack time due to maybe the hospital is full of patients’.

According to Participant 10, due to the high and heavy workload, they only get a chance to perform hand hygiene when it is suitable, like when there are no emergencies when the work is done, or when the given tasks have been finished. It is obvious that in the clinical areas where the participating learner nurses are practicing, there is a shortage of staff, which contributes to a high and heavy workload. This results in limited time to implement and maintain five moments of hand hygiene.

This paper reports on the barriers to implementing and maintaining five moments of hand hygiene in clinical facilities among university learner nurses. The participants in our study considered limited resources in the allocated clinical facilities and high workload as barriers to implementing and maintaining the five moments of hand hygiene. Regarding limited resources in the allocated clinical facilities, our study findings are in accordance with the findings of the study conducted on adherence to hand hygiene among nurses and clinicians at Chiradzulu district hospitals in southern Malawi (Nzanga et al. 2022). Many participants reported that inadequate hand hygiene resources are the main reasons for not performing hand hygiene. Lack of resources as a cause of poor hand hygiene was also raised by the participants in a rural hospital, in India (Diwan et al. 2016). In the current study, limited resources were discussed as the shortage of water supply and inadequate equipment and supplies for hand hygiene, as well as the shortage of human resources.

The supply of water to many healthcare facilities is a challenge. The 2020 WHO report reveals that globally, one in four healthcare facilities do not have basic water services. The situation is worse in low-income countries, especially healthcare facilities in rural areas. A narrative review reporting on the barriers to hand hygiene practices among healthcare workers in sub-Saharan African countries alluded that running water is often recognized as an impediment to performing hand hygiene sufficiently or as required (Ataiyero et al. 2019). Kamanga et al. (2022) confirmed this challenge of inadequate water supply when trying to improve the implementation of hand hygiene in the burn unit at Kamuzu Central Hospital in Malawi. Inadequate running water was also identified as an obstacle to performing hand hygiene by the study that assessed emotional motivators for improving hand hygiene among healthcare workers, whereby the lack of running water nearby was a challenge for the participants to wash their hands in the healthcare facilities (McCay 2015).

Some of our participants were uncomfortable washing hands with cold water and referred to the cold water as an inadequate water supply. The same comments as water being too cold for handwashing and preventing participants from performing hand hygiene routines were reported by nurses in the overcrowded setting of resource-limited healthcare (Salmon et al. 2015). To confirm that adequate water supply is an enabler for implementing and maintaining five moments of hand hygiene, Engdaw et al.’s (2019) study discovered that participants who have adequate water for handwashing were 5.10 times more likely to have good hand hygiene compliance as compared to those who have not adequate water for handwashing. In Nigeria, Nwaokenye et al. (2020) reported frequent shortages in water supply as a reason for not practicing hand hygiene sufficiently. Water is the essential element for washing hands, and without it the five moments of hand hygiene are impossible. However, in South Africa, the issue of water remains a crisis due to inadequate resources, which include basic physical systems built to distribute water in the country. The water is unevenly distributed, and the urban receives a better supply than rural areas. Hence, the current study learner nurses highlighted inadequate water supply because they practice in the healthcare facilities that are in rural areas, where it is still a milestone to achieve sufficient running water.

Inadequate equipment and supplies for hand hygiene also led to poor or no handwashing by our study participants. They indicated that soap, paper towels, or any other materials for drying hands after washing, dysfunctional sinks, and taps are the reasons they are not implementing or maintaining five moments of hand hygiene. In many instances, the learner nurses highlighted that the above-mentioned issues inconvenience them and make it difficult to practice hand hygiene as recommended by the five moments of hand hygiene. Moreover, it was observed that if there is no soap to wash hands, there is a high number of healthcare workers who do not wash hands as required (Engdaw et al. 2019). Similar to our findings, the lack of soap and towels, broken sinks, or soap dispensers were previously reported (Sickder et al. 2017).

The study conducted in the United States in eight hospitals, on perceived barriers to appropriate hand hygiene, showed that noncompliance to hand hygiene included insufficient equipment and supplies such as broken sinks and soap dispensers as well as soap and paper towels to dry hands (Chassin et al. 2015). A narrative review conducted in sub-Saharan African countries confirms that poor hand hygiene in healthcare facilities is due to infrastructural deficits such as lack of water, soap, hand sanitizers, blocked/leaking sinks, and poorly positioned facilities (Ataiyero et al. 2019). Different from the current study, unpleasantness and harmfulness caused by antimicrobial soap were mentioned as one of the barriers to maintaining hand hygiene (Calcagni et al. 2021).

The findings also showed that some of the learner nurses do not wash their hands as required because of the distance to the washing bays or sinks or none in certain cubicles. This was found inconvenient and time-consuming; hence they ended up not implementing or maintaining five moments of hand hygiene. The learner nurses reported that in between the activities provided to the patients, they walk or run to other cubicles to wash their hands. Therefore, they forget handwashing because of the inconvenient distance between the washing bays. This is in line with the findings that assessed hand hygiene practice and factors affecting compliance among nurses in Black Lion specialized referral hospital, in Addis Ababa, Ethiopia (Negewo et al. 2017). The study by Niyonzima et al. (2018) reported that insufficient inaccessible, or inconveniently placed sinks are a major barrier to effective handwashing in healthcare facilities.

The previous study reported the worst findings, whereby nurses had to walk to other departments or locker rooms to wash their hands in between the work routine (Salmon et al. 2015). This challenge is long-standing as it was previously reported in the study that investigated handwashing facilities in the outpatient department of a tertiary care teaching hospital in India (Devnani et al. 2011). Drawing from the data, it was obvious that the insufficient equipment and other supplies are more disturbing. Having access to resources such as sinks makes it easier for learner nurses to perform hand hygiene. Moreover, it is recommended that more studies should be conducted to observe handwashing practices and assess the effect of the availability of handwashing facilities, knowledge, practices, and attitudes toward hand hygiene among healthcare workers in Africa (Mtweve & Sangeda 2022).

Many participating learner nurses reported high and heavy workloads as a barrier to implementing and maintaining the five moments of hand hygiene. They considered the workload too strenuous to allow them time to perform hand hygiene. Inconsistent with the current study findings, heavy workload was mentioned as an obstacle to handwashing practice (Atif et al. 2019). This workload was related to a high number of patients to be cared for and the shortage of nursing staff to take care of the patients. Kamanga et al. (2022) argue that poor hand hygiene practices in healthcare facilities are compounded by a high workload. Such challenges are too common and have been reported before in other settings. For example, in a tertiary care hospital, in Haryana Northern India, nurses and physicians reported that they are less likely to practice infection control measures such as hand hygiene properly because of high and heavy workload (Barker et al. 2017).

In China, an observational study identified workload as one of many challenges resulting in noncompliance with hand hygiene (Zhang et al. 2019). In Marjan Teaching Hospital, Iraq, the main reason for not observing hand hygiene practices consistently among intensive care unit nursing staff during the COVID-19 pandemic was the high workload (Alwatifi & Hattab 2022). Ataiyero et al. (2019) reported workload in relation to the shortage of staff as a reason for poor hand hygiene in sub-Saharan African countries. The doctors in a government tertiary care hospital perceived increased workload as the major barrier to maintaining hand hygiene (Semwal et al. 2020). Ahmadipour et al. (2022) argue that a high workload increases the risk of not maintaining the five moments of hand hygiene.

Gould et al. (2022) argue that hand hygiene can be compromised by high workload. In support, Peters et al. (2020) elaborate that a shortage of staff means fewer hands to perform duties correctly and increased shortcuts in performing duties. Therefore, a shortage of staff compromises day-to-day duty allocation per member, whereby a staff member is given more duties than expected (high workload) and has implications on observing basic requirements such as hand hygiene to control the transmission of infection in healthcare facilities. Fewer hands make the routine too busy; in Semwal et al.’s (2020) study, failure to wash their hands due to workload was related to the busy schedule. Participants indicated that it became so busy that they lacked time to wash their hands. It is obvious that in most instances, healthcare providers often get so busy that they either forget or are unable to perform hand hygiene (Nwaokenye et al. 2020).

In Australia, White et al. (2015) alluded to being too busy as a barrier to hand hygiene. Insufficient time to wash hands when the ward is busy was also indicated in the study that was conducted to improve hand hygiene targeting specific causes of noncompliance at eight hospitals in the United States (Chassin et al. 2015). The reason might be that healthcare workers avoid delays in providing immediate and continuous care to the patients rather than washing hands in between. It is obvious that when the pace of work is high and demanding, learner nurses proceed from one task to another without pausing or even multitasking. This hinders them from maintaining five moments of hand hygiene.

The high workload was also related to the time pressure. Similar to what some of the participants shared in the current study, Derksen et al. (2020) identified hindering factors to perform hand hygiene as time pressure, which is caused by a high workload. According to Peters et al. (2020), high workload, which is usually caused by the nursing staff shortage, leads to decreased time for infection–prevention precautions such as hand hygiene. Kamanga et al. (2022) indicated that the high workload gives the staff less time to put toward improving and sustaining good hand hygiene practices. Given the learner nurses as the study participants, the authors of this paper argue that insufficient time can also easily impact compliance to hand hygiene practices even to the providers with a very high level of hygiene. Of concern, is that the shortage of staff may worsen considering the overwhelming pressures experienced by the health workforce during the Covid-19 pandemic. Therefore, more nursing staff should be recruited, trained, and hired to address the existing staff shortage.

The study participants were only the learner nurses from one university in the Limpopo Province, and data collection would have included the learners from other universities and nursing colleges within the province for generalizability. However, the findings are generalizable to clinical facilities that the selected university allocates its learners.

This study explored the barriers that affect the capacity of learner nurses in implementing and maintaining five moments of hand hygiene in Limpopo Province, South Africa. Our study findings demonstrated that the learner nurses are aware that they should always implement and comply with the five moments of hand hygiene in the clinical facilities. However, there are barriers such as limited resources in the allocated clinical facilities and the high and heavy workload that prevented them from following recommended hand hygiene protocols. The practices driven by this barrier put the learner nurses and their patients at continued risk for cross-transmission of infections and communicable diseases. Hand hygiene practices are necessary to control infection transmission and other health risks in healthcare facilities. Therefore, addressing the identified barriers will encourage healthcare workers to observe and practice the five moments of hand hygiene when carrying out day-to-day activities.

The authors acknowledged the undergraduate research group for their contribution in undertaking the study.

T.E.M. drafted the manuscript, wrote the initial draft, and conceptualized the manuscript. M.M.R. compiled the findings, edited, and finalized the manuscript.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.