key: cord-332083-135iic7m
authors: Xia, Wei; Fu, Lin; Liao, Haihan; Yang, Chan; Guo, Haipeng; Bian, Zhouyan
title: The Physical and Psychological Effects of Personal Protective Equipment on Health Care Workers in Wuhan, China: A Cross-Sectional Survey Study
date: 2020-09-29
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2020.08.004
sha: 
doc_id: 332083
cord_uid: 135iic7m

INTRODUCTION: The purpose of this study was to rapidly quantify the safety measures regarding donning and doffing personal protective equipment, complaints of discomfort caused by wearing personal protective equipment, and the psychological perceptions of health care workers in hospitals in Wuhan, China, responding to the outbreak. METHODS: A cross-sectional online questionnaire design was used Data were collected from March 14, 2020, to March 16, 2020, in Wuhan, China. Descriptive statistics and χ square analyses testing were used. RESULTS: Standard nosocomial infection training could significantly decrease the occurrence of infection (3.6% vs 13.0%, χ(2) = 4.47, P < 0.05). Discomfort can be classified into 7 categories. Female sex (66.0% vs 50.5%, χ(2) = 6.37), occupation (62.7% vs 30.8%, χ(2) = 5.33), working at designated hospitals (44.8% vs 26.7%, χ(2) = 5.17) or in intensive care units (70.4% vs 57.9%, χ(2) = 3.88), and working in personal protective equipment for > 4 hours (62.2% vs 39.2%, χ(2) = 9.17) led to more complaints about physical discomfort or increased occurrence of pressure sores (all P < 0.05). Psychologically, health care workers at designated hospitals (60.0% vs 42.1%, χ(2) = 4.97) or intensive care units (55.9% vs 41.5%, χ(2) = 4.40) (all P < 0.05) expressed more pride. DISCUSSION: Active training on infection and protective equipment could reduce the infection risk. Working for long hours increased the occurrence of discomfort and skin erosion. Reducing the working hours and having adequate protective products and proper psychological interventions may be beneficial to relieve discomfort.

Coronavirus disease , which is now known to be caused by the severe acute respiratory syndrome coronavirus 2, has become a worldwide pandemic. [1] [2] [3] [4] The virus has now spread to 6 continents, endangering more than 10 million people. 5 The cumulative number of diagnosed patients had reached 85,204 in China as of June 29, 2020. 6 Controlling the spread of the disease and providing medical care to the infected patients has been an unprecedented challenge. Despite wearing personal protective equipment (PPE), there is evidence of health care workers (HCWs) becoming infected. [7] [8] [9] In addition, owing to the heavy workload at the forefront and discomfort from wearing PPE for long periods, HCWs, especially nurses in highworkload departments such as the emergency department, are suffering from considerable physical and mental burdens. [10] [11] [12] [13] Owing to its rapid spread and highly contagious nature, as of February 11, 2020, 1,716 HCWs in China had been infected by COVID-19 according to a report from the Chinese Center for Disease Control and Prevention. 14 HCWs' main complaints include difficulty seeing owing to the misting of eye protection and difficulty breathing through protective masks. A proper method of donning and doffing PPE is highly important to protect HCWs from inadvertent exposure. The National Health Commission of the People's Republic of China has issued standard protocols for putting on and removing PPE according to different protective grades. 15 There are 3 levels of protection in China depending on different departments and degrees of exposure risk. Equipment and N95 masks are required, and certain procedures must be followed in donning and doffing level II PPE and above. (Level III protection is for those who are performing operations such as tracheal intubation that may produce aerosols in patients suspected of having, or confirmed to have, COVID-19.) Level II protection is required for HCWs working in emergency departments with patients with fevers; those who enter observation rooms or isolation wards with suspected cases; those who transport patients suspected of having, or confirmed to have, COVID-19; and those who dispose of the corpses of patients who died owing to COVID-19. Because level II PPE is used under most circumstances, with the exception of invasive operations, our research focused mainly on the use of level II PPE. Detailed donning and doffing procedures are described in the Supplementary Figure The purpose of this study was to rapidly quantify the safety measures of donning and doffing PPE, complaints of discomfort caused by wearing PPE, and the psychological perceptions of HCWs in hospitals in Wuhan, China, responding to the COVID-19 outbreak. Furthermore, we aimed to explore group differences in safety measures by infection status; complaints of discomfort by sex, working time, occupation, department, age, and workplace; and psychological perceptions by demographic characteristics.

We used a cross-sectional design. We conducted an anonymous questionnaire survey (Supplementary Table 2 Table 2 ). The authors were actively involved in frontline clinical care in Wuhan, China, and the survey was based on their expert experience with PPE in the early phases of the COVID-19 pandemic. There were 25 multiple-choice questions-6 had multiple-response options-with 5 questions per page, 5 pages in total.

We used the Questionnaire Star survey program (Wise Talent Information Technology Co, Ltd) to collect the information. A link to the questionnaire was published on the WeChat platform (Tencent), the most widely and frequently used social networking platform in China. 16 It was open to all HCWs in Wuhan and those HCWs came to support them. The survey was voluntary, with no incentives offered, and completing the survey was considered implied informed consent.

We also attached a completeness check to the questionnaire, and responding to all 25 questions was mandatory; therefore, the participants had to choose at least 1 answer for each question listed. Participants were not permitted to review after submitting the questionnaire; therefore, the participants could not change their answers once they were submitted.

Because our participants were all HCWs in Wuhan hospitals, we divided their demographic information as follows: the demographic variables included sex (male or female); age (20-30 years, 30-40 years, 40-50 years, and >50 years); occupation (physician, nurse, pharmacist, medical technician, or other); workplace (a designated hospital for patients critically ill with severe COVID-19; an undesignated hospital for patients uninfected with COVID-19; and Fangcang Hospital for patients with mild symptoms of COVID-19); and department (general isolation ward, intensive care unit [ICU], emergency department for patients with fevers, and other).

The evaluation questionnaire included (1) whether or not the HCW had standard nosocomial infection training before treating patients in the wards, (2) whether or not the HCW was well acquainted with the standard operating procedure (SOP) of donning and doffing PPE, (3) the presence of a full-length dressing mirror, (4) measures that the HCW thought were necessary to standardize the donning procedure, and (5) the best length of the HCW's hair at work. The respondents were also asked if they had been infected by COVID-19 owing to exposure at work.

We asked questions on the specific time that the HCW spent in the ward wearing PPE, their discomfort owing to PPE, and possible solutions. The questions included:

Time. (1) The time it took for an HCW to put on PPE, (2) the maximum time an HCW had spent in PPE, and (3) the maximum tolerance time of an HCW in PPE.

Discomfort in PPE at Work. (1) Discomfort: dizziness or palpitation; chest distress or dyspnea; nausea or vomiting; micturition desire; retroauricular pain (mask pressurerelated); thirst or dry throat; inconvenience at work; other symptoms of discomfort, for example, how an HCW felt in PPE, which was formatted as a multiple-response option.

Questions considering several vulnerable areas according to our clinical observation were also included: (2) Was there mist on the HCW's goggles? (3) What were the effective methods that the HCW used to prevent misting in practice? (This question allowed for multiple-response options.) (4) Did the HCW have pressure sores on their face? (5) In which areas did the HCW have pressure sores? (6) Did the HCW have skin injury owing to gloves? (7) What type of glove-related skin damage did the HCW have?

(1) Discomfort that the HCW felt after doffing PPE, which was also a multiple-response option. (2) The first thing on an HCW's mind after doffing PPE.

We asked about the amount of time off that the HCW felt was necessary to recover from work between shifts.

The HCW's state of mind after donning PPE was also assessed. In a multiple-response-option format, the HCW was asked about experiencing 1 or more of 6 emotions: proud, excited, anxious, afraid, uncomfortable, or other.

First, among the demographic information and safety measures, continuous variables were divided into categorical variables and were shown as numbers and percentages. Second, complaints owing to PPE were reported (also as numbers and percentages), and the chi-square test or Fisher exact test was used for intergroup comparisons (sex, occupation, age, workplace, department, and time in PPE). Third, the psychological states of the HCW was described in a table categorized into different groups: occupation, age, sex, workplace, department, and time in PPE. A post hoc power analysis was performed to recommend the sample size for a replication study. All data were analyzed using SPSS version 26.0 (IBM Corp). P values less than 0.05 were considered statistically significant.

A total of 299 individuals agreed to participate, with 297 valid and complete questionnaires for a completion rate of 99.33%.

The demographic characteristics are shown in Supplementary Regarding the measures that the HCWs believed were necessary for standardizing the donning procedure, 14 HCWs thought that only a full-length mirror was necessary (4.7%), 33 believed in having a checking monitor (11.1%), 15 thought that checking with a partner was adequate (5.1%), and 234 HCWs attached importance to all of these measures to standardize the donning procedure (78.8%). For the best length of hair at work, 14 HCWs believed that "fully shaved" was the best (4.7%), 89 thought that their hair should be as short as possible (23.0%), 90 believed that just tying it up was adequate (30.3%), and 104 thought that the length did not matter as long as it was properly handled when donning PPE (35.0%). Table 1 explores the relationship between standard nosocomial training, familiarity with the SOP, the availability of a dressing mirror, and the incidence of infection among the respondents. Standard training on nosocomial infection before treating patients in the wards could significantly decrease the infection rate compared with the no-training group (3.6% vs 13.0%, x 2 ¼ 4.47, P < 0.05), whereas the unavailability of dressing mirrors could lead to a higher rate of infection (3.6% vs 13.0%, P < 0.05).

The time it took the HCWs to don PPE varied. A total of 52 HCWs claimed to be able to don PPE within 10 minutes (17.5%), 111 needed 10 minutes to 15 minutes (37.4%), 79 needed 15 minutes to 20 minutes (26.6%), and 55 spent more than 20 minutes donning PPE (18.5%). After donning PPE, most of the HCWs spent a maximum time of 4 hours to 6 hours (48.2%) or 6 hours to 8 hours (28.0%) working in it. For the maximum PPE tolerance time, 179 HCWs believed that 4 hours to 6 hours was their limit (60.3%), 66 thought that 2 hours to 4 hours should be the maximum (22.2%), whereas 46 HCWs believed that they could endure 6 hours to 8 hours in PPE at most (15.5%).

All the types of discomfort with multiple-response options demonstrated a comparatively high occurrence (more than 40%, Figure) . Retroauricular pain (mask pressure-related) was the most reported complaint (81.8%), chest distress or dyspnea was the second (78.5%), inconvenience at work (for auscultatory tests, blood sample collection, and punctures) was the third (61.3%), followed by thirst or dry throat (60.3%), dizziness or palpitation (58.9%), micturition desire (55.6%), nausea or vomiting (42.1%), and other symptoms (14.8%). Overall, 240 HCWs reported misting on their goggles (81.8%). To prevent misting, most HCWs thought it was useful to apply cleaning agents (63.3%) or spray antimist agents on their goggles or glasses (47.1%). A total of 173 HCWs reported having pressure sores on their faces (58.3%), mainly distributed on the nose (81.0%), cheek (66.5%), forehead (45.1%), and retroauricular areas (43.6%). Overall, 154 HCWs reported glove-related skin damage (51.9%): eczema (59.1%), dry skin (57.8%), and skin erosion (53.9%) were the main injuries.

The symptoms reported after doffing PPE included dizziness or palpitation (27.3%), chest distress or dyspnea (33.0%), nausea or vomiting (16.8%), and other symptoms (6.1%), whereas 160 HCWs reported none of these symptom (55.2%). After doffing PPE, 130 HCWs reported that the first thing on their mind was to drink water (43.8%), whereas 104 wanted to clean themselves (35.0%), and 36 wanted to rest (12.1%).

Discomfort in PPE, Misting on Goggles, Pressure Sores, and Skin Injury Stratified by Sex, Occupation, Age, Workplace, Department, and Working Time Discomfort in PPE, misting on goggles, pressure sores, and skin injury stratified by sex, occupation, age, workplace, department, and working time are shown, respectively, in 

Bar chart of the discomfort caused by personal protective equipment in the study sample. The respondents reported a relatively high level of discomfort.

Month 2020 VOLUME -ISSUE -WWW.JENONLINE.ORG Table 3) .

More than half the participants believed that an HCW needed 24 hours off between shifts (53.5%), and 27.61% felt that they needed 12 hours off between shifts. 

A post hoc power analysis was conducted to recommend the sample size for a future replication study on the basis of our results. Here, we calculated the sample size using the ratebased sample size estimation formula in cross-sectional studies: n ¼ (Zs/d)2 3 p(1-p). Estimating the incidence of the survey population with 95% confidence level (Zs is taken as 1.96), the prevalence, p, of discomforts in PPE is approximately 80% (p takes a value of 80%), q ¼ 1-p, and the tolerance, d, takes a value of 5%. In this case, the required sample size is calculated to be 246. Considering the 5% invalid response, a sample size of 258 may meet the requirements.

Here, we add uniquely to the published literature by rapidly quantifying the safety measures of donning and doffing PPE, complaints of discomfort owing to PPE, and the psychological perceptions of HCWs at hospitals in Wuhan, China, responding to the COVID-19 outbreak in March 2020. According to our online questionnaire survey, there was a high prevalence of uncomfortable symptoms suffered by the HCWs during their fight against the COVID-19 epidemic, although active and timely training was helpful for the effective prevention of infection. More complaints of discomfort were reported by women, physicians, nurses, and those working at a designated hospital or in an ICU. The HCWs working at a designated hospital or in an ICU were prouder than their comparable groups after doffing PPE.

Training on nosocomial infection before treating patients in the wards is of considerable significance for preventing HCWs from contracting COVID-19, which was also demonstrated in previous studies. 17, 18 Adding a dressing mirror at all sites would support staff during donning and doffing PPE, and it is an easy improvement to implement. We strongly recommend strictly adhering to the correct procedure for donning and doffing PPE. 15 Timely, interactive training on the prevention of nosocomial infection and on the SOP for wearing PPE can considerably reduce the risk of HCWs' exposure to COVID-19. Studies have shown that adding computer stimulations or video-based learning methods could increase compliance and performance scores. [19] [20] [21] Taking help from an assistant or partner, sometimes coupled with a mirror, was often resorted to Month 2020 VOLUME -ISSUE -WWW.JENONLINE.ORG while donning PPE, and a hygienist supervised doffing. 22 We recommend using a full-length dressing mirror, being checked by a partner before entering the wards, and assigning a "dofficer" (or donning/doffing officer) for both donning and doffing PPE. Hair length may not influence working or create extra risks of infection, but short hair is definitely easier to cover with a surgical cap, and saves time when putting on and removing PPE. According to a consensus by Chinese experts, 23 hair should be cleaned with running water once PPE is removed, hair should be cleaned before taking a shower, and the head should be lowered when cleaning hair to keep the contaminated water out of the eyes, nose, and mouth.

Female HCWs are more likely to suffer uncomfortable symptoms such as chest distress or dyspnea, retroauricular pain (mask pressure-related), thirst or dry throat, and inconvenience at work (for auscultatory tests, blood sample collection, and punctures), which suggests that there might be gender differences. These gender differences may be due to a difference in the types of work male and female HCWs are assigned, the design of PPE, the cultural and gendered norms of expressing and reporting discomfort, or in both physical strength and psychological reaction. Previous studies have shown that male HCWs are prone to a higher rate of skin erosion than female HCWs. 24 Physicians, nurses, or HCWs in an ICU were more likely to complain about the inconvenience of working while wearing PPE than those in other positions or departments. This may be due to the different tasks and work intensity because clinical practices such as auscultatory tests, blood sample collection, and venipuncture are usually performed by physicians or nurses, and HCWs in an ICU treat patients with the most severe or complicated conditions; therefore, their work intensity or duration of PPE wear is much higher than that of those working in other departments. Among the HCWs working at designated hospitals for patients critically ill with severe COVID-19, the prevalence of nausea or vomiting and inconvenience at work and pressure sores were significantly higher, further suggesting that the discomfort the HCWs felt was positively correlated with their workload. Complaints about inconvenience at work and pressure sores were more frequently reported by the HCWs who worked in PPE for more than 4 hours; the longer the duration of wearing PPE, the greater the rate of complaints about discomfort.

The following measures should be considered to alleviate discomfort owing to PPE: apply moisturizer before putting on and after taking off gloves; and refer to dermatologists if necessary. [25] [26] [27] We recommend routinely supplying protective supplies such as hand moisturizer. As for maskrelated discomfort, we recommend wearing a properly fitted mask and applying moisturizer or gel beforehand for lubrication. 28 We recommend nonirritating products for handwashing, and applying adhesive bandages on the portions of the skin in contact with the mask to help reduce friction. Because of the possibility of conjunctival transmission of COVID-19-first reported by a Chinese expert 29 and later confirmed by scientific studies 30 -we strongly recommend using face shields in conjunction with goggles. 31 In addition, applying cleaning or antimist agents on the goggles might also help prevent misting. According to the results of the intergroup comparison, the working time in PPE at designated hospitals and in an ICU should be reduced to approximately 4 hours, whereas in other workplaces and departments, 6 hours could be considered the maximum duration. A 24-hour break between shifts is recommended for HCWs to be refreshed from fatigue and work pressure, but a 12-hour break between shifts might be more feasible. Maintaining hydration before and after wearing PPE is recommended.

Timely psychological interventions that build confidence and relieve stress are important considerations. 32 According to a survey on HCWs' emotional problems and coping strategies, positive attitudes in the workplace, clinical improvement of infected colleagues, and halting disease transmission among HCWs after adopting strict protective measures alleviated their fear and supported them through the pandemic. 33 Thus, a rational focus on facts and timely psychological assistance such as offering coping strategies and measures to provide adequate medical equipment to treat patients and prevent HCW infection are beneficial.

We were motivated to conduct this research to share our useful experience and help reduce the discomforts of HCWs worldwide during the COVID-19 pandemic. Many of our recommendations here were adopted at our hospital site, which is designated as a special hospital for patients with COVID-19. These adoptions include every HCW receiving training on nosocomial infection before treating patients, adding dressing mirrors to assist with both donning and doffing PPE, creating 4-hour shifts for nurses, and staffing the emergency and ICU departments with more nurses. Medical isolation pads were used to prevent pressure sores caused by wearing N95 masks, and hand creams were provided to every HCW. Informally, we found that most of the HCWs in our hospital thought that these recommendations were very helpful, and future study is needed to confirm the efficacy and effectiveness of these recommendations.

This study has several limitations. First, we used a questionnaire designed for the purposes of this study; further work is needed to test the validity and reliability of the survey. Second, nurses working at a designated hospital made up most of the survey participants. Third, owing to the COVID-19 pandemic, this survey was administered online; therefore, the sampling was voluntary and Web-based, creating possible selection bias, and we could not confirm that the participants were who they reported they were. As a crosssectional survey, no causation can be inferred. We conducted multiple group testing without applying a P value correction, which may have resulted in spuriously significant results.

As our results demonstrated, discomfort owing to PPE is widespread among HCWs, especially among nurses fighting COVID-19 on the front lines. Female sex as well as working under relatively high pressure for long hours closely correlated with the occurrence of uncomfortable symptoms and skin erosion. Active training on the PPE donning and doffing procedure as well as education on nosocomial infection significantly reduced the risk of exposure. Most of our study participants were nurses at a designated hospital for patients critically ill with severe COVID-19, and these nurses are under tremendous pressure, which differs from ordinary times. We believe that working long hours in PPE as well as the heavy workload is quite comparable to work patterns in emergency departments, and thus our evidence and practical suggestions will be beneficial for daily emergency nursing practice.

Only 10% of our participants worked in the emergency department setting, and a replication study is warranted in this unique population alone.

HCWs in isolation wards should receive standard training on the PPE donning and doffing protocol, along with proper psychological encouragement and timely support. Fighting the COVID-19 pandemic is an unprecedented global challenge, and HCWs are shouldering considerable responsibility as well as pressure. In light of this highly infectious disease, PPE remains the first-line recommendation for effective prevention; however, PPE-related discomfort is widely experienced by HCWs. This study revealed the main types of discomfort, analyzed the relationship between demographic information and the occurrence of different physical complaints and mental states, and offered practical strategies for improvement. SUPPLEMENTAL 

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We acknowledge all the health care workers who are providing patient treatment and care.

Conflicts of interest: none to report.

The procedure for donning and doffing the personal protective equipment Donning procedure In the clean zone for donning: (1) Clean your hands according to the hand hygiene rules for HCW;(2) Put on the medical protective mask (N95, and perform a seal-check; medical isolation pad could be used beforehand to prevent pressure sores); (3) Put on the surgical cap; (4) Put on the goggle; (5) Put on the first layer of shoe coverings; (6) Put on the protective clothing; (7) Put on the first pair of gloves (covering the sleeves of the protective clothing); (8) Put on the medical surgical mask; (9) Put on the surgical cap (covering the upper edge of the goggle) and face shield (if available); (10) Put on the gown; (11) Put on the second layer of gloves (covering the sleeves of the gown); (12) Put on the second layer of shoe coverings; (13) Put on the face shield. Doffing procedure 1. In the contaminated area: Hand hygiene 2. In the first buffer room for doffing: (1) Hand hygiene, take off the face shield;(2) Hand hygiene, take off the shoe coverings(the outer layer); (3) Hand hygiene, take off the gown with the gloves (the outer layer) together (Attention: roll the gown inside-out without touching the contaminated outer surface, as shown in the Supplementary video 1); (4) Hand hygiene, take off the surgical cap and medical surgical mask; (5) Hand hygiene, enter the second buffer room for doffing. 3. In the second buffer room for doffing: (1) Hand hygiene, take off the protective clothing and the gloves (the inner layer) together (Attention: roll the protective clothing inside-out without touching the contaminated outer surface, as shown in the Supplementary video 2); (2) Hand hygiene, take off the goggle;(3) Hand hygiene, take off the surgical cap; (4) Hand hygiene, take off the shoe coverings (the inner layer); (5) Hand hygiene, take off the medical protective mask; (6) Nasal vestibule cleansing; (7) Put on the medical surgical mask. 4. In the clean zone: (1) Hand hygiene;(2) Take a shower.HCW, health care worker. The Designated Hospital, which is for severe and critical COVID-19 patients. à The Undesignated Hospital, which is for patients uninfected with COVID-19.

x Fangcang Hospitals which belong to field mobile medical system are a number of movable cabins with multiple medical functions and the ability of rushing to the scene during emergency, during the epidemic of COVID-19, they're mainly used for the treatment of mild patients.
