Leadership-as-practice to improve hand hygiene: a mixed-methods study in a Nepal emergency department

This study aims to examine the application of a leadership-as-practice (L-A-P) approach to improve hand hygiene compliance in a resource-limited emergency department (ED) in Nepal. Poor hand hygiene remains a major contributor to health care-associated infections, and traditional hierarchical leadership approaches often fail to achieve sustained behavioural change. By conceptualising leadership as a shared, practice-based process, this study aimed to embed hand hygiene into everyday clinical work, promote shared accountability and strengthen patient safety culture within a high-pressure ED setting.

A mixed-methods intervention was conducted in three phases: pre-training baseline assessment, immediate post-training evaluation and a 14-day follow-up. Sixty health-care workers, including doctors, nurses, paramedics and support staff, participated. The intervention combined experiential hand hygiene training using Glo Germ gel and ultraviolet light with facilitated discussion, real-time feedback and peer engagement, guided by L-A-P principles. Quantitative data on hand hygiene knowledge and observed compliance were analysed using appropriate statistical tests, while qualitative data were thematically analysed to explore leadership behaviours, teamwork and cultural change.

Observed hand hygiene adherence increased from 31% at baseline to over 80% immediately post-training and was maintained at the 14-day follow-up. Knowledge scores improved significantly across all professional groups. Qualitative findings indicated enhanced peer accountability, increased willingness to challenge unsafe practice across hierarchical boundaries and early signs of cultural change towards shared leadership and collective responsibility for patient safety.

This study was conducted in a single ED using a convenience sample and a short 14-day follow-up, which limits generalisability and long-term inference. Observational assessment may have been influenced by the Hawthorne effect, although triangulation with qualitative data strengthens credibility. As an exploratory pilot, the findings highlight the feasibility and potential value of L-A-P for patient safety improvement. Future research should use multi-site designs, longer follow-up periods and patient-level outcomes to assess sustainability, transferability and clinical impact.

This study shows that even in a busy, low-resource ED, real change is possible using simple tools and shared leadership. By involving staff in hands-on training and making leadership part of everyday work, hand hygiene practices improved quickly and those improvements lasted. Tools like Glo Germ and UV light made the training engaging and memorable. The approach did not rely on external experts or expensive resources, which makes it easy to repeat in similar settings. Hospitals looking to improve infection control can learn from this model of practical, team-based change built from the ground up.

Beyond better hand hygiene, this project helped change how staff worked together. Nurses, doctors and support staff started reminding and supporting each other, regardless of their position. The usual hierarchy softened, and everyone felt more included in the process. People began to see hand hygiene not just as a rule, but as part of their shared responsibility to protect patients. In a setting like Nepal, where leadership is often top-down, this showed that real cultural change can happen when everyone is given a voice and when leadership is something we all share in our daily work.

This study demonstrates how L-A-P can be operationalised as a patient safety strategy in a low-resource ED. By embedding leadership within routine clinical interactions, L-A-P offers a practical framework for strengthening hand hygiene behaviour, supporting teamwork and addressing the challenges of complexity and hierarchy in acute care settings.