Centre conducting review:
National University Health System, Singapore
Koh Yiwen, 4th year nursing student, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore
Professor Desley Hegney, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore
Dr. Vicki Drury, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.
Emerging infectious diseases, defined as diseases that have “newly appeared in a population or have existed previously but are rapidly increasing in incidence or geographic range”,1 have always been a threat to nations worldwide and are the second leading cause of death worldwide.2 More specifically, the World Health Organization listed acute respiratory tract infections as the infectious disease with the highest mortality rate worldwide.2 Significant acute respiratory tract infections which have emerged in the 21st century include - Severe Acute Respiratory Syndrome (SARS) in 2003, the Avian Influenza A/H5N1 virus in early 2004 and the Influenza A/H1N1 virus in 2009. SARS and the Influenza A viruses share the same modes of transmission, which is via respiratory droplets and person-to-person contact.3 They are also contagious and can spread rapidly within populations worldwide, leading quickly to a global pandemic. Additionally, these viruses are virulent with high morbidity and mortality rates.4 They are also predisposed to rapid and efficient mutations which may increase their virulence and resistance to current drug regimens.5, 6
These features of the emerging respiratory infectious diseases pose a problem for health authorities and healthcare professionals,7 especially nurses who are in constant close contact with affected patients and their body fluids - primarily respiratory droplets - through which respiratory viruses are transmitted.4 For example, the attack rates on health care workers during nosocomial influenza outbreaks were estimated to be as high as 60%.4 Apart from personal health risks8 from emerging respiratory infectious diseases, nurses are also at risk of social isolation and stigmatization because of the social basis of disease transmission.9, 10 In addition, they face risks of spreading the diseases to friends and family, resulting in emotional conflict and guilt.9
According to the Health Belief Model, a person's risk perceptions are instrumental in influencing their behavior.8 Very high risk perceptions may hinder the retention of qualified nurses11 as they fear for the health and safety of themselves and their loved ones. Some may also be less devoted in the care provided to patients due to an internal conflict between professional conduct in caring for patients and the innate sense of self-preservation.12 On the other end of the spectrum, nurses with very low risk perceptions may be non-compliant to protective behavior such as vaccinations4 and facial protection,13 increasing both their risk and propagation of nosocomial transmission within the hospital and community. In short, it is evident that nurses' workplace behaviors in response to their risk perceptions have a major impact on themselves, the workforce, individual patient care as well as the wider community.
Many factors play a part in one's risk perceptions and may vary between individuals. Hence there needs to be a greater understanding on how individual nurses perceive such risks, including how these are influenced by their associated socio-cultural, psychological and attitudinal factors and how such perceptions affect their workplace behavior. This knowledge can inform the creation of strategies to acknowledge and manage the personal risks to nurses from these emerging respiratory infectious diseases and maximize the quality of care delivered. Some strategies suggested in the literature include the implementation of social, emotional and psychological coping mechanisms to address nurses' distress and fears in relation to their exposure (i.e. the provision of psychosocial support by nursing administrators and educational interventions to keep nurses up-to-date with current developments10, 14). Another suggested strategy is the usage of verbal approval or monetary rewards to reinforce proper behavior (i.e. adoption of facial protection and vaccinations) and attitudes.14 Examination and evaluation of this wide repertoire of strategies in primary research, namely, its effectiveness and applicability to the hospital and community settings will inform policy development that will hopefully not only protect nurses but also minimize the disruption of healthcare provision during such crises.
The overall aim of this systematic review is to critically appraise, synthesize and present the best available evidence in relation to the risk perceptions and behaviors of nurses to emerging acute respiratory infectious diseases in acute hospital and community healthcare settings; and to make recommendation for practice that will protect both nurses and their patients/clients.
More specifically, the qualitative component of the review seeks to determine:
- How do nurses practicing in hospitals and community healthcare settings perceive the meaning of being exposed to recently emerging acute respiratory infectious diseases?
- What are the socio-cultural, psychological, attitudinal and environmental factors influencing the nurses' risk perceptions?
The quantitative component of the review seeks to determine:
- What is the effectiveness of the strategies used to manage the nurses' risk perceptions and therefore their perceptions of workplace safety and quality of life?
- How effective are current directives in ensuring the adherence of nurses to recommended hospital and government protocols?
- What are the behaviors evident in nurses when exposed to emerging acute respiratory infectious diseases?
- What are the other key organizational, environmental and individual factors influencing their behavior?
The review will consider publications that include male and female nurses practicing in acute hospital and community health care settings. If there are insufficient studies which specifically focus on nurses, the review will also consider studies that address all health personnel.
Interventions (Phenomena of interest)
The qualitative component of this review will consider studies that investigate the meaning of being exposed to recently emerging acute respiratory infectious diseases and the strategies used to protect nurses and patients.
The quantitative component of the review will consider studies that investigate the effectiveness of strategies used to protect nurses and patients. Additionally studies that examine the workplace behaviors of nurses and the associated factors in response to recently emerging acute respiratory infectious diseases will be included.
This review will consider studies which focus on acute hospital and community health care settings in both developing and developed countries.
The main focus of the qualitative component of the SR is the nurse's perceived meaningfulness of the experience to the disease/s and the strategies used to protect them.
The outcomes of interest for the quantitative component of the SR consider the objective or subjective measures of the following:
- Compliance and adherence to hospital infection control policies and precautionary measures (i.e. use of personal protective equipment (PPE))
- feelings of wellbeing (incorporating anxiety and quality of life)
Secondary outcome measures of interest may include:
- Availability of personal protective equipment (PPE)
- key organisational, environmental and individual factors influencing their behaviour
The outcome measures used, as reported in the studies, should also meet the following criteria of reliability, validity and feasibility.
Types of studies
The qualitative component of the review will consider any interpretive studies that draw on the experiences of being exposed to emerging acute respiratory infectious diseases in male and female nurses practicing in acute hospital and community healthcare settings including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
The quantitative component of the review will consider any meta-analyses and randomised controlled trials (RCTs); in the absence of meta-analyses and RCTs, other research designs of a quantitative nature, such as non-randomised controlled trials, before and after studies, cohort studies, case control studies, descriptive studies, case series/reports will be considered for inclusion in a narrative summary to enable the identification of current best evidence regarding male and female nurses' exposure to emerging acute respiratory infectious diseases in acute hospital and community healthcare settings.
This review will exclude the following:
- Studies involving expert opinions & secondary research papers unless there is a lack of primary research studies
- Studies written in any languages other than English
- Studies which were conducted before the year 1997. This time frame is chosen first, to ensure that the findings are contemporary and relevant and second, because the year 1997 marked the emergence of a novel respiratory communicable disease of pandemic potential - avian H5N1 influenza virus - in Hong Kong, the first in two decades since the 1977 Russian Flu (H1N1) pandemic.15
SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES
Prior to the commencement of this systematic review, the Cochrane Library, Joanna Briggs Institute (JBI) database and CINAHL database were searched and no previous systematic reviews on this specific topic were identified.
The search strategy aims to find both published and unpublished primary research studies printed during the last 12 years (between years 1997-2009) in the English Language. A three-step search strategy will be utilised in each component of this review. An initial limited search of PubMed (MEDLINE) and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second extensive search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list and bibliographies of all identified reports and articles will be searched for additional studies. A hand search of relevant key journals not indexed in the databases will not be conducted due to time and resources constraints.
The electronic databases to be searched include:
- PubMed (MEDLINE)
- Sociological Abstracts
- Web of Science (Social Sciences Citation Index
Because of economic and time limitations databases such as MEDNAR and Dissertation Abstracts International will not be searched. Additionally conference proceedings and any grey literature will not be included in this review.
A list of initial keywords used in the search strategy can be found in Appendix I.
ASSESSMENT OF METHODOLOGICAL QUALITY
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).*
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).*
*Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (Dr. Vicki Drury).
The checklists used to aid in the determination of eligibility for inclusion of reviewed articles can be found in Appendix II.
Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument JBI-QARI.*
Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI.*
*The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
The checklists used to aid in the extraction of data from papers included in the review can be found in Appendix III.
Data will be extracted by two independent reviewers. Qualitative research findings will, where possible be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rates according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.
We would like to thank the National Medical Research Council (NMRC) of Singapore for their support and funding to the study.
POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest is anticipated.
1. Morens DM, Folkers GK, Fauci AS. The challenge of emerging and re-emerging infectious diseases. Nature 2004 Jul 8;430(6996):242-9.
2. Fauci AS. Infectious diseases: considerations for the 21st century. Clinical Infectious Diseases 2001 Mar 1;32(5):675-85.
3. Cutter J. Preparing for an influenza pandemic in Singapore. ANNALS Academy of Medicine Singapore 2008 Jun;37(6):497-503.
4. Low JG, Wilder-Smith A. Infectious respiratory illnesses and their impact on healthcare workers: a review. ANNALS Academy of Medicine Singapore 2005 Jan;34(1):105-10.
5. Maines TR, Chen LM, Matsuoka Y, Chen H, Rowe T, Ortin J, et al. Lack of transmission of H5N1 avian-human reassortant influenza viruses in a ferret model. Proceedings of the National Academy of Sciences U S A 2006 Aug 8;103(32):12121-6.
6. Moscona A. Medical management of influenza infection. Annual Review of Medicine 2008;59:397-413.
7. Blendon RJ, DesRoches CM, Cetron MS, Benson JM, Meinhardt T, Pollard W. Attitudes toward the use of quarantine in a public health emergency in four countries. Health Affairs (Millwood) 2006 Mar-Apr;25(2):w15-25.
8. Leppin A, Aro AR. Risk perceptions related to SARS and avian influenza: theoretical foundations of current empirical research. International Journal of Behavioral Medicine 2009;16(1):7-29.
9. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal 2003 May 13;168(10):1245-51.
10. Nickell LA, Crighton EJ, Tracy CS, Al-Enazy H, Bolaji Y, Hanjrah S, et al. Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. Canadian Medical Association Journal 2004 Mar 2;170(5):793-8.
11. Stone PW, Clarke SP, Cimiotti J, Correa-de-Araujo R. Nurses' working conditions: implications for infectious disease. Emerging Infectious Diseases 2004 Nov;10(11):1984-9.
12. Masur H, Emanuel E, Lane HC. Severe acute respiratory syndrome: providing care in the face of uncertainty. Journal of the American Medical Association 2003 Jun 4;289(21):2861-3.
13. Nichol K, Bigelow P, O'Brien-Pallas L, McGeer A, Manno M, Holness DL. The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals. American Journal of Infection Control 2008 Sep;36(7):481-7.
14. Ko NY, Feng MC, Chiu DY, Wu MH, Feng JY, Pan SM. Applying theory of planned behavior to predict nurses' intention and volunteering to care for SARS patients in southern Taiwan. Kaohsiung Journal of Medical Sciences 2004 Aug;20(8):389-98.
15. Snacken R, Kendal AP, Haaheim LR, Wood JM. The next influenza pandemic: lessons from Hong Kong, 1997. Emerging Infectious Diseases 1999 Mar-Apr;5(2):195-203.
APPENDIX I: Initial keywords or terms used in search strategy
APPENDIX II: Critical appraisal tools for MASTARI & QARI
JBI Critical Appraisal Checklist for Systematic Reviews
JBI Critical Appraisal Checklist for Experimental Studies
JBI Critical Appraisal Checklist for Comparable Cohort/Case Control
JBI Critical Appraisal Checklist for Descriptive/ Case Series
JBI QARI Critical Appraisal Checklist for Interpretive & Critical Research
APPENDIX III: Data extraction tools from MASTARI & QARI
JBI Data Extraction Form for Experimental/Observational Studies
JBI QARI Data Extraction Form for Interpretive & Critical Research
APPENDIX IV: Joanna Briggs Institute Levels of Evidence (new)