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2020 ; 4
(4
): CD013582
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Barriers and facilitators to healthcare workers adherence with infection
prevention and control (IPC) guidelines for respiratory infectious diseases: a
rapid qualitative evidence synthesis
#MMPMID32315451
Houghton C
; Meskell P
; Delaney H
; Smalle M
; Glenton C
; Booth A
; Chan XHS
; Devane D
; Biesty LM
Cochrane Database Syst Rev
2020[Apr]; 4
(4
): CD013582
PMID32315451
show ga
BACKGROUND: This review is one of a series of rapid reviews that Cochrane
contributors have prepared to inform the 2020 COVID-19 pandemic. When new
respiratory infectious diseases become widespread, such as during the COVID-19
pandemic, healthcare workers' adherence to infection prevention and control (IPC)
guidelines becomes even more important. Strategies in these guidelines include
the use of personal protective equipment (PPE) such as masks, face shields,
gloves and gowns; the separation of patients with respiratory infections from
others; and stricter cleaning routines. These strategies can be difficult and
time-consuming to adhere to in practice. Authorities and healthcare facilities
therefore need to consider how best to support healthcare workers to implement
them. OBJECTIVES: To identify barriers and facilitators to healthcare workers'
adherence to IPC guidelines for respiratory infectious diseases. SEARCH METHODS:
We searched OVID MEDLINE on 26 March 2020. As we searched only one database due
to time constraints, we also undertook a rigorous and comprehensive scoping
exercise and search of the reference lists of key papers. We did not apply any
date limit or language limits. SELECTION CRITERIA: We included qualitative and
mixed-methods studies (with a distinct qualitative component) that focused on the
experiences and perceptions of healthcare workers towards factors that impact on
their ability to adhere to IPC guidelines for respiratory infectious diseases. We
included studies of any type of healthcare worker with responsibility for patient
care. We included studies that focused on IPC guidelines (local, national or
international) for respiratory infectious diseases in any healthcare setting.
These selection criteria were framed by an understanding of the needs of health
workers during the COVID-19 pandemic. DATA COLLECTION AND ANALYSIS: Four review
authors independently assessed the titles, abstracts and full texts identified by
our search. We used a prespecified sampling frame to sample from the eligible
studies, aiming to capture a range of respiratory infectious disease types,
geographical spread and data-rich studies. We extracted data using a data
extraction form designed for this synthesis. We assessed methodological
limitations using an adapted version of the Critical Skills Appraisal Programme
(CASP) tool. We used a 'best fit framework approach' to analyse and synthesise
the evidence. This provided upfront analytical categories, with scope for further
thematic analysis. We used the GRADE-CERQual (Confidence in the Evidence from
Reviews of Qualitative research) approach to assess our confidence in each
finding. We examined each review finding to identify factors that may influence
intervention implementation and developed implications for practice. MAIN
RESULTS: We found 36 relevant studies and sampled 20 of these studies for our
analysis. Ten of these studies were from Asia, four from Africa, four from
Central and North America and two from Australia. The studies explored the views
and experiences of nurses, doctors and other healthcare workers when dealing with
severe acute respiratory syndrome (SARS), H1N1, MERS (Middle East respiratory
syndrome), tuberculosis (TB), or seasonal influenza. Most of these healthcare
workers worked in hospitals; others worked in primary and community care
settings. Our review points to several barriers and facilitators that influenced
healthcare workers' ability to adhere to IPC guidelines. The following factors
are based on findings assessed as of moderate to high confidence. Healthcare
workers felt unsure as to how to adhere to local guidelines when they were long
and ambiguous or did not reflect national or international guidelines. They could
feel overwhelmed because local guidelines were constantly changing. They also
described how IPC strategies led to increased workloads and fatigue, for instance
because they had to use PPE and take on additional cleaning. Healthcare workers
described how their responses to IPC guidelines were influenced by the level of
support they felt that they received from their management team. Clear
communication about IPC guidelines was seen as vital. But healthcare workers
pointed to a lack of training about the infection itself and about how to use
PPE. They also thought it was a problem when training was not mandatory.
Sufficient space to isolate patients was also seen as vital. A lack of isolation
rooms, anterooms and shower facilities was a problem. Other important practical
measures described by healthcare workers included minimising overcrowding,
fast-tracking infected patients, restricting visitors, and providing easy access
to handwashing facilities. A lack of PPE, and equipment that was of poor quality,
was a serious concern for healthcare workers and managers. They also pointed to
the need to adjust the volume of supplies as infection outbreaks continued.
Healthcare workers believed that they followed IPC guidance more closely when
they saw the value of it. Some healthcare workers felt motivated to follow the
guidance because of fear of infecting themselves or their families, or because
they felt responsible for their patients. Some healthcare workers found it
difficult to use masks and other equipment when it made patients feel isolated,
frightened or stigmatised. Healthcare workers also found masks and other
equipment uncomfortable to use. The workplace culture could also influence
whether healthcare workers followed IPC guidelines or not. Across many of the
findings, healthcare workers pointed to the importance of including all staff,
including cleaning staff, porters, kitchen staff and other support staff when
implementing IPC guidelines. AUTHORS' CONCLUSIONS: Healthcare workers point to
several factors that influence their ability and willingness to follow IPC
guidelines when managing respiratory infectious diseases. These include factors
tied to the guideline itself and how it is communicated, support from managers,
workplace culture, training, physical space, access to and trust in personal
protective equipment, and a desire to deliver good patient care. The review also
highlights the importance of including all facility staff, including support
staff, when implementing IPC guidelines.