Primary Reviewer Jan Whitelaw
Discipline of Nursing
University of Adelaide
Secondary Reviewers Anne Wilson
Aye Aye Gyi
Date: July 2007
What specific barriers have been identified that influence compliance to hand hygiene practices by neonatal health care workers?
The objective is to systematically review identifiable barriers to the compliance of effective hand hygiene practices by health care workers in the neonatal care environment.
Recent decades have witnessed significant advancements in neonatal care lowering the viability boundaries of premature and sick infants1 yet this is with insignificant improvement in morbidity statistics2. From this a vulnerable population, highly susceptible to infections acquired from the health care environment has emerged3.
Nosocomial infection (NCI) is a principal source of neonatal morbidity and mortality.4 Immature immunity, an altered skin barrier, high numbers of patient care contact episodes and abnormal skin colonization by environmental organisms with a dependence on invasive medical technology for survival4 contribute to the complexity of inherent risk factors that predispose this group to an intrinsically high incidence of infection. Presenting signs of neonatal sepsis are generally non specific and can progress rapidly5.
Blood stream infections are particularly significant in this group by nature of their frequency and their potential for life-threatening consequences4. Empiric antibiotic prophylaxis may often be advocated as standard management where there is an identifiable risk or suspicion of infection. Antibiotic therapy compounds the risk for multi-resistant pathogen infection in this setting6. Compliance to hand hygiene is a proven indicator of effectiveness in the prevention of spread of such diseases7.
Prolonged hospital stay as a consequence of neonatal infection generates a significant economic burden8,9. The neuro-developmental impact on long term outcomes furthermore perpetuates far reaching detrimental lifelong economic and quality of life issues for the infant, family and community.
The contaminated hands of health care workers are consistently cited as being responsible for a significant majority of NCI7. Effective hand hygiene is the simplest and most effective method to prevent hospital infection10 however low levels of compliance is extensively documented11 with only transient improvements witnessed from hand hygiene promotion strategies. Staunch adherences to basic infection control practices have been shown to be effective1 however adherence of health care workers to hand hygiene policies are poor12.
The communication and uptake of evidenced Infection Control practices is synonymous with hand hygiene compliance. An appropriate level of performance in hand hygiene techniques is essential to the sum effect of hand decontamination if to be effective in the prevention of NCI. Hand jewellery and artificial/long fingernails of health care workers have been inextricably linked to high levels of bacterial contamination that is difficult to remove during routine hand hygiene yet the undervaluing of this prospective risk has been demonstrated13.
Recent literature indicates that recognizable infection control behaviours of health care workers in the neonatal setting considerably impact on rates of NCI14. Low compliance is bound up in a complex web of individual, cultural and organizational issues which culminate in behaviour practice norms3,15 with various cited reasons correlated with skin integrity, lack of time and physical resources. Inconsistent relationships between health care worker knowledge, attitudes and hand hygiene practices have been identified which may be facilitated by a lack of commitment of organizations to policy implementation13.
Intrinsic aspects of individual health care worker group cultures and behaviors have a significant impact on hand hygiene adherence issues and warrant consideration when addressing appropriate interventions16. Observational surveys suggest a lowered perception of the risk of transmission of organisms during regular newborn care procedures. Low adherence to standard precautions has been demonstrated in this setting. An observational study by Cohen, Saiman, Cimiotti & and Larson17 reported NICU nurses, although accountable for the majority of patient contacts, to have lower compliance with appropriate hand hygiene and wearing of gloves than other health care worker groups.
Current literature predominantly focuses on multimodal strategies and effectiveness of their interventions to improve hand hygiene compliance. Creedon18 reports compliance improvement of only 12% from many of these approaches and cites a lack of the inclusion of behavioral theories as an important factor. A review of studies identifying barriers to effective evidence uptake within the neonatal setting is indicated to provide valuable insight into the many factors that affect behaviors impacting on poor hand hygiene compliance, and thereby provide a more informed framework upon which to develop culturally perceptive infection control guidelines relevant to this environment.
Types of Participants
Health care workers in the neonatal setting are the participants of interest in this review. This group is limited to multi disciplinary health professionals that come into direct contact with neonates including nurses, medical officers, physiotherapists, radiologists and pathology collection staff, but does not include patient support service personnel such as chaplains, domestic services, volunteers, social workers etc.
Phenomena of Interest
The phenomenon of interest is the barriers to effective hand hygiene practices as defined by organisational Infection Control policies. Hand hygiene incorporates a milieu of definitions that culminate in effective practice. These include the absence of hand jewellery, nail care, appropriate technique in the intervention using either hand washing or topically applied alcohol based preparations, and appropriate timing of the hand hygiene intervention in relation to hand contamination or point of patient contact.
Types of outcomes measures
The primary outcome of interest
Measures of outcomes will be compliance to recommended hand hygiene practices as defined by universally acknowledged Infection Control standards.
Measures of outcome will include but not be limited to Barriers, Adherence, Compliance, Attitudes, Knowledge, Beliefs, Perceptions, Behaviours and Opinions.
Types of studies
The review will consider both quantitative and qualitative studies that examine barriers to compliance with effective hand hygiene practices including but not limited to designs such as surveys, observational studies, and phenomenology. In the absence of these, discussion papers, reports and expert opinion that fulfill the inclusion criteria will be considered in a narrative summary.
The search strategy aims to find both published and unpublished studies. The search will be limited to studies published in the English language. An initial limited search of Medline and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all the identified keywords and index terms will then be undertaken. Thirdly the reference lists of all identified reports and articles will be searched.
The search will be limited to literature published during the period from 1996 to July 2007, being representative of the improved survival in the past 10 years of extremely low birth weight infants that have a significantly higher morbidity and mortality associated with NCI.
The second search will include the following databases:
- Cochrane Library
- Proquest Medical Library
- ERIC(Educational Resources Information Center) database
- Ebesco Biomedical Collection
- Maternity and Infant Care
- CDC (Centres for Disease Control and Prevention)
A search for unpublished studies will include New York Academy Grey Literature, Dissertation Abstracts International, conference proceedings, abstracts, reports, hand searching of peer reviewed journals
Initial keywords to be used include
Hand hygiene, handwashing, compliance, neonatal, infant/newborn, nursery, intensive care, health care workers, barriers, attitudes, knowledge, beliefs, practices behaviours, perceptions.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information package (SUMARI). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer.
1. Quantitative studies
Data will be extracted from papers included in the review using standardised data extraction tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information package (Appendix 1).
2. Qualitative Studies
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 (Appendix 2). Where no comparative studies are identified, quality of methodology of relevant opinion and text papers that have been retrieved will be assessed using the Joanna Briggs Institute Narrative, Opinion and Text Assessment Review Instrument (NOTARI) (Appendix 3) critical appraisal tool.
1. Quantitative data synthesis
Where possible, study results will be pooled in a statistical meta- analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review instrument (JBI MASTARI). All results will be double entered. Odds ratio (for categorical data) and standard weighted or 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 a narrative form.
2. Qualitative data synthesis
Where meta-synthesis is possible, qualitative research findings will be pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the finding (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 meta-synthesis 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 using Narrative Opinion and Text Assessment Review Instrument (NOTARI).
Conflicts of Interest
Singh N, 2004, Large infection problems in small patients merit a renewed emphasis on prevention.’, Infection Control and Hospital Epidemiology25(9), pp.714-715
2. Wilder MA, 2000, ‘Ethical issues in the delivery room: resuscitation of extremely low birth weight infants’, Journal of Perinatal and Neonatal Nursing
, Sept, 14(2) pp44-57
3. Pessoa-Silva C, Posfay-Barbe K, Pfister R, Perneger T, Pittett D, 2005, ‘Attitudes and perceptions among healthcare workers caring for critically ill neonates’, Infection Control and Hospital Epidemiology, 2004 26, pp.305-311
4. Brady M, 2005, ‘Health care-associated infections in the neonatal intensive care unit’, American Journal of Infection Control
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5. Hashim M, Guillet R, 2002, ‘Common issues in the care of sick neonates.’, American Family Physician
, 66(9), pp.1685-1783
6. Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath PT, 2005,
Neonatal sepsis: an international perspective Archives of Disease in Childhood Fetal and Neonatal Edition
7. Boyce J, Pittett D, 2002, ‘Guidelines for Hand Hygiene in Health-Care Setting; Recommendations of the Healthcare Infection Control Practices advisory committee and the HISPAC/SHEA/APIC/IDSA Hand Hygiene Taskforce’, MMWR Recommendations and Reports,
8. Kawagoe J, Conceicao A, Pereira C, Cardoso M, Fukushima J, 2001, ‘Risk factors for nosocomial infections in critically ill newborns; a 5 year prospective cohort study.’ American Journal of Infection Control
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9. Ng P, Wong H, Lyon D, So K, Liu F, Lam R, Wong E, Cheng A, Fok T, 2004, ‘Combined use of alcohol hand rub and gloves reduces the incidence of late onset infection in very low birthweight infants’, Archives of Disease in Childhood Fetal and Neonatal Edition
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11. Pittet D, 2002, ‘Promotion of Hand Hygiene: Magic, Hype or Scientific Challenge?’, Infection Control & Hospital Epidemiology,
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13. Kennedy A, Elward A, Fraser V, 2004, ‘ Survey of knowledge, beliefs and practices of Neonatal Intensive Care Unit health care workers regarding nosocomial infection, central venous catheter care and hand hygiene’, Infection Control and Hospital Epidemiology,
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14. Won SP, Chou H, Chen C, Hseih WS, 2004, ‘Hand washing program for the prevention of nosocomial infections in a Neonatal Intensive Care Unit’, Infection Control and Hospital Epidemiology,
25(9), pp. 742-747
15. O'Boyle C Henly S ’ Larson E, 2001“Understanding adherence to hand hygiene recommendations: The theory of planned behavior American Journal of Infection Control
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16. Howell K, Fontes D, Hamvas A, Mathur A, Holzmann-Pazgal G, 2005, ‘Compliance with contact precautions in a neonatal intensive care unit’, American Journal of Infection Control
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17. Cohen B. Saiman L. Cimiotti J. Larson E., 2003 ‘Factors associated with hand hygiene practices in two neonatal intensive care units. [Comparative Study.’ Journal Article. Research Support, U.S. Gov't, P.H.S.] Pediatric Infectious Disease Journal. 22(6):494-9, Jun
18. Creedon S, 2006 Infection Control: behavioural issues for health care workers’, Clinical Governance International Journal