4
Using PPE: Individual and Organizational Issues

Workers in a wide range of industries are required to wear personal protective equipment (PPE) to reduce or prevent exposures to hazardous chemicals, fire, particulates, or other health risks. As noted in Chapter 3, researchers, designers, and manufacturers continue to look for improvements to the equipment that can reduce the physiological burdens, improve communication, and be more comfortable and less of an encumbrance to wear. For healthcare personnel, the trade-offs of hazardous exposures with the challenges of donning, wearing, and doffing PPE often end up with healthcare personnel not fully adhering to PPE and infection control protocols. This chapter focuses on what has been learned about use of PPE by healthcare personnel and efforts to improve the safety culture in healthcare facilities. The chapter concludes with recommendations for future research.

BACKGROUND AND CONTEXT FROM THE 2008 REPORT

Although healthcare personnel often face hazardous working conditions with potential exposures to a variety of toxic and infectious agents, adherence to PPE protocols is often quite low. Observational studies and survey questionnaires of individual workers have looked at the reasons for the noncompliance and barriers to use, which often include the host of comfort and workability issues discussed in Chapter 3. Few studies have tested interventions to improve adherence rates.



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4 Using PPE: Individual and Organizational Issues Workers in a wide range of industries are required to wear personal protective equipment (PPE) to reduce or prevent exposures to hazardous chemicals, fire, particulates, or other health risks. As noted in Chapter 3, researchers, designers, and manufacturers continue to look for improve- ments to the equipment that can reduce the physiological burdens, im- prove communication, and be more comfortable and less of an encumbrance to wear. For healthcare personnel, the trade-offs of hazard- ous exposures with the challenges of donning, wearing, and doffing PPE often end up with healthcare personnel not fully adhering to PPE and infection control protocols. This chapter focuses on what has been learned about use of PPE by healthcare personnel and efforts to improve the safety culture in healthcare facilities. The chapter concludes with recommendations for future research. BACKGROUND AND CONTEXT FROM THE 2008 REPORT Although healthcare personnel often face hazardous working condi- tions with potential exposures to a variety of toxic and infectious agents, adherence to PPE protocols is often quite low. Observational studies and survey questionnaires of individual workers have looked at the reasons for the noncompliance and barriers to use, which often include the host of comfort and workability issues discussed in Chapter 3. Few studies have tested interventions to improve adherence rates. 113

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114 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL The range of factors that impact PPE-related behaviors and com- pliance were organized in the 2008 Institute of Medicine (IOM) report and in other studies into three categories: 1. individual factors, such as knowledge, beliefs, attitudes, percep- tion of risk, history, and sociodemographics; 2. environmental factors, including availability of equipment and negative-pressure rooms; and 3. organizational factors, such as management’s expectations and performance feedback, workplace policies, and training and edu- cation programs. Discussion in the 2008 report focused on the concerted efforts needed by individual healthcare personnel, managers, and institutions to improve the safety culture in healthcare facilities. This culture requires “an organization-wide dedication to the creation, implementation, evalu- ation, and maintenance of effective and current safety practices” (IOM, 2008, p. 8). Although organizational and cultural factors in the context of patient safety have received a great deal of attention in recent years, less attention has been focused on healthcare worker safety. In industrial set- tings, such as chemical and power plants, a focus on achieving high safe- ty performance has been found to result from a sustained emphasis on safety factors at all levels of the organization: the individual level (e.g., attitudes, training), microorganizational level (e.g., management support, safety representatives, accountability), and macroorganizational level (e.g., communication, organization of technology, work processes) (Hofmann et al., 1995). Much can be learned from “high-reliability or- ganizations” (e.g., nuclear power industry; certain military operations, including aircraft carriers; commercial aviation), which are given that term because of their highly complex and hazardous missions and few safety-related failures. Characteristics of these organizations include commitment to safety articulated from the highest level of the organiza- tion; resources, incentives, and rewards to carry out the commitment; continuous emphasis on safety; safety as the priority even at the expense of production or efficiency; communication across all levels that is fre- quent and candid; openness about errors and issues as well as regular reporting; and valuing organizational learning and improvements (Gaba et al., 2003; Roberts, 1990; Rochlin, 1999; Singer et al., 2003; Weick et al., 1999). In many industrial work situations PPE use is considered a mandatory practice with a specific type of PPE or PPE ensemble re-

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115 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES quired whenever a certain job or task is performed. In health care, PPE use is often indicated for certain tasks, but often only under certain conditions. Implementing a culture of safety can require changes in the organiza- tion’s policies, procedures, managerial actions and priorities, and re- sources dedicated to safety with access to effective safety equipment. Furthermore, the commitment to, and support of, safety is conveyed to workers at all levels through active and sincere engagement by those in leadership positions who model, encourage, and enforce appropriate PPE use and safety. Finally, and importantly, individual accountability is key to improving and sustaining PPE use. The 2008 report identified four key factors in promoting a culture of safety within healthcare facilities; factors where research is still needed to improve PPE adherence are as follows: 1. Provide leadership, commitment, and role modeling for worker safety: Employees who perceive a strong organization- wide commitment to safety have been found to be more than 2.5 times more likely to adhere to safety protocols than those who lack such perceptions (Gershon et al., 1995). 2. Emphasize healthcare worker education and training: The presence of safety education within a hospital or other healthcare facility demonstrates the organization’s commitment to safety and increases individual knowledge of safety practices. 3. Improve feedback and enforcement of PPE policies and use: The purpose of developing a positive and strong culture of safety in the workplace is to promote habitual safety practice. As noted in the IOM report, Employees should feel uncomfortable when not wearing PPE dur- ing appropriate situations, and supervisors should reinforce the im- portance of PPE and enforce policies so that noncompliance is the rare exception and not the rule. . . . Each healthcare employer should assume responsibility for taking an active role in facilitat- ing, 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 equip- ment, and extensive training efforts that utilize protocols requiring specific safety actions and detailing consequences for noncom- pliance. (IOM, 2008, p. 8)

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116 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL 4. Clarify worksite practices and policies: Much remains to be learned about specific issues related to wearing PPE in the healthcare setting, particularly during an influenza pandemic. A concerted effort to identify best practices in infection control and to disseminate this information to other healthcare facilities could increase worker and patient safety and have positive rami- fications well beyond preparedness for an influenza pandemic. As noted throughout the prior report, the use of PPE is only one component of promoting a strong safety culture in healthcare settings. In addition to PPE, the continuum of infection prevention and safety con- trols includes environmental and engineering controls (e.g., number of air exchanges, availability of isolation rooms with negative-pressure ven- tilation) and administrative or work practice controls (e.g., protocols to ensure early disease recognition, vaccination policies, infection control guidelines for patients and visitors). UPDATE ON RECENT RESEARCH Organizational Factors Influencing Use of PPE In healthcare organizations much of the emphasis on safety in the past decade has focused on patient safety (IOM, 2000). The relationship between patient safety and worker safety is beginning to be further ex- plored, and research continues into delineating the role of a number of factors in creating and sustaining a culture of safety in the healthcare workplace (Lowe, 2008; Singer et al., 2009; Tucker et al., 2008). High- hazard industries, such as commercial aviation and nuclear power, are a major source for research on safety culture and provide useful information to mitigate hazard risk. For example, Lombardi and colleagues (2009) conducted a series of focus group discussions with 51 personnel— primarily from manufacturing, construction, and retail industries as well as a few in health care—on the use of protective eyewear. The authors reported that risk perception, barriers to use of PPE, and enforcement and reinforcement are important safety culture concepts. Investigators further indicated that safety culture emerged as an important theme in encourag- ing PPE use, which included proper training, personal responsibility, peer pressure to use PPE, and appropriate and comfortable equipment. Supervisor and peer use of PPE was deemed important. As noted by

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117 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES Lombardi and colleagues, “If the supervisor doesn’t have [protective eyewear] on, no one else is going to wear them” (2009, p. 758). Positive reinforcement was seen as encouraging; however, personnel often re- ported negative reinforcement by supervisors, such as being written up or threatened with job loss. Without enforcement, personnel questioned management’s sincerity about safety. A recent experimental study of social modeling of PPE use found a moderate positive correlation in the number of participants wearing PPE (hearing protection in this study) and the number of safety model peers who wore the hearing protection (Olson et al., 2009). Safety leaders should consider peer influence as one important factor in the use of PPE as well as interventions such as training, adequate PPE supply, and posi- tive reinforcement as a package. In another example of the impact of safety culture, Lowe (2008) sur- veyed 5,131 allied healthcare personnel, including emergency medical staff, community health personnel, and long-term care providers, about safety culture. Lowe reported that in the healthcare setting, teamwork, fair workplace processes, supportive and people-centered supervisors, leadership, a learning environment, and evidence that employers were working collaboratively to improve the work environment contributed to a culture that values safety. This broader research base that examines safety culture influences and barriers should be further explored in order to inform the work of healthcare organizations. An in-depth review of Canada’s experience with severe acute respi- ratory syndrome (SARS) by the SARS Commission emphasized the im- portance of a robust safety culture in healthcare facilities and pointed to the need for close cooperation between infection control and occupation- al safety and health programs and personnel (Possamai, 2007). Although safety culture issues in health care go well beyond a discussion of PPE, they are important components of those discussions. Recent research on organizational factors that impact the use of PPE (Cavazza and Serpe, 2009; Lombardi et al., 2009; Olson et al., 2009) has reinforced many of the factors identified in the 2008 IOM report, including • availability of and participation in training and refresher courses, • supervisor use of PPE, • peer use of PPE, • organizational support for worker safety and health—the extent to which the company minimizes hazards and prioritizes safety goals. Support is also evidenced by senior manager support of

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118 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL safety practices and the level of encouragement for worker par- ticipation in health and safety discussions, • positive reinforcement of individual compliance behavior, and • negative reinforcement (e.g., verbal warnings). Nichol and colleagues (2008) reported results from 177 nurses in 2 acute care hospitals in Canada. They found that compliance with PPE use was significantly related to organizational support for health and safety (however, no details were provided on what constituted organizational support). Other factors positively affecting the use of facial PPE included full-time employment status, more than 5 years of experience as a nurse, monthly or more frequent use of PPE, and belief in media coverage about the risks of communicable diseases. The absence of job hin- drances, such as heavy workloads, was an important contributor. Saint and colleagues (2009) conducted telephone and in-person in- terviews with 86 hospital staff in 14 U.S. hospitals about barriers to im- plementing evidence-based practices to prevent healthcare-associated infections. The authors identified two types of personnel barriers: “active resisters” and “organizational constipators.” Active resisters were identi- fied as hospital staff who actively and openly opposed changes in prac- tice. One person identified this group as “entrenched culture.” Another type of active resister was one who had competing authorities on new practice implementation, such as hospital policy being in conflict with Centers for Disease Control and Prevention guidelines. Organizational constipators tended to be mid- to high-level executives who prevented or delayed certain actions, thereby acting as barriers to evidence-based change implementation. They appeared to undercut changes and put their own interests ahead of those of organizations and patients. Strategies to overcome these behaviors need to be identified and implemented. Additional studies point to the need for better training, equipment, and facilities. Ganczak and Szych (2007) conducted research on 601 sur- gical nurses in Poland and found that compliance with PPE varied con- siderably, ranging from 83 percent compliance with glove use to only 9 percent compliance with eye protection. Only 5 percent routinely used PPE when in contact with potentially infectious material. Compliance was higher among nurses who had received training in infection control. The most common reason reported for noncompliance was lack of PPE availability (37 percent). These findings related to adequate training were also found in a survey of 1,290 healthcare personnel as demonstrating the organization’s commitment to keeping employees informed and up to

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119 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES date on best practices (Yassi et al., 2007). Yassi and colleagues (2009) used questionnaires, workplace assessments, and discussion groups at a South African hospital to gather information from health and safety rep- resentatives and occupational health practitioners. Findings showed weaknesses in knowing how to use N95 respirators and handle sharps, as well as limited supplies and training related to practice procedures. Turnberg and investigators (2008) conducted a survey of 653 hospital staff in 5 medical centers in Washington state and found lack of knowl- edge by healthcare personnel about, and limited training on, recommend- ed infection control practices and PPE usage, as well as limited resource support. Investigators indicate there is a clear need to identify and reduce barriers to safe practice. Recent research highlights the importance of the worker–task inter- face and work organization factors. Previous PPE research has often shown that physicians display poorer compliance than other categories of healthcare personnel. Although some recent data confirm this gradation (Manian and Ponzillo, 2007), other work suggests that these differences may be at least partially related to task assignments and the general or- ganization of work (Chiang et al., 2008). Chiang and colleagues found that physicians complied better than nurses with PPE requirements dur- ing resuscitation activities in an intensive care unit. In this study, the poorer compliance of nurses was linked to the lack of specific task as- signments, inadequate preparation for procedures, and the spatial charac- teristics and arrangement of the workspace. Lack of readily available PPE and time pressures continue to play a role in poor compliance (Shigayeva et al., 2007; Visentin et al., 2009). Other research shows that compliance may be more problematic in healthcare settings where staff vary on a day-to-day basis or rotate in and out of the setting (Trick et al., 2007). Job and task design, workgroup factors, supervisory practices, and other micro- and macro-work organization factors may also help to ex- plain observed inconsistencies in compliance rates among healthcare per- sonnel. These inconsistencies have been attributed previously to individual characteristics, such as job category, training level, job tenure, age, and even gender. Individual Factors Research published since 2007 on healthcare personnel and PPE shows that a number of individual factors continue to contribute to poor

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120 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL compliance and other safety-related outcomes. Three sets of factors de- serve mention. First, studies continue to show knowledge gaps and train- ing deficiencies among healthcare personnel with respect to proper PPE usage, modes of transmission, and other infection control topics. Re- search by Bryce and colleagues (2008) found that even though healthcare personnel may use appropriate PPE, they often do so incorrectly or in- completely. Examples include not doing a fit check after donning a respi- rator, continuing to use familiar devices regardless of fit test results, and not getting fit tested annually. Composite compliance and comfort scores were assessed for use of N95 respirators and eye protection (goggles, face shields, and other protective eyewear) among nurses, respiratory therapists, and other healthcare personnel at a tertiary care hospital that provides treatment for patients infected with tuberculosis (Bryce et al., 2008). For respirators, the composite compliance score was 86 percent of full compliance, and eye protection use was 74 percent of full com- pliance. No significant differences in compliance were observed for the three different models of N95 respirators used. The composite comfort score for N95 respirators was 68 percent of full comfort. For protective eyewear, the ability to see clearly was significantly and positively asso- ciated with both compliance and comfort. No association was reported between compliance and comfort for either respirators or protective eye- wear. Healthcare personnel reported that they “felt better protected” with N95 respirators than with face masks. Knowledge gaps also have been identified with respect to properly removing PPE (Hitoto et al., 2009), differentiating the protection levels offered by different types of PPE and PPE materials (Kanjirath et al., 2009), and having familiarity with newer protective devices (Ellison et al., 2007). This research highlights the fact that most PPE compliance behaviors are not simple, discrete actions. Rather, they are sets or se- quences of behaviors that can vary under different circumstances. Total and perfect compliance with PPE use is a daunting task under the best of circumstances. Second, research continues to indicate that healthcare personnel of- ten rely on their own personal assessments of risk in deciding whether or not to use PPE. Results from a study by Visentin and colleagues (2009) suggest that, despite administrative directives, emergency medical tech- nicians may fail to use certain PPE when they are not convinced it is needed in particular situations. Shigayeva and colleagues (2007) pro- duced similar findings with respect to barrier protection during the SARS outbreak in Canada. One study found that healthcare personnel may be-

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121 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES lieve they know more about PPE and infection control than they actually do (Shigayeva et al., 2007). Studies on the willingness of healthcare pro- viders to work during crises involving infectious diseases have shown that having an adequate supply of PPE is an influential factor in being willing to respond and work (Balicer et al., 2010; Chaffee, 2009; Gershon et al., 2010a; Mackler et al., 2007; Wicker et al., 2009). Third, recent research shows that healthcare personnel still believe that PPE can interfere with the patient–provider relationship and/or re- duce the quality of care. For example, concerns about PPE include de- creases in the field of vision or reductions in manual dexterity (Daugherty et al., 2009; Ellison et al., 2007; Visentin et al., 2009). Fifty- four healthcare personnel in a hospital emergency department were asked to wear a respirator (P2, an N95 equivalent) for a 4-week period during the influenza season whenever they were working within 1 meter of a patient with respiratory symptoms (Seale et al., 2009). During the first week, 24.1 percent of the participants wore the respirator “occasionally,” while 42.6 percent never wore the respirator. In week 2, only 3 of the 54 participants wore the respirator “on most shifts.” During weeks 3 and 4, only 1 healthcare worker wore the respirator “on most shifts.” By week 4, 70.4 percent of the healthcare personnel reported that they never wore the respirator. Their reasons were that it was hot, was difficult to breathe through, interfered with patient communication, and had to be stored somewhere between uses. Patient perceptions of PPE and its impact on provider behaviors is an area of ongoing research. Recent findings are providing insights into pa- tient expectations and preferences with respect to PPE. Routine use of PPE by dental care providers seems to be well accepted by patients and expected as the norm (Molinari, 2010). Using a set of pictures of physi- cians with transparent face shields and traditional surgical masks, Forgie and colleagues (2009) asked parents and children (ages 4 to 10) which set of physicians they would prefer for patient care. Although 62 percent of parents thought their children would choose face shields, 59 percent of the children did not have a preference and found neither set to be fright- ening. A survey of dental patients found that face mask use was pre- ferred by a majority of the patients (72 percent), with younger patients (< 46 years of age) more supportive of face mask use (McKenna et al., 2007).

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122 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL Interventions to Improve Infection Control and/or PPE Compliance Gammon and colleagues (2007) conducted a literature review of re- search on healthcare worker compliance with standard/universal infec- tion control precautions. They found suboptimal compliance in 24 studies that assessed compliance and only short-term improvements in the 13 studies examining interventions (primarily training classes) to im- prove compliance. In most intervention studies, compliance was moni- tored for only a few months after the intervention, and compliance often returned to baseline levels within a relatively short time. For example, a study of emergency medical services personnel found poor retention of donning and doffing procedures at a point approximately 6 months after the initial training (Northington et al., 2007). Since 2007, several training-related intervention studies have been done. Howard and colleagues (2009) tested a clean-practice protocol and found that it significantly improved hand decontamination and overall infection control after 3 months. However, this was a small study without a control or comparison group. No further follow-up assessment was conducted to assess long-term maintenance. Hon and colleagues (2008) reported that an online infection control course adequately transferred knowledge regarding PPE selection and use. But again, no control group was used, and the online course was not compared to other instructional modalities. In one better designed study, Trick and colleagues (2007) conducted a 3-year intervention study of hand hygiene and glove usage. Hygiene significantly improved in two of the three treatment hospitals compared with the control hospital. The best performing hospital also showed a reduced incidence of antimicrobial- resistant bacteria infections. The third treatment hospital showed insig- nificant improvement. This hospital was a large, public teaching hospital. These recent studies tentatively suggest that multicomponent training interventions may be more effective than single-component efforts and that communications and convenient reminders placed throughout the work environment may boost compliance. Training and other interven- tions that make use of social-cognitive and other behavioral theories also appear to hold promise (Godin et al., 2008).

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123 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES Use of PPE by Home and Community Healthcare Personnel A segment of the healthcare workforce often overlooked in discus- sions on PPE and pandemic influenza planning is the more than 1.5 mil- lion home healthcare personnel and those working in community settings other than hospitals and large clinics (e.g., schools, physician’s offices, long-term care settings) in the United States (Baron et al., 2009). These settings do not generally offer the administrative and environmental safe- ty controls that should be available in hospitals or other large healthcare facilities. A recent study examined factors relevant to the willingness and ability of home healthcare personnel to take care of their patients during an influenza pandemic (Gershon et al., 2010b). Of the 384 home health- care personnel responding to the questionnaire, 16 percent (57 workers) reported that their employer gave them a “respirator mask,” with 41 workers reporting that they received training on how to use the equip- ment and 16 reporting that they had been fit tested on the equipment they were provided. When asked about whether they would be willing to pro- vide care during a pandemic to their current patients, respiratory protec- tion was a significant factor, with willingness to work being associated with “being confident that the mask would protect me” (51 percent) and “being given a respirator mask” (47 percent). Hinkin and colleagues (2008) conducted a literature review and found poor compliance with standard precautions among community nurses. Employers must provide suitable facilities, sufficient supplies of PPE, and adequate training. The authors note that most research has been done in hospitals, which has only limited applicability to other communi- ty settings. SUMMARY OF PROGRESS Research during the past several years reveals modest gains in un- derstanding that self-protective behavior in the healthcare settings in- volves a constellation of interacting and independent components. At a minimum, consideration should be given to the user, the device, the task, and the general work and organizational context. Daugherty and col- leagues (2009) found that knowledge and task hindrances were related to poor compliance among critical care clinicians, with the authors conclud- ing that organizational factors were more important than individual fac-

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124 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL tors in explaining PPE usage. The growing acknowledgment of contex- tual and organizational factors means that research on PPE and health- care personnel is closing in on the larger body of occupational safety research, which increasingly emphasizes contextual and organizational factors in understanding occupational safety performance. Although there are clear gaps and deficiencies in our knowledge base about PPE usage in health care, existing knowledge is sufficient to rec- ommend a four-pronged strategy for immediate implementation. The four elements are as follows: (1) deliberate planning and preparation at the leadership and organizational levels; (2) comprehensive training, in- cluding supervisors and managers; (3) widespread and convenient avail- ability of appropriate PPE devices; and (4) accountability at all levels of the organization. In essence, there should be universal acknowledgment that PPE usage is an integral component of providing quality health care. As with other priorities, this aspect of healthcare delivery needs to be planned carefully at the organizational/institutional level, managers and frontline workers alike need to understand and accept their roles and re- sponsibilities, and PPE usage needs to be as easy and convenient as pos- sible. PPE should be factored into all decisions involving task design, staffing, and work assignments. Input from frontline workers should be used to facilitate planning and decision making and maximize accep- tance. Environmental/engineering controls should be utilized wherever possible to control exposures, with PPE used as a supplement or alterna- tive when environmental/engineering controls are not sufficient or feasi- ble. The overall implementation of the PPE program should be monitored regularly, with the goals of continuous improvement, adoption of best practices, and accountability of both supervisor and worker. FINDINGS AND RESEARCH NEEDS This is an opportune time for research on promoting and enhancing healthcare worker safety and the use of PPE. As noted throughout the chapter, extensive work has been done in recent years on improving pa- tient safety. Efforts are needed to build on those efforts and identify the linkages between patient safety and worker safety, particularly with the use of PPE. Additionally, safety research conducted in other types of work settings has potential applicability to improving safety performance and PPE use in health care. Furthermore, much can be learned from re- cent experience by healthcare personnel and organizations during the

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125 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES 2009 H1N1 influenza, and exploring lessons learned can be instructive for moving research efforts forward. Increased knowledge and commu- nication on the severity of the disease will also be important as decisions are made by organizations regarding PPE compliance. Box 4-1 highlights the committee’s findings in this area. The committee has identified the following research needs and rec- ommendations. Some of these can and need to be addressed expeditious- ly; others will require longer-term efforts. The goals will be to identify and evaluate strategies to mitigate organizational and other barriers that limit the use of PPE by healthcare personnel and to identify incentives and enforcement mechanisms to ensure ongoing organizational commit- ment and continuous improvement. Efforts should be aimed across the spectrum of healthcare personnel and should consider language, educa- tional, and cultural issues. Studies have examined barriers to PPE use; however, research gaps remain on identifying effective strategies for sustaining PPE use related to training, policies, and actions, including assessment of the knowledge, attitudes, and priorities of healthcare personnel and senior management about PPE. Research is needed on the following issues: • PPE issues in health science school curriculums: Studies are needed to determine the level of inclusion of contemporary con- cepts and applications regarding PPE in the curriculums of BOX 4-1 Findings • Self-protective behavior in healthcare settings involves a constella- tion of interacting and independent factors. • Organizational and individual changes are complex, time consum- ing, and difficult to sustain. • Personal protective equipment usage presents varied challenges across different types of healthcare settings. • Existing knowledge is sufficient to begin to incorporate the following practices into PPE usage in health care: deliberate planning and preparation at the leadership and organizational levels; compre- hensive training, including supervisors and managers; widespread and convenient availability of appropriate PPE devices; and ac- countability at all levels of the organization.

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126 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL health science and allied health schools. These studies should in- clude all levels of education where practice is a component. Recommendations should be made for closing identified gaps and improving the development, content, and dissemination of PPE training materials. • Healthcare worker safety culture: Recent efforts focused on patient safety should be expanded to examine the worker safety climate specific to the healthcare arena and PPE use. This in- cludes examining the applicability to health care of research findings in the areas of patient safety, high-reliability organiza- tions, high-hazard industries, and general industry. Lessons learned from the experience with 2009 H1N1 influenza could be informative in identifying best practices, learning from organiza- tions successful with PPE compliance by healthcare personnel as well as from those with lower rates of compliance, and examin- ing issues relevant to PPE policy and implementation relevant to both large and small healthcare employers. To improve appro- priate use of PPE, it will be vital to better understand the motiva- tions and risk assessment processes used by healthcare personnel regarding use of and demand for PPE. • Incentives and enforcement: Innovative approaches to incident reporting systems and other incentive and enforcement actions need to be examined that promote PPE use by fostering a strong and positive culture of safety in the workplace and learning from mistakes. • Task and work organization: Efforts are needed to examine the contribution of task and work organization factors (how work processes are structured and managed) to PPE usage and other safe work practices in healthcare settings. • Metrics: Similar to measures of the patient safety culture, met- rics are needed to measure worker and organizational safety cul- ture and use of PPE. • Varying healthcare settings: In order to determine practice needs in different work settings, research is needed to examine and differentiate PPE policy and implementation strategies in large and small healthcare delivery settings.

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127 USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES RECOMMENDATIONS Recommendation: Explore Healthcare Safety Culture and Work Organization The National Institute for Occupational Safety and Health (NIOSH) and other relevant agencies, such as the Agency for Healthcare Research and Quality, and professional organiza- tions should conduct research to better understand the role of safety culture and other behavioral and organizational factors on PPE usage in healthcare settings. These efforts should include • conducting human factors and ergonomics research relevant to the design and organization of healthcare work tasks to improve worker safety by reducing hazardous exposures and effectively using PPE (e.g., reduce unnecessary PPE donning and doffing), • exploring the links between patient safety and healthcare worker safety and health that are relevant to the use of PPE, and • identifying and evaluating strategies to mitigate or- ganizational barriers that limit the use of PPE by healthcare personnel. Recommendation: Identify and Disseminate Effective Lead- ership and Training Strategies and Other Interventions to Improve PPE Use NIOSH and other relevant agencies and professional organi- zations should support intervention effectiveness research to assess strategies, including innovative participatory ap- proaches to training, for healthcare and supervisory staff at all levels to improve PPE usage and other related outcomes across the range of healthcare settings. To identify best prac- tices, efforts should be made to • conduct observational studies of PPE usage by health- care personnel in different types of work settings; • develop, implement, and evaluate comprehensive leadership and training strategies and interventions that go beyond simple knowledge-based training;

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128 PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL • design training interventions specifically for supervi- sory and managerial personnel in different types of healthcare settings; • examine long-term practice change and safety culture implementation related to educational interventions; • improve use and understanding of PPE by home and community healthcare personnel; • develop assessment tools and metrics that take a broader approach to PPE and acknowledge the inter- action of worker, task, and environmental factors; and • be informed by a lessons-learned summit on PPE use by healthcare personnel during the 2009 H1N1 expe- rience. REFERENCES Balicer, R. D., D. J. Barnett, C. B. Thompson, E. B. Hsu, C. L. Catlett, C. M. Watson, N. L. Semon, H. S. Gwon, and J. M. Links. 2010. Characterizing hospital workers’ willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment. BMC Public Health 10:436. Baron, S., K. McPhaul, S. Phillips, R. Gershon, and J. Lipscomb. 2009. Protecting home health care workers: A challenge to pandemic influenza preparedness planning. American Journal of Public Health 99(Suppl. 2):S301-S307. Bryce, E., L. Forrester, S. Scharf, and M. Eshghpour. 2008. What do healthcare workers think? A survey of facial protection equipment user preferences. Journal of Hospital Infection 68(3):241-247. Cavazza, N., and A. Serpe. 2009. Effects of safety climate on safety norm violations: Exploring the mediating role of attitudinal ambivalence toward personal protective equipment. Journal of Safety Research 40(4):277-283. Chaffee, M. 2009. Willingness of health care personnel to work in a disaster: An integrative review of the literature. Disaster Medicine and Public Health Preparedness 3(1):42-56. Chiang, W.-C., H.-C. Wang, S.-Y. Chen, L.-M. Chen, Y.-C. Yao, G. H.-M. Wu, P. C.-I. Ko, C.-W. Yang, M.-T. Tsai, C.-C. Hsai, C.-P. Su, S.-C. Chen, and M. H.-M. Ma. 2008. Lack of compliance with basic infection control measures during cardiopulmonary resuscitation—are we ready for another epidemic? Resuscitation 77(3):356-362. Daugherty, E. L., T. M. Perl, D. M. Needham, L. Rubinson, A. Bilderback, and C. S. Rand. 2009. The use of personal protective equipment for control of

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