Key messages
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If healthcare workers feel they have good support from managers, receive IPC training, and are told about IPC guidelines in a clear and helpful way, they are better able to follow the guidance.
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If there is not enough space where they work, they are too busy, do not have enough personal protective equipment (PPE) and other supplies, or if patients do not follow advice, then it is more difficult for healthcare workers to follow the IPC guidelines.
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Healthcare workers who want to protect themselves, their families, and their patients tend to try to follow the guidelines as much as possible, but the quality and fit of the PPE they have can make it more difficult.
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More research is needed on training, communication and education to make it easier for healthcare workers to follow guidelines, on developing systems to minimise patient contact, and on providing appropriate PPE to enable them to be prepared for pandemics.
Background
COVID‐19 is a respiratory infectious disease that spread worldwide in 2020. During the COVID-19 pandemic, healthcare workers needed to prevent the virus from spreading the disease to other patients, themselves, or people in the public. Infection prevention and control (IPC) guidelines are used to give healthcare workers information about using personal protective equipment (PPE) like masks, gloves, and gowns; separating patients with COVID-19; and stricter cleaning routines. However, some factors make it easier for healthcare workers to follow these guidelines, while others make it harder.
What did we want to find out?
We wanted to find out:
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what made it easier and what made it harder for healthcare workers to follow IPC guidelines for COVID-19;
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compare our findings with our existing Cochrane review, published in 2020, to see what was similar and what was different about COVID-19 compared to other respiratory infectious diseases.
What did we do?
We searched for studies that looked at healthcare workers’ views and experiences of following IPC guidelines for COVID‐19.
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Guidelines could be local, national, or international, for any healthcare setting.
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Studies could take place in hospitals, long-term care places or community health care.
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Healthcare workers could include either clinical or support staff working in the above places.
We then looked for themes (important elements) that came from the data:
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Organisational: supporting safety, communication and training;
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Environmental: workspace, ventilation, facilities, availability of PPE;
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Individual: knowledge, attitudes, use of PPE.
We rated our confidence in each study and each finding based on the quality of their methods.
What did we find?
We found 170 studies. To make it easier to handle the data, we selected 26 studies that best represented all the studies. They explored the views and experiences of nurses, doctors, and other healthcare workers dealing with COVID-19 in hospitals and nursing places where people live and receive care.
Several factors influence how well healthcare workers follow IPC guidelines. They reported that:
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it was easier to follow guidelines when they had support from their managers and when guidelines were communicated in a clear and accessible way.
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it was more difficult to follow guidelines if they were very busy, short-staffed, or if patients and visitors refused to wear masks and keep social distancing.
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training was very important. However, they did not all have the chance to attend IPC training.
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they need enough space, PPE and other supplies, hand-washing stations, and showers to follow the IPC guidelines.
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those with good knowledge and attitude towards IPC were more likely to follow the guidelines.
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healthcare workers worried about infecting themselves and other people, but some worried less once people started being vaccinated.
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PPE was uncomfortable to wear for long periods and, if it did not fit properly or was of poor quality, it was more difficult for them to practice IPC.
Many factors affect healthcare workers’ willingness and ability to follow IPC guidelines. For the public and patients attending healthcare settings, this review highlights that there will be better adherence to infection prevention and control in places where staff are supported, trained, and have adequate supplies. However, it is important to note that many of the challenges (e.g. crowded spaces) are structural and not the fault of individual staff.
Our review includes a set of questions based on our findings to help healthcare providers plan, implement, or manage IPC strategies to ensure their workers follow IPC guidelines for diseases like COVID-19, which can spread worldwide and affect many people at once.
What are the limitations of the evidence?
We were very confident of some of the evidence, but mainly our confidence in the evidence was limited. This was because no studies explored mental health and issues for children, meaning we are not sure how our findings apply to these groups. Also, the data from the studies were mostly collected at the peak of the pandemic (in 2020), so we have no way of knowing whether IPC guideline practices, training, and PPE evolved at later stages.
How up‐to‐date is this review?
This review updates (and extends) our previous review (2020). The evidence is up-to-date to April 2024.
Read the full abstract
The COVID-19 pandemic, declared in 2020, brought unprecedented challenges to our healthcare services in relation to the prevention and treatment of the disease. Additionally, preventing transmission within healthcare settings was critical. Infection Prevention and Control (IPC) guidelines are important for providing strategies on the use of personal protective equipment (PPE), the separation of patients with respiratory infections from others, and stricter cleaning routines. It is important to examine how the context of the pandemic impacts healthcare workers' (HCW) ability to adhere to IPC guidance in pandemic situations in the future. This is an update of an earlier review version, published in 2020, titled 'Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis'. We built on available evidence for infectious respiratory diseases, but also importantly, given the unprecedented global scale of COVID-19 and its unique challenges for healthcare systems, explored additional factors influencing IPC adherence specific to respiratory diseases with pandemic potential, i.e. infectious respiratory pathogens (such as novel influenza subtypes or coronaviruses) judged capable of causing a pandemic.
Objectives
Our primary objective is to identify the factors that impact on HCWs' adherence to IPC guidelines for COVID-19. A second objective is to update an existing rapid review, published in 2020, to identify similarities, differences, and novel insights specific to COVID-19 compared with other respiratory infectious diseases.
Search strategy
We searched MEDLINE (Ovid), CINAHL (EBSCO), Scopus, Ovid PsycINFO (EBSCO), and Epistemonikos. We did not apply any language limits but only searched from 2020 to the present (last search 5 April 2024). In the interest of timeliness and relevance, we only included studies published from 2020. We chose this as it marks the year when the COVID-19 pandemic was declared.
Selection criteria
We included qualitative and mixed methods studies that focused on the experiences and perceptions of HCWs towards factors that impact on their ability to adhere to IPC guidelines for COVID-19. We included studies of any type of healthcare worker with responsibility for patient care. We included studies that focused on IPC guidelines (local, national, or international) for COVID-19 in any healthcare setting. We excluded studies that collected data using qualitative methods (e.g. open-ended survey questions) in which the response data were analysed only with descriptive statistics.
Data collection and analysis
We used a purposive sampling frame to identify data-rich studies that represented a range of HCWs, healthcare settings, and geographical spread. We assessed methodological strengths and limitations in the same studies using an adapted version of the Critical Skills Appraisal Programme (CASP) tool for qualitative studies. We used the 'best-fit framework approach' to analyse and synthesise the evidence from our included studies. We used the GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence guideline adherence and developed implications for practice.
Main results
We found 170 studies eligible for inclusion; of these, 26 were sampled for analysis using a purposive sampling frame for a balance of variation and richness of data. Seven of the 26 sampled studies were from high-income countries. Of the 15 middle-income countries, seven were upper middle-income countries, and eight were lower middle-income countries. There were four low-income countries included in the sample. In terms of geographical spread, ten were from Asia, eight from Africa, three were from North America, one from South America, one from Oceania, and three from Europe.
Most of the studies included nurses (15 studies) or doctors (11 studies). Other types of healthcare workers included in the studies were other clinical staff (11 studies), such as midwives, allied health professionals, medical and radiologic technologists, dental professionals, neonatologists, radiographers, pharmacists, and support staff (7 studies), such as hospital cleaners, clerical staff, technicians, and hospital attendants. Healthcare settings ranged across and within studies, including hospitals, long-term care settings, and community healthcare settings. Specific units such as maternity, intensive care, emergency care, critical care, and operating rooms were identified in five of the sampled studies.
We identified 27 findings that outline the factors that impact on HCWs' adherence to IPC guidelines. We have low (n = 3), moderate (n = 12), and high (n = 12) confidence in these findings.
HCWs found it easier to follow IPC guidelines with managerial support, and when IPC guidelines were communicated in a clear, structured, and accessible way. They found it more difficult to follow guidelines if they were busy, short-staffed, or when patients and visitors refused to wear masks and maintain social distancing. Training was considered very important, but not all HCWs had the opportunity to attend IPC training. In terms of the working environment, HCWs need adequate space, hand-washing stations, and showers to follow the IPC guidelines.
HCWs worried about infecting other people, but some worried less once people started being vaccinated. It was very important that all HCWs had sufficient and equitable access to PPE and other supplies to follow guidelines. If PPE did not fit properly or was not of good quality, it was more difficult for HCWs to practice IPC.
Many factors affect HCWs' willingness and ability to follow IPC guidelines. Our review includes a set of questions based on our findings to help healthcare providers plan, implement, or manage IPC strategies to help their workers follow IPC guidelines for pandemic diseases like COVID-19. It is worth noting that our included studies were conducted primarily during the earlier phase of the pandemic, based on practical considerations to not update the search after April 2024.
Authors' conclusions
We identified several factors that influence the ability of healthcare workers to adhere to IPC guidelines. Practical implications, such as communication strategies and the provision of training and supplies, should guide policymakers and decision-makers in disease outbreaks and future pandemics.
Funding
This Cochrane review had no dedicated funding.
Registration
This Cochrane review extends the work by a published rapid review, available via DOI: 10.1002/14651858.CD013582.
