International Journal of

Environmental Research

and Public Health

Review

Hand Hygiene Teaching Strategies among Nursing Staff: A Systematic Review

María B. Martos-Cabrera 1, Emilio Mota-Romero 1 , Raúl Martos-García 1,2 , José L. Gómez-Urquiza 3, Nora Suleiman-Martos 4,* , Luis Albendín-García 1,3 and Guillermo A. Cañadas-De la Fuente 3

1 Andalusian Health Service, Avenida del Sur N. 11, 18014 Granada, Spain 2 Red Cross School of Nursing, University of Sevilla, Avenida la Cruz Roja N. 1, 41009 Sevilla, Spain 3 Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain 4 Faculty of Health Sciences, University of Granada, Calle Cortadura Del Valle S.N., 51001 Ceuta, Spain * Correspondence: [email protected]; Tel.: +34-958-248-047

Received: 12 July 2019; Accepted: 18 August 2019; Published: 22 August 2019 ���������� �������

Abstract: Background: Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. The aim here was to analyze hand hygiene training and the effectiveness of different methods and educational strategies among nurses and whether they maintained correct adherence over time. Methods: A systematic review was conducted in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus. The search equation with Medical Subject Headings (MeSH) descriptors was “Nurs* AND (handwashing OR hand hygiene) AND clinical trial”. The review was performed following the recommendations of the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: n = 17 clinical trials were included, with a total of 5747 nurses and nursing students. Strategies such as reminder sounds, practical simulations, videos, and audiovisual media improved handwashing compliance. Adherence overtime increased by up to 60%. The greatest effectiveness was related to the use of povidone–iodine, which reduced colony formation compared Hand hygiene teaching strategies among nursing staff: a systematic review to soap. Conclusions: The strategies that go beyond teaching techniques such as lectures may be more effective at increasing hand hygiene compliance. Combined approaches to learning/instruction improve user satisfaction by enabling self-management, flexibility, and repetition.

Keywords: hand hygiene; handwashing; infection control; nurses; nursing education

1. Introduction

In 2005, the World Health Organization (WHO) launched its “Clean Care Is Safer Care” campaign, an international initiative to promote patient safety [1]. This was followed in 2009 with “Save Lives: Clean Your Hands”, which is the main strategy program currently being promoted worldwide [2]. In accordance with these actions, health organizations around the world, such as the Health Foundation, are targeting health personnel to promote effective hand hygiene, thus enhancing patient safety and reducing the incidence of adverse effects such as nosocomial diseases [3]. The correct technique of handwashing is based in the following five steps: (1) Wet the hands and apply soap or use a hydroalcoholic solution. (2) Rub the hands together, following the order of palm to palm, with the

Int. J. Environ. Res. Public Health 2019, 16, 3039; doi:10.3390/ijerph16173039 www.mdpi.com/journal/ijerph

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back of the left hand to the right palm with interlaced fingers, repeating with the other hand, with palms together with fingers interlaced, with the backs of the fingers against the palms, with fingers interlocked. Clasp the left thumb with the right hand and rub in rotation. (3) Repeat with the left hand and the right thumb, rubbing the tips of the fingers in the other palm in a circular motion, going backwards and forwards and repeating with the other hand. (4) Rub for at least 20 s. (5) If the washing was with soap, rinse with water and dry [1].

Hospital-acquired infections (HAIs) pose major problems for health systems around the world. They are of multifactorial origin, but appropriate hand hygiene among health personnel is the most effective measure for preventing their propagation. Therefore, adherence to hygiene recommendations is of crucial importance [4] and has been reflected in many studies, which have demonstrated a clear relationship between the control of HAIs and proper hand hygiene [5].

Unfortunately, few studies on the training and adherence of health personnel to hygiene recommendations have been done, despite the obvious implications for patient safety [6]. In view of these considerations, it would be useful to investigate the degree of awareness among health staff in general, and nurses in particular, of these questions. It has been observed that although nurses may be perfectly acquainted with the underlying ideas of hand hygiene and may be willing to put them into practice (up to 94% agree with these statements), the technique is performed correctly by only 52% of nurses [7], and sometimes by even fewer. This gap between theory and practice raises serious concerns. Therefore, it is important to analyze training strategies and the degree of adherence of nurses to hand hygiene guidelines, taking into account that effective performance in this respect contributes greatly to preventing the spread of nosocomial infections [8].

Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. For this purpose, this study was undertaken to examine the effectiveness of different methods and training strategies to increase handwashing compliance and to determine long-term adherence. The question for this review was, “Which educational strategies are most effective at improving hand hygiene technique (and/or compliance) among nurses and nursing students?”

2. Methods

2.1. Search Strategy

A bibliographic search was carried out in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus in accordance with the recommendations made in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [9]. The search equations used were “Nurs* AND (handwashing OR hand hygiene) AND clinical trial” and its equivalent in Spanish. The descriptors of the search equation were taken from the Medical Subject Headings (MeSH) thesaurus.

2.2. Study Selection, Data Collection, Critical Review, and Level of Evidence

The inclusion criteria were clinical trials; analyzing handwashing techniques and the effectiveness of different methods used by nurses or nursing students; being published in English or Spanish during the period January 2008 to July 2018; and being related to the subject of the present study.

Studies focused on preventing nosocomial diseases among patients were excluded, as were studies not applied to human subjects and duplicated studies.

The search and study selection process was conducted by two members independently: a third member was consulted in cases of disagreement. First, the title and abstract were read, and then the

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paper selected was read in full. A reverse and forward literature search was made of the references cited in the selected studies.

A data coding manual was used. The following variables were obtained from each study: (1) author, (2) country, (3) year of publication, (4) study design, (5) interventions (educational strategies and effectiveness of different methods), (6) characteristics of the sample, and (7) rate of compliance (initial and over time).

The levels of evidence and degrees of recommendation used were those stipulated by the Oxford Center for Evidence-Based Medicine (OCEBM) [10]. The risk of bias was evaluated using a critical reading checklist for randomized clinical trials (CONSORT) [11].

3. Results

In total, 3939 articles were obtained from the literature search, of which 43 were duplicates and were hence excluded. After reading the titles and abstracts, a further 3922 were excluded because they did not meet the inclusion criteria, finally leaving 17 articles available for analysis. Figure 1 shows a flow chart with the selection process for the studies included.

Int. J. Environ. Res. Public Health 2018, 15, x 3 of 15

and effectiveness of different methods), (6) characteristics of the sample, and (7) rate of compliance

(initial and over time).

The levels of evidence and degrees of recommendation used were those stipulated by the Oxford

Center for Evidence-Based Medicine (OCEBM) [10]. The risk of bias was evaluated using a critical

reading checklist for randomized clinical trials (CONSORT) [11].

3. Results

In total, 3939 articles were obtained from the literature search, of which 43 were duplicates and

were hence excluded. After reading the titles and abstracts, a further 3922 were excluded because

they did not meet the inclusion criteria, finally leaving 17 articles available for analysis. Figure 1

shows a flow chart with the selection process for the studies included.

Figure 1. Flow chart of included studies.

The sample population was composed of 5747 nurses and nursing students. Five of the studies

considered were based on a mixed sample of physicians and nurses, but the numbers belonging to

each group were stated.

The nurses studied worked in the following areas: intensive care units (ICUs) (n = 6 studies),

geriatrics (n = 2), and mixed nursing wards (n = 7). The other articles were carried out on nursing

students. The details of each included article are provided in Table 1.

The risk of bias, assessed using CONSORT criteria [11], showed two points: an inadequate

blinding of the outcome assessor (use of different people as outcome assessors) and no reports on

whether the data analysts were blinded.

Figure 1. Flow chart of included studies.

The sample population was composed of 5747 nurses and nursing students. Five of the studies considered were based on a mixed sample of physicians and nurses, but the numbers belonging to each group were stated.

The nurses studied worked in the following areas: intensive care units (ICUs) (n = 6 studies), geriatrics (n = 2), and mixed nursing wards (n = 7). The other articles were carried out on nursing students. The details of each included article are provided in Table 1.

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Table 1. Characteristics of included studies (n = 17).

Author, Country, (Year)

Design Interventions Sample Hand Hygiene

Compliance Main Results LE/GR

Educational strategies

Fisher et al., Singapore, (2013) [12]

Randomized controlled trial

HH compliance using ultrasound + audio reminders n = 72 ICU nurses - Higher HH compliance after intervention of 6.8% (95% CI, 2.5–9.5)

1a/A

Ho et al., China, (2012) [13]

Randomized controlled trial by

groups

CG: reception of intervention package (posters, talks, hydroalcoholic solution)IG 1: same + glove pack slightlypowderedIG 2: same + powderless gloves

n = 612 geriatric nurses CG n = 189 IG1 n = 180 IG2 n = 243

CG = 19.5% IG1 = 27% IG2 = 22%

Increase in HH compliance 1 month/4 months after interventionCG = 19.8%/21.6% IG1 = 59.2%/60.6% IG2 = 59.9%/48.6%

1a/A

Huis et al., Netherlands, (2013a)

[14]

Randomized controlled trial

Adherence to two improvement strategies of HH Group led by leaders (GLD) (classic education) State-of-the-art strategy group (SASG): education, reminders, feedback, facilities and products, establishment of norms and objectives, social influence, and leadership

n = 67 nurses GLD: n = 20 SASG: n = 47

GLD: 19.1% SASG: 21.8%

Increase of HH adherence through social influence and enhanced leadership in HH improvement strategies Postintervention/follow-up (at 6 months): GLD: 34%/33% SASG: 18.6%/24.1%

1a/A

Huis et al., Netherlands, (2013b)

[15]

Randomized controlled trial by

groups

Strategy of HH compliance that was leader-directed CG: education, reminders, feedback, and orientation (led by leaders) IG: same as the last group + social influence and leadership (state-of-the-art wards)

n = 914 nurses, 67 wards CG: n = 402 IG: n = 512

CG: 20% IG: 22%

HH compliance rates improved from 22% (just before implementing strategies) to 47% (after the intervention) and to 48% (six months after). The vanguard group improved from 23% to 42% in the short term and 46% in the long term. Compliance in CG increased from 20% to 53% (short term) and remained at 53% in the long term

1a/A

Kukanich et al., United States, (2013)

[16]

Randomized controlled trial

Improved HH in two outpatient healthcare clinics Outpatient clinic oncology (G1) Gastrointestinal specialist outpatient clinic (G2)Disinfectant gel and informational signs were introduced together as an intervention

n = 56 nurses G1: n = 41 G2: n = 15

G1: 11% G2: 21%

The frequency of HH improved significantly after intervention G1: 36% G2: 54%

1a/A

Martín-Madrazo et al., Spain, (2012) [17]

Cluster randomized controlled trial

5MHH to evaluate HH CG: - IG: training of HWs through teaching sessions, the implementation of hydroalcoholic preparations, and the installation of reminder posters

n = 198 nurses CG n = 99 IG n = 99

Overall baseline compliance level: 8.1% Increased adherence to HH: 21.6% At 6 months: CG: 3.6%IG: 16.1%

1a/A

Rodríguez et al., Argentina, (2015) [18]

Conglomerate randomized

controlled trial

Improving HWs compliance with HH Shipping one time per month of an intervention: (i) leadership commitment, (ii) surveillance of materials necessary to comply with hand hygiene and alcohol consumption, (iii) use of reminders, (iv) a screenplay of the project, and (v) feedback

n = 468 ICU nurses 50% A multimodal strategy was effective for HH compliance Handwashing after interventions was 70%

1a/A

Rupp et al., United States, (2008) [19]

Randomized clinical trial

Adherence in the use of alcohol-based hand gel Unit A: educational program, reminders of handwashing, and leaflets with questionnaires. After 12 months, introduction of hydroalcoholic gel Unit B: installation of hydroalcoholic solution containers inside and outside of each patient care room

n = 174 ICU nurses Unit A: 47% Unit B: 38%

Increase in the use of alcohol-based hand gel at 31% in both units Unit A: • After the educational program: 62% • With hand gel available: 66% Unit B: • Hand gel available: 74%

1a/A

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Table 1. Cont.

Author, Country, (Year)

Design Interventions Sample Hand Hygiene

Compliance Main Results LE/GR

Stewardson et al., Switzerland, (2016)

[20]

Conglomerate randomized

controlled trial

Control group (G1): observation of participants Improved performance feedback group (G2): observation + feedback (verbal comments, reminder of 5MHH) Improved performance feedback and participation group (G3): observation + feedback + reports and posters every 3 months

n = 67 nurses G1 = 21 G2 = 24 G3 = 22

G1: 66% G2: 65% G3: 66%

HH compliance increase from 65% to 77% G1: 73% G2: 75% G3: 77% Effect of the intervention: G1 = OR, 1.41 CI (1.21–1.63) G2 = OR, 1.61 CI (1.41–1.84) G3 = OR, 1.73 CI (1.51–1.98)

1a/A

von Lengerke et al., Germany, (2017) [21]

Randomized controlled trial

CG: training measures on “clean hands action” (adaptation of World Health Organization’s (WHO’s) “Cleaner Care Is Safer Care” program) IG: application of 29 patterns of behavior change

n = 572 ICU nurses CG: n = 367 IG: n = 205

CG: 55% IG: 54%

(compliance with HH in 2013)

Increased adherence to HH through behavioral interventions in 2013 vs 2015 CG: +9% (95% CI, 5.1–11.8) IG: +16% (95% CI, 11.9–18.9)

1a/A

Xiong et al., China, (2017) [22]

Randomized controlled trial

CG: self-directed readings IG: education sessions, with lectures, videos, role play + 15–20 min of individual online supervision and feedback sessions after each class

n = 84 nursing students (n = 42 in each group)

The level of knowledge about HH increased by 15% in the intervention group

1a/A

Effectiveness of Different Methods

Chow et al., Singapore, (2012) [23]

Randomized controlled trial

Compared the effectiveness of 3 HH protocols Protocol 1 (P1): hand rubbing with alcohol covering all hand surfaces in no particular order Protocol 2 (P2): manual scraping with alcohol using the standard seven-step technique Protocol 3 (P3): washing hands with chlorhexidine using the standard seven-step technique

n = 60 nurses

In terms of daily care, alcohol hand rubbing covering all hand surfaces was the most effective intervention The effectiveness of the three interventions was shown to be equally effective Time spent on chlorhexidine HH was 79.7 s vs alcohol HH at 26 s

1a/A

Sharma et al., India, (2013) [24]

Randomized controlled trial

Comparison of 3 HH methods

• Group hand washing soap (G1) • Alcohol solution group (G2) • Povidone iodine group (G3)

n = 105 NICU nurses

Povidone–iodine scrub and alcohol hand rubbing were superior to plain soap hand washing In the groups using alcoholic solution and povidone, the measurement of colony-forming units was lower than in the group using soap. Mean reduction was 38.6%.

1a/A

Prevention-Focused Training

Dulon et al., Germany, (2009) [25]

Randomized controlled trial

Increase protective behavior through a skincare program reducing skin disease CG: training seminar IG: training seminar + advice on interventions and protection of the skin by instructors

n = 388 geriatric nurses CG: n = 242IG: n = 146

CG: 19% IG: 26%

No differences between groups in work behavior (prevalence post-intervention= 17% in both groups). In IG, increase in the use of moisturizers and hand disinfection instead of hand washing.

1a/A

Van der Meer et al., Netherlands, (2014)

[26]

Randomized controlled trial

Effects of a multifaceted implementation strategy on behavior, behavioral determinants, knowledge, and awareness of HWs regarding the use of recommendations to prevent hand eczema CG: only brochure IG: education, participatory work groups, and role models

n = 1649 nurses CG: n = 773 IG: n = 876

CG: 10.3% IG: 7.3%

IG group was significantly more likely to report hand eczema CG: 9.7% IG: 11.3% The intervention had a positive effect on the frequency of HH, the use of a moisturizer, and wearing cotton gloves

1a/A

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Table 1. Cont.

Author, Country, (Year)

Design Interventions Sample Hand Hygiene

Compliance Main Results LE/GR

Training with Audiovisual Media

Bloomfield et al., UK, (2010) [27]

Randomized controlled trial

Effects of a computer-assisted learning module (IG) vs conventional face-to-face classroom teaching (CG)

n = 231 nursing students CG: n = 113 IG: n = 118

- Computer-assisted learning was effective in teaching both the theory and the skill of knowledge of hand washing

1a/A

Jansson et al., Finland, (2016) [28]

Randomized controlled trial

follow-up study

Four phases: (1) Simulation; (2) Orientation to mannequin capabilities; (3) Practical scenario; (4) Post-scenario debriefing session.

n = 30 ICU nurses IG: n = 15 CG: n = 15

IG = 40.8% HH adherence in IG increased to 59.2% (6 months after the intervention) and decreased to 50.8% (24 months after)

1a/A

Note: CG = control group; GR = grade of recommendation; HH = hand hygiene; HWs = health workers; ICU = intensive care unit; IG = intervention group; LE = level of evidence; NICU = neonatal intensive care unit; 5MHH = five moments for hand hygiene.

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The risk of bias, assessed using CONSORT criteria [11], showed two points: an inadequate blinding of the outcome assessor (use of different people as outcome assessors) and no reports on whether the data analysts were blinded.

3.1. Characteristics of the Clinical Trials

The period of observation of the nurses from the start of the intervention to the measurement of the results obtained ranged from 1 to 24 months [13–15,17–19,21,28]. The average degree of adherence to hand hygiene guidelines prior to the intervention ranged from 6.8% to 66% [12,13,15–20,28]. After the interventions, this rose in all cases, by 18%–70% [13,14,16–20,28]. In certain studies, changes were maintained through the follow-up period (ranges from 16.1% to 51%) [14,16,17,20,28]: on the other hand, others authors found that the adherence over time decreased by 8.4% after 24 months [28]. The degree of compliance with hand hygiene in all selected studies was evaluated by external observers.

Significant variations in compliance were observed according to the nursing department in which the study was conducted. The highest levels of compliance were recorded in intensive care services. In ICUs, nurses showed a hand hygiene compliance only in high-risk contact situations (such as endotracheal suction). Intervention groups increased from 60% to 72.7% before patient contact and from 20% to 70% after patient contact. Regarding the duration of hand rubbing, rotational rubbing of thumbs increased 16.9% [28].

In addition, some authors showed a relationship between sociodemographic variables in relation to the compliance of handwashing in ICUs, with nurses with less experience showing greater compliance [18,28].

3.2. Educational Strategies of Healthcare Staff in Hand Hygiene

For the interventions, the “Five Moments for Hand Hygiene” recommendations of the WHO were taken as a reference. Most of the interventions formed part of professional training and consisted of promoting behavioral changes. The personnel concerned agreed to change their hand hygiene technique for one month, and the reported improvements in adherence to the new handwashing technique ranged from 9% to 20% [18,21].

There were also various educational interventions such as the use of sounds as a reminder, posters, practical simulations in workshops, practical scenarios, videos, and role-playing (simulations with different roles) [12,14–17,20]. According to Xiong et al. [22], an approach to training nursing students in hand hygiene consisted of providing mixed interventions based on elements such as lectures, videos, and role-play. These authors reported that learning and adherence improved with respect to self-directed training. Thus, after six months, 95% of the mixed-intervention group complied with hand hygiene recommendations, compared to 57.5% of the self-directed training group.

Another tool was training with audiovisual media through an e-learning methodology representing real clinical situations [27,28]. A study of nursing students reported that adherence to hygiene guidelines was greater among those who received audiovisual training rather than by the standard classroom approach after 8 weeks, achieving a greater adherence to good handwashing skills, performance, and knowledge [27].

3.3. Effectiveness of Different Methods

Only one of the studies reviewed assessed the hand hygiene techniques performed. Hand rubbing with hydroalcoholic solution was compared, in no particular order, to hand rubbing with a hydroalcoholic solution according to the standard seven-step technique and to handwashing with chlorhexidine solution following the same technique [23]. A 7.5% reduction in colony-forming units (CFUs) was obtained by handwashing performed according to the standard seven-step technique with the hydroalcoholic solution and also with the chlorhexidine solution. However, the group using the hydroalcoholic solution required the least time for the process, making this the best option.

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In the last case, one study evaluated the use of soap versus a hydroalcoholic solution or povidone–iodine and recorded 88% of CFUs among the nurses who washed their hands with a hydroalcoholic solution [24].

3.4. Educational Materials and Feedback Concerning Hand Hygiene

Several studies observed that, apart from providing training, healthcare institutions also seek to maintain adherence via reminder mechanisms such as posters, placing gloves near the work area, and providing more hydroalcoholic solution dispensers [13,14,16,19]. The use of such reminder methods improved long-term (defined as “at least four months”) adherence to handwashing recommendations, from 24.1% to 60.6% of the staff addressed. Another reminder measure that was employed was to instruct patients in the importance of handwashing, in addition to the use of posters. This approach obtained results similar to those reported in other studies, but awareness of the issue was extended to patients as a parallel benefit [17,20].

Another study of this question analyzed an intervention based on hand hygiene reminder measures such as the prominent display of containers with hydroalcoholic solution located in strategic areas of the hospital and even fitted with acoustic signals such as tags with reminder beeps [12].

Others authors reported that better results were obtained when teaching was provided by means of audiovisual media, achieving a greater adherence to good handwashing skills, performance, and knowledge [27].

According to Huis et al. [14,15], in addition to appropriate training for nursing staff and the provision of sufficient resources for hand hygiene, interventions based on leadership and social support are important to promote long-term adherence to handwashing standards. In the case analyzed, compliance with hand hygiene standards rose from 20% to 50%, and this persisted for at least six months.

3.5. Prevention-Focused Training

Research has also been conducted into preventing the appearance of hand eczema, as this condition can dissuade nurses from putting hand hygiene into good clinical practice. Thus, one study described an intervention in which training was based on participatory working groups and complementary teaching materials. Although there were no statistically significant differences in the prevention of eczema, there was an increase in the use of resources to prevent it, such as moisturizers or cotton gloves [26].

In contrast, other authors [25] reported that prevention and even improvements were achieved by an intervention group on hand eczema among a population of geriatric nurses. The main intervention consisted of a training seminar on eczema and its prevention, together with individualized advice on skin protection. As a result, the prevalence of hand eczema fell from 26% to 17% in the intervention group.

4. Discussion

The systematic review described obtained data on 5432 nurses and 315 nursing students who took part in 17 studies on hand hygiene techniques. Despite the low number of clinical trials carried out in this area, with specific reference to nursing staff, the selected articles all described clinical trials presenting high methodological quality and low levels of bias, which corroborated their good internal validity [10,11].

Previous studies in ICUs have shown data on hand hygiene adherence similar to those reported in this review, from 29% [29] to 74% [30]. Although the results of this study showed that after the intervention, the duration of hand rubbing, and specifically the rotational rubbing of thumbs, increased, other studies found that all of the steps of handwashing were practiced minimally by the staff [31], which could be attributed to a high workload and a lack of time in an emergency. In addition, the

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association between hand hygiene adherence and related variables such as age, gender, experience, or a profession in the ICU supported the same results [32].

Various techniques have been described for instructing healthcare personnel with respect to hand hygiene. Meanwhile, others, such as role-playing, that have been used in educational contexts could also be considered, and the results obtained from the latter approach were in line with those reported here [33]. Training with audiovisual media considerably improved the outcomes achieved compared to traditional teaching methods, since it provided a visual representation of real situations of clinical care. Furthermore, the use of audiovisual media improved user satisfaction by enabling self-management, flexibility, and repetition. However, some authors advocated combined approaches to learning/instruction in the view that traditional and other techniques are complementary [34]. For example, in medical students, training methods through traditional instruction and the use of audiovisual equipment under similar conditions of time and content were found to achieve 12% greater adherence to good handwashing techniques [35].

Although methodical hand rubbing with an antiseptic solution using the seven-step technique has been shown to reduce the formation of CFUs [36], there remains controversy, as some researchers claim that no single technique is clearly superior to any other, since the results obtained may be affected by other factors, such as the thoroughness of performance or the time employed in the procedure [37].

The relationship between better hand hygiene and fewer cases of cross-infection has been well established [38]. Logically, intensive care services and operating rooms pay particularly careful attention to questions of hygiene, applying strict antisepsis programs such as the “Zero-ventilator-associated pneumonia (VAP)” program, which has been shown to achieve high levels of adherence [39].

Among interventions aimed at raising standards of hand hygiene, the approach most commonly taken in the training of health personnel is to emphasize the need to take necessary action where and when appropriate, as has been noted by the World Health Organization [2]. However, as observed above, levels of adherence are uneven, depending on the service, and so this measure alone is insufficient to ensure patient safety in this respect [40,41].

Education and adherence behavior should begin in academic institutions because they are optimal environments to encourage good habits [4], since knowledge among nurses and students seems to be deficient [42], maybe due to some barriers such as allergic reactions, lack of staff, or lack of awareness [43–46]. Although traditional methods provide the necessary notions for the development of practical skills, they do not ensure the acquisition of knowledge [47]. The approach for nursing students is to learn and become competent for professional life, and therefore sufficient time must be guaranteed to learn and develop appropriate attitudes and practices (since some studies identified time as a barrier related to adherence) [48,49]. In addition, new teaching methods should enhance independence, autonomy [50], and motivation [51] and guarantee the acquisition of theoretical principles and their innate implementation, increasing adherence to handwashing [51].

The best way to achieve this is multifocal teaching with mixed methodologies, because it is not completely clear which teaching methods are better than others [52]. However, some systematic reviews have shown that tailored interventions addressing the determinants of practice improve hand hygiene compliance [53,54].

Some authors believe that the synergy of stimuli, including training as a basic pillar, enhances adherence to hand hygiene recommendations. The strategy of applying a saturation of external stimuli can be very effective in the short to medium term, but the positive impact usually slows or even reverses in the long term, partly due to increasing tolerance or the normalization of overstimulation [55]. Moreover, in the workplace, this saturation should be accompanied by cultural awareness of the importance of patient safety, in the absence of which adherence to hygiene standards may decrease [56].

According to some authors, the use of posters and/or specific trainings to raise the levels of hand hygiene is not as effective as strategies based on seeking a change in habits. Apparently, better results are achieved by implementing gradual changes in guidelines for nurses, thus motivating them

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to maintain levels of compliance and fostering a working environment in which patient safety is paramount [8,56].

Finally, it is important to highlight the role played by managers and their leadership skills. The support that they provide is essential to achieve good handwashing in health professionals. Furthermore, it is very important that during the implementation process, managers retain focus to prolong adherence [57].

Limitations

The present study presented certain limitations. First, due to the small number of studies that have been conducted on nursing staff and their compliance with hand hygiene standards, together with considerable heterogeneity within these research activities, it was not possible to perform a meta-analysis, and therefore our findings have limited external validity. Moreover, we did not investigate the reasons for nurses failing to maintain levels of hand hygiene despite their awareness of its importance. This question is probably related to motivational aspects and/or situations of overload and stress in the workplace [58]. Another limitation was related to the nature of the measurements (through external observation), which could affect the behavior of nurses, increasing their adherence to handwashing during the observation period (Hawthorne effect).

In view of these considerations, we suggest that future research in this area should address not only the degree of adherence to recommended techniques of hand hygiene, but also nurses’ motivation to do so and/or the workplace factors that may influence performance of these techniques.

5. Conclusions

It is essential to ensure the appropriate training of healthcare personnel in order to increase adherence to hand hygiene recommendations. In addition, strategies based on complementary stimuli should be adopted, since they improve adherence to handwashing by up to 70%. Finally, better results in increasing adherence to handwashing are obtained when traditional teaching methods are accompanied by the use of audiovisual media. The domination of skills is based on practice. Thus, it is essential to find strategies that go beyond the usual teaching techniques through the use of more innovative and flexible digital techniques.

Author Contributions: Conceptualization, M.B.M.-G., E.M.-R., R.M.-G., J.L.G.-U., N.S.-M., L.A.-G., and G.A.C.-D.l.F.; methodology, M.B.M.-G., N.S.-M., and J.L.G.-U.; validation, L.A.-G. and G.A.C.-D.l.F.; investigation, M.B.M.-G., E.M.-R., R.M.-G., and J.L.G.-U.; writing—original draft preparation, M.B.M.-G., E.M.-R., R.M.-G., and N.S.-M.; writing—review and editing, J.L.G.-U., L.A.-G., and G.A.C.-D.l.F.; visualization, M.B.M.-G., E.M.-R., R.M.-G., J.L.G.-U., N.S.-M., L.A.-G., and G.A.C.-D.l.F.; supervision, L.A.-G. and G.A.C.-D.l.F.

Funding: This research received no external funding.

Conflicts of Interest: The authors declare no conflicts of interest.

References

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Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

English/Portuguese

J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4572

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

CONTRIBUTION OF THE WORK LOAD TO THE OCCURRENCE OF MEDICATION ERRORS IN NURSING

CONTRIBUIÇÃO DA CARGA DE TRABALHO PARA A OCORRÊNCIA DE ERROS DE MEDICAÇÃO NA ENFERMAGEM

CONTRIBUCIÓN DE LA CARGA DE TRABAJO PARA LA OCURRENCIA DE ERRORES DE MEDICACIÓN EN LA ENFERMERÍA

Ketri Fagondes Aires1, Jamila Geri Tomaschewski Barlem2, Catharine Silva de Souza3, Laurelize Pereira

Rocha4, Deciane Pintanela de Carvalho5, Carolina Domingues Hirsch6

ABSTRACT

Objective: to analyze the contribution levels of the workload for the occurrence of medication errors in nursing. Method: this is an exploratory-descriptive study with a quantitative approach, conducted with 49 nurses in a public hospital in the South of Brazil, using an instrument built and validated by the authors of the research. Data were analyzed by descriptive and inferential statistics. Results: most participants had experienced some medication error in their work unit, with dose errors being the most frequent and the number of staff contributing to the occurrence of medication errors. Conclusion: the study facilitated the recognition of elements of the workload that contribute to the occurrence of medication errors in nursing, which may support the construction of strategies necessary to minimize the occurrence of medication errors

and patient safety. Descriptors: Workload; Nursing; Patient Safety; Medication Errors.

RESUMO

Objetivo: analisar os níveis de contribuição da carga de trabalho para a ocorrência de erros de medicação na enfermagem. Método: estudo exploratório-descritivo, de abordagem quantitativa, realizado com 49 enfermeiros em um hospital público do Sul do Brasil, mediante aplicação de um instrumento construído e validado pelos autores da pesquisa. Os dados foram analisados a partir de estatística descritiva e inferencial. Resultados: a maioria dos participantes já vivenciou algum tipo de erro de medicação em sua unidade de trabalho, sendo os erros de dose os mais frequentes e o quantitativo de pessoal o fator que mais contribui para ocorrência de erros de medicação. Conclusão: o estudo oportunizou o reconhecimento de elementos da carga de trabalho que contribuem para a ocorrência de erros de medicação na enfermagem, o que poderá subsidiar a construção das estratégias necessárias para a minimização da ocorrência dos erros de medicação e segurança do paciente. Descritores: Carga de Trabalho; Enfermagem; Segurança do Paciente; Erros de

Medicação.

RESUMEN

Objetivo: analizar los niveles de contribución de la carga de trabajo para la ocurrencia de errores de medicación en la enfermería. Método: estudio exploratorio-descriptivo, de enfoque cuantitativo, realizado con 49 enfermeros en un hospital público de Sur de Brasil, mediante aplicación de un instrumento construido y validado por los autores de la investigación. Los datos fueron analizados a partir de estadística descriptiva e inferencial. Resultados: la mayoría de los participantes ya vivió algún tipo de error de medicación en su unidad de trabajo, siendo los errores de dosis los más frecuentes y el cuantitativo de personal el factor que más contribuyó para ocurrencia de errores de medicación. Conclusión: el estudio mostró el reconocimiento de elementos de la carga de trabajo que contribuyen para la ocurrencia de errores de medicación en la enfermería, lo que podrá subsidiar la construcción de las estrategias necesarias para la minimización de la ocurrencia de los errores de medicación y seguridad del paciente. Descriptores: Carga de Trabajo;

Enfermería; Seguridad del Paciente; Errores de Medicación. 1Nurse (graduated), Nursing School of the Federal University of Rio Grande/FURG. Rio Grande (RS), Brazil. E-mail: [email protected]; 2,4Nurses, Professors, Nursing School of the Federal University of Rio Grande/FURG. Rio Grande (RS), Brazil. E-mail: [email protected]; [email protected]; 3,5Nurses, Master´s, Graduate Program, Federal University of Rio Grande/FURG. Rio Grande (RS), Brazil. E-mails: [email protected]; [email protected]; 6Nurse, Ph.D. students, Graduate Program of the Federal University of Rio Grande/FURG. Rio Grande (RS), Brazil. E-mail: [email protected]

ORIGINAL ARTICLE

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

English/Portuguese

J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4573

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

The nursing workload is associated with the

time the staff performs their activities, which

are directly influenced by the patients´

needs. These activities may be affected by

the patient´s level of dependence, the

severity of the disease, the institution´s

environment, the characteristics of the work,

the physical space and the profile of the

team's workers.1

The imbalance in professional activities,

motivated by factors of the environment or

intrinsic to the professional can lead to

overwork, characterizing the work overload

that compromises the quality of care and puts

the safety of the patient at risk.2

In this sense, the evaluation of the

variables that make up the nursing workload

becomes an important instrument to improve

the quality of care and, especially, contribute

to patient safety.

In Brazil, the National Patient Safety

Program (PNSP), instituted by Administrative

Rule MS/GM Nº 529, of April 1, 2013,

recommends the elaboration and

implementation of a set of basic protocols to

minimize errors and adverse events.3 Among

the patient safety priorities, issues related to

drug prescription and administration deserve

to be highlighted, as they are responsible for

the largest number of adverse events in health

facilities.4

Medication errors can be defined as any

preventable event that can lead to improper

or inappropriate use of medication or harm

the patient.5

The nurse together with the nursing team

plays a fundamental role in the medication

system, considering that they act in the last

stage of the system, administering medication

and monitoring the reactions of the client.

Thus, the actions performed by this

professional are decisive in the prevention of

medication errors, being the legal

responsibility of the professional to administer

medication.6

In many health institutions, there is not a

safety culture, but rather a punitive system,

which leads to underreporting, weakening the

identification of factors that contribute to the

event. The variables that compose the nursing

work process can contribute to the occurrence

of medication errors. Thus, to identify the

contribution of these variables in the

occurrence of medication errors is of

fundamental importance for the construction

of strategies that minimize the occurrence of

adverse events and contribute to the safety of

the patient, which justified the

accomplishment of this study.

Thus, the research question of this study

presents is: what are the levels of workload

contribution to the occurrence of medication

errors in nursing? The purpose of this study

was to analyze the levels of contribution of

the workload to the occurrence of medication

errors in nursing.

This is an exploratory-descriptive study

with a quantitative approach, performed at a

University Hospital in the South of Brazil, with

49 nurses selected by non-probabilistic

sampling for convenience. The inclusion

criterion was to be a nurse in one of the care

units of the selected hospital.

A self-administered questionnaire was used

as a collection instrument composed of 25

questions in Likert format, elaborated and

validated by the authors of the research,

using face, content and construct validity.

The nurses were invited to participate in

the study at the place and work shift, and the

instruments were delivered directly to the

informants in a brown paper envelope,

without identification, and the scheduling of

the collection was carried out.

After applying the instrument to the

selected sample, a factorial analysis was

performed to reduce and summarize the data,

aiming the formation of factors and the

validation of the instrument construct. The

formation of the factors obeyed two criteria:

the level of association between the variables

found through the factorial loads (>, 450); and

their level of subjectivity. Cronbach´s alpha

was used to test the reliability of the

instrument by checking the consistency of

different characteristics of each of the

factors, measured through instrument

questions.

The results referring to the studied sample

were obtained through descriptive statistics,

using the means and frequency distribution of

the constructs and their indicators, and

inferential statistics. The data were submitted

to the Kolmogorov-Smirnov normality test,

and a non-parametric distribution was

verified. Thus, the Mann-Whitney test was

used to compare the means in the case of

variables with two nominal categories.

Numerical data analysis was performed using

Spearman's Rho correlation. P <0.05 was

considered statistically significant.

Statistical Package for Social Sciences

(SPSS) software version 22.0 was used to

analyze the data, facilitating the process of

data organization in tables that allowed a

INTRODUCTION

METHOD

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

English/Portuguese

J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4574

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

better visualization of the results and their

interpretation.

Ethical aspects were respected, by the

recommendations of Resolution 466/12 of the

National Health Council. Thus, the study was

approved by the Local Research Ethics

Committee (Opinion Nº 144/2015).

Regarding the construct validity, five of the 25 questions of the instrument submitted to the exploratory factorial analysis were excluded because they presented low factor loads (less than 0.450), forming blocks with a single question or because they did not express conceptual coherence with the proposed block.

Thus, in its final version, the instrument,

consisting of 20 items, presented five

constructs: patient conditions; infrastructure;

conflicts and dissatisfactions; the number of

staff; and work organization. The five

dimensions of the instrument explain 71.77%

of the variation of the original questions,

which represents an adequate degree of

synthesizing the data, facilitating its handling

and interpretation.

The reliability of the five constructs of the

instrument was tested by calculating the

Cronbach´s alpha. The Cronbach´s alpha of

the instrument presented a value of 0.89,

while the coefficients of the five constructs

were between 0.78 and 0.90, values

considered high for exploratory studies,

evidencing the reliability of the instrument in

the selected sample. Table 1 presents the

factorial loads of each construct according to

their formation in the factors, the explained

variance, as well as the Cronbach´s alpha

values.

Regarding the characteristics of the sample

studied, it was verified that the 49 nurses had

an average of 37 years old (37.23) and most of

them were female (93.9%). The average time

of professional training was 12 years (12.33),

ranging from three months to 34 years of

training. The time of professional

performance varied between one month and

35 years, being 12 years (12,24) the average

time of professional performance.

Regarding the units of action of the 49

nurses, it was verified that five of them

worked in surgical units, seven in a prompt

care unit and risk classification, six in the unit

of medical clinic and hospital day, 12 in

General Intensive Care Unit and Neonatal, five

in obstetric units, five in the pediatric unit

and nine were spare substitutes, working in all

care units. Nine Of the 49 nurses had

graduation, 24 had a residency or

specialization degree, 11 were masters, and

three had a Ph.D. course.

When questioned about participation in

continuing education activities, 63.3% of the

nurses affirmed participating in the proposed

activities. When questioned about the

performing meetings in the work unit, 64.60%

of the participants stated that they

participated in meetings.

Considering the experience of medication

errors, 85.7% of the nurses said they had

experienced some medication error in their

work unit. Among the types of error, 49% were

dose errors, 36.7% medication errors, 30.6%

patient errors, 18.4% time errors and 16.3%

route errors. On the frequency of the errors,

39.5% of the nurses stated that the errors

occur once every six months and 39.5%

mentioned that they occur once every year.

When questioned about reporting the

occurrence of errors, 61.5% answered that

they report medication errors that occurred in

their work unit.

The descriptive analysis (Table 2) allowed

verifying the contribution levels of each

construct for the occurrence of medication

errors by nursing. The construct conditions of

the patient presented the lowest mean (3.42)

among the factors that contribute to the

occurrence of medication errors in nursing. It

was observed that the level of patient

dependence, work in units that provide care

to patients in critical conditions or terminally

ill patients and constant work with human

suffering are indifferent in the occurrence of

medication errors. In this construct, the issue

“Working in units that provide care to patients

in critical conditions” had the highest mean

(3.53).

The infrastructure construct presented an average of 3.78, evidencing that, according to the nurses surveyed, the absence of computerized systems for drug prescriptions, poor infrastructure and the quality of materials and equipment, including those for individual protection, are also indifferent to the occurrence of medication errors. The issue of “precarious infrastructure” presented the highest mean in this construct (3.94).

Also, in the construct conflicts and

dissatisfactions, the average of 3.98 was

obtained, noting that professional

dissatisfaction, patients that exceed the

complexity of care unit, the amount of

medication used by the patient and the

conflicts in interpersonal relationships are

indifferent to the occurrence of medication

errors. However, in this construct, the issue of

“ineffective communication among health

professionals” presented an average of 4.37,

showing that the lack of communication or

inadequate communication between the

RESULTS

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

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J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4575

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

health team contributes to the occurrence of

medication errors.

The construct of quantitative of personnel

presented the highest mean of the instrument

(4.41), noting that nurses believe that the

quantitative of nursing workers, the

quantitative/qualitative dimensioning of

inadequate nursing personnel and working in

more than one health institution or having

other professional occupations contribute to

the occurrence of medication errors. In this

context, the issue “quantitative of nursing

workers” presented the highest average

(4.49).

The construct of work organization

presented a mean of 3.82, noting that nurses

believe that the absence of

continuous/continuing education training,

nursing care prescriptions and norms and

routines manuals are indifferent to the

contribution of the occurrence of medication

errors. However, nurses believe that the

absence/lack of knowledge of protocols for

safe practices in medication administration

(4.06) contributes to the occurrence of errors.

Table 1. Average workload contribution levels for medication errors. Rio Grande (RS), Brazil, 2015.

Factors n Average

Patient conditions 49 (3.42) Q9 Working in units that provide care to patients in critical conditions 49 3.53 Q10 Working in units that provide care to terminal patients 49 3.43 Q11 Dealing constantly with human suffering 49 3.35 Q12 Level of dependence of the patient Infrastructure

49 49

3.37 (3.78)

Q19 Lack of computerized systems for drug prescriptions 49 3.59 Q20 Quality of materials and equipment 49 3.45 Q21 Precarious infrastructure 49 3.94 Q22 Quality of personal protective equipment 49 3.43 Conflicts and dissatisfaction 49 (3.98) Q8 Professional dissatisfaction 49 4.06 Q13 Patients who exceed the complexity of the care unit 49 4.02 Q14 Number of medications used by the patient 49 3.86 Q24 Ineffective communication among health professionals 49 4.37 Q25 Conflicts in interpersonal relationships 49 3.59 Quantitative of personnel 49 (4.41) Q1 Quantitative nursing workers 49 4.49 Q2 Quantitative/qualitative dimensioning of inadequate nursing staff 49 4.47 Q5 Work in more than one health institution or have another occupation 49 4.27 Organization of work 49 (3.82) Q15 Lack of Continuous/Continuing Education Training 49 3.86 Q16 Absence of nursing care prescriptions 49 3.61 Q17 Absence/misunderstanding of standards and routines manuals Q18 Absence/lack of knowledge of protocols for safe practices in drug administration

49 49

3.76 4.06

Regarding the tests to verify significant

differences between the samples, the Mann-

Whitney test (Table 2) allowed to analyze the

existence of possible differences in the

average of the factors that contribute to the

occurrence of medication errors, considering

the characteristics of the sample. Nurses who

participate in continuing education activities

believe that the infrastructure factor

contributes more to the occurrence of

medication errors than those who do not

participate. Also, nurses who work in units

where meetings occur, believe that the

patient´s condition factor contributes more to

the occurrence of medication errors than

those who work in units where meetings do

not occur.

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

English/Portuguese

J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4576

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

Table 2. Relationship between the characteristics of the sample and the identified constructs. Rio Grande (RS), Brazil, 2015.

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5

Works in another institution No Yes

N 38 11

m p m P m p m p m p

24.24 27.64

.485 26.34 20.36

.218 24.30 27.41

.523 26.36 20.32

.203 25.45 23.45

.681

Permanent education No Yes

N 17 31

22.94 25.35

.566 19.12 27.45

.047*

22.26 25.73

.410 23.00 25.32

.571 19.65 27.16

.073

Experience of errors No Yes

N 7 42

26.57 24.74

.769 28.57 24.40

.492 22.29 25.45

.605 30.43 24.10

.291 21.43 25.60

.492

Meetings No Yes

N 17 31

16.79 28.73

.005* 24.32 24.60

.948 22.12 25.81

.380 20,00 26.97

.089 26.74 23.27

.409

Error notification No Yes

N 15 24

19.83 20.10

.942 18.00 21.25

.382

20.93 19.42

.684 22.87 18.21

.201 21.17 19.27

.610

* Significance at the level of 5

The Rho-Spearman test demonstrated that

there were no significant differences in the

“training time” and “professional

performance time” and the constructs patient

conditions, infrastructure, conflicts and

dissatisfactions, personnel quantitative and

work organization.

It was possible to verify that most nurses

participating in this study had experienced

some medication error during their

professional career in nursing, and the dose

errors were evidenced as those that occur

more frequently and the route errors as those

less occurring. These results agree with the

findings of the literature, which point out that

dose-related errors in medication are the

most prevalent in health institutions,

including absence of dose and inadequate

dose, and mistakes of wrong-way

administration are the infrequent ones.7

It is worth noting that the frequency and

the most prevalent type of medication errors

contribute to reducing the number of errors in

different health institutions.8 Currently, based

on actions directed at patient safety, a new

culture has been implemented in health

institutions since, culturally, the idea that

health professionals do not make mistakes or

cannot make mistakes is widespread in

society.3

Thus, to implant a culture of safety in

health institutions, individual guilt for errors

has been replaced by the reorganization of

care processes to notify and anticipate the

errors and correct them before injury or harm

to the patient. Thus, error reporting aims to

generate error-prevention alerts, enabling the

construction of strategies that contribute to

the reduction of adverse events in the context

of health.4

In this sense, it was verified that most of

the nurses participating in this study stated

that they report medication errors when they

occur in their work units. However, there are

still hospitals that do not notify their errors,

preventing the opportunity to improve the

service and implementation of safe practices

to minimize similar errors.10

Regarding the evaluation of the levels of

contribution of the workload to the

occurrence of medication errors in nursing, it

was possible to perceive that the quantitative

of personnel is the factor that contributes

most to the occurrence of such errors. Similar

results have been found in other studies,

which have shown that the adequate number

of nursing professionals is directly related to

the safety of the patient and health workers,

so hospitals that do not demonstrate

initiatives that contribute to good working

conditions and can contribute to the existence

of a greater number of adverse events.9

In general, health institutions show

insufficient and inadequate numbers of

nursing workers to meet the routine and needs

of the unit, which can compromise the health

and safety of the worker and the patient,

generating a risk of errors.11 In this sense, the

personnel dimensioning is a system that must

be used to plan and evaluate the quantitative

necessary for institution, as well as the

qualitative of the nursing professional

adjusted to offer the assistance in the way

that the health service needs, guaranteeing

the safety of patients and professionals and

avoiding adverse events.12

DISCUSSION

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

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J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4577

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

It should also be noted that, besides the

number of personnel, other factors can cause

work overload in nursing, for example, the

institution´s precarious infrastructure,

including lack of materials, lack of

professionals in other areas in the institution,

absence of individual protective equipment,

lack of continuous and continuing education

capacities.13 However, in this study, the

infrastructure, including the different

elements that compose it, was evidenced by

nurses as indifferent to the occurrence of

medication errors.

Concerning the contribution of conflicts

and dissatisfactions to the occurrence of

medication errors, especially professional

dissatisfaction, patients that exceed the

complexity of unit care, the number of

medications used by the patient and conflicts

in interpersonal relationships, it was possible

to verify that these were also considered

indifferent by nurses for the occurrence of

such errors. It should be stressed that

overload is one of the major reasons for

professional dissatisfaction, which can

increase job rotation and abstention, harming

the multi-professional team, patient care, and

the institution.14

The workload varies according to the

inpatient complexity, clinical status,

procedures and therapy used so that the more

critical the patient´s condition or, the greater

the number of adverse events, the greater the

burden. The use of a system that assesses the

workload is extremely important for nursing

professionals, providing safety for patients

and employees and alerting the institution to

the recruitment of an adequate number of

professionals.16

Regarding the contribution of conflicts and

dissatisfaction to the occurrence of

medication errors, it was verified that the

lack of communication or ineffective

communication contributes to the occurrence

of errors in nurses´ vision. This result is in line

with a study that analyzed the strategies to

promote patient safety from the perspective

of care nurses, in which it was verified that

errors in the medication administration

process begin with ineffective communication

between the pharmacy professional who the

dispensing physician, the prescribing

physician, and the nursing team administering

the medication.17

Thus, communication failure is evidenced

as one of the main causes of errors, of

medication errors in health institutions, which

also end up not being properly notified and

analyzed by those involved, causing, again,

communication errors in the team and new

adverse events.12 One of the main goals of the

National Patient Safety Program (PNSP) is to

improve communication among health

professionals to create strategies to solve this

problem.3

The nurses in this study also showed that

the patient´s conditions are indifferent to the

occurrence of errors. However, the workload

varies according to the complexity of the

hospitalized patient, clinical status, necessary

procedures and therapeutics used, so that the

more critical the patient´s condition or, the

greater the number of adverse events, the

greater will be the burden.15 Thus, some

specificities of nursing care deserve special

attention, for example, care for patients in

the terminal state, which in addition to

physical exhaustion also causes emotional

exhaustion, which may contribute to the

occurrence of medication errors.13

Regarding the contribution of work

organization to the occurrence of medication

errors, the nurses of this research also

evidenced this factor with indifferent to the

occurrence of medication errors. However,

they showed that the absence/ignorance of

protocols for safe practices in drug

administration contributes to the occurrence

of medication errors.

In this sense, one of the current initiatives

of the National Patient Safety Program in

Brazil refers to the implementation of safe

practices in health institutions, based on basic

protocols.3 Nursing has a great responsibility

for patient safety and care that medication

administration requires, as the “right nine,”

patient-centered, medication, route, dose,

time, registration, form, orientation and right

response, recommended by the Protocol of

Safety in Prescribing, Use and Administration

of Medications.4

Regarding adverse drug administration

events, the role of nursing is directly

associated with the reduction of errors, since

the last stage of drug therapy is under the

responsibility of the nursing team, so that

when there is an error in the previous

processes, it may be Identified and

interrupted, avoiding failures in patient

safety.18 Thus, a protocol-based care plan, as

well as the use of technologies,

computerization in nursing, electronic medical

prescriptions, systems for calculating doses,

dilution and reconstitution volumes,

interactions, records for patients to see

contraindications and drug allergies, bar codes

for medication and modern infusion pumps

generate more safety for the professional and

the patient, minimizing the occurrence of

errors.19

Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

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J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4578

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

In this study, it was also possible to verify

that nurses participating in continuing

education activities believe that the

infrastructure factor contributes more to the

occurrence of medication errors than those

who do not participate. Thus, it is possible to

affirm that the nurses who participate in the

permanent education know better the

materials and equipment that can be used in

their work and are updated on their use to

minimize medication errors. As already

identified in the literature, active

participation in continuing education activities

contributes to the construction of collective

strategies to promote harm minimization,

adverse events, and reduce risk of incidents.20

Finally, it was found that nurses who work

in units in which meetings take place believe

that the factor conditions of the patient

contribute more to the occurrence of

medication errors than those who work in

units where meetings do not occur. It is

possible to infer that nurses who hold

meetings with their teams better visualize the

conditions of their inpatients, discuss

situations, expose and share more their

difficulties in the care they provide, which

allows a better visualization of the

contribution of the patient´s conditions to the

occurrence of medication errors.21

Given this research, it can be verified that

most of the participating nurses have

experienced some medication error in their

work unit, with dose errors being the most

frequent and the route errors the less

frequent. There was a predominance of nurses

who reported reporting the occurrence of

medication errors occurring in their work unit,

which allows affirming that the nurses of the

research institution have already been seeking

to implement a safety culture and to carry out

joint preventive measures to reduce the

occurrence of errors.

Regarding the levels of contribution of the

workload, it can be identified that the

number of nursing staff is the factor that

contributes most to the occurrence of

medication errors in the nurses´ view. Also, it

was verified that the factors patient's

conditions, infrastructure, conflicts and

dissatisfaction and work organization were

evidenced by nurses as indifferent to the

occurrence of medication errors in nursing.

However, some issues present in such

factors have been pointed out as important

elements that contribute to the occurrence of

medication errors in nursing, such as lack of

communication or ineffective communication

among health professionals, and absence/lack

of knowledge of protocols for safe practices in

nursing in the administration of medicines. In

this sense, it is highlighted that both the

improvement of communication among health

professionals and the adoption of protocols for

safe practices in medication administration

have been widely encouraged by the National

Patient Safety Program as strategies to

minimize medication errors and avoid adverse

events.

It is expected that this study will

contribute to the construction of the

necessary strategies to minimize the

occurrence of medication errors and patient

safety, from the recognition of workload

variables that contribute to the occurrence of

such errors. Such strategies may focus on the

adequate design of nursing personnel in health

institutions, actions aimed at improving

communication among health professionals

and adopting protocols for safe practices in

drug administration.

As a limitation of the study, it is

emphasized that it was done with a specific

sample of nurses from a hospital in the south

of Brazil due to the short time possible for its

execution, which does not allow the

generalization of its results. It is also possible

to highlight the difficulty of the nurses in

collaborating and in participating in the

research.

1. Altafin JAM, Grion CMC, Tanita MT, Festti

J, Cardoso LTQ, Veiga CFF, et al. Nursing

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4. Anvisa. Boletins Informativos: Segurança

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Aires KF, Barlem JGT, Souza CS de et al. Contribuição da carga de trabalho para a ocorrência...

English/Portuguese

J Nurs UFPE on line., Recife, 10(12):4572-80, Dec., 2016 4580

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9978-88449-6-ED1012201619

http://www.scielo.br/pdf/reeusp/v42n4/en_

v42n4a08.pdf.

Submission: 2016/06/09 Accepted: 2016/11/04 Publishing: 2016/12/01

Corresponding Address

Carolina Domingues Hirsch Rua Visconde de Paranaguá, 102

CEP 96203-900  Rio Grande (RS), Brazil

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American Journal of Infection Control 48 (2020) 940−947

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

State of the Science Review

Notice to comply: A systematic review of clinician compliance with guidelines surrounding acute hospital-based infection management

Kendall E. McKenzie MEng a,*, Maria E. Mayorga PhD b, Kristen E. Miller MSPH, DrPH c, Nishant Singh BS b, Ryan C. Arnold MD d, Santiago Romero-Brufau MD e,f

a Department of Design, North Carolina State University, Raleigh, NC b Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC c MedStar Institute for Innovation, MedStar Health, Washington, DC d Department of Emergency Medicine, Cottage Health System, Santa Ynez, CA e Department of Medicine, Mayo Clinic, Rochester, MN f Department of Biostatistics. Harvard T.H. Chan School of Public Health, Boston, MA

Key Words:

* Address correspondence to Kendall E. McKenzie M Carolina State University, 50 Pullen Road, Raleigh, NC 276

E-mail address: [email protected] (K.E. McKenzie) Conflicts of interest: None to report. Funding: This work was supported by the N

(IIS1522072, IIS1522106, IIS1522107, IIS1833538).

https://doi.org/10.1016/j.ajic.2020.02.006 0196-6553/© 2020 Association for Professionals in Infect

Purpose: To identify and characterize studies evaluating clinician compliance with infection-related guide- lines, and to explore trends in guideline design and implementation strategies. Data sources: PubMed database, April 2017. Followed the PRISMA Statement for systematic reviews. Study selection: Scope was limited to studies reporting compliance with guidelines pertaining to the preven- tion, detection, and/or treatment of acute hospital-based infections. Initial search (1,499 titles) was reduced to 49 selected articles. Data extraction: Extracted publication and guideline characteristics, outcome measures reported, and any results related to clinician compliance. Primary summary measures were frequencies and distributions of characteristics. Interventions that led to improved compliance results were analyzed to identify trends in guideline design and implementation. Results of data synthesis: Of the 49 selected studies, 18 (37%), 13 (27%), and 10 (20%) focused on sepsis, pneumonia, and general infection, respectively. Six (12%), 17 (35%), and 26 (53%) studies assessed local, national, and international guidelines, respectively. Twenty studies (41%) reported 1-instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or control group studies), and 1 study (2%) described compliance qualitatively. Average absolute change in compliance for minimal, decision support, and multimodal interventions was 10%, 14%, and 25%, respectively. Twelve studies (24%) reported no patient outcome alongside compliance. Conclusions: Multimodal interventions and quality improvement initiatives seem to produce the greatest improvement in compliance, but trends in other factors were inconsistent. Additional research is required to investigate these relationships and understand the implications behind various approaches to guideline design, communication, and implementation, in addition to effectiveness of protocol impact on relevant patient outcomes. © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All

rights reserved.

Guideline adherence Practice patterns (physicians) Quality Program evaluation Professional practice gaps Outcome and process assessment (health care)

Eng, College of Design, North 07 .

ational Science Foundation

ion Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Best practice protocols are often communicated to clinicians in the form of guidelines. The Institute of Medicine formally defines clinical practice guidelines as “statements that include recommenda- tions, intended to optimize patient care, that are informed by a

systematic review of evidence and an assessment of the benefits and harms of alternative care options.”1 The primary benefit of guidelines is their potential to improve the quality of patient care.2 Common characteristics of “good” guidelines, as described in the literature, include validity, reliability, reproducibility, clinical applicability, clini- cal flexibility, clarity, multidisciplinary process, review of evidence, and documentation.3 Clinical guidelines are issued by multiple differ- ent entities (eg, public health organizations, research institutions, hospital management), have varying levels of presence across the world’s health care domain (ie, international, national, local), and are

Fig 1. Results of each phase of the review process were used to produce the final set of articles for analysis. The 2 paths depicted began with different pools of articles: the results of the original PubMed search and then the relevant references from the articles selected in the original search.

K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947 941

usually communicated with an attached adherence expectation (ie, mandatory, optional).

The goal of any guideline is to provide recommendations that will translate into improve quality of patient care, and ultimately improve patient outcomes. Yet, many challenges arise when clinicians (ie, health care professionals with clinical education) attempt to put guidelines’ written, evidence-based instructions into action.4 In clini- cal scenarios, multiple competing guidelines often exist, yet little research has focused on identifying characteristics of existing guide- lines that commonly elicit compliance.5,6 Given the wide variety of clinical practice guidelines communicated and regulated by authori- tative bodies, it is not surprising that clinician’s uptake of guidelines is low.7 Success in implementation and improvement of practice seems particularly resource intensive.8 Guideline “success” is difficult to evaluate because it connects two important outcomes: clinician adherence to the guideline, and patient outcomes associated with guideline recommendations. While many studies have focused on how guideline recommendations affect patient outcomes, there has been less focus on how compliance with guidelines fits into the equa- tion. To improve compliance with guidelines, it is important to first understand how compliance with guidelines has been evaluated and achieved in previous research.

Guidelines are widely used for infectious disease care. A key example is sepsis guidelines, which have recently garnered increased international attention, due to the deadly and costly nature of the dis- ease.9-11 To inform and support current efforts toward improving such guidelines, it is valuable to investigate acute hospital-based infection guidelines in general, to understand how they have been designed, implemented, and evaluated for compliance. Although many studies report compliance with guidelines, there is a clear gap in the research toward understanding what makes a guideline suc- cessful, as well as how guidelines can be implemented to produce a higher standard of care.

We limit the scope of this systematic review to focus solely on studies that reported compliance with guidelines pertaining to the prevention, detection, and/or treatment of acute hospital-based infections. Examples of such guidelines include recommendations for antibiotic administration, pneumonia treatment, sepsis management, and hand hygiene. The objectives of this systematic review are (1) to evaluate trends in infection guideline design and implementation strategies and (2) to identify and characterize studies that have eval- uated clinician compliance and, if present, associated outcomes.

METHODS

We performed a systematic review of studies that reported clini- cian compliance with guidelines related to acute hospital-based infections, where guidelines are defined as written statements devel- oped by medical specialty societies, disease-focused organizations, or expert panels to assist practitioner and patient decisions about appropriate care under specific clinical circumstances.3 The format of this review follows the PRISMA Statement for reporting of systematic reviews that evaluate health care interventions.12 Supplemental Digi- tal Content 1 identifies locations of PRISMA components within this document.

Study eligibility

Our search was limited to studies published in the 10 years prior to our initial search date (May 13, 2016), as well as any additional articles published between the initial search date and the date collab- orators completed the article selection process (April 30, 2017). Thus, the study dates were May 13, 2006 through April 30, 2017. We looked at studies in this time period because it corresponded to the release of new international guidelines for a prominent infection:

sepsis. Studies included in the final set of articles were required to present results of clinician adherence or compliance. During the review phase, we limited our scope to only acute hospital-based infections, which were defined as acute infections (which excluded chronic or long-term infections like HIV or tuberculosis), that were also severe enough to often require a hospitalization.

Search criteria

The search was conducted in the PubMed database, using a com- bination of Medical Subject Heading (MeSH) terms, keywords, and publication types. The specific search criteria, developed with the help of a university library consultant to ensure a highly inclusive approach, returned all eligible studies (ie, those within in our publica- tion date range, written in English, and pertaining to human adults) containing information related to 4 key concepts corresponding to the population-intervention-comparison-outcome framework.13 We wanted studies that (1) focused on a population of clinicians, (2) investigated an intervention related to a guideline for acute hospital- based infections, (3) compared effects of the this intervention to the effects of not having an intervention (if a comparison was reported), and (4) evaluated their impact on the outcome of compliance. Supple- mental Digital Content 2 shows search strategy details.

Selection process

The selection process (depicted in Fig 1) involved narrowing 2 dif- ferent pools of articles into subsets (ie, Subset A and Subset B) which were then combined into our final set of articles. The first pool of articles was those returned by the original PubMed search under- went 4 phases of review (title review, abstract review, full-text review, and expert clinician review) to produce article Subset A. Rele- vant studies referenced by articles in Subset A were combined with any articles meeting our search criteria that were added to the PubMed database during the selection period for Subset A, to form a second pool of articles for review. These articles underwent the same 4 phases of article elimination, which produced article Subset B. Finally, Subsets A and B were combined to form the final set of selected studies analyzed.

A clinical expert and 2 contributor pairs participated in the study selection process. Throughout the process, contributors were instructed to include any studies that seemed likely to discuss clini- cian compliance in any way, and to err on the side of inclusion when in doubt.

Division of labor among contributor pairs was different in each review phase. In the title and abstract review phases, each article was independently reviewed by 2 contributors. Disagreements were resolved by discussion (title review) and a third tie-breaking reviewer (abstract review). During full-text review, each article was reviewed individually by a contributor. Finally, a clinical expert reviewed excluded articles from all phases to double-check other

Table 1 Characteristics of studies selected for review

Study characteristics of selected articles (N = 49) n (%)

Infection of focus Infection (general) 10 (20) Pneumonia 13 (27) Sepsis 18 (37) Other 8 (16)

Type of guideline assessed Local 6 (12) National 17 (35) International 26 (53) Surviving sepsis campaign (SSC) 17 (35)

Study region United States (US) 14 (29) Europe 18 (37) Country outside of United States/Europe 13 (27) Cross-continental 4 (8)

Publication audience Surgery 3 (6) Internal medicine 3 (6) Emergency medicine 3 (6) Critical care/ICU 14 (29) Infection/epidemiology 11 (22) Specific disease or specialty 12 (24) Health services/quality 3 (6)

Number of compliance results One-instance compliance 20 (41) Two-instance compliance 28 (57) Qualitative compliance description 1 (2)

Reporting of patient outcomes Reported patient outcomes and compliance 37 (76) Reported compliance only 12 (24)

Intervention type None 16 (33) Minimal 5 (10) Decision support 19 (39) Multimodal 9 (18)

Level of care General inpatient 15 (31) ED only 12 (24) ICU only 14 (29) Multiple levels 6 (12) Other 2 (4)

Sample size <100 3 (6) 100-9,999 28 (57) 10,000-99,999 12 (24) 100,000 or more 2 (4)

Study design Prospective only 43 (88) Retrospective and prospective 6 (12)

Study period Less than 1 year 13 (27) 1-2 years 19 (39) More than 2 years 14 (29) Not specified 3 (6)

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contributors’ work and to ensure that relevant articles were not elim- inated due to lack of clinical expertise.

Outcome measures and analysis

Details extracted from each selected study included guideline name and characteristics, compliance definition, study region, study design, publication audience, infection of focus, level of care, outcome measures reported, and any results relating to clinician compliance and/or adherence. We categorized the type of intervention employed to affect compliance. Intervention types, in order of increasing com- plexity, were none (no intervention was described or only 1 compli- ance result was presented), minimal (simple presentation of guidelines), decision support (usually electronic or paper-based), and multimodal (quality improvement (QI) initiative and/or educational program with multiple components). We also extracted specific details about the interventions used to promote guideline compli- ance, as well as results about compliance with sepsis bundles. The primary summary measures calculated in our analysis include fre- quencies and distributions of extracted information.

Risk of bias assessment

The Newcastle-Ottawa Scale for quality assessment was used to evaluate and quantify the potential for bias in compliance results reported.14 Similar to previously published studies,15 we developed a modified version of the tool (Supplemental Digital Content 3) to fit the context of this review. Each article was assessed by 2 indepen- dent reviewers and results were aggregated.

RESULTS

Study selection

The original PubMed search yielded 1,499 unique titles (Fig 1), resulting in 40 articles in Subset A. An additional 330 articles were included (see Methods), resulting in 9 articles in Subset B, for a total of 49 articles selected in the final set.

Study characteristics

Table 1 summarizes study characteristics. Of the 49 articles reviewed, 43 studies (88%) were solely prospective and 6 studies (12%) had both prospective and retrospective components. The majority of studies were located in either the United States (14 stud- ies; 29%) or Europe (18 studies; 37%). Eighteen studies (37%) focused on sepsis, 13 (27%) on pneumonia, and 10 (20%) on general infection. Most studies assessed international (26 studies; 53%) or national (17 studies; 35%) guidelines. The most common international guideline assessed was the Surviving Sepsis Campaign (17 studies; 35%). Stud- ies were disseminated to 3 primary journal audiences: critical care (14 studies; 29%), medical specialties (12 studies; 24%), and epidemi- ology (11 studies; 22%). Studies were distributed relatively evenly across general inpatient (15 studies; 31%), critical care (14 studies; 29%), and emergency (12 studies; 24%) settings. The publication dates of sepsis-related studies showed a steady increase in their prevalence throughout the duration of the eligible time window, until a sudden drop in 2015 (see Supplemental Digital Content 4). All individual study characteristics are provided in Supplemental Digital Content 5.

Compliance results

When reporting compliance results, 20 studies (41%) reported 1- instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or studies with a

control group), and 1 study (2%) described compliance results quali- tatively. Interventions were categorized as minimal in 5 studies (10%), decision support in 19 studies (39%), multimodal in 9 studies (18%), and none in 16 studies (33%). Definitions of compliance varied across studies, as did the methods used to measure it (eg, clinician surveys, independent record review).

The distribution of 1-instance compliance results ranged from 2% to 94% (Fig 2). When stratified by infection of focus, average compli- ance for sepsis, pneumonia, general infection, and other infections were 29%, 49%, 80%, and 61%, respectively.

Figure 3 shows the absolute change in compliance from studies that reported 2-instance compliance, organized by infection of focus (Fig 3A) and intervention type (Fig 3B). Values of initial compliance results (shown on the x-axis) ranged from 0% to 91%, values of final compliance results (shown on the y-axis) ranged from 9% to 100%,

Fig. 2. Distribution of 1-instance compliance results. The bolded result is from a study16 that only reported a compliance range, the minimum of which is displayed in the figure. Further description of the result is provided in Supplemental Digital Content 5.

Fig. 3. Absolute change in compliance percentage in studies reporting 2-instance compliance results. (A) Group results by infection of focus. (B) Group results by intervention type. Intervention types (defined in methods section) in order of increasing complexity were none, minimal, decision support, and multimodal. Note the feasible region of each graph; the maximum possible change in compliance is equal to 100 minus the initial compliance measurement. Total N = 28 + 5 + 2 = 35, since 5 studies 17-21 reported 2 two-instance com- pliance results, and 1 study22 reported 3 two-instance compliance results. Bolded markers indicate these compliance results. Definitions of these compliance results and interven- tion descriptions are provided in Supplemental Digital Content 5.

K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947 943

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and the absolute change in compliance (final result minus initial result) ranged from a decrease of 6% to an increase of 51%. When grouped by infection of focus (Fig 3A), the average change in compli- ance was an improvement of 26% in sepsis-related studies, 11% in pneumonia-related studies, 15% in studies related to general infec- tion, and 16% in studies related to other infections. When grouped by intervention type (Fig 3B), the average change in compliance was an improvement of 10% for studies using minimal interventions, 14% for studies using decision support interventions, and 25% for studies using multimodal interventions.

Patient health outcomes were reported alongside compliance results in 37 studies (76%). Within these studies, the most common patient outcomes reported were mortality (36 studies; 97%) and length of stay (25 studies; 68%). Supplemental Digital Content 6 pro- vides additional patient outcome distribution details. Other outcome measures reported were clinical treatment success rate,14,15 surgical site infection incidence rate,16,17 and readmission rate.18

Bundled guidelines

Bundled guidelines appeared in more than half of the studies. Examples included a treatment bundle for ventilator-associated pneu- monia,19 centers for disease control and prevention 12-step process to reduce antimicrobial resistance,20 and most prevalently, the Surviving Sepsis Campaign bundles for sepsis resuscitation (6-hour time win- dow) and sepsis management (24-hour time window), which were evaluated for compliance in 18 studies (37%). Since 2 of these sepsis studies did not report results for an entire bundle,23,24 they were excluded from the bundle analysis. The remaining 16 articles and the bundle components for which they report compliance are shown in Table 2.

Risk of bias assessment

Conversion of the scores from the modified Newcastle-Ottawa Scale into quality levels yielded 26% good quality, 33% fair quality, and 41% poor quality, with agreement >75% between raters. The large proportion of poor-quality articles was influenced heavily by discrep- ancies surrounding the comparability of the compliance results, which was often unclear or difficult to extract due to the inclusive nature of this review. When comparability is satisfied across all articles, the adjusted quality-level distribution becomes 37% good, 43% fair, and 20% poor. Supplemental Digital Content 7 details assess- ment results.

As evidenced by the low comparability scores in the risk of bias assessment, there was substantial heterogeneity between studies, primarily associated with the level of detail used when measuring and reporting compliance. For example, studies reporting 1-instance compliance were usually not focused on this result, and so details about compliance measurement were often limited or not provided. Studies reporting 2-instance compliance varied in the length and execution of their interventions. Additionally, studies in which com- pliance was timing-based were required to define a “time-zero” when measuring compliance, whereas other studies did not include this element.

DISCUSSION

Trends in compliance achievement

From our analysis, several trends emerged that appeared to corre- late with achieving high compliance with guidelines. Trends in inter- vention type, infection of focus, and bundled guidelines are described below.

Intervention-related trends wIn general, multimodal interventions had a higher average

improvement in compliance (25%) compared to decision support inter- ventions (14%) or minimal interventions (10%; Fig 3B). Multimodal interventions were more often used in low-compliance situations as an aggressive improvement strategy. Decision support interventions (usually an electronic decision support system) seemed to be used in situations where baseline compliance was measured but could be heavily impacted by the addition of an automated system at a single complex decision point. It is also worth noting that none of the deci- sion support interventions relied on “hard-stops,” which either pre- vent the user from taking an action altogether or require the user to obtain external override of a third party in order to proceed.

Sepsis-related trends Overall, initial compliance was lower in studies of sepsis-related

guidelines (Fig. 2 and 3A), often with less than 30% compliance. How- ever, the group also showed the greatest average absolute change in compliance. This may relate to the newness of these guidelines at the time and/or the complexity of the sepsis bundles themselves. Multi- modal interventions were employed in all but one26 of the sepsis- related studies, and these interventions generally resulted in large improvements in compliance.

Bundle-related trends Compliance with bundled guidelines is difficult to track and com-

municate because it requires both standardized definitions of bundle steps across institutions and standardized definitions of time zero for temporal bundle components. The difficulty in reporting compliance with bundles is evidenced by the fact that no study in Table 2 received all checkmarks possible. Additionally, bundled compliance results can be misleading when taken at face value, since (1) bundles are tied to pay and thus more likely to be complied with and (2) compliance with the entire bundle is a binary measure and provides no information about partial compliance. In general, less-invasive bundle components correlated with higher compliance and/or better outcomes.17,27-30

Comments on decreased compliance Interestingly, 2 studies reported a decrease in compliance from

first to second instance,26,31 but neither of them were statistically sig- nificant and likely reflect random variation. Ozgun et al reported a 6% decrease in compliance with appropriate choice, dose, and duration of antimicrobial prophylaxis31; this result may have been skewed due to detailed requirements for adherence. Westphal et al reported a 4% decrease and a 2% decrease in compliance with the 6-hour and 24-hour sepsis bundles, respectively26; this was the only sepsis study to employ a minimal intervention.

Relating compliance to its impact on patient outcomes

Although the majority of studies (76%) reported patient health out- comes alongside compliance results, the primary outcome reported was mortality, a measure that can be represented in various ways32

and does not capture the full scope of the patient experience, as survival does not describe positive and negative patient health trajectories.33

There may be other useful outcome measures that would be more proximal in timing and more specific to a particular guideline. For example, studies related to sepsis guidelines could assess sepsis-specific upstream outcomes (eg, reduced organ failure, fewer ICU admissions). Twelve studies (24%) did not relate compliance back to patient health, which is the true outcome compliance aims to represent.

While tracking compliance with guidelines can be important for improving quality of care, compliance as an outcome measure has limitations that emerged in our review. First, there is no clear definition of what compliance represents, as evidenced by the

Table 2 Compliance results reported by studies that investigated Surviving Sepsis Campaign bundles

Sepsis bundle studies Compliance reported for 6-hour resuscitation bundle component* Compliance reported for 24-hour management bundle component* Compliance percentage reported for entire bundley

Lactate Blood culture

Antibiotics Fluids or vasopressors

MAP CVP SvO2 Low-dose steroids

Activated protein Cz

Glucose control

Inspiratory plateau (PiP)

-hour Bundle esult 1 Result 2)

24-hour Bundle Result 1 (Result 2)

Both bundles Result 1 (Result 2)

Almeida 2013 @ @ @ @ ‘ @ @ 2 Castellanos-Ortega 2011

@ @ @ @ @ @ @ 11

Coba 2011 @ @ @ @ @ @ @ @ @ @ @ 13 ‘ ‘ Girardis 2009 ‘ @ @ @ ‘ ‘ @ @ @ @ @ 8 (60) 8 (60) 8 (35) Jeon 2012 ‘ ‘ @ @ @ @ @ 1 (50) Kuan 2013 @ @ @ @ @ @ @ 0 (40) Levy 2010 @ @ @ @ ‘ @ @ @ @ @ @ 1 (31) 18 (36) ‘ Na 2012 @ @ @ @ @ @ @ 3 (55) Nakornchai 2014 @ @ @ @ @ @ @ 1 Nguyen 2007* @ @ @ @ @ @ @ @ @ 0 (51) Nguyen 2011 @ @ @ @ @ @ @ 0 (44) Schramm 2011 @ @ @ @ @ ‘ ‘ 3 (54) Van Zanten 2014 @ @ @ @ ‘ @ @ @ @ @ @ 0 (68) 70 (89) 38 (62) Wang 2013 @ @ @ @ ‘ @ @ @ ‘ @ @ 1 (13) 1 (9) ‘ Westphal 2011* ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ 2 (29) 50 (48) ‘ Zambon 2008 @ @ @ @ ‘ ‘ @ @ @ @ @ 68 72 ‘

CVP, central venous pressure; MAP, Mean arterial pressure; SvO2, mixed venous oxygen saturation. @indicates that a compliance result was reported; ‘ indicates that no compliance result was reported, even though all information appeared to have been available *Bundles were broken into standard components using the summary reproduced in Levy et al.25. yAll studies reporting two-instance compliance results for entire bundles were statistically significant at the 0.05 level, except those identified by an asterisk. zThe activated protein C portion of the 24-hr management bundle was discontinued in a 2012 revision of the sepsis guidelines by Dellinger et al.9

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946 K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947

heterogeneous definitions of compliance across studies. Second, com- pliance metrics usually imply a target goal of 100%, but this is mislead- ing, since some situations require clinicians to intentionally deviate from a guideline in order to produce the best health outcome for a patient. In fact, existing research discourages targeting 100% for any metric.4 Third, the magnitudes of improvement in compliance and patient health outcomes do not necessarily correlate. In cases where extensive and costly efforts are made to drastically improve compli- ance, there is always a chance that this effort will produce only a very small change in patient outcomes. Compliance with a protocol that does not translate to a meaningful improvement in patient outcomes is of questionable utility. Finally, all studies discussed compliance in terms of the percentage of patient cases that were compliant across all providers and did not compare compliance distributions between pro- vider types or individual providers. Further analysis related to pro- viders may be informative in guideline design and implementation.

Sustaining compliance

Following any intervention related to compliance with infection guidelines, there should be considerations for sustainability. How- ever, in the risk of bias assessment, contributors agreed that adequate consideration was given for sustainability (meaning measured at least 6 months after the intervention) in only 35 studies (71%). One of the biggest factors in sustainability is cost of an intervention, but only 5 studies discussed this factor.16,20,31,34,35 Additionally, key opera- tional considerations (eg, training time required, effect on workload) were ignored almost completely. One study surveyed physicians to investigate specific barriers (eg, not sure how to do it, patient refused, forgot to do it) to guideline compliance.29

Bias and limitations

The authors note there is a risk of bias both within and across the studies included in this review. Some common themes emerged in the limitations of compliance-related studies, such as varying defini- tions of “time zero” for temporal interventions. The potential for reporting bias is also evident, since a negative effect on compliance was reported in only 2 studies26,31; other studies may have also pro- duced negative results but did not report them.

The primary limitation of our review relates to the initial search strategy. Under the guidance of a university librarian subject-matter consultant, we primarily used MeSH terms (instead of keywords) in our search structure because they are assigned systematically by the PubMed database and represent the main ideas of each study. Thus, any studies with peripheral connection to our main ideas were not returned in our initial search. We note that another review article iden- tified additional PubMed studies reporting sepsis bundle compliance results, due primarily to the use of keywords in their search strategy.36

Although our respective analyses agree (for the articles we both selected), this brings up concerns about relying on database-specific categorization as a true representation of study content. One final limi- tation of this study was the English-only language restriction.

CONCLUSIONS

In this systematic review of studies that reported compliance for the prevention, detection, and/or treatment of acute hospital-based infections. Multimodal interventions (often including quality improvement initiatives) seem to result in the greatest improvement in compliance (25% improvement), followed by decision support (14%). More research is required to understand the implications of different approaches to guideline design, communication, and imple- mentation, especially in relation to patient outcomes and various cli- nician types.

Acknowledgments

This work was part of a collaboration among North Carolina State University, Mayo Clinic, Drexel University, and MedStar Health. The authors wish to thank Joshua Barclay for his contributions to the arti- cle selection process.

SUPPLEMENTARY MATERIALS

Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.ajic.2020.02.006.

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30. Zambon M, Ceola M, Almeida-de-Castro R, et al. Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: we could go faster. J Crit Care. 2008;23:455–460.

31. Ozgun H, Ertugrul BM, Soyder A, et al. Peri-operative antibiotic prophylaxis: adher- ence to guidelines and effects of educational intervention. Int J Surg. 2010;8:159–163.

32. Walkey AJ, Lindenauer PK. Keeping it simple in sepsis measures. J Hosp Med. 2017;12:1019–1020.

33. Venkatesh B, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378:797–808.

34. Arboe B, Laub RR, Kronborg G, Knudsen JD. Evaluation of the decision support sys- tem for antimicrobial treatment, TREAT, in an acute medical ward of a university hospital. Int J Infect Dis. 2014;29:156–161.

35. Rimawi RH, Mazer MA, Siraj DS, et al. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med. 2013;41:2099–2107.

36. Damiani E, Donati A, Serafini G, et al. Effect of performance improvement pro- grams on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2015;10: e0125827.

ww.sciencedirect.com

Journal of Hospital Infection 91 (2015) 202e210

Available online at w

Journal of Hospital Infection

journal homepage: www.elsevierheal th.com/journals / jh in

Review

Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review

J.A. Srigley a,*, K. Corace b, D.P. Hargadon a, D. Yu a, T. MacDonald c, L. Fabrigar c, G. Garber a

a Public Health Ontario, Toronto, Ontario, Canada bUniversity of Ottawa, University of Ottawa Institute of Mental Health Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada cDepartment of Psychology, Queen’s University, Kingston, ON, Canada

A R T I C L E I N F O

Article history: Received 12 April 2015 Accepted 27 June 2015 Available online 4 August 2015

Keywords: Behaviour Hand hygiene Psychology

* Corresponding author. Address: BC Childre V6H 2N9. Tel.: þ1 604 875 2305.

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.jhin.2015.06.019 0195-6701/Crown Copyright ª 2015 Published

S U M M A R Y

Background: Despite the importance of hand hygiene in preventing transmission of healthcare-associated infections, compliance rates are suboptimal. Hand hygiene is a complex behaviour and psychological frameworks are promising tools to influence healthcare worker (HCW) behaviour. Aim: (i) To review the effectiveness of interventions based on psychological theories of behaviour change to improve HCW hand hygiene compliance; (ii) to determine which frameworks have been used to predict HCW hand hygiene compliance. Methods: Multiple databases and reference lists of included studies were searched for studies that applied psychological theories to improve and/or predict HCW hand hygiene. All steps in selection, data extraction, and quality assessment were performed indepen- dently by two reviewers. Findings: The search yielded 918 citations; seven met eligibility criteria. Four studies evaluated hand hygiene interventions based on psychological frameworks. Interventions were informed by goal setting, control theory, operant learning, positive reinforcement, change theory, the theory of planned behaviour, and the transtheoretical model. Three predictive studies employed the theory of planned behaviour, the transtheoretical model, and the theoretical domains framework. Interventions to improve hand hygiene adherence demonstrated efficacy but studies were at moderate to high risk of bias. For many studies, it was unclear how theories of behaviour change were used to inform the interventions. Predictive studies had mixed results. Conclusion: Behaviour change theory is a promising tool for improving hand hygiene; however, these theories have not been extensively examined. Our review reveals a sig- nificant gap in the literature and indicates possible avenues for novel research. Crown Copyright ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection

Society. All rights reserved.

n’s & Women’s Hospital, Laboratory Medicine, Room 2J3, 4500 Oak Street, Vancouver, BC, Canada

(J.A. Srigley).

by Elsevier Ltd on behalf of the Healthcare Infection Society. All rights reserved.

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210 203

Introduction Data extraction and quality assessment

Healthcare worker (HCW) hand hygiene compliance rates are known to be suboptimal, despite pressure from regulatory bodies worldwide to improve compliance and abundant evi- dence that hand hygiene prevents healthcare-associated in- fections (HCAIs).1,2 Improvement strategies to date have largely focused on a multimodal approach, typically including provision of soap and water and/or alcohol-based hand rub (ABHR) at point of care, training and education, reminders, administrative support, and measurement of compliance rates.2 However, achieving significant and sustained improve- ment has been challenging.3

Hand hygiene is increasingly recognized as a complex behaviour with numerous motivators and barriers.2 Re- searchers have begun to focus on applying behavioural psy- chology to bring about improvement. Psychological frameworks have been shown to be effective tools in guiding behaviour change in a variety of settings, including HCW behaviour.4

The primary objective of this systematic review was to determine the effectiveness of interventions based on psy- chological frameworks to improve HCW hand hygiene compli- ance. The secondary objective was to determine which psychological frameworks/theories have been used to predict HCW hand hygiene compliance, including facilitating factors and barriers, as these may be used to design interventions in the future.

Methods

Search strategy

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, The Joanna Briggs Institute, SocINDEX, and Cochrane Database of Systematic Reviews (CENTRAL) from database inception until June 5th, 2014. We also searched reference lists of included studies and relevant review articles for additional eligible studies. The search strategy was developed by a team of experienced librarians (Appendix A).

Eligibility criteria

Randomized controlled trials (RCTs), non-RCTs, time series, controlled beforeeafter studies, and quasi-experimental studies (including uncontrolled beforeeafter) were consid- ered for inclusion if they applied a psychological theory to improve and/or predict HCW hand hygiene. Based on the guidance of the Medical Research Council that complex in- terventions involving behaviour should be grounded in theory, studies that did not explicitly name a psychological framework were excluded.5 The study population had to consist of any HCW group (e.g. physicians, nurses, allied health practitioners, technicians) and could be conducted in any healthcare setting, including acute care and long-term care. Studies had to include hand hygiene compliance as an outcome but were excluded if self-reported hand hygiene compliance was the only outcome.

Only published, peer-reviewed studies were included; studies published solely in abstract form were excluded. Studies were excluded if they were not published in English or if they did not supply primary data.

The eligibility criteria were pilot-tested on a selection of studies and then all retrieved titles and abstracts were inde- pendently assessed by two reviewers (D.Y., D.P.H.). If the in- clusion/exclusion criteria could not be adequately assessed, the full article was obtained and reviewed. Disagreements were resolved by a third reviewer (J.A.S.) when the primary reviewers could not reach consensus.

After piloting a data extraction form, two reviewers (D.Y., D.P.H.) independently assessed each included article and extracted information including study methodology, setting, interventions, and outcomes. Disagreements were resolved by a third reviewer (J.A.S.).

The risk of bias of each included study was assessed inde- pendently by two investigators (D.P.H., J.A.S.) using an intern- ally developed resource, the Public Health Ontario MetaQAT tool, to guide the critical appraisal process.

Data synthesis

Summary tables of included studies were developed. Narrative synthesis was conducted based on the Economic and Social Research Council guidance report.6 We also evaluated study quality in relation to the demonstrated efficacy of each psychological framework for each of the primary outcomes.

Results

The literature search yielded 918 citations, of which seven studies met eligibility criteria (Figure 1). Four studies addressed our primary objective by evaluating interventions based on psychological frameworks, and three predictive studies of hand hygiene behaviour met our secondary objective (Table I). It was not possible to perform meta-analysis due to heterogeneity in study design, intervention, and outcomes.

Studies of hand hygiene interventions based on psychological frameworks

Fuller et al. performed a three-year stepped wedge cluster RCT involving 60 wards [44 acute care units for the elderly (ACEs) and 16 intensive therapy units (ITUs)] across 16 hospitals in England and Wales that were already implementing the na- tional multimodal hand hygiene programme.7 Following a baseline period, hospitals were randomized into the interven- tion every two months. The first component of the intervention was based on goal-setting and control theories. In goal-setting theory, specific and challenging goals, in combination with clear feedback, are used to increase the frequency of a desired behaviour.8 Control theory focuses on the role of feedback in reducing discrepancy between ideal and performed behav- iours.9 HCWs were encouraged to set goals and action plans to perform hand hygiene, and feedback was provided on their compliance. The second phase of the intervention was informed by operant learning theory, which emphasizes the importance of reinforcing desired behaviours.10 HCWs were provided positive reinforcement in the form of praise or re- wards for following recommended hand hygiene practices. The primary, secondary, and tertiary outcome measures were directly observed hand hygiene compliance, ABHR and soap

Id en

tif ic

at io

n Sc

re en

in g

In cl

ud ed

El ig

ib ili

ty

Records identified through database searching

(n = 918)

Records after duplicates removed (n = 876)

Records screened (n = 876)

Full-text articles assessed for eligibility

(n = 232)

Studies included in qualitative synthesis

(n = 7)

Not informed by behavioural or psychological theory (n = 194)

No objective measure of hand hygiene compliance (n = 22)

Non-HCW population (n = 4)

Not peer reviewed (n = 2)

Study did not use primary data (n = 3)

Records excluded (n = 644)

Full-text articles excluded, with reasons

(n = 255)

Figure 1. Overview of study selection.

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210204

consumption, and the prevalence of meticillin-resistant Staphylococcus aureus (MSRA)-positive swabs, respectively.

Thirty-three of the randomized units implemented the intervention. Intention-to-treat analysis revealed a significant increase in hand hygiene compliance in ITUs [odds ratio (OR): 1.44; P < 0.001] but not on ACEs (OR: 1.06; P ¼ 0.5). Per- protocol analysis demonstrated significant increases in hand hygiene compliance on both types of ward, with improvements of 10e13% in ACUs and 13e18% on ACEs. A significant 30% in- crease in liquid soap procurement was also observed in ITUs but there was no significant change in ABHR procurement on either type of ward. Due to difficulties with data collection and MRSA screening, no conclusions about the effect of the intervention on HCAIs could be drawn.

Harne-Britner et al. performed a controlled beforeeafter study of staff education and positive reinforcement among registered nurses and patient care assistants across three medicalesurgical units at an urban hospital in the USA.11 The study was informed by change theory and operant learning, combined with aspects of behavioural, organizational, and social science that were not further specified by the au- thors.10,12 Change theory postulates that driving forces push individuals towards performing behaviour whereas restraining forces oppose such changes; driving forces must be greater than restraining forces in order for change to occur.12 Partici- pants in the control group received education by completing a

self-study module on handwashing, whereas the intervention groups completed the same module but also received positive reinforcement (a sticker-reward system) or information on the risks of non-compliance with hand hygiene. Hand hygiene compliance and unit HCAI rates were measured.

Although the intervention resulted in a 15.5% increase in hand hygiene compliance among the positive reinforcement group during the first month (c2 ¼ 4.27, P ¼ 0.039), this effect was not sustained throughout the intervention period. After six months, there were no significant differences in hand hygiene compliance or HCAI rates between the groups.

Mayer et al. conducted a six-year, two-part study on 12 patient care units at a single tertiary-care hospital in the USA.13

The initial phase was a one-year stepped wedge study of an intervention informed by the theory of planned behaviour.14

According to this theory, intentions to perform a given behav- iour are determined by attitudes (subjective evaluation of the behaviour and outcomes of the behaviour), subjective norms (assessments of whether close others would approve of the behaviour) and perceived behavioural control (assessment of whether one is ready and able to enact the behaviour); in- tentions are then predictive of behaviour. In this study, atti- tude change was attempted via educational campaigns. Subjective norms were communicated through monthly audits and reports of hand hygiene compliance, and perceived behavioural control was addressed by strategically positioning

Table I

Summary of included studies

Study Year Region Study design Study type Setting Participants N Theoretical

framework

Outcome

variable(s)

Results

Fuller et al.7 2012 UK Stepped-wedge cluster randomized trial

Intervention 16 acute general and two teaching hospitals

Nurses, doctors, healthcare assistants and others

Not reported Operant learning theory

Observed hand hygiene compliance; alcohol rub and soap procurement

Intention-to-treat analysis showed significant increase in hand hygiene compliance in intensive treatment units (odds ratio: 1.44; P < 0.001) but not acute care of the elderly units after implementation of intervention campaign. 30% increase in soap procurement in intensive treatment units.

Harne-Britner et al.11

2011 USA Quasi- experimental (controlled beforeeafter)

Intervention Tertiary care teaching hospital

Nurses and personal care assistants

1203 Change theory and othersa

Observed hand hygiene compliance; unit infection rates

No significant differences in hand hygiene adherence between positive reinforcement, risk of non-adherence, and control groups at six-month follow- up (P ¼ 0.69). No significant change in unit infection rates at six-month follow-up (P ¼ 0.09).

Mayer et al.13 2011 USA Controlled beforeeafter and time-series

Intervention Tertiary care hospital

Healthcare workersa

36,123 hand hygiene moments

Theory of planned behaviour and positive reinforcement

Observed hand hygiene compliance; MRSA and VRE infection rates

Hand hygiene compliance in experimental groups significantly increased compared to controls following implementation of the theory of planned behaviour intervention (P < 0.001). Overall increase in hand hygiene compliance following implementation of positive reinforcement campaign.b No significant change in MRSA or VRE infection rates.c

Pontivivo et al.15 2012 Australia Uncontrolled beforeeafter

Intervention Four teaching hospitals

Nurses 11,247 hand hygiene moments

Theory of planned behaviour and positive reinforcement

Observed hand hygiene compliance; MRSA bacteraemia rates

Hand hygiene compliance increased from 62% to 75% following intervention.c

Significant increases in observed compliance for nurses and medical staff (c2 ¼ 43.05, P < 0.001 and c2 ¼ 33.8, P < 0.001,

(continued on next page)

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Table I (continued )

Study Year Region Study design Study type Setting Participants N Theoretical

framework

Outcome

variable(s)

Results

respectively). No significant change in observed compliance for allied health workers. Rates of S. aureus infections decreased from 0.6e2.55 to 0e0.65 infections per 10,000 occupied bed-days following intervention.b

Eiamsirakoon et al.19

2013 Thailand Observational Prediction Tertiary care hospital

Nurses, nurse assistants, doctors, technicians, and students

123 Transtheoretical model and theory of planned behaviour

Observed and self-report of hand hygiene compliance

Higher mean observed 5MHH compliance was predicted by higher transtheoretical model stage of change (11.1% for precontemplation vs 28.4% for maintenance; P ¼ 0.04). Positive attitude associated with 5MHH compliance (odds ratio ¼ 1.49, P ¼ 0.04). Significant positive correlations for attitude (r ¼ 0.19, P ¼ 0.03), perceived behavioural control (r ¼ 0.20, P ¼ 0.02), total theory of planned behaviour scores (r ¼ 0.21, P ¼ 0.2) and observed 5MHH compliance.

Fuller et al.20 2014 UK Qualitative cross-sectional survey

Prediction 13 hospitals Nurses, doctors, allied healthcare workers, ancillary staff and other/unknown

Not reported Theoretical domains framework

Observed hand hygiene compliance

Majority of non-compliant hand hygiene episodes were explained by the memory/attention/ decision-making (42%) and knowledge (26%) domains.

O’Boyle et al.18 2001 USA Longitudinal observational

Prediction Four teaching hospitals

Nurses 120 Theory of planned behaviour

Observed hand hygiene compliance

Theory of planned behaviour variables were significantly associated with intention and self-reported hand hygiene compliance, but not observed compliance.

MRSA, meticillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci; 5MHH, five moments for hand hygiene. a Not further specified by authors. b No control group and no time-series analysis performed. c Authors did not report statistical significance.

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ABHR in convenient locations. Following the initial interven- tion, positive reinforcement strategies (e.g. rewards and motivational campaigns) were implemented hospital-wide for five years. The study outcomes were directly observed hand hygiene compliance and hospital-acquired MRSA and vancomycin-resistant enterococci infection rates.

Hand hygiene compliance in the experimental groups increased significantly compared to controls (P < 0.001) following the initial theory of planned behaviour intervention. At the start of the hospital-wide positive reinforcement inter- vention, hand hygiene compliance rates were 28e68%, increasing to 59e81% by the end of the study. No significant changes in infection rates were reported.

Pontivivo et al. tested an intervention based on the trans- theoretical model of change and the Pathman awareness-to- adherence model at a teaching hospital in Sydney, Australia, using a beforeeafter design.15e17 In the transtheoretical model, behaviour change is conceptualized as a readiness-to- change model, in which an individual progresses through a series of stages from precontemplation (not ready to change) to action and maintenance (adopting the new behaviour and sustaining it).16 Pathman’s model was developed to assist the adoption of clinical guidelines and employs a combination of education, auditing, and feedback to assist individuals in adopting and adhering to recommended practices.17 The ma- jority of HCW participants were nurses, and outcomes included directly observed hand hygiene compliance and healthcare- associated Staphylococcus aureus bacteraemia rates. Their theory-based intervention consisted of coaching, competi- tions, group evaluation and feedback, and executive endorse- ment of hand hygiene compliance. It was unclear how the transtheoretical model was used to inform their intervention; rather, the intervention appeared to address the various stages in the Pathman model.

Following implementation of the intervention, rates of hand hygiene compliance were significantly greater among nurses (c2 ¼ 43.05, P < 0.001) and medical staff (c2 ¼ 33.8, P < 0.001). There was no significant change in compliance among allied health practitioners. A non-significant reduction in S. aureus bacteraemia rates was also observed.

Studies using psychological frameworks to predict hand hygiene behaviour

O’Boyle et al. were among the first to apply psychological theory to HCW hand hygiene compliance.18 Using a longitudinal observational design, they compared compliant and non- compliant nurses at four teaching hospitals in the USA using the theory of planned behaviour. Nurses filled out a theory- based questionnaire and were then observed for 2 h or 10 hand hygiene opportunities. Whereas the model successfully predicted intention to handwash, which was related to self- reported hand hygiene, the correlation between self- reported and observed hand hygiene was low (r ¼ 0.21, P < 0.05). None of the theory of planned behaviour constructs were significantly related to observed hand hygiene compliance.

Eiamsitrakoon et al. conducted a study in a tertiary care hospital in Thailand with a sample comprised primarily of nurses.19 Researchers observed hand hygiene according to the World Health Organization ‘five moments of hand hygiene’ and

then gave participants a survey based on the theory of planned behaviour and transtheoretical model constructs.2 There was a weak but significant positive correlation between total theory of planned behaviour scores and observed hand hygiene compliance (r¼ 0.21, P¼ 0.02), and a stronger correlation with self-reported hand hygiene compliance (r¼ 0.53, P< 0.001). In addition, self-reported and observed hand hygiene compliance tended to increase with higher transtheoretical model stages of change. For example, self-reported hand hygiene compli- ance was lower for individuals in the precontemplation stage compared to those in the maintenance stage (64.7% vs 84.4%, P ¼ 0.01); similarly, observed compliance was lower among participants in precontemplation compared to those in main- tenance (11.1% vs 28.4%, P ¼ 0.04).

Fuller et al. used the theoretical domains framework to identify behavioural domains associated with hand hygiene compliance.20 They surveyed a sample of HCWs from 13 hos- pitals in England. The theoretical domains framework is an amalgam of 33 behaviour change theories and was developed primarily as an assessment tool to identify areas of focus for implementation researchers.21 Participants in the 2012 Fuller et al. RCT who were observed practising poor hand hygiene were asked to provide an explanation, which was coded and categorized using the theoretical domains framework. The majority of self-reported explanations for non-compliance were found to be related to memory/attention/decision- making (42%) and knowledge (26%) domains. Memory/ attention/decision-making includes forgetting to perform hand hygiene, lapses in concentration or awareness that result in missed hand hygiene opportunities, and being distracted by interruptions. Instances in which HCWs were unaware that hand hygiene practice was necessary were included in the knowledge domain.

Quality assessment

The risk of bias of the included studies was moderate to high (Table II). Among studies examining theory-informed in- terventions, the most significant limitation was a lack of clear descriptions indicating how interventions were designed to address theoretical behavioural constructs.7,11,13,15 Lack of adequate controls, unrepresentative HCW samples, and attri- tion also negatively influenced risk of bias and study quality.7,11,13

The quality of included predictive studies was influenced by a lack of clear inclusion/exclusion criteria and unrepresenta- tive samples.7,18,19 In addition, the Hawthorne effect could have influenced the behaviour of participants who were aware that their hand hygiene adherence was being evaluated, and social desirability bias may have affected self-reported reasons for non-compliance.18,20

Discussion

The goal of this systematic review was to identify studies that used psychological theories of behaviour change to inform interventions to increase or predict hand hygiene compliance among HCWs. In addition, we hoped to identify promising behavioural constructs that can be used to guide the devel- opment of assessment tools and inform future hand hygiene interventions. We identified four intervention studies that used

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J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210208

operant learning (positive reinforcement), change theory, the theory of planned behaviour, and the transtheoretical model, as well as three prediction studies based on the theory of planned behaviour, the transtheoretical model, and theoret- ical domains framework.

The study of HCW hand hygiene has produced a considerable amount of literature; however, very few studies are grounded in behaviour change theory. A previous systematic review of behaviour change strategies in infection prevention and con- trol found no interventions that specifically mentioned any theory.22 However, that review considered all infection pre- vention and control behaviours, not just hand hygiene, and included only studies conducted in acute care settings. To our knowledge, this is the first review of psychological theories that have been applied to hand hygiene compliance in healthcare settings.

Interventions based on behavioural constructs (e.g. atti- tudes, intentions, self-efficacy) have been found to be more successful at increasing hand hygiene behaviour than in- terventions that address knowledge, awareness, and facilita- tion alone.4 Of the studies included in this review, theory- informed interventions had mixed results but generally pro- duced increases in hand hygiene compliance among HCWs, and two of three studies found that behavioural theory could pre- dict hand hygiene behaviour. This indicates the potential benefit of applying behaviour change theory in infection pre- vention and control, although sustainability of improvement and generalizability across divergent clinical settings is yet to be demonstrated.

Our review underscores the importance of clearly describing how the specific behavioural constructs are applied to inform the development of intervention strategies. We found that in some cases where behavioural theories have been applied, the precise operationalizations used in these studies have not fully captured the constructs specified in the theories. In some cases, measures have not corresponded to the theoretical definitions specified by the models. In other cases, failures to effectively represent key constructs have been more subtle. For example, the theory of planned behaviour stresses the importance of targeting constructs at the same level of speci- ficity as the behavioural outcome of interest. Thus, if the goal of a study was to predict or influence the degree to which healthcare workers apply ABHR prior to each patient contact, the operationalization of the theory of planned behaviour variables should be at the same level of specificity rather than focusing on attitudes, subjective norms, and perceived behavioural control related to hand hygiene in general.

Moreover, whereas many studies cited behavioural frame- works, the interventions tended to rely on standard multimodal programmes focusing on education, reminders, and availability of hand hygiene products.23 Specifically, interventions relied heavily on audit and feedback, education, and positive rein- forcement.7,11,13,15 Whereas positive reinforcement is an important construct in the behaviourist approach, the suit- ability and sustainability of interventions that rely on rewarding appropriate hand hygiene behaviour is questionable. Individuals can habituate to rewards quickly and thus rewards can lose their reinforcing properties.10 We posit that if in- terventions are to have lasting effects, they must go beyond simply increasing knowledge and incentivizing good behaviour. Like other health behaviours (e.g. dieting, exercise, and smoking cessation), hand hygiene is best understood in terms of

No. Searches

1 Hand Disinfection/ or Hand Hygiene/ 2 (((clean* or disinfect* or hygiene* or wash* or

scrub*) adj3 hand?) or handwash*).mp. 3 limit 2 to (‘in data review’ or in process or

‘pubmed not medline’) 4 1 or 3 5 exp Health Personnel/ or Allied Health

Personnel/ or Emergency Medical Technicians/ or Infection Control Practitioners/ or Medical Staff/ or Nursing Staff/ or Nurses/ or Nurse Practitioners/ or Physicians/

6 (((health* or hospital or acute care or primary care or medical or infection control) adj2 (worker? or staff or personnel or practitioner? or provider? or technician?)) or HCW? or HCP? or doctor$ or physician? or nurs* or paramedic* or clinician* or pediatrician* or general practitioner* or pharmacist* or hospitalist* or midwi*).mp.

7 5 or 6 8 ((theor* adj2 (‘reasoned action’ or (planned

adj1 behavio?r) or ‘normative conduct’ or ‘social cognitive’ or ‘self efficacy’)) or (model? adj2 (‘habit-goal’ or transtheoretical or ‘health belief’ or ‘habit goal’ or (behavio? r* adj1 change?))) or ‘health action process’).mp.

9 (fishbein or ajzen or fazio or cialdini or prochaska or diclemente or rosenstock or bandura or schwarzer or wood).mp.

10 8 or 9 11 (((behavio?r* or habit? or practice?) adj2

(chang* or alter* or modif*)) or positive devian* or ((psychology or psychological*) adj3 (framework? or intervention* or theor*))).mp.

12 motivation/ or health behavior/ or guideline adherence/ or health knowledge, attitudes, practice/ or emotions/ or psychological theory/ or px.fs.

13 11 or 12 14 attitude of health personnel/ 15 4 and 7 and 10 16 4 and 7 and 13 17 4 and 14 18 15 or 16 or 17 19 limit 18 to english language 20 limit 19 to (comment or editorial or letter) 21 19 not 20

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210 209

socio-cultural, organizational, perceptual, cognitive, and psy- chological determinants.

Although the included studies add to our understanding of HCW hand hygiene behaviour, many gaps in the literature remain. Thus far, studies have used models that are best suited to explain deliberative behaviours.24 However, hand hygiene is a repetitive, automatic behaviour that may lead to the for- mation of a habit.14 It may be beneficial to consider hand hy- giene as a spontaneous behaviour involving non-thoughtful behavioural responses shaped by perceptions of the context and environment.24 Future interventions may benefit by drawing from theories that are well suited to explain sponta- neous, habitual behaviours, such as the MODE model of atti- tudeebehaviour consistency, the focus theory of normative conduct, or habit theories.24e26

Importantly, the types of intervention strategies suggested by theories designed to explain spontaneous behaviour are likely to differ from the intervention strategies that have thus far been explored in the literature. For example, although social norms have been a focus of deliberative theories such as the theory of planned behaviour, the focus theory of normative conduct postulates that the types of norms most likely to in- fluence spontaneous behaviours are different from those that have been the focus of past interventions. Specifically, past interventions have focused on targeting injunctive norms (i.e. perceptions of what other people think we should do), whereas descriptive norms (i.e. perceptions of what other people are actually doing) are more likely to influence spontaneous be- haviours. Further, habit theories stress the importance of establishing strong automatic associations between perfor- mance of a behaviour and contextual cues at the time the behaviour is initially instantiated and then ensuring that these contextual cues are present in the environment where the behaviour will later be performed.

Several limitations must be acknowledged when considering the findings of this review. First, studies were only included if the authors identified that their research had been informed by a specific theory. If a theory was not named, the study would not have been included, resulting in the exclusion of potentially relevant works. Second, studies that did not use an objective measure of hand hygiene compliance and included only self- report were excluded, which eliminated some studies that applied psychological theories. However, issues with the accu- racy and reliability of self-reported hand hygiene behaviour among HCWs are well documented, justifying the use of directly observed compliance as a more robust outcome.2 Third, as non- English publications were excluded, this review may have omitted pertinent studies published in other languages. Finally, we focused this review at the level of individual behaviour and excluded studies based on sociological theories, such as positive deviance or frontline ownership; however, these strategies are also promising areas for future study.27

Psychological frameworks of behaviour change demonstrate significant potential for predicting hand hygiene behaviour and informing interventions to improve hand hygiene compliance. There is a clear need for additional research into the utility and applicability of psychological models of behaviour change to inform interventions to improve hand hygiene compliance among HCWs. The development of theory-based interventions to improve HCW hand hygiene compliance has the potential to increase the quality of care received by patients and limit the spread of infections in healthcare settings.

Conflict of interest statement None declared.

Funding sources None.

Appendix A. Medline search strategy

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210210

References

1. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283e294.

2. World Health Organization. WHO guidelines on hand hygiene in health care: First Global Patient Safety Challenge. Clean Care is Safer Care. Available at: http://www.ncbi.nlm.nih.gov/books/ NBK144028/; 2009 [last accessed January 2015].

3. Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2010;(9):CD005186.

4. Huis A, van Achterberg T, de Bruin M, Grol R, Schoonhoven L, Hulscher M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7:92.

5. Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. London: MRC. 1e19. Available at: http://www.mrc.ac.uk/ documents/pdf/rcts-for-complex-interventions-to-improve- health/; 2000 [last accessed January 2015].

6. Popay J, Roberts H, Sowdem A, et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC methods programme. Lancaster: Institute for Health Research. Available at: http://www.lancaster.ac.uk/shm/ research/nssr/research/dissemination/publications/NS_ Synthesis_Guidance_v1.pdf; 2006 [last accessed January 2015].

7. Fuller C, Michie S, Savage J, et al. The Feedback Intervention Trial (FIT) e improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial. PLoS One 2012;7:e41617.

8. Locke EA. Toward a theory of task motivation and incentives. Organ Behav Hum Perform 1968;3:157e189.

9. Carver CS, Scheier MF. Control theory: a useful conceptual framework for personalityesocial, clinical, and health psychology. Psychol Bull 1982;92:111e135.

10. Skinner B. Science and human behavior. New York: Macmillan; 1953.

11. Harne-Britner S, Allen M, Fowler KA. Improving hand hygiene adherence among nursing staff. J Nurs Care Qual 2011;26:39e48.

12. Lewin K. Field theory and experiment in social psychology: con- cepts and methods. Am J Sociol 1939;44:868.

13. Mayer J, Mooney B, Gundlapalli A, et al. Dissemination and sus- tainability of a hospital-wide hand hygiene program emphasizing positive reinforcement. Infect Control Hosp Epidemiol 2011;32: 59e66.

14. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991;50:179e211.

15. Pontivivo G, Rivas K, Gallard J, Yu N, Perry L. A new approach to improving hand hygiene practice in an inner city acute hospital in Australia. Healthcare Infect 2012;17:57e63.

16. Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WR, Heather N, editors. Treating addictive behaviors: processes of change. Berlin: Springer; 1986. 3e27.

17. Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. Med Care 1996;34:873e889.

18. O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29:352e360.

19. Eiamsitrakoon T, Apisarnthanarak A, Nuallaong W, Khawcharoenporn T, Mundy LM. Hand hygiene behavior: trans- lating behavioral research into infection control practice. Infect Control Hosp Epidemiol 2013;34:1137e1145.

20. Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Appli- cation of a theoretical framework for behavior change to hospital workers’ real-time explanations for noncompliance with hand hygiene guidelines. Am J Infect Control 2014;42:106e110.

21. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care 2005;14:26e33.

22. Whitby M, McLaws ML, Slater K, Tong E, Johnson B. Three suc- cessful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible? Am J Infect Control 2008;36:349e355.

23. Mathai AS, George SE, Abraham J. Efficacy of a multimodal inter- vention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6e15.

24. Fazio RH, Towles-Schwen T. The MODE model of attitude-behavior process. In: Chaiken S, Trope Y, editors. Dual-process theories in social psychology. New York: Guilford Press; 1999. 97e116.

25. Cialdini RB, Kallgren CA, Reno RR. A focus theory of normative conduct: a theoretical refinement and reevaluation of the role of norms in human behavior. Adv Exp Soc Psychol 1991;24:201e234.

26. Wood W, Neal DT. A new look at habits and the habitegoal interface. Psychol Rev 2007;114:843e863.

27. Zimmerman B, Reason P, Rykert L, Gitterman L, Christian J, Gardam M. Front-line ownership: generating a cure mindset for patient safety. Healthcare Pap 2013;13:6e22.

American Journal of Infection Control 48 (2020) 940−947

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

State of the Science Review

Notice to comply: A systematic review of clinician compliance with guidelines surrounding acute hospital-based infection management

Kendall E. McKenzie MEng a,*, Maria E. Mayorga PhD b, Kristen E. Miller MSPH, DrPH c, Nishant Singh BS b, Ryan C. Arnold MD d, Santiago Romero-Brufau MD e,f

a Department of Design, North Carolina State University, Raleigh, NC b Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC c MedStar Institute for Innovation, MedStar Health, Washington, DC d Department of Emergency Medicine, Cottage Health System, Santa Ynez, CA e Department of Medicine, Mayo Clinic, Rochester, MN f Department of Biostatistics. Harvard T.H. Chan School of Public Health, Boston, MA

Key Words:

* Address correspondence to Kendall E. McKenzie M Carolina State University, 50 Pullen Road, Raleigh, NC 276

E-mail address: [email protected] (K.E. McKenzie) Conflicts of interest: None to report. Funding: This work was supported by the N

(IIS1522072, IIS1522106, IIS1522107, IIS1833538).

https://doi.org/10.1016/j.ajic.2020.02.006 0196-6553/© 2020 Association for Professionals in Infect

Purpose: To identify and characterize studies evaluating clinician compliance with infection-related guide- lines, and to explore trends in guideline design and implementation strategies. Data sources: PubMed database, April 2017. Followed the PRISMA Statement for systematic reviews. Study selection: Scope was limited to studies reporting compliance with guidelines pertaining to the preven- tion, detection, and/or treatment of acute hospital-based infections. Initial search (1,499 titles) was reduced to 49 selected articles. Data extraction: Extracted publication and guideline characteristics, outcome measures reported, and any results related to clinician compliance. Primary summary measures were frequencies and distributions of characteristics. Interventions that led to improved compliance results were analyzed to identify trends in guideline design and implementation. Results of data synthesis: Of the 49 selected studies, 18 (37%), 13 (27%), and 10 (20%) focused on sepsis, pneumonia, and general infection, respectively. Six (12%), 17 (35%), and 26 (53%) studies assessed local, national, and international guidelines, respectively. Twenty studies (41%) reported 1-instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or control group studies), and 1 study (2%) described compliance qualitatively. Average absolute change in compliance for minimal, decision support, and multimodal interventions was 10%, 14%, and 25%, respectively. Twelve studies (24%) reported no patient outcome alongside compliance. Conclusions: Multimodal interventions and quality improvement initiatives seem to produce the greatest improvement in compliance, but trends in other factors were inconsistent. Additional research is required to investigate these relationships and understand the implications behind various approaches to guideline design, communication, and implementation, in addition to effectiveness of protocol impact on relevant patient outcomes. © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All

rights reserved.

Guideline adherence Practice patterns (physicians) Quality Program evaluation Professional practice gaps Outcome and process assessment (health care)

Eng, College of Design, North 07 .

ational Science Foundation

ion Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Best practice protocols are often communicated to clinicians in the form of guidelines. The Institute of Medicine formally defines clinical practice guidelines as “statements that include recommenda- tions, intended to optimize patient care, that are informed by a

systematic review of evidence and an assessment of the benefits and harms of alternative care options.”1 The primary benefit of guidelines is their potential to improve the quality of patient care.2 Common characteristics of “good” guidelines, as described in the literature, include validity, reliability, reproducibility, clinical applicability, clini- cal flexibility, clarity, multidisciplinary process, review of evidence, and documentation.3 Clinical guidelines are issued by multiple differ- ent entities (eg, public health organizations, research institutions, hospital management), have varying levels of presence across the world’s health care domain (ie, international, national, local), and are

Fig 1. Results of each phase of the review process were used to produce the final set of articles for analysis. The 2 paths depicted began with different pools of articles: the results of the original PubMed search and then the relevant references from the articles selected in the original search.

K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947 941

usually communicated with an attached adherence expectation (ie, mandatory, optional).

The goal of any guideline is to provide recommendations that will translate into improve quality of patient care, and ultimately improve patient outcomes. Yet, many challenges arise when clinicians (ie, health care professionals with clinical education) attempt to put guidelines’ written, evidence-based instructions into action.4 In clini- cal scenarios, multiple competing guidelines often exist, yet little research has focused on identifying characteristics of existing guide- lines that commonly elicit compliance.5,6 Given the wide variety of clinical practice guidelines communicated and regulated by authori- tative bodies, it is not surprising that clinician’s uptake of guidelines is low.7 Success in implementation and improvement of practice seems particularly resource intensive.8 Guideline “success” is difficult to evaluate because it connects two important outcomes: clinician adherence to the guideline, and patient outcomes associated with guideline recommendations. While many studies have focused on how guideline recommendations affect patient outcomes, there has been less focus on how compliance with guidelines fits into the equa- tion. To improve compliance with guidelines, it is important to first understand how compliance with guidelines has been evaluated and achieved in previous research.

Guidelines are widely used for infectious disease care. A key example is sepsis guidelines, which have recently garnered increased international attention, due to the deadly and costly nature of the dis- ease.9-11 To inform and support current efforts toward improving such guidelines, it is valuable to investigate acute hospital-based infection guidelines in general, to understand how they have been designed, implemented, and evaluated for compliance. Although many studies report compliance with guidelines, there is a clear gap in the research toward understanding what makes a guideline suc- cessful, as well as how guidelines can be implemented to produce a higher standard of care.

We limit the scope of this systematic review to focus solely on studies that reported compliance with guidelines pertaining to the prevention, detection, and/or treatment of acute hospital-based infections. Examples of such guidelines include recommendations for antibiotic administration, pneumonia treatment, sepsis management, and hand hygiene. The objectives of this systematic review are (1) to evaluate trends in infection guideline design and implementation strategies and (2) to identify and characterize studies that have eval- uated clinician compliance and, if present, associated outcomes.

METHODS

We performed a systematic review of studies that reported clini- cian compliance with guidelines related to acute hospital-based infections, where guidelines are defined as written statements devel- oped by medical specialty societies, disease-focused organizations, or expert panels to assist practitioner and patient decisions about appropriate care under specific clinical circumstances.3 The format of this review follows the PRISMA Statement for reporting of systematic reviews that evaluate health care interventions.12 Supplemental Digi- tal Content 1 identifies locations of PRISMA components within this document.

Study eligibility

Our search was limited to studies published in the 10 years prior to our initial search date (May 13, 2016), as well as any additional articles published between the initial search date and the date collab- orators completed the article selection process (April 30, 2017). Thus, the study dates were May 13, 2006 through April 30, 2017. We looked at studies in this time period because it corresponded to the release of new international guidelines for a prominent infection:

sepsis. Studies included in the final set of articles were required to present results of clinician adherence or compliance. During the review phase, we limited our scope to only acute hospital-based infections, which were defined as acute infections (which excluded chronic or long-term infections like HIV or tuberculosis), that were also severe enough to often require a hospitalization.

Search criteria

The search was conducted in the PubMed database, using a com- bination of Medical Subject Heading (MeSH) terms, keywords, and publication types. The specific search criteria, developed with the help of a university library consultant to ensure a highly inclusive approach, returned all eligible studies (ie, those within in our publica- tion date range, written in English, and pertaining to human adults) containing information related to 4 key concepts corresponding to the population-intervention-comparison-outcome framework.13 We wanted studies that (1) focused on a population of clinicians, (2) investigated an intervention related to a guideline for acute hospital- based infections, (3) compared effects of the this intervention to the effects of not having an intervention (if a comparison was reported), and (4) evaluated their impact on the outcome of compliance. Supple- mental Digital Content 2 shows search strategy details.

Selection process

The selection process (depicted in Fig 1) involved narrowing 2 dif- ferent pools of articles into subsets (ie, Subset A and Subset B) which were then combined into our final set of articles. The first pool of articles was those returned by the original PubMed search under- went 4 phases of review (title review, abstract review, full-text review, and expert clinician review) to produce article Subset A. Rele- vant studies referenced by articles in Subset A were combined with any articles meeting our search criteria that were added to the PubMed database during the selection period for Subset A, to form a second pool of articles for review. These articles underwent the same 4 phases of article elimination, which produced article Subset B. Finally, Subsets A and B were combined to form the final set of selected studies analyzed.

A clinical expert and 2 contributor pairs participated in the study selection process. Throughout the process, contributors were instructed to include any studies that seemed likely to discuss clini- cian compliance in any way, and to err on the side of inclusion when in doubt.

Division of labor among contributor pairs was different in each review phase. In the title and abstract review phases, each article was independently reviewed by 2 contributors. Disagreements were resolved by discussion (title review) and a third tie-breaking reviewer (abstract review). During full-text review, each article was reviewed individually by a contributor. Finally, a clinical expert reviewed excluded articles from all phases to double-check other

Table 1 Characteristics of studies selected for review

Study characteristics of selected articles (N = 49) n (%)

Infection of focus Infection (general) 10 (20) Pneumonia 13 (27) Sepsis 18 (37) Other 8 (16)

Type of guideline assessed Local 6 (12) National 17 (35) International 26 (53) Surviving sepsis campaign (SSC) 17 (35)

Study region United States (US) 14 (29) Europe 18 (37) Country outside of United States/Europe 13 (27) Cross-continental 4 (8)

Publication audience Surgery 3 (6) Internal medicine 3 (6) Emergency medicine 3 (6) Critical care/ICU 14 (29) Infection/epidemiology 11 (22) Specific disease or specialty 12 (24) Health services/quality 3 (6)

Number of compliance results One-instance compliance 20 (41) Two-instance compliance 28 (57) Qualitative compliance description 1 (2)

Reporting of patient outcomes Reported patient outcomes and compliance 37 (76) Reported compliance only 12 (24)

Intervention type None 16 (33) Minimal 5 (10) Decision support 19 (39) Multimodal 9 (18)

Level of care General inpatient 15 (31) ED only 12 (24) ICU only 14 (29) Multiple levels 6 (12) Other 2 (4)

Sample size <100 3 (6) 100-9,999 28 (57) 10,000-99,999 12 (24) 100,000 or more 2 (4)

Study design Prospective only 43 (88) Retrospective and prospective 6 (12)

Study period Less than 1 year 13 (27) 1-2 years 19 (39) More than 2 years 14 (29) Not specified 3 (6)

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contributors’ work and to ensure that relevant articles were not elim- inated due to lack of clinical expertise.

Outcome measures and analysis

Details extracted from each selected study included guideline name and characteristics, compliance definition, study region, study design, publication audience, infection of focus, level of care, outcome measures reported, and any results relating to clinician compliance and/or adherence. We categorized the type of intervention employed to affect compliance. Intervention types, in order of increasing com- plexity, were none (no intervention was described or only 1 compli- ance result was presented), minimal (simple presentation of guidelines), decision support (usually electronic or paper-based), and multimodal (quality improvement (QI) initiative and/or educational program with multiple components). We also extracted specific details about the interventions used to promote guideline compli- ance, as well as results about compliance with sepsis bundles. The primary summary measures calculated in our analysis include fre- quencies and distributions of extracted information.

Risk of bias assessment

The Newcastle-Ottawa Scale for quality assessment was used to evaluate and quantify the potential for bias in compliance results reported.14 Similar to previously published studies,15 we developed a modified version of the tool (Supplemental Digital Content 3) to fit the context of this review. Each article was assessed by 2 indepen- dent reviewers and results were aggregated.

RESULTS

Study selection

The original PubMed search yielded 1,499 unique titles (Fig 1), resulting in 40 articles in Subset A. An additional 330 articles were included (see Methods), resulting in 9 articles in Subset B, for a total of 49 articles selected in the final set.

Study characteristics

Table 1 summarizes study characteristics. Of the 49 articles reviewed, 43 studies (88%) were solely prospective and 6 studies (12%) had both prospective and retrospective components. The majority of studies were located in either the United States (14 stud- ies; 29%) or Europe (18 studies; 37%). Eighteen studies (37%) focused on sepsis, 13 (27%) on pneumonia, and 10 (20%) on general infection. Most studies assessed international (26 studies; 53%) or national (17 studies; 35%) guidelines. The most common international guideline assessed was the Surviving Sepsis Campaign (17 studies; 35%). Stud- ies were disseminated to 3 primary journal audiences: critical care (14 studies; 29%), medical specialties (12 studies; 24%), and epidemi- ology (11 studies; 22%). Studies were distributed relatively evenly across general inpatient (15 studies; 31%), critical care (14 studies; 29%), and emergency (12 studies; 24%) settings. The publication dates of sepsis-related studies showed a steady increase in their prevalence throughout the duration of the eligible time window, until a sudden drop in 2015 (see Supplemental Digital Content 4). All individual study characteristics are provided in Supplemental Digital Content 5.

Compliance results

When reporting compliance results, 20 studies (41%) reported 1- instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or studies with a

control group), and 1 study (2%) described compliance results quali- tatively. Interventions were categorized as minimal in 5 studies (10%), decision support in 19 studies (39%), multimodal in 9 studies (18%), and none in 16 studies (33%). Definitions of compliance varied across studies, as did the methods used to measure it (eg, clinician surveys, independent record review).

The distribution of 1-instance compliance results ranged from 2% to 94% (Fig 2). When stratified by infection of focus, average compli- ance for sepsis, pneumonia, general infection, and other infections were 29%, 49%, 80%, and 61%, respectively.

Figure 3 shows the absolute change in compliance from studies that reported 2-instance compliance, organized by infection of focus (Fig 3A) and intervention type (Fig 3B). Values of initial compliance results (shown on the x-axis) ranged from 0% to 91%, values of final compliance results (shown on the y-axis) ranged from 9% to 100%,

Fig. 2. Distribution of 1-instance compliance results. The bolded result is from a study16 that only reported a compliance range, the minimum of which is displayed in the figure. Further description of the result is provided in Supplemental Digital Content 5.

Fig. 3. Absolute change in compliance percentage in studies reporting 2-instance compliance results. (A) Group results by infection of focus. (B) Group results by intervention type. Intervention types (defined in methods section) in order of increasing complexity were none, minimal, decision support, and multimodal. Note the feasible region of each graph; the maximum possible change in compliance is equal to 100 minus the initial compliance measurement. Total N = 28 + 5 + 2 = 35, since 5 studies 17-21 reported 2 two-instance com- pliance results, and 1 study22 reported 3 two-instance compliance results. Bolded markers indicate these compliance results. Definitions of these compliance results and interven- tion descriptions are provided in Supplemental Digital Content 5.

K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947 943

944 K.E. McKenzie et al. / American Journal of Infection Control 48 (2020) 940−947

and the absolute change in compliance (final result minus initial result) ranged from a decrease of 6% to an increase of 51%. When grouped by infection of focus (Fig 3A), the average change in compli- ance was an improvement of 26% in sepsis-related studies, 11% in pneumonia-related studies, 15% in studies related to general infec- tion, and 16% in studies related to other infections. When grouped by intervention type (Fig 3B), the average change in compliance was an improvement of 10% for studies using minimal interventions, 14% for studies using decision support interventions, and 25% for studies using multimodal interventions.

Patient health outcomes were reported alongside compliance results in 37 studies (76%). Within these studies, the most common patient outcomes reported were mortality (36 studies; 97%) and length of stay (25 studies; 68%). Supplemental Digital Content 6 pro- vides additional patient outcome distribution details. Other outcome measures reported were clinical treatment success rate,14,15 surgical site infection incidence rate,16,17 and readmission rate.18

Bundled guidelines

Bundled guidelines appeared in more than half of the studies. Examples included a treatment bundle for ventilator-associated pneu- monia,19 centers for disease control and prevention 12-step process to reduce antimicrobial resistance,20 and most prevalently, the Surviving Sepsis Campaign bundles for sepsis resuscitation (6-hour time win- dow) and sepsis management (24-hour time window), which were evaluated for compliance in 18 studies (37%). Since 2 of these sepsis studies did not report results for an entire bundle,23,24 they were excluded from the bundle analysis. The remaining 16 articles and the bundle components for which they report compliance are shown in Table 2.

Risk of bias assessment

Conversion of the scores from the modified Newcastle-Ottawa Scale into quality levels yielded 26% good quality, 33% fair quality, and 41% poor quality, with agreement >75% between raters. The large proportion of poor-quality articles was influenced heavily by discrep- ancies surrounding the comparability of the compliance results, which was often unclear or difficult to extract due to the inclusive nature of this review. When comparability is satisfied across all articles, the adjusted quality-level distribution becomes 37% good, 43% fair, and 20% poor. Supplemental Digital Content 7 details assess- ment results.

As evidenced by the low comparability scores in the risk of bias assessment, there was substantial heterogeneity between studies, primarily associated with the level of detail used when measuring and reporting compliance. For example, studies reporting 1-instance compliance were usually not focused on this result, and so details about compliance measurement were often limited or not provided. Studies reporting 2-instance compliance varied in the length and execution of their interventions. Additionally, studies in which com- pliance was timing-based were required to define a “time-zero” when measuring compliance, whereas other studies did not include this element.

DISCUSSION

Trends in compliance achievement

From our analysis, several trends emerged that appeared to corre- late with achieving high compliance with guidelines. Trends in inter- vention type, infection of focus, and bundled guidelines are described below.

Intervention-related trends wIn general, multimodal interventions had a higher average

improvement in compliance (25%) compared to decision support inter- ventions (14%) or minimal interventions (10%; Fig 3B). Multimodal interventions were more often used in low-compliance situations as an aggressive improvement strategy. Decision support interventions (usually an electronic decision support system) seemed to be used in situations where baseline compliance was measured but could be heavily impacted by the addition of an automated system at a single complex decision point. It is also worth noting that none of the deci- sion support interventions relied on “hard-stops,” which either pre- vent the user from taking an action altogether or require the user to obtain external override of a third party in order to proceed.

Sepsis-related trends Overall, initial compliance was lower in studies of sepsis-related

guidelines (Fig. 2 and 3A), often with less than 30% compliance. How- ever, the group also showed the greatest average absolute change in compliance. This may relate to the newness of these guidelines at the time and/or the complexity of the sepsis bundles themselves. Multi- modal interventions were employed in all but one26 of the sepsis- related studies, and these interventions generally resulted in large improvements in compliance.

Bundle-related trends Compliance with bundled guidelines is difficult to track and com-

municate because it requires both standardized definitions of bundle steps across institutions and standardized definitions of time zero for temporal bundle components. The difficulty in reporting compliance with bundles is evidenced by the fact that no study in Table 2 received all checkmarks possible. Additionally, bundled compliance results can be misleading when taken at face value, since (1) bundles are tied to pay and thus more likely to be complied with and (2) compliance with the entire bundle is a binary measure and provides no information about partial compliance. In general, less-invasive bundle components correlated with higher compliance and/or better outcomes.17,27-30

Comments on decreased compliance Interestingly, 2 studies reported a decrease in compliance from

first to second instance,26,31 but neither of them were statistically sig- nificant and likely reflect random variation. Ozgun et al reported a 6% decrease in compliance with appropriate choice, dose, and duration of antimicrobial prophylaxis31; this result may have been skewed due to detailed requirements for adherence. Westphal et al reported a 4% decrease and a 2% decrease in compliance with the 6-hour and 24-hour sepsis bundles, respectively26; this was the only sepsis study to employ a minimal intervention.

Relating compliance to its impact on patient outcomes

Although the majority of studies (76%) reported patient health out- comes alongside compliance results, the primary outcome reported was mortality, a measure that can be represented in various ways32

and does not capture the full scope of the patient experience, as survival does not describe positive and negative patient health trajectories.33

There may be other useful outcome measures that would be more proximal in timing and more specific to a particular guideline. For example, studies related to sepsis guidelines could assess sepsis-specific upstream outcomes (eg, reduced organ failure, fewer ICU admissions). Twelve studies (24%) did not relate compliance back to patient health, which is the true outcome compliance aims to represent.

While tracking compliance with guidelines can be important for improving quality of care, compliance as an outcome measure has limitations that emerged in our review. First, there is no clear definition of what compliance represents, as evidenced by the

Table 2 Compliance results reported by studies that investigated Surviving Sepsis Campaign bundles

Sepsis bundle studies Compliance reported for 6-hour resuscitation bundle component* Compliance reported for 24-hour management bundle component* Compliance percentage reported for entire bundley

Lactate Blood culture

Antibiotics Fluids or vasopressors

MAP CVP SvO2 Low-dose steroids

Activated protein Cz

Glucose control

Inspiratory plateau (PiP)

-hour Bundle esult 1 Result 2)

24-hour Bundle Result 1 (Result 2)

Both bundles Result 1 (Result 2)

Almeida 2013 @ @ @ @ ‘ @ @ 2 Castellanos-Ortega 2011

@ @ @ @ @ @ @ 11

Coba 2011 @ @ @ @ @ @ @ @ @ @ @ 13 ‘ ‘ Girardis 2009 ‘ @ @ @ ‘ ‘ @ @ @ @ @ 8 (60) 8 (60) 8 (35) Jeon 2012 ‘ ‘ @ @ @ @ @ 1 (50) Kuan 2013 @ @ @ @ @ @ @ 0 (40) Levy 2010 @ @ @ @ ‘ @ @ @ @ @ @ 1 (31) 18 (36) ‘ Na 2012 @ @ @ @ @ @ @ 3 (55) Nakornchai 2014 @ @ @ @ @ @ @ 1 Nguyen 2007* @ @ @ @ @ @ @ @ @ 0 (51) Nguyen 2011 @ @ @ @ @ @ @ 0 (44) Schramm 2011 @ @ @ @ @ ‘ ‘ 3 (54) Van Zanten 2014 @ @ @ @ ‘ @ @ @ @ @ @ 0 (68) 70 (89) 38 (62) Wang 2013 @ @ @ @ ‘ @ @ @ ‘ @ @ 1 (13) 1 (9) ‘ Westphal 2011* ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ 2 (29) 50 (48) ‘ Zambon 2008 @ @ @ @ ‘ ‘ @ @ @ @ @ 68 72 ‘

CVP, central venous pressure; MAP, Mean arterial pressure; SvO2, mixed venous oxygen saturation. @indicates that a compliance result was reported; ‘ indicates that no compliance result was reported, even though all information appeared to have been available *Bundles were broken into standard components using the summary reproduced in Levy et al.25. yAll studies reporting two-instance compliance results for entire bundles were statistically significant at the 0.05 level, except those identified by an asterisk. zThe activated protein C portion of the 24-hr management bundle was discontinued in a 2012 revision of the sepsis guidelines by Dellinger et al.9

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3

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heterogeneous definitions of compliance across studies. Second, com- pliance metrics usually imply a target goal of 100%, but this is mislead- ing, since some situations require clinicians to intentionally deviate from a guideline in order to produce the best health outcome for a patient. In fact, existing research discourages targeting 100% for any metric.4 Third, the magnitudes of improvement in compliance and patient health outcomes do not necessarily correlate. In cases where extensive and costly efforts are made to drastically improve compli- ance, there is always a chance that this effort will produce only a very small change in patient outcomes. Compliance with a protocol that does not translate to a meaningful improvement in patient outcomes is of questionable utility. Finally, all studies discussed compliance in terms of the percentage of patient cases that were compliant across all providers and did not compare compliance distributions between pro- vider types or individual providers. Further analysis related to pro- viders may be informative in guideline design and implementation.

Sustaining compliance

Following any intervention related to compliance with infection guidelines, there should be considerations for sustainability. How- ever, in the risk of bias assessment, contributors agreed that adequate consideration was given for sustainability (meaning measured at least 6 months after the intervention) in only 35 studies (71%). One of the biggest factors in sustainability is cost of an intervention, but only 5 studies discussed this factor.16,20,31,34,35 Additionally, key opera- tional considerations (eg, training time required, effect on workload) were ignored almost completely. One study surveyed physicians to investigate specific barriers (eg, not sure how to do it, patient refused, forgot to do it) to guideline compliance.29

Bias and limitations

The authors note there is a risk of bias both within and across the studies included in this review. Some common themes emerged in the limitations of compliance-related studies, such as varying defini- tions of “time zero” for temporal interventions. The potential for reporting bias is also evident, since a negative effect on compliance was reported in only 2 studies26,31; other studies may have also pro- duced negative results but did not report them.

The primary limitation of our review relates to the initial search strategy. Under the guidance of a university librarian subject-matter consultant, we primarily used MeSH terms (instead of keywords) in our search structure because they are assigned systematically by the PubMed database and represent the main ideas of each study. Thus, any studies with peripheral connection to our main ideas were not returned in our initial search. We note that another review article iden- tified additional PubMed studies reporting sepsis bundle compliance results, due primarily to the use of keywords in their search strategy.36

Although our respective analyses agree (for the articles we both selected), this brings up concerns about relying on database-specific categorization as a true representation of study content. One final limi- tation of this study was the English-only language restriction.

CONCLUSIONS

In this systematic review of studies that reported compliance for the prevention, detection, and/or treatment of acute hospital-based infections. Multimodal interventions (often including quality improvement initiatives) seem to result in the greatest improvement in compliance (25% improvement), followed by decision support (14%). More research is required to understand the implications of different approaches to guideline design, communication, and imple- mentation, especially in relation to patient outcomes and various cli- nician types.

Acknowledgments

This work was part of a collaboration among North Carolina State University, Mayo Clinic, Drexel University, and MedStar Health. The authors wish to thank Joshua Barclay for his contributions to the arti- cle selection process.

SUPPLEMENTARY MATERIALS

Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.ajic.2020.02.006.

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