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Understanding routine (non-outbreak) respiratory protective equipment behaviour of hospital workers in different clinical settings – lessons for the future post-COVID-19
Westmead Clinical School, University of Sydney, Westmead, NSW, AustraliaSydney Institute for Infectious Diseases, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
The coronavirus disease 2019 (COVID-19) pandemic has drawn attention to the importance of facial (respiratory and eye) protective equipment (FPE). Optimal use of FPE in non-outbreak situations will enable front-line staff, such as emergency department (ED) clinicians, to adapt more rapidly and safely to the increased demands and skills required during an infectious disease outbreak.
Methods
A survey, designed to determine the attitudes, beliefs and knowledge of healthcare workers around the use of FPE for protection against respiratory infections, was distributed to staff in a respiratory ward, an adult ED and a paediatric ED in Sydney, Australia prior to COVID-19.
Results
The survey revealed differences between the respiratory ward and the EDs, and between professional groups. ED staff, particularly paediatric clinicians, were less likely than ward staff to use FPE appropriately during routine care. Medical staff were more likely to work outside of infection prevention and control policies.
Discussion
The busy, relatively chaotic ED environment presents unique challenges for optimal compliance with safe use of FPE when caring for patients with respiratory symptoms.
Conclusions
Building upon the lessons of the pandemic, it is timely to address the specific infection prevention and control needs of the ED environment to improve compliance with the use of FPE during non-outbreak situations.
The coronavirus disease 2019 (COVID-19) pandemic has drawn attention to the importance of facial protective equipment [FPE; i.e. medical mask, particle filter respirator (PFR), goggles, face shield] as an important component of the hierarchy of control measures required to prevent transmission of respiratory infection within healthcare settings and elsewhere. Similarly, previous outbreaks of emerging respiratory diseases, such as severe acute respiratory syndrome, Middle East respiratory syndrome and pandemic influenza H1N1 09, saw increased awareness and use of FPE among healthcare workers (HCWs) [
]. However, outside of known outbreaks, compliance with the use of FPE to prevent patients or clinicians from acquiring, or becoming vectors of, respiratory infections, is (or has been) suboptimal [
]. Eye protection is an important component of FPE but is used much less consistently. The protective properties of masks or respirators can be undermined by a lack of protection to the eyes [
]. Respiratory and eye protection are important for staff safety when there is a risk of exposure of mucosae and airways to respiratory pathogens. Regular training of HCWs in the optimal use of personal protective equipment (PPE) during routine care in non-outbreak situations will enable them to adapt more rapidly and safely to the increased demands and skills required during an infectious disease outbreak. This is important for front-line staff, such as emergency department (ED) clinicians, who are at high risk of exposure to both established and emerging pathogens.
The use of FPE is influenced by multiple factors. Barriers to its use include lack of awareness of risk and/or a local safety culture; excessive workload; unavailability of, and ease of access to, supplies [
Improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study.
]; and poor visability and incompatability with corrective lenses when using eye protection. Although knowing when FPE should be used is important, workplace culture and behavioural norms may influence the behaviours of clinicians. Individuals also have their own constructs and perceptions of risk, which affect their risk-taking behaviour. These perceptions vary between individuals and clinical departments. Therefore, an understanding of personal, professional and contextual factors is needed to inform successful behavioural change interventions. To date, there have been few detailed studies of the use of FPE during routine care in different clinical departments. However, evidence that it is often suboptimal [
] indicates a need for improvement, based on a better understanding of decision-making and behaviours of HCWs. For the purposes of this study, ‘routine care’ refers to non-outbreak patient interactions for which FPE is indicated as part of either standard precautions or transmission-based (respiratory) precautions.
The aim of this study was to explore the knowledge, attitudes and risk-taking behaviours of HCWs in relation to the use of FPE to prevent pathogen transmission during routine care. Specific objectives were: (a) to identify the personal, environmental, organizational, sociocultural, professional and/or practical factors that influence the use of FPE; and (b) to determine whether the perception of infectious disease risk influences the use of FPE.
Methods
Design
The theoretical underpinnings of this study are grounded in behavioural science, primarily using an ethnographic approach. The Theoretical Domains Framework (TDF), which synthesizes multiple theories of behaviour and behaviour change into 14 domains, provided a framework for examining the cognitive, affective, social and environmental determinants of FPE behaviour [
This was a mixed methods study comprising a staff survey, field observation, semi-structured interviews, focus groups and video-reflexive methods. This article reports on the findings from the staff survey. Findings from the qualitative methods will be reported separately.
The survey was developed by RB. Its content and format were designed to determine the attitudes, beliefs and knowledge of HCWs around the use of FPE for protection against respiratory infections. The questionnaire was designed when respirators were commonly referred to as ‘masks’; therefore, the word ‘mask’ was used to refer to both a surgical mask and a PFR within the survey instrument (see Figure A1, see online supplementary material).
Setting and participants
The research was undertaken sequentially between 2017 and 2019 (pre-COVID-19) in two large metropolitan teaching hospitals in Sydney, Australia. Both hospitals incorporated PPE training into orientation for new staff as part of their infection prevention and control (IPC) programmes, but, at the time of this research, updates were irregular and PPE compliance was not measured. Staff known to have been exposed to an infectious disease, without adequate PPE, were followed up according to incident reporting policy, but data on exposure frequency or outcomes were not collected.
For this survey, convenience sampling was used to target professional and non-professional staff who used FPE in three different clinical departments – an adult respiratory medical ward, an adult ED and a paediatric ED. Unit educators assisted by encouraging staff to complete either an online or paper version of the survey. The survey was made available to staff working in the targeted departments at different time periods for each site during 2018 and 2019.
Analysis
Inferential statistics were used to compare survey results, between different clinical departments and professional groups, in relation to their risk perception and other constructs of risk relating to the use of FPE and their knowledge of appropriate use of FPE. The four professional groups used for detailed analysis comprised nursing and medical staff derived from the participant choices listed in the survey.
(i)
senior registered nurse, including nurse unit manager, clinical nurse consultant, clinical nurse specialist, nurse educator and clinical nurse educator;
(ii)
nurse, including registered nurse and enrolled nurse;
(iii)
senior medical officer, including consultant and specialist trainee/fellow; and
(iv)
junior medical officer, including registrar, resident medical officer and intern.
Mean scores for items in the survey were compared between departments using analysis of variance (ANOVA). As there were three departments, pre-planned post-hoc comparisons were made for all variables. One-way ANOVA and ad-hoc tests were also computed for the four different professional groups. Alpha was set to 0.05. There was no adjustment for multiple testing as such corrections can be overly conservative and fail to reveal potentially interesting findings. SPSS Version 26 (IBM Corp., Armonk, NY, USA) was used to analyse the statistical data.
The results were explored further using the COM-B model of behaviour [
]. The COM-B model classifies the 14 TDF domains into three categories that interact to influence behaviour, as follows.
–
Capability: knowledge; skills; memory, attention and decision processes; behavioural regulation.
–
Opportunity: environmental context and resources; social influences.
–
Motivation: professional role and identity; beliefs about capabilities; beliefs about consequences; reinforcement; emotion; optimism; intentions.
Ethics
This study was approved by the Human Research Ethics Committee for Western Sydney Local Health District (AU RED HREC/18/WMEAD/324). Informed consent was implied in completing and submitting the survey.
Results
In total, 188 completed surveys were returned (response rate 70%) from the three departments, with approximately proportional representation of doctors and nurses. Overall, 59% (N=111) of respondents were nurses and 31% (N=60) were doctors (Table I); they had worked an average of 7.14 years (range 1 month to >40 years) in their current professions.
Table IRespondents who returned complete questionnaires – professional groups and workplaces
Further analysis of completed surveys from these participants was undertaken. Responses to the 15 survey statements are summarized in Figure 1 and Table A1 (see online supplementary material). Responses to knowledge questions about eye protection (Q1–2), mask use (Q3–7) and mask choice (Q8–11) are summarized in Figure 2, Figure 3, Figure 4 and in Table A2a–c (see online supplementary material).
Figure 1Proportions of responses to Statements 1–15 in staff survey (see Figure A1 for survey instrument, including full texts of statements, and Table A1 for numbers and percentages of responses to each statement). Dark blue bars, strongly disagree; orange bars, disagree; grey bars, neither agree nor disagree; yellow bars, agree; light blue bars, strongly agree.
Figure 2Proportions of responses to knowledge question: ‘Please tell us how frequently you wear eye protection (goggles or visor) in the following situations’ (Q1–2). Blue bars, when taking a flu swab; orange bars, when within 1 m of a patient with symptoms of influenza-like illness.
Figure 3Proportions of responses to knowledge question: ‘Please tell us how frequently you wear a protective respiratory mask in the following situations (patient is NOT wearing a mask)’ (Q3–7). Dark blue bars, never; orange bars, rarely; grey bars, sometimes; yellow bars, often; light blue bars, always; green bars, no response. ILI, influenza-like illness; TB, tuberculosis.
Figure 4Proportions of responses to knowledge question: ‘Please indicate which type of mask would be your preference to wear in the following situations’ (Q8–11) (see Figure A1 for survey instrument and full texts of Q8–11, and Table A2c for data). Blue bars, when entering the room of a patient with active pulmonary tuberculosis; orange bars, when taking a flu swab; grey bars, when entering a patient's bedspace or room that has a droplet precautions isolation sign; yellow bars, when entering a patient's room that has an airborne precautions isolation sign.
ANOVA results showing differences in responses between workplaces and professional groups are shown in detail in Table A3 (see online supplementary material). Significant differences between professional groups are compared in Table A4 (see online supplementary material). Briefly, both groups of nurses were more likely than junior medical officers to agree with five statements: they know when to use a mask for patient protection (S1); eye protection was readily available when needed (S3); wearing facial protection reduces risk of respiratory infection (S5); type of mask available in the department (S13); and the patient wearing a mask (S14) could protect them from infection. In addition, senior registered nurses were more likely to agree that FPE can reduce the risk of respiratory infection compared with senior medical officers (S5).
There were also significant differences in responses to statements between staff of the three workplace settings, as shown in Tables A5 and A6 (see online supplementary material). Respiratory ward staff were more likely to agree with six statements (S1, S2, S8, S9, S10, S13) relating to accessibility or ease of use of respiratory protective equipment compared with staff of paediatric or both EDs. They more likely to disagree with three statements (namely S6, risk of respiratory infection at work; S12, mask requirement after influenza vaccination; and S15, working with symptoms of respiratory infection). These differences are further described within the three COM-B categories.
Capability
The knowledge and skills required for optimal use of FPE varied between workplaces and professional groups. Most respondents (N=156, 91.5%) agreed that they knew when to use FPE in their work (S1), but this knowledge was not confirmed by responses to the survey questions (Q1–6, 8–11) that tested their application of FPE knowledge. Eye protection was rarely or never used by HCWs when taking a flu swab (N=115, 67%) or within 1 m of a symptomatic patient (N=122, 72%). Similarly, 40% and 31% of HCWs would never or rarely wear a mask in the same scenarios (Figure 3 and Table A2a,b, see online supplementary material). When it came to the choice of mask, only 78% of staff correctly chose to use an N95/P2 PFR for patients in airborne precautions.
ANOVA analysis revealed that respiratory ward staff had greater knowledge of optimal use of FPE than paediatric ED HCWs (S1) (P=0.005) (Table A5, see online supplementary material). Staff in the paediatric ED were least likely to use protective masks during activities that involved risk of droplet transmission (Q3, Q5 and Q6) (P≤0.001) (Table A5, see online supplementary material), and only 61% (N=33) of paediatric staff who responded said that they would use an N95/P2 PFR (as recommended) for airborne precautions (Q11) (Table A6, see online supplementary material). Commonly, ED staff could not distinguish indications for the use of a medical mask vs an N95/P2 PFR, resulting in incorrect selection (Q8–11) (Table A6, see online supplementary material). In contrast, the majority of participants from all three departments demonstrated knowledge of correct FPE for care of a patient with tuberculosis (Tables A2c and A6, see online supplementary material). Among professional groups, junior doctors were less confident in their knowledge than senior nursing staff (P=0.018) (Table A4, see online supplementary material).
Opportunity
The physical and social environments in which participants worked influenced FPE practices. Despite working in a ward specifically managing patients with respiratory diseases, staff in the respiratory ward perceived a lower level of risk of acquiring a respiratory infection in their workplace than those working in the paediatric ED (S6) (P=0.012 and 0.002) (Table A5, see online supplementary material). Respiratory ward staff reported greater access to FPE (S2) (P=0.012), less discomfort when wearing it (S9) (P<0.001), and had time to don and doff it correctly (S8) (P=0.039 and 0.019) (Table A5, see online supplementary material).
Only one-third (N=58, 33.9%) of participants agreed/strongly agreed that eye protection was readily available (S3), with post-hoc comparison showing that junior doctors were less likely to locate eye protective equipment than nursing staff (P=0.014) (Table A4, see online supplementary material).
Motivation
The survey findings indicated that an individual's beliefs about the consequences of acquiring a respiratory infection was a motivation for the use of FPE. However, despite >94% of survey respondents acknowledging a risk of acquiring a respiratory infection at work (S6), this was not a sufficiently strong motivation for many staff in the EDs to don FPE when attending to patients with respiratory symptoms. Conversely, as identified in the survey, staff in all departments were strongly motivated to wear a PFR when caring for a patient with suspected or confirmed tuberculosis.
The survey findings suggested motivation to use a mask as protection for others. Eighty-six percent of respondents ‘agreed’ or ‘strongly agreed’ with the statement ‘Other patients are at risk if I don't wear a mask when caring for infectious patients’ (S7) (Table A1, see online supplementary material). However, this finding was not supported by the high number of survey respondents (67%) who would attend work with respiratory symptoms (S15), and of whom one-third would not wear a mask (Q7) (Table A2b, see online supplementary material). Respiratory ward staff were less likely (P<0.001) than paediatric ED staff to work when they had respiratory symptoms (S15), and were more likely (P=0.012) to wear a medical mask if symptomatic (Q7) (Table A5, see online supplementary material).
Paediatric ED respondents were less likely (P<0.001) than staff of the other departments to consider respiratory infections as serious (S10) (Table A5, see online supplementary material). Respiratory staff were more compliant with accepted guidelines/indications for the use of FPE than staff from the two EDs (Q8–11) (Table A6, see online supplementary material), and had greater confidence in the protection it afforded (S13) (Table A5, see online supplementary material). This may partly explain why they felt less at risk.
Medical staff had less confidence than nurses in the protective properties of FPE, whether worn by themselves or by the patients (Table A4, see online supplementary material).
One of the findings in this category that was specific to the adult ED was HCWs' optimism that they would be protected if the patient was wearing a mask, as symptomatic patients were asked to do during the winter virus season when presenting to the ED. However, junior doctors were less likely to rely on this protective factor than nursing staff (P=0.001–0.006) (Table A4, see online supplementary material). Conversely, although paediatric staff were significantly more confident than other HCWs in not using a mask if they had received the annual influenza vaccine (P<0.001), other HCWs indicated that they did not rely on the vaccine completely to protect them (Table A5, see online supplementary material).
Discussion
This study aimed to determine the risk-taking knowledge, attitudes and behaviours of HCWs with respect to the use of FPE for infectious diseases in three different clinical departments. The survey revealed differences between the inpatient respiratory ward and both EDs, and between different professional groups.
The findings highlight a gap in clinicians' self-assessed knowledge about the use of FPE and its application in the ED clinical setting, including when to use it and how to use it correctly. This may be attributed to a lack of regular PPE training or education, consistent with other pre-pandemic studies [
] reported that HCWs in an Iranian hospital had adequate knowledge to correctly select and use appropriate FPE. Having a good understanding of standard precautions and disease transmission should improve understanding of and compliance with FPE [
]. In a recent study involving ED clinical staff in the USA, frequent PPE training was associated with a good understanding of the use of PPE (odds ratio 1.7, 95% confidence interval 1.0–2.9) [
Self-reported use of personal protective equipment among emergency department nurses, physicians and advanced practice providers during the 2020 COVID-19 pandemic.
]. However, a rapid evidence review by Brooks et al. found no strong evidence that existing education and training programmes improved compliance reliably; they argued that training should be adapted for different roles, and include the ‘why’ as well as the ‘how’ [
Factors affecting healthcare workers’ compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review.
In the event of an infectious disease emergency, up-to-date IPC knowledge and recent training are necessary, but not always sufficient, prerequisites for adequate understanding of and compliance with appropriate FPE [
Healthcare worker perception of a global outbreak of novel coronavirus (COVID-19) and personal protective equipment: survey of a pediatric tertiary-care hospital.
]. Other prerequisites include timely risk assessment, availability and accessibility of appropriate FPE, and a workplace expectation of compliance. Before the current pandemic, the use of goggles or faceshields was even less consistent than appropriate use of masks during routine care, even when respiratory precautions were indicated [
Canadian Nosocomial Infection Surveillance Program. Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals.
]. When the pandemic began, unfamiliarity with PPE was a key driver for urgent training of clinicians in PPE skills to prevent occupational exposure and infection [
PPE training and the effectiveness of universal masking in preventing exposures: the importance of the relationship between anesthesia and infection prevention.
Factors affecting healthcare workers’ compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review.
Improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study.
], staff from all departments involved in this study perceived a patient with tuberculosis or entering a room in airborne precautions to be a high risk that merited compliance with FPE. However, compliance of ED (particularly paediatric ED) staff with the use of FPE, especially eye protection, when caring for patients with respiratory symptoms was poor. Patients presenting to the adult ED where this study was undertaken with respiratory symptoms were asked to wear a mask as source control, yet neither this, nor annual influenza vaccination, was considered to protect staff adequately from occupational respiratory infection. Paediatric staff perceived a lower and less serious risk of infection from children and infants, which influenced their FPE behaviour. Although compliance with the use of FPE may improve during infectious disease outbreaks [
ED clinicians were more likely to report that they had too little time to don and doff PPE. This may be attributable to the chaotic, busy ED environment, model of care and workload which create barriers to FPE compliance [
]. Nevertheless, time is a significant factor when a higher level of PPE is required. A recent study found that almost 80% of paediatricians surveyed reported that PPE used for COVID-19 interfered with their procedural skills [
Assessment of hospital emergency department response to potentially infectious diseases using unannounced mystery patient drills – New York City, 2016.
The divergence from organizational FPE policy was more prevalent in the EDs than the respiratory ward, and may reflect a unique organizational ED subculture [
The current COVID-19 pandemic has highlighted the importance of FPE, along with engineering and administrative controls as effective IPC measures to prevent the transmission of infection in healthcare settings. A high perception of personal risk for this disease has resulted in improved compliance with the use of FPE, despite barriers such as lack of confidence in or sub-standard equipment, supply shortages and adverse reactions from extended use of FPE. Nevertheless, incorrect use of PPE remains frequent in the ED environment [
Rapid development and implementation of a behaviour change strategy to improve COVID-19 personal protective equipment use in a regional Australian emergency department.
], and as the pandemic continues, pandemic fatigue may result in further complacency. Now is the time for health systems to build upon the lessons learnt during this pandemic, and promote a culture of occupational infection prevention and a climate of worker protection which will ultimately have a positive impact on patient care.
Compliance with the use of FPE can be enhanced through establishing policy requirements for the use of PFRs, improving the physical environment to allow better access to PPE and enabling better, more consistent, effective and ongoing training. Training should be part of curricula in nursing and medical schools, and ongoing, regular training should be adapted for specific roles and contexts (e.g. for ED staff). Rostering should ensure adequate staff levels to allow time for training, donning/doffing PPE safely (including the use of PPE buddies), and to enable staff to stay home when ill. A review of the ED environment and workflow is timely [
], with practical modifications that facilitate the use of FPE and provide cues for using it, such as point-of-use placement of PPE supplies. IPC teams should recognize that although organization-wide policies are key to compliance, the ED (and other clinical settings) may require context-specific procedures [
In conclusion, this study clearly demonstrated suboptimal use of FPE in the ED setting before the COVID-19 pandemic. Any subsequent improvements in the use of FPE will only be sustained by review of IPC procedures to tailor them specifically to the ED environment, and a commitment to effective implementation.
Conflict of interest statement
None declared.
Funding source
This work was supported by the Australian Partnership for Preparedness Research on Infectious Diseases Emergencies (APPRISE), of which GLG is a chief investigator and RB is recipient of a doctoral scholarship. The research presented in this article is solely the responsibility of the authors and does not reflect the views of APPRISE.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
Improving healthcare worker adherence to the use of transmission-based precautions through application of human factors design: a prospective multi-centre study.
Self-reported use of personal protective equipment among emergency department nurses, physicians and advanced practice providers during the 2020 COVID-19 pandemic.
Factors affecting healthcare workers’ compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review.
Healthcare worker perception of a global outbreak of novel coronavirus (COVID-19) and personal protective equipment: survey of a pediatric tertiary-care hospital.
Canadian Nosocomial Infection Surveillance Program. Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals.
PPE training and the effectiveness of universal masking in preventing exposures: the importance of the relationship between anesthesia and infection prevention.
Assessment of hospital emergency department response to potentially infectious diseases using unannounced mystery patient drills – New York City, 2016.
Rapid development and implementation of a behaviour change strategy to improve COVID-19 personal protective equipment use in a regional Australian emergency department.
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