Addressing the Challenges of PPE Non-Compliance

By Kelly M. Pyrek

Although personal protective equipment (PPE) is one of the best lines of protection against hazardous exposures, many healthcare workers either shun this protective apparel or do not wear it in an appropriate manner at the appropriate time. In a recent survey released by Kimberly-Clark Professional, 89 percent of safety professionals said they had observed workers not wearing safety equipment when they should have been and 29 percent said this had happened on numerous occasions.

The Occupational Safety & Health Administration (OSHA) requires the use of personal protective equipment to reduce employee exposure to hazards when engineering and administrative controls are not feasible or effective. Yet, data from the Bureau of Labor Statistics (BLS) show that of the workers who sustained a variety of on-the-job injuries, the vast majority were not wearing PPE. Seventy-eight percent of survey respondents said workplace accidents and injuries were top concerns. Worker compliance with safety protocols was also cited as the top workplace safety issue. Twenty-eight percent of respondents chose this, while 21 percent selected "fewer workers." "Insufficient management support for health and safety functions" and "meeting the safety needs of an aging workforce" tied at 18 percent. Lack of funds to implement safety programs was last at 8 percent.

Given the importance of PPE in ensuring worker safety, the survey examined the reasons for such high levels of noncompliance. Of those respondents who observed PPE noncompliance in the workplace, 69 percent said the primary cause was workers thinking that PPE wasn't needed. This was followed by PPE being uncomfortable, too hot, a poor fit, not available near work task, and unattractive-looking. The top strategies taken by safety managers to encourage greater PPE compliance were: improving existing education and training programs (61 percent) and increased monitoring of employees (48 percent), as well as purchasing more comfortable PPE tying compliance to individual performance evaluations, purchasing more stylish PPE, and developing incentive programs.

When it comes to compliance with PPE protocols, eye protection was found to be the "most challenging" PPE category, according to 24 percent of respondents. This was a disturbing though not unexpected finding considering that nearly three out of five workers who experienced eye injuries were found not to be wearing eye protection at the time of the accident or were wearing the wrong kind of eye protection for the job. Add to this the fact that that thousands of workers are blinded each year from work-related eye injuries that could have been prevented and the magnitude of the problem becomes clear. The next highest category for noncompliance was hearing protection (18 percent), followed by respiratory protection/masks (17 percent), protective apparel (16 percent), gloves (14 percent) and head protection (4 percent).

The Imperatives for PPE and the Challenges of Compliance

While the aforementioned survey does not reflect the experience at all places of employment, it indicates the need for constant vigilance, especially during seasonal influenza season, a pandemic or other outbreak scenario. The importance of PPE and its inherent compliance challenges are summed up nicely by a 2008 report from the National Academies: "Personal protective equipment is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members and others who interact in the healthcare setting. Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE."

Despite recommendations in numerous guidelines and the prevalence of high-risk conditions, healthcare workers still exhibit low rates of PPE use, and the National Academies (2008) says that "assessments of the explanations for noncompliance and the solutions to these issues need to focus beyond the individual and address the institutional issues that prevent, allow or even favor non-compliance."

A number of studies have documented the barriers to PPE compliance:

- Lack of time

- Perception that using PPE interferes with the ability to perform the job

- Physical discomfort/difficulty communicating when wearing masks

- PPE not available when needed

Boosting Compliance in a Culture of Safety

While healthcare workers should demonstrate personal responsibility for donning PPE when needed, the legal responsibility for employee PPE usage and adherence falls to the employer. OSHA states that the employer is responsible for designing and implementing a respiratory protection program, monitoring and evaluating program effectiveness, and maintaining proper records regarding the program. This responsibility is part of a larger culture of safety, conceivably an organization-wide dedication to the creation, implementation, evaluation and maintenance of effective and current safety practices. According to the National Academies (2008), "An organization that has a functional and healthy safety culture is one in which all employees show a concern for safety issues within the infrastructure and act to maintain or update safety standards. Further, the organizational commitment to safety is evidenced by the organizations policies, procedures, management support, and resources dedicated to safety, which include access to effective, appropriate, and state-of-the-art safety equipment. An institutional commitment to a culture of safety establishes systems, policies, and practices to ensure that safety is the highest priority of the organization. If need be, productivity or efficiency are willingly sacrificed in order to maintain safety In the healthcare setting, a strong culture of safety has been shown to result in a higher rate of adherence to standard infection control precautions among employees, a decreased incidence of exposure mishaps in hospitals, and fewer workplace injuries among employees. In order to establish an effective culture of safety, responsibility for both personal safety and the safety of others should be a joint employer-employee responsibility. Although much of the responsibility for creating and monitoring a safety program is managerial, staff members should be responsible for applying the safety practices to their work environment."

PPE compliance does not happen in a vacuum; instead, it is part of a number of other safety-related interventions including environmental and engineering controls, administrative or work practice controls (such as protocols to ensure early disease recognition, vaccination policies, disease surveillance, infection control guidelines for patients and visitors, decontamination of healthcare equipment and patient-care rooms, risk assessment education programs for healthcare workers). According to the National Academies (2008), "The hierarchy of controls is meant to address hazards through direct control at the source of the infection and along the path between the infectious source and the employee. PPE is implemented at the individual level and is one component of effective infection prevention and control measures that particularly emphasize hand hygiene as a critical action for reducing disease transmission. When all of these measures are integrated and implemented, a continuum of safety exists; deploying evidence-based improvements at any level can enhance the safety culture."

Gershon et al. (2000) explain that a factor analysis of the results of a survey of 789 healthcare workers identified six organizational factors underlying the hospital safety climate: senior management support for safety programs; absence of workplace barriers to safe work practices; cleanliness and orderliness of the worksite; minimal conflict and good communications among staff; frequent safety-related feedback and training by supervisors; and availability of PPE and engineering controls. Three of these factors -- senior management support, absence of workplace barriers, and cleanliness or orderliness -- were associated with significant adherence to safe work practices.

The National Academies (2008) identified four key factors in promoting a culture of safety within healthcare facilities that are pertinent to PPE:

- Provide leadership, commitment, and role modeling for worker safety

- Emphasize healthcare worker education and training

- Improve feedback and enforcement of PPE policies and use

- Clarify worksite practices and policies

Researchers have studied the triggers that invoke behavioral changes. For employees, engaging in the proper use of PPE may be motivated by the desire to protect themselves from occupational hazards, while for institutions, change might be provoked by the desire to attain accreditation, preserve funding or realize cost-savings related to reduced worker illness and absenteeism. Either way, healthcare institutions are encouraged to identify healthcare workers who fall into distinct categories -- innovators who are focused on being first and leading the way; early adopters who are opinion leaders; the early majority who want to remain competitive and are influenced by peer groups and more developed performance data; the late majority who bow to competitive pressures; and the laggards who adopt change only after it is mandated or regulated (Rogers, 1995; Weinstein et al., 2007).

This behavioral change is further prompted by a commitment to healthcare worker and patient safety by the institutional leadership, whether it's from members of the C-suite or clinical staff such as physicians and nurses. Gershon (1995, 2000) reported that workers who perceive a strong organization-wide commitment to safety have been found to be significantly more likely to adhere to safety protocols than those who lack such perceptions, and that they were half as likely to have experienced an occupational exposure incident. Close collaboration between staff in occupational health and infection control and their joint leadership in worker safety issues will be particularly important. Trust is a crucially important characteristic of a positive safety culture and necessitates the creation of an organizational context that encourages and supports communication and information exchange and the open reporting of safety issues.

Some researchers have found that observational rounds boosted compliance with PPE, while others noted that role modeling worked successfully. Still other researchers have pointed to the success of employee safety teams or task forces that help raise awareness of safety issues and the importance of responsibility. And no matter which approach is taken, it is important that non-compliance is addressed, further demonstrating to staff members that the culture of safety is of value. Concurrently, "An essential aspect of establishing a culture of safety is ensuring open lines of communication among all employees while routinely involving staff members in policy development. In order to address safety issues of concern, healthcare workers must be able to provide input on safety policies and have access to a system that makes reporting and remedying safety issues easy, non-punitive and effective Participation in the decision-making process increases the likelihood of acceptance and utilization of protective equipment. For example, employee input into the selection of respirators, gowns, or gloves can provide administrators and purchasers with key information on the wearability of specific types of equipment. Efforts should be made to identify best practices for communications regarding worker safety across a variety of healthcare settings and to further explore and disseminate best practices in planning for these communications during an influenza pandemic. A recent OSHA report recommends that a designated multidisciplinary planning committee be responsible for preparedness for and response to a pandemic and that managers be empowered with the authority and resources to formulate policies, implement training, enforce work practices to protect employees and patients, and develop systems for surveillance. Cross-training individuals for leadership roles as well as identifying a contingency workforce will be critical." (National Academies, 2008)

Education and Training is Key

Whether a healthcare worker uses PPE or not has everything to do with their perceived risk inherent in any job-related task. As various researchers have demonstrated, perception or risk depends upon the worker's education/awareness level, experience and propensity for adherence to safety measures; if occupational risk is not perceived to be real, use of risk reduction measures is far less probable. For example, DeJoy, et al. (2000) found that healthcare workers who had repeated occupational exposures to blood and body fluids but who did not acquire infection, had poorer PPE compliance and may have perceived a decreased risk of acquiring infection compared to those who had not been exposed. This experience may lead to a false sense of invulnerability, resultant noncompliance with standards, and increased risk taking, which ill prepare the worker for the next unknown infectious disease.

As a solution to this potential bravado, the National Academies (2008) emphasize, "Training and continuing education efforts focused on understanding risks and engraining the rationale and policies of the institutions safety culture are needed. Further, ongoing work to delineate the critical elements of risk communication relevant to the use of PPE should be conducted. Healthcare facilities need to develop strong and culturally competent risk communication resources as part of pandemic planning for the diverse communities and employees that they serve. Moreover, risk communication materials should be available in formats accessible to individuals with disabilities and/or limited English proficiency and should also target the educational level of the intended audienceMandatory training is needed across all levels of the organization to communicate the institutions safety rules. Significant portions of training resources should be devoted to training managers and supervisors in techniques that can be used to promote and manage good safety practices. Further, training should involve peer educators and draw from a range of healthcare occupations and professions as well as involving workers proficient in various languages. Best practices have to be identified for tailoring the training efforts to provide various types of healthcare workers with the practical information they need to appropriately use PPE while completing their daily work tasks."

An OSHA report on healthcare workers and pandemic influenza (OSHA, 2007) provides examples of educational goals and objectives for pandemic infection control strategies that emphasize the following:

- Education about recommended control precautions

- Prompt reporting of cases by clinicians

- Communications about confirmed cases admitted to or present in a facility

- Correct use of PPE, hand hygiene, and respiratory hygiene and etiquette

- Training of infection control monitors to observe and correct deficiencies in PPE use and proper hygiene

- Use of simulations to allow for practice

- Development of risk communication materials

- Information about vaccination and antiviral medications

Training should focus on helping workers to reduce barriers in working with patients and performing their job duties while wearing PPE and complying with infection control standards.. As the National Academies (2008) explain, "Employees should feel uncomfortable when not wearing PPE during appropriate situations and supervisors should reinforce the importance of PPE and enforce policies so that noncompliance is the rare exception and not the rule. Safety protocols should be mandatory and exceptionless. Holding managers and supervisors accountable for safety performance within their spheres of responsibility can go a long way toward creating a positive context for safety. Each healthcare employer should assume responsibility for taking an active role in facilitating, promoting and requiring safety actions. Healthcare facilities need to foster and promote a strong culture of safety that includes a commitment to worker safety, adequate access to safety equipment, and extensive training efforts that utilize protocols requiring specific safety actions and detailing consequences for noncompliance. By incorporating safety expectations into the job requirements, individual employees know that this is a part of their job responsibilities and that worker safety is a high priority in the organization with accountability at multiple levels."

The training process should also facilitate improved feedback and enforcement, and policies should:

- Encourage reporting

- Provide incentives for appropriate use of PPE

- Be specific

- Be enforced uniformly

Enforcement of safety precautions by management requires a procedure to assess the extent of adherence to safety protocols. Suggestions include:

- Observational rounds

- Staff surveys that are conducted anonymously

- Anonymous reporting

- Regularly scheduled audits

- Use of monitoring systems and checklists

- Engaging staff champions as role models

As the National Academies (2008) note, "Efforts are needed to identify and disseminate a set of best practices for feedback, monitoring, and enforcement policies and mechanisms regarding use of PPE. Challenges to be examined include developing and disseminating effective supervisory and reporting procedures that encourage feedback and fairly enforce adherence to infection prevention practices."

The National Academies (2008) outlined areas to be explored for promoting worker safety in healthcare facilities, noting that increased efforts are needed to identify and disseminate best practices, conduct pilot studies and conduct research. Immediate opportunities that were identified include:

- A commitment by healthcare employers to promoting, training, and enforcing PPE compliance could increase adherence to PPE protocols and foster the expectation and norm for appropriate PPE use.

- Efforts by the Joint Commission and state health departments to emphasize PPE compliance in accreditation and other assessments could focus attention on PPE issues and enhance adherence to PPE protocols.

Immediate research needs include:

- Define and promote strategies to increase adherence to infection control.

- Improve the safety culture of healthcare facilities

- Define the best feedback mechanisms

- Identify the best ways to train healthcare workers on appropriate use of PPE

- Examine how worker safety and patient safety interact

Recommendations from the National Academies (2008) include:

1. Emphasize Appropriate PPE Use in Patient Care and in Healthcare Management, Accreditation, and Training

- Appropriate PPE use and healthcare worker safety should be a priority for healthcare organizations and healthcare workers, and in accreditation, regulatory policy, and training.

- Healthcare employers should strengthen their organizations commitment to a culture of safety by providing leadership in worker safety; instituting comprehensive, state-of-the-art training and education programs; facilitating easy access to PPE; giving feedback on PPE adherence; and enforcing disciplinary actions for noncompliance.

- Healthcare workers should take responsibility for their safety by working to enhance the culture of safety in the workplace and by adhering to PPE protocols.

- Healthcare accrediting organizations (including the Joint Commission and state health departments) should set, implement, and enforce work standards in hospitals and other healthcare facilities to ensure that proper use of PPE is a priority and a sentinel event subject to controls at the administrative, supervisory, and individual levels.

- Healthcare accrediting and credentialing organizations should ensure that PPE training is part of the accreditation and testing curricula of health professional schools of nursing, medicine, and allied health and that PPE concepts and practice are included on certification examinations and as continuing education training requirements.

2. Identify and Disseminate Best Practices for Improving PPE Compliance and Use

- CDC and AHRQ should support and evaluate demonstration projects on improving PPE compliance and use. This effort would identify and disseminate relevant best practices that are being used by hospitals and other healthcare facilities to Demonstrate, implement, evaluate, and improve the integration of worker safety into the protocols and practice of the organization.

- Develop, implement, and evaluate evidence-based training programs on risk assessment and the use of PPE, including addressing practical realities of wearing PPE, donning and doffing, decontamination, and waste disposal.

- Develop, implement, and evaluate worker safety communication programs focusing on infection control, PPE, and reduction of risk and barriers during an influenza pandemic.

- Monitor, enforce and provide feedback to supervisors and employees regarding appropriate use of PPE.

- Evaluate and determine which practices are most effective regarding PPE use by healthcare workers, patients, and visitors, with a focus on respirator use.

3. Research and Research Translation Efforts Relevant to PPE Compliance

- NIOSH, the National Institutes of Health, AHRQ, and other relevant agencies and organizations should support research on improving the human factors and behavioral issues related to ease and effectiveness of PPE use for extended periods and in patient care-interactive work environments. Translational research efforts should include a focus on identifying effective approaches to donning and doffing PPE, including enhancements in PPE ensemble design; developing standard-of-use protocols based on infection prevention and control policy with clear, simple-to-use algorithms; and examining behavioral implementation strategies for sustained use of PPE, including a focus on patient and community education as well as healthcare provider education.

PPE and Influenza

To help answer the vital questions surrounding PPE compliance especially during an outbreak, in 2007, the National Institute for Occupational Safety and Health (NIOSH) requested that the Institute of Medicine (IOM) investigate the urgent need to address the lack of preparedness regarding effective PPE for use in an influenza pandemic. In 2008, a report was released. In 2009, the H1N1 influenza pandemic brought to the forefront the many unknowns about the virulence, spread, and nature of the virus, as well as questions regarding PPE use among healthcare personnel. Researchers still have much to learn about how influenza is transmitted from person to person, and one major question that arose during the H1N1 influenza pandemic was determining what types of PPEparticularly face masks or respiratorsare needed to protect healthcare workers from disease transmission. Because the focus of research efforts often shifts to other health concerns between pandemics, the IOM stated that continuing the research momentum is critical to ensure that the nation is prepared for the next influenza pandemic.

In January 2011, NIOSH and the National Personal Protective Technology Laboratory (NPPTL) released a new report, "Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel, Update 2010," as an update to assess progress achieved over the past several years. In light of the unanswered research questions following the 2009 H1N1 influenza pandemic, the NPPT at NIOSH asked the IOM to assess the progress of PPE research and to identify future directions for PPE for healthcare personnel. While the IOM found that there are gaps and deficiencies in the research about PPE use in healthcare, there is sufficient knowledge to recommend a four-pronged strategy for effective PPE use:

- Deliberate planning and preparation at the leadership and organizational levels

- Comprehensive training for all personnel, including supervisors and managers

- Widespread and convenient availability of appropriate PPE devices

- Accountability at all levels of the organization

The IOM also offered several recommendations for continuing the momentum of PPE research that are detailed in the report and the report brief. The more scientists and researchers know about how to maximize the effectiveness of PPE and its use, the more prepared the country will be for the next influenza pandemic, the IOM emphasized. The committee conducting the investigation into this issue identified a set of criteria as a starting point for decisions on PPE selection and use. They agreed that PPE for healthcare workers should:

- Reduce the risks of disease and injury to healthcare personnel

- Minimize negative interactions with or effects on patients and their families

- Be acceptable and usable by healthcare personnel in their daily tasks

- Be practical regarding issues of cost, time and training to use

- Be appropriate to the occupational risk being encountered

References:

National Academies Press. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers (2008). Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic. Goldfrank LR and Liverman CT, eds. Washington, D.C.

Institute of Medicine (IOM). Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel, Update 2010.