key: cord-313409-3n4vyszl
authors: Hines, Stella E.; Oliver, Marc S.; Gucer, Patricia; McDiarmid, Melissa A.
title: Self-reported Impact of Respirator Use on Healthcare Worker Ability to Perform Patient Care
date: 2020-06-11
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.06.005
sha: 
doc_id: 313409
cord_uid: 3n4vyszl

In a study of 1152 healthcare workers surveyed prior to the COVID-19 pandemic, most disagreed that respiratory protective equipment use interferes with patient care but reported that it would affect respirator use compliance if it did. A patient's fear reaction variably influenced self-reported healthcare worker compliance with respirator use. Strategies to improve protective equipment design may remove potential barriers to respirator use and allow better healthcare worker-patient relationships.

In a study of 1152 healthcare workers surveyed prior to the COVID-19 pandemic, most disagreed that respiratory protective equipment use interferes with patient care but reported that it would affect respirator use compliance if it did. A patient's fear reaction variably influenced self-reported healthcare worker compliance with respirator use.

Strategies to improve protective equipment design may remove potential barriers to respirator use and allow better healthcare worker-patient relationships.

Key words: respirators, personal protective equipment, patient interaction, facial mask, interference

Human factors associated with respirator use have long been a topic of concern, from comfort, communication, heat tolerance and impact on care, including relationships with patients (1-7). HCWs have stated that they may avoid patients when PPE use is required and that patients feel uneasy when respirators are required (5) . Earlier literature showed that while HCW mask use did not impact patient satisfaction, it did reduce perceptions of HCW empathy (4). In the setting of widespread mask use for patient care during coronavirus disease 2019 (COVID-19), findings from a previous assessment of HCW opinions on this topic during non-pandemic use were explored.

HCWs enrolled in a medical system's respiratory protection program (RPP) were queried both during a focus group interview of eleven hospital staff members and a larger medical system-wide electronic survey of 1152 HCWs regarding their perceptions and beliefs about the impact of respirators on their ability to provide patient care (8) (9) .

During a focus group interview in 2015, HCWs were asked to describe how use of respirators impacted their ability to provide care and whether patients or their family members interact differently with them when they are wearing respirators. The interview was recorded, transcribed, and iteratively reviewed by four researchers for key themes, facilitated by use of NVivo 10 software (8) .

In a subsequent electronic survey, HCWs in RPPs in a medical system with approximately 9600 respirator users were queried in the fall of 2016. Eligibility to participate included age ≥ 18 years, employment with current employer ≥ three months, and having worn a respirator at least once within the previous year. Settings included a large US academic urban hospital and four affiliated community hospitals or ambulatory practice. Participants were recruited via email invitations and in-unit visits by the study team and received gift cards limited by the study budget to the first 1152 respondents.

The study was approved by the local Institutional Review Board.

Survey frequencies were calculated for demographic characteristics and four questions related to perceived respirator impact on patient care, the latter asked as five category Likert-style scales. Two questions addressing impact on compliance were prefaced with the statement: "Consider a situation in which you must enter the room of a patient who is on Airborne Precautions, where there is high suspicion for active tuberculosis. How are important are the following factors in regard to your compliance with wearing your respirator?" For presentation here, responses were combined to make three categories. Both "strongly agree" and "agree" and "strongly disagree" and "disagree" were combined. Chi-square analysis was performed to evaluate participant response across respirator user groups.

Focus group participants reported that while patients or families often initially have questions about respirator use, these questions typically subside after an understanding of why the mask is necessary. HCWs recognized that while mask use did not create conflict with patients or family members, it limited the ability to be seen smiling, and they speculated that a transparent mask might be better.

Survey participants were predominantly female nurses from a large academic medical center and users of N95 respirators (Table 1) . Most respondents did not find that use of respirators and PPE impacted their ability to perform patient care (62%) or that it was inconvenient (51%) ( Table 2 ). Most reported that if respirator use interfered with their ability to perform care, it would influence their compliance with respirator use.

Participant responses were evenly distributed regarding whether patients' fearful reactions toward caregiver respirator use would impact compliance with their use.

Among the minority of respondents who did find that respirators interfered with patient care, responses differed by user groups (p<0.05 for overall comparison). More PAPR users (27%) than N95 (17%) and elastomeric (16%) users agreed that respirator use interferes with patient care. This pattern was not directly related to low frequency of use, as use 1% of the time or less was similar in PAPR (55%) and N95 users (54%), compared to 44% of elastomeric users (3). While more nurses (22%) and providers (28%) agreed that use of respiratory protection interferes with patient care, only 9% of respiratory therapists and 10% of patient support staff also agreed.

This survey, performed prior to the COVID-19 pandemic, suggests that any interference with patient care caused by PPE use would influence HCW compliance with its use. Fortunately, here, most HCWs reported that PPE use did not interfere with patient care and was not inconvenient. This may reflect a willingness of HCWs to use protective equipment that may be cumbersome or uncomfortable, when the tradeoff is protection of their own health. For example, previous research found that elastomeric respirator users, who rated the respirators less favorably with respect to comfort, but higher in perceived level of protection, still preferred to use them in certain higher risk scenarios, such as during pandemic influenza (9) . Acceptance of less convenient but more protective safeguards may be more pronounced among HCWs while providing care to COVID-19 patients.

This report reflects responses of HCWs during general care provision. It does not address PPE interference with specific tasks or induced by combinations of PPE, such as ensembles including face shields, gowns and head covers. Thus, there may be limitations in applying these broad findings about respiratory protective equipment to specific care scenarios. Additionally, during crisis times when PPE use may be prolonged, HCW perceptions may differ from when assessed under routine scenarios.

Changes in PPE design to allow visible facial expression, decreased mask size and better voice transmission might alleviate many existing challenges to the caregiverpatient relationship and to enhance its utility in clinical settings (6) . Additionally, enhanced HCW training and patient and family education on the necessity for mask use may foster better therapeutic alliance between patients and their HCW clinical providers. 

B95: A new respirator for health care personnel

Effect of facemasks on empathy and continuity: a randomized controlled trial in primary care

Health care workers' reported discomfort while wearing filtering face-piece respirators

The Use and Effectiveness of Powered Air Purifying Respirators in Health Care: Workshop Summary

A tolerability assessment of new respiratory protective devices developed for health care personnel: A randomized simulated clinical study

Qualitative Analysis of Origins and Evolution of an Elastomeric Respirator-based Hospital Respiratory Protection Program

User acceptance of reusable respirators in health care

Table 1 -Demographic characteristics of Healthcare Worker Respirator Users completing survey