The search resulted in 1414 unique records of which 180 full-text articles were assessed for eligibility and 57 were included in the review. From the grey literature four articles met the inclusion criteria for the review. The most common reasons for exclusion were no healthcare professional related factors described, mixed sample with unclear reporting of results for healthcare professionals, not in hospital setting or setting unclear, or not a healthcare professional sample.
A total of 27 qualitative studies, 20 quantitative studies, six literature reviews, and four mixed-method studies were included in the review. Figure 1 demonstrates the inclusion and exclusion of records at each stage of the screening process, using the PRISMA flow diagram [21].
Resilience factors influencing healthcare professionals’ adaptive capacity
The factors influencing healthcare professionals’ adaptive capacity with hospital standardization practices were grouped in eight categories as described in Table 4. The eight categories constitute a combination of individual and group/social factors deciding whether hospital healthcare professionals comply with or adapt their practices to standardization practices. Below the eight categories are described in more detail.
[Insert here Table 4 Resilience factors]
Psychological and emotional factors
In most cases, the literature concerning healthcare professionals’ psychological and emotional factors are related to feelings of anxiety or stress related to the use or not use of infection prevention guidelines or protocols. In many instances professionals choose to adhere to infection prevention guidelines due to the psychological pressure or fear of contracting or spreading infections [25, 33, 42]. Adverse incidents with infection prevention equipment are perceived as stressful and worrying [52], while following standard precautions would decrease their anxiety [42]. Uncertainty regarding the effect of infection control measures and/or belonging guidelines could on the other hand result in poor use of standardization practices [57].
Healthcare professionals’ sense of invulnerability and confidence would lead them to adapt to hospital standardization [23, 32, 56, 64, 76]. Reasons would differ from physicians considering themselves to be entitled to work independently without protocols to guide them [32], to professionals feeling minor concerns for infection transmission over time when not acquiring any infection [56] to nurses expressing psychological gratification about their own ability to creatively solve problems and work around standardization practices [76].
Cognitive factors
Various attitudes and beliefs were reported in several studies as influencing healthcare professionals’ adaptive capacity or compliance to hospital standardization [29, 30, 34, 38, 42, 46, 48–49, 53, 56, 62–63, 70, 74, 76]. Some of these attitudes and beliefs were patient related [42, 46, 53, 63, 70, 75–76]. For example, in a study on the use of personal protective equipment in the emergency room during the COVID-19 pandemic, 46% of healthcare professionals believed that the equipment did not protect patients from COVID-19, while 52% believed that it was protective for patients [53]. In another study, physicians believed that diarrhoea was a low-risk disease with overrepresentation among poor people but adapted the diarrhoea treatment to patients with higher social status [46]. The literature also showed that nurses justified adaptations when they believed that use of gloves or masks was an exaggeration when treating children at low risk and not contagious [42].
Attitudes and beliefs were also related to the professional group that healthcare professionals belonged to [30, 62]. Physicians and nurses had opposing views on surgical count protocol violations and what constitutes safe clinical practice [62]. Nurses believed that physicians had lower hand hygiene compliance, while physicians believed that they were role models and leaders of hand hygiene and would warn other staff members [30]. A study exploring hand hygiene found that healthcare professionals self-reported hand hygiene was believed to be better than the actual observed practice [29].
Healthcare professionals’ agreement or disagreement with specific guidelines also led to adaptations to hospital standardization. Adaptations were made when for example radiologists considered diagnostic imaging guidelines not useful, too rigid, or that they failed to include specific information about changes [48] or were perceived as inefficient or unnecessary [76], especially for children believed to be at low risk [42].
Adaptations were furthermore done when guidelines were not believed to be relevant for the clinical practice [38, 65], or relevant for certain care systems [49], or when healthcare professionals doubted the effectiveness of isolation precautions to prevent disease contagion [56]. A systematic review reported that healthcare professionals’ adaptive capacity was influenced when they believed that guidelines and other standardized practices were too generic, promoted 'cookbook medicine', oversimplified difficult or controversial treatment decisions, or when the evidence they were based on was conflicting [63]. By contrast healthcare professionals complied to standards, protocols and guidelines when believed to be useful tools [50] in clinical decision making and providing uniform care [49, 63], were easy to understand, highly relevant to clinical practice and patient population, and based on credible information sources [63].
Motivational factors
Motivational factors for healthcare professionals’ adaptive capacity are mainly reported in studies on infection prevention and control. Personal motivational drivers such as moral responsibility, obligation and duty are reported by different professional groups related to infection control practices in the emergency room and on hospital wards in general [27, 34], within tuberculosis infection control measures [23], within hand hygiene obligations [30], within venous thromboembolism prophylaxis management [47], within respiratory infectious diseases [25], and with clinical practice guidelines to prevent falls and injuries [72]. The moral responsibility would be directed towards themselves as professionals to reduce transmission of pathogens or expressed as a duty of care to their patients. Motivational factors were most often internally driven in the sense of professionals’ own intent and feelings of psychological safety [31, 76], while some studies reported on external drivers such as a motivational person in their organization [72], the intensity of activity in the clinical setting [31] or organizational neglect of occupational health and safety [61].
Healthcare professionals’ comfort or discomfort with personal protective equipment would influence their motivation to adapt to infection prevention and control standardization practices [25, 34, 42, 52, 54, 57]. For example, breathing difficulties, overheat, dehydration, claustrophobia, and headache would sometimes reduce adherence to the use of such equipment [25, 54], while in other situations healthcare professionals adapted the use of the equipment to better fit their body or they adapted better to it over time [52, 57].
Knowledge and experience factors
Knowledge and training of standardization practices was described as important and increased compliance among nurses [35, 43–44] and younger physicians [56], but was not seen as sufficient for physicians and nurses in other studies [26, 45, 48, 51, 56, 59, 60].
Often healthcare professionals’ increased knowledge and training would lead them to adapt to hospital standardization [62]. The main contributing factor for these adaptations was length and type of clinical experience [36, 42, 56, 60, 68, 74]. For example, senior nurses due to increased experience had more confidence to adapt protocols, policies, and guidelines in their daily practice in intensive care units [60] or during fever management [74], while less experienced nurses with barcode medication administration technology avoided adaptations [69]. Among surgical team members, physicians relied on their experience and tactical knowledge [62], nurses on their repeated experience of working daily with the same instrument trays [60] and forgot surgical count guidelines or made workarounds on surgical safety checklist use [59]. However, in another study increased length of experience was reported as a contributing factor to compliance with hand hygiene for both physicians and nurses [44].
Lack of or insufficient knowledge and training led healthcare professionals to make various adaptations. For example, knowledge deficits about tuberculosis led healthcare professionals to use ineffective measures in preventing transmission [34]. Similarly, midwives’ limited knowledge of aspects of infection prevention control guidelines [24] or being unaware that national postnatal care protocols had been updated led them to make adaptations based on inappropriate experiential knowledge [61].
For some healthcare professionals, negative experiences during clinical practice increased their compliance with the clinical guidelines to prevent falls and fall injuries [72], while experience of lack of consequences due to e.g., not getting infected after repeated exposures to body fluids led nurses to continue their adaptations to universal precautions [56].
Professional role factors
In many cases, the clinical role or profession of healthcare workers influenced their ability and desire to adapt to hospital standardization [12, 56, 58, 61, 76]. Nurses defined problem solving as part of their job thus contributing to workarounds from standardization practices [76]. Physicians often defined their role in authoritative ways contributing to lower compliance with hospital standardization than other professions, for example within hand hygiene [12], the surgical safety checklist [58, 61], and MRSA precautions [56]. In one study, professional status and reputation were identified to influence physicians’ clinical decision-making [46]. Healthcare professionals’ perception of their own roles also challenged their possibility to intervene in each other’s work tasks and their ability to collectively adapt to standardization practices [32, 46, 58]. Authoritative structures led professionals to work in silos, resulting in nurses not being able to speak up [46, 58]. Depending on the clinical situation, one study documented that nurses were able to challenge consultants on infection issues while not on managing catheters or anaesthetic procedures [32].
Furthermore, autonomy and clinical and/or professional judgment were seen as vital elements of healthcare professionals’ adaptive capacity [40, 60, 63, 76]. For example, commitment to infection prevention and control was high in a neonatal unit, however, severely constrained resources made improvisation a vital element of professionals’ clinical judgment and adaptive capacity [24]. In some cases, healthcare professionals expressed a contradictory relationship between hospital standardization measures and their application of clinical judgment, degree of discretion, and freedom to decide what should be done in a particular patient situation [40, 63].
Risk management factors
Healthcare professionals adapted their practices to meet hospital standardization due to individual perceptions of risk and belonging personal costs. They adhered to infection prevention guidelines to protect themselves from being infected or from infecting family and others [25, 28, 30, 34, 42, 54, 57], or they wanted to avoid reprimands and litigations [47, 63, 72–73]. The perceived risk for reprimands or litigations might for example lead to nurses performing fall prevention according to the guideline “just in case” even with non-risk patients [72] p90. The same goes for physicians sending patients for x-rays “just to be safe” [72] p90. However, in another study perceived enforcement of rules in the form of monitoring and threats of punishment or sanctions had no direct or indirect effect on physicians’ compliance [41]. The media is also experienced to affect healthcare professionals’ practices as they want to avoid clinical situations finding their ways into the newspapers and fear to miss out on required reporting [72].
Clinical practice guidelines were adapted or disregarded if healthcare professionals perceived them to constitute a potential risk to patients [60, 68, 70, 76]. This could involve physicians using more highly concentrated medications than recommended to prevent fatal arrythmia [70], nurses to disregard the protocol for surgical count of instruments in life-threatening emergencies [60], or midwives to ignore or modify post-natal care protocols if they were uncertain of the patient’s health condition (e.g. to avoid harm to the mother by giving her treatment when she did not in fact have a hypertensive disorder) [61].
Patient and family factors
The main reason for healthcare professionals wanting to adapt their hospital standardization practice within this category was to meet patient needs. In general, this involved that they deviated from hospital guidelines or policies when they saw them as barriers to patient care and/or patient safety. Patient needs were exemplified as timely care, customized care, patient-centred care, quality of patient communication, privacy, or improved outcomes [37, 56–57, 68, 75–76]. Several studies related to infection prevention in pandemic situations pointed at adaptations made to personal protective equipment protocols to improve patient communication, reduce patients’ feeling of isolation, and better establish therapeutic relationships [23, 53, 55–57]. This was especially relevant for older patients [56] and children [42, 57]. In emergencies workarounds of protocols were justified not to jeopardise the patients’ safety [76], while in surgical settings compliance with the checklist protocol was seen as preserving patient safety [61].
Adaptations were also made to customize treatment when for example cancer recommended protocols were seen as inappropriate for specific types of patients [63], or when administration protocols for certain medications were not followed for patients with heart failure or low body weight in children [70].
Family factors were related to presence and expectations, and cultural conflicts. Examples of adaptations span from clinicians not complying with the family witnessed resuscitation protocol as they value it as traumatic for relatives with risk of PTSD [73] to pressure for antibiotics and intravenous fluids in diarrheal management [46] to disapproval of pre-operative skin preparation policy due to cultural preferences [77].
Work relationship factors
Most studies reporting on work relationship factors were related to conditions negatively affecting the adaptive capacity or resilience of healthcare professionals such as power issues, group norms, hierarchical relationships, and breakdown in communication [22, 24, 32, 42, 58, 60, 62, 66]. This could entail surgeons’ power influencing the practice of the surgical count procedure negatively where nurses felt unable to demand to undertake the count even though it constitutes a crucial safeguard for the outcome of the surgery [60, 62]. Another example would be junior physicians experiencing negotiation of antimicrobial prescribing to be a challenging task as they found it difficult to break away from norms set by their seniors [32]. Hierarchical relationships were shown to negatively affect the use of the safe surgery checklist as surgeons and anaesthetists would disincline to volunteer information and openly communicate with each other and other team members [58]. Breakdown in communication was identified as a barrier to healthcare professionals’ adaptive capacity in practices related to antimicrobial prophylaxis [22], postnatal care protocols [61], and infection outbreaks [56].
A few studies reported on positive effects of work relationship factors such as peer pressure in the forms of healthcare professionals’ reminding each other to wear protective equipment [25], physicians acting as positive role models to other staff members on hand hygiene [30], nurse leaders modelling practicing safety rounds to staff [39] or collegial support from senior medical and nursing staff to junior professionals to improve adherence to standardization practices in the emergency department [71]. When physicians perceived that hospital rules were suggested through dialogue higher levels of compliance were reported [41].
Contextual factors influencing healthcare professionals’ adaptive capacity
Based on our synthesis of studies we identified several contextual factors that impacted on the healthcare professionals’ capacity to adapt to hospital standardization practices. These were factors “outside” the individual and group/social level. Even though the review did not focus specifically on the organizational or institutional level, the contextual factors formed parts of healthcare professionals’ explanations for degree of adaptation or compliance with hospital standardization practices.
Guideline “system”
Some studies described characteristics of the guidelines per se to influence how healthcare professionals adapted to them or not [25, 48, 49, 69, 72]. For example, guidelines that were too long and ambiguous or unclear [25, 48] or complex [65] were considered as barriers as healthcare professionals were confused and unsure how to adhere to them. Too many guidelines in diagnostic imaging that contained unnecessary, outdated, or obvious information were not prioritized by radiologists [48]. Moreover, constantly changing guidelines given the time restrictions of daily clinical practice overwhelmed healthcare professionals who could not keep up with the updates or changes [25]. Contradicting guidelines, for example use of belt to restrain while considering ethical aspects and patient integrity in fall prevention [72], or insufficient guidelines which lacked specific information in Duchenne muscular dystrophy [49] were seen as a barrier and practical implementation depended on the healthcare professionals’ expertise.
However, ease of use of bar-code medication administration [69] and guidelines that reflected national or international guidelines of infection prevention and control for respiratory diseases facilitated healthcare professionals’ compliance with hospital standardization [25].
Cultural norms
Workplace culture was described to influence adaptation or compliance with hospital standardization [25, 34, 42]. For example, adaptations were made when standard precautions were not the routine practice in the clinical department [42], when there was complacency to infection prevention control guidelines [25] or when workplace culture was part of a national culture regarding tuberculosis: ‘If you are going to get TB, you will get TB” [34] p3. When hospital standardization practices were followed by senior colleagues [42] or by all staff the compliance was high [25].
Leadership support
Several studies reported that the level of adaptation or compliance with hospital standardization practices was influenced by the level of support healthcare professionals received by their clinical leadership [25, 30, 34, 61, 63, 66, 72]. Leadership support was understood as ‘making rounds on the units and offering words of encouragement’ to follow infection prevention guidelines and policies [25] p10 and by modeling compliance to standardization practices [25, 30, 39, 66].
Physical environment
Healthcare professionals described various factors in the physical environment that led to adaptations to hospital standardization practices [25, 46, 63, 68, 72]. For example, limited access to cancer treatment services and facilities [63], diarrheal wards being too crowded, noisy and dirty with unpleasant smells [46], lack of adequate ventilation, isolation rooms, and shower facilities to prevent infection transmission [25], narrow hospital bathrooms being a barrier to prevent falls [72], lack of vital space, doors, privacy and cooling system in examination cubicles made midwives skip examination of mothers and relied on their statements instead [61].
Time
Time constraints were in several studies described as a reason for adaptations [30, 37, 49, 50, 58–59]. For example, during emergencies there was no time to either perform proper hand hygiene or proper use of gloves [30], or to perform time-out procedure during an emergency operation [58]. Often the pressure to start and finish surgery on time while managing many clinical activities at the same time resulted in the surgical safety checklist being left out, or not done at the specified time [59]. However, a systematic review suggested that implementation of the surgical safety checklist reduced time delays by one third as miscommunication and confusion were avoided [61].
Workload issues
Increased workload as a factor for healthcare professionals’ adaptations to hospital standardization was mainly reported in the studies on infection prevention practices (standard precautions, hand hygiene, use of personal protective equipment) [12, 22, 25, 30, 56]. Similarly, in a study about perinatal care obstetricians reported that they were more likely to comply with the changes in selective episiotomy and active labor management if their workloads did not increase [35]. Staff shortages leading to demanding workloads was also a contributing factor for midwives to collectively decide not to update their knowledge of the new post-natal care protocols, despite training being offered at an off-the-hospital-site [61].