Feasibility and barriers to implementing a nurse-led hand hygiene intervention in intensive care units: a mixed-methods study

Background: Hand hygiene (HH) is essential for infection prevention, but compliance in intensive care units (ICUs) often falls short of recommended standards. Leadership-driven audit and feedback could enhance compliance, though its practicality in resource-limited, high-acuity settings is still unclear. Aim: To evaluate the feasibility of a nurse-led, real-time HH audit and feedback intervention in ICUs and to explore contextual barriers influencing its implementation. Methods: A mixed-methods study was conducted over 6 weeks in two Jordanian ICUs. Fourteen supervisors were trained to deliver digital HH audits and real-time feedback. A total of 128 HH observations were recorded pre- and post-intervention, and qualitative data were obtained through post-intervention semi-structured interviews with 22 supervisors. Results: HH compliance increased from 63.5% to 89.5% ( p < 0.001; Cohen’s d = 1.29). However, qualitative findings revealed that the intervention was not implemented as intended. Supervisors identified four major barriers: competing workload demands, technological challenges, role ambiguity and lack of managerial reinforcement. Compliance gains were instead attributed to contextual influences, including heightened awareness, peer accountability and observational effects. Conclusions: In resource-limited ICUs, HH improvement efforts should prioritise low-burden, context-sensitive strategies that leverage peer accountability, observational effects and organisational support mechanisms.