title: Barriers to implementing infection prevention and control guidelines during crises: experiences of health care professionals.
abstract: BACKGROUND
  Communicable disease crises can endanger the health care system and often require special guidelines. Understanding reasons for nonadherence to crisis guidelines is needed to improve crisis management. We identified and measured barriers and conditions for optimal adherence as perceived by 4 categories of health care professionals.
  
  
  METHODS
  In-depth interviews were performed (n = 26) to develop a questionnaire for a cross-sectional survey of microbiologists (100% response), infection preventionists (74% response), public health physicians (96% response), and public health nurses (82% response). The groups were asked to appraise barriers encountered during 4 outbreaks (severe acute respiratory syndrome [SARS], Clostridium difficile ribotype 027, rubella, and avian influenza) according to a 5-point Likert scale. When at least 33% of the participants responded "strongly agree," "agree," or "rather agree than disagree," a barrier was defined as "often experienced." The common ("generic") barriers were included in a univariate and multivariate model. Barriers specific to the various groups were studied as well.
  
  
  RESULTS
  Crisis guidelines were found to have 4 generic barriers to adherence: (1) lack of imperative or precise wording, (2) lack of easily identifiable instructions specific to each profession, (3) lack of concrete performance targets, and (4) lack of timely and adequate guidance on personal protective equipment and other safety measures. The cross-sectional study also yielded profession-specific sets of often-experienced barriers.
  
  
  CONCLUSIONS
  To improve adherence to crisis guidelines, the generic barriers should be addressed when developing guidelines, irrespective of the infectious agent. Profession-specific barriers require profession-specific strategies to change attitudes, ensure organizational facilities, and provide an adequate setting for crisis management.
authors.affiliation: Center for Infectious Diseases, National Institute for Public Health and the Environment, Bilthoven, The Netherlands. Aura.Timen@rivm.nl
authors.forename: Aura
authors.initials: A
authors.lastname: Timen
authors.forename: Marlies E J L
authors.initials: ME
authors.lastname: Hulscher
authors.forename: Laura
authors.initials: L
authors.lastname: Rust
authors.forename: Jim E
authors.initials: JE
authors.lastname: van Steenbergen
authors.forename: Reinier P
authors.initials: RP
authors.lastname: Akkermans
authors.forename: Richard P T M
authors.initials: RP
authors.lastname: Grol
authors.forename: Jos W M
authors.initials: JW
authors.lastname: van der Meer
mesh_terms: D001291:Attitude of Health Personnel; D002959:Civil Defense / Q000379:methods*; D003140:Communicable Disease Control / Q000379:methods*; D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D011795:Surveys and Questionnaires