Problems Encountered by Nurses Due to the Use of Personal Protective Equipment During the Coronavirus Pandemic: Results of a Survey

Coronavirus disease 2019 (COVID-19) was first seen in Wuhan, China, in December 2019, before spreading all around the world.^1,2 Since the initial outbreak, health care professionals have faced the risk of contracting the virus through contact with infected individuals or contaminated surfaces.³ In light of this pandemic, the importance of hand hygiene and the use of personal protective equipment (PPE) in health institutions became even more critical than it was previously.^4,5 The use of PPE protects health care professionals from direct contact with body fluids and infectious microorganisms as well as transmission through droplets in the air. The United States Centers for Disease Control (CDC) has recommended that N95 masks, eye protection (googles or face shield), gloves, and gowns be worn to protect health care professionals against COVID-19.⁶  

The first case of COVID-19 in Turkey was identified on March 10, 2020; since then, the number of cases has increased rapidly.⁷ As is the case across the world, since the first day of the pandemic, nurses in Turkey have been the primary health care professionals responsible for managing the care of infected individuals. A survey conducted in China showed that nurses’ shifts were an hour longer than preferred (5 versus 4), work intensity was high, and wearing PPE for extended periods caused discomfort, including respiratory problems, hunger, and dehydration.⁸ Properly applied PPE creates a physical barrier between microorganisms and the user, and also prevents contamination of hands, eyes, clothes, and hair. It is crucial therefore that PPE such as gloves, face shields, air-purifying masks, goggles, face shields, respiratory apparatus, and gowns are used consistently and effectively to prevent transmission of the virus to health care professionals and patients.^9–11

The requirement for health care professionals to wear PPE for infection control has led to an increased incidence of health care professionals with PPE-related complications.^12–17 A descriptive study by Foo et al¹² evaluated the prevalence of adverse skin reactions to PPE among 322 health care workers. They reported that 59.6% developed facial acne, 51.4% reported itching, and 35.8% experienced facial redness from using N95 masks. Lim et al¹³ conducted a survey among health care workers following the the severe acute respiratory syndrome (SARS) epidemic and found that the incidence of N95-mask–related headaches was 37.3%. Another study of intensive care nurses reported that the use of N95 masks was related to headaches,¹⁴ and Ong et al¹⁶ suggested a correlation between increased headache in health care professionals and the use of PPE. In a multicenter, cross-sectional study conducted by Jiang et al¹⁵ to evaluate skin injuries in 3801 nurses and 505 doctors, the prevalence of device-related pressure injuries and moisture-associated dermatitis was 30% and 10.8%, respectively. The purpose of the current study was to further examine PPE-related physical problems experienced by nurses as well as the role of wear time on these problems. 

A descriptive, cross-sectional study was conducted between May 1 and May 15, 2020, among nurses working for state or university hospitals across Turkey and providing care to patients diagnosed with COVID-19. The total population consisted of  190.499 nurses working in public and private hospitals in Turkey.¹⁸ 

Sample size. The G-power analysis program was used to calculate the sample size (270 nurses) with medium influence quantity (0.3), 80% power, and a 90% confidence interval. A total of 314 nurses were invited to participate, allowing for an estimated data loss of 20%. Data collection forms that were incomplete, or completed incorrectly, were not included. The final study sample consisted of 307 nurses who actively provided care for patients with confirmed COVID-19 and who provided informed consent for participation. 

Inclusion and exclusion criteria. The inclusion criteria stipulated that participant nurses must be providing care to patients diagnosed with COVID-19. 

Data collection. Researchers used a questionnaire form developed in accordance with the literature to collect the data.^12,15,17,19 The first draft of the form was reviewed by 5 different nurses, each with more than 10 years of clinical experience, and amended to take account of their expert opinions. A group of 10 nurses was used for a preliminary test of the questionnaire form, and the finalized version included their suggestions for changes. The form was composed of 2 parts. Part 1 contained questions about the personal characteristics of the nurses (including age, sex, and work years as a nurse). Part 2 focused on the use of, and issues encountered by, the nurses when using PPE in providing care to patients with COVID-19. It included the type of PPE used and the length of time nurses were required to wear it. The other questions about the problems of using PPE were asked as yes/no. The survey was sent as a Google questionnaire form. Completion time was approximately 10 minutes. 

Data analysis. The data were entered into the Statistical Package for Social Sciences (SPSS) for Windows 22.0, and numbers, percentages, mean, standard deviation, and logistic regression analysis were used to analyze the data.

Ethical considerations. Before conducting the study, approval of the ethical committee was obtained from the health institution where the research was conducted (decision no. 2020-07). All participating nurses were provided with a written explanation of the purpose of the study before providing consent.

The 307 nurses who met the inclusion criteria voluntarily supplied their email addresses. The majority (86.3%) were female, the mean age was 30.30 ± 7.64 years, and they had worked as a nurse for an average of 8.26 ± 7.96 years. The nurses reported that 49.5% of them worked continuously for 24 hours and 52.8% rested for 48 hours or more after work during the pandemic. A total of 59.9% of nurses included in the study reported that they did not have a separate room to put on and take off their PPE. When providing care to patients with COVID-19, 96.7% of nurses wore surgical masks, 79.2% wore an N95 mask, 98.0% wore gloves, 87.0% wore goggles/face shields, and 93.8% wore overalls or gowns. 

With regard to the duration for which the nurses were required to wear PPE, the majority reported that N95 masks (66.3% of nurses), surgical masks (77.8% of nurses), gloves (85.3% of nurses), goggles or face shields (70.0% of nurses), and overalls/gowns (74.8% of nurses) were most frequently worn for more than 4 hours (Table 1). 

With regard to wearing an N95 mask, the most commonly reported physical problems (Table 2) were as follows: 64.2% sweating (165 of 243), 61.5%  redness of cheeks (163 of 243), 55.6% dry mouth (143 of 243), 53.0% redness across the bridge of the nose (132 of 243), 50.0% headache (130 of 243), and 47.4% redness of the ears (118 of 243). Wearing a surgical mask was reported to cause 50.9% sweating (139 of  297),  41.2% redness of the cheeks (110 of 297), 50.2% dry mouth (154 of 297), 38.3% redness on the bridge of the nose (101 of 297), and 46.4% redness of the ears (124 of 297). The reported physical effects of wearing gloves included 73.9% dry hands (215 of 301), 63.7% sweating (177 of 301), 61.3% redness (174 of 301), 56.1% itching (162 of 301), and 56.1% chapped hands (160 of 301). For goggles and face shields, 47.9%  of nurses reported problems with vision (147 of 267), 47.6% sweating (117 of 267), 38.0% headaches (95 of 267), and 27.1% redness around the eyes (67 of 267). Finally, wearing overalls/gowns was reported to cause 84.1% sweating (243 of 288) and 83.3% feeling hot (240 of 288). 

Compared to shorter (4 hours or less) wear time, wearing an N95 mask continuously for more than 4 hours significantly increased the odds of developing redness of the cheeks (OR 1.6 times; 95% confidence interval [CI], 1.03-2.18; P < .05) dryness of the mouth (OR 2.18; 95% CI, 1.39-3.46; P < .05), redness of the bridge of the nose (OR 2.02, 95% CI, 1.36-3.04; P < .05), and redness of ear flaps (OR 3.44; 95% CI, 1.14-0.34; P < .05). The odds of developing dry mouth were significantly higher when wearing a surgical mask for more than 4 hours (OR 1.47 times; 95% CI, 1.01-2.13; P < .05). Compared to shorter wear times, wearing gloves for more than 4 hours increased the odds of dry hands (OR 2.39; 95% CI, 1.05-5.47; P < .05), sweating (OR 3.03; 95% CI, 1.26-3.37; P < .05), and redness (OR 1.52; 95% CI, 1.02-2.16; P < .05), whereas the odds of reporting a headache were significantly higher when goggles or a face shield were worn for > 4 hours (OR 1.51; 95% CI, 0.99-2.14; P < .05), as were the odds of sweating when wearing overalls or a gown (OR 2.02; 95% CI, 1.41-3.83; P < .05).

The increased rate of nosocomial transmission of COVID-19 across the world requires all health institutions to ensure effective implementation of infection prevention and control precautions.^1,4 The CDC recommends that health care professionals wear N95 masks, eye protection (goggles or face shields), gloves, and gowns to protect against COVID-19. It is especially recommended that N95 masks be worn during aerosol-generating procedures such as intubation, extubation, and related procedures as well as manual ventilation and open suctioning of the respiratory tract.⁴

In the current study, the majority of nurses reported wearing N95 masks (66.3% of nurses), surgical masks (77.8% of nurses), and goggles or face shields (70.0% of nurses) for more than 4 hours. The literature indicates that constant or prolonged use of masks, goggles, and face shields causes friction and pressure, leading to an increased risk of the development of skin lesions.^17,19–21 

Human skin is the first defensive barrier against physical, chemical, and mechanical agents. The functioning of this protective barrier can be negatively affected by the continuous use of PPE as a result of continuous pressure, shear forces, friction, and dampness.^17,20 

A study conducted with 542 physicians and nurses in China by Lan et al¹⁹ found that using an N95 mask and goggles for more than 6 hours significantly increased the risk of damage to the skin. They found that the increased risk of the incidence of cutaneous irritation was increased among medical staff through the use of PPE, particularly N95 masks and goggles, and that this risk increased with the length of time that the PPE was worn. To counter this, it is recommended that a thin hydrocolloid or foam protective covering with a skin-friendly adhesive is placed on the areas where PPE contacts the skin (eg, nasal bone, cheekbones, forehead, chin, ears, and behind the ears). This protective covering should be cut to the exact size for the particular location.^22,23 In the case of prolonged use of PPE, it is recommended that it should be loosened or lifted periodically (at least every 2 hours) to relieve pressure on the skin.²²

From our study data, it can be seen that 85.3% of nurses wore gloves for longer than 4 hours. Prolonged use of protective gloves can lead to occlusion and hyperhydration, thereby increasing the risk of maceration and erosion.²¹ 

In the case of N95 masks, the nurses reported that they commonly had problems with sweating (64.2%), redness of the cheeks (61.5%), dry mouth (55.6%), redness of the bridge of the nose (53%), headache (50.0%), and redness of the ears (47.4%). In their study, Foo et al¹²  identified face acne (59.6%), itching (51.4%), and redness of the face (35.8%) in health care professionals as a result of wearing N95 masks. It is suggested that skin complications in individuals treating COVID-19 infection are mainly caused by the hyperhydration effect of PPE, friction, impairment of the epidermal barrier, and contact reactions.²⁴ Shorter shifts are recommended to reduce the opportunity for skin reactions caused by PPE.²⁵

The literature includes a limited number of studies about the effects of PPE, particularly in relation to headaches caused by N95 masks and googles. A cross-sectional study by Lim et al¹³ following the 2003 SARS epidemic in Singapore, reported that the incidence of headache was 37.3% in medical staff due to the use of N95 masks. 

In 2013, a repeated-measures, cross-over study conducted in Louisville, KY, by Rebmann et al¹⁴ found that nurses working in intensive care units reported that one of the causes of headache was the N95 mask. In 2020, in a cross-sectional study conducted in Singapore among 158 health care professionals, researchers reported that the use of PPE led to an increase in complaints of headaches.¹⁶

Limitations of this study are the small number (307) of nurses included in the sample and the limited time to collect the data. 

The purpose of this study was to examine PPE-related physical problems experienced by nurses as well as the role of wear time on these problems. Nurses who cared for patients with COVID-19 (N = 307) completed the survey. The majority of nurses experienced problems with the use of PPE, especially when worn for longer than 4 hours. For most problems, the probability of their occurrence was significantly higher when the device was worn for 4 or more hours. The results of this and other studies indicate that efforts should be made to implement shorter shifts for nurses caring for patients with COVID-19 whenever possible to reduce the risk of PPE-related problems. Further investigation is also required into the quality of the PPE provided, and studies to compare their safety and effectiveness are warranted. 

Dr. Atay is an associate professor, Canakkale Onsekiz Mart University, Faculty of Health Sciences, Fundamental Nursing Department, Canakkale, Turkey. Dr. Cura is an assistant professor, Canakkale Onsekiz Mart University, Faculty of Health Sciences, Fundamental Nursing Department, Canakkale, Turkey. Address all correspondence to: Selma Atay, PhD, Canakkale Onsekiz Mart University, Faculty of Health Sciences, Fundamental Nursing Department, 17100 Canakkale/Turkey; tel: 0(286) 218 13 97; fax: 0(286) 218 13 79; email: atayselma@gmail.com.