The burden of personal protective equipment and its effect on the work efficiency in health-care workers

Bhavani Vaidiyanathan; Sophia Amalanathan; Satish Kumar Chokalingam; Kumaran Ramesh Colbert; Irudhayaraj Raajesh Joseph; Prathiba Kishore

doi:10.4103/jcls.jcls_78_22

ORIGINAL RESEARCH REPORT

Year : 2023 | Volume : 20 | Issue : 1 | Page : 30-34

The burden of personal protective equipment and its effect on the work efficiency in health-care workers

Bhavani Vaidiyanathan¹, Sophia Amalanathan², Satish Kumar Chokalingam², Kumaran Ramesh Colbert², Irudhayaraj Raajesh Joseph¹, Prathiba Kishore²
¹ Department of Anaesthesiology, Indira Gandhi Medical College and Research Institute, Puducherry, India
² Department of ENT, Indira Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission	07-Nov-2022
Date of Acceptance	24-Feb-2023
Date of Web Publication	29-Mar-2023

Correspondence Address:
Dr. Bhavani Vaidiyanathan
Department of Anaesthesiology, Indira Gandhi Medical College and Research Institute, Puducherry
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcls.jcls_78_22

Abstract

Introduction: Personal protective equipment (PPE) has become a necessity in the COVID pandemic for containing, protecting, and preventing the spread of the virus among the health-care workers; however, there are limitations to its use due to its associated adverse effects. The objective is to determine the adverse effects of PPE and its effect on work efficiency in health-care workers. Methods: This is a single-center descriptive cross-sectional survey done among 384 health-care workers by a consecutive sampling method. A semi-structured questionnaire was sent through the Google platform and the data were analyzed using SPSS 20. Results: 79.7% of study participants reported irritability and 59.9% had difficulty reading and writing during working hours in PPE, both factors had a significant association with their work efficiency (P = 0.019, P = 0.031). A feeling of being in a closed tight environment (85.7%), headache (71.95%), difficulty in drawing samples and intravenous cannulation (60.2%), and difficulty in adjusting the ventilatory settings and infusion pumps (39%) were reported by the study participants. However, these factors did not affect their work efficiency. On multivariate analysis, most health-care workers (HCWs) in the intensive care unit had more adverse effects than the others posted in other clinical areas. Conclusion: Our survey has identified several factors affecting HCWs during their working hours. These physical and cognitive adverse effects need to be alleviated to maintain a healthy, productive, and efficient work environment. We need to encourage reporting and find ways to mitigate their difficulties regarding PPE.

Keywords: Adverse effects, health-care workers, personal protective equipment

How to cite this article:
Vaidiyanathan B, Amalanathan S, Chokalingam SK, Colbert KR, Joseph IR, Kishore P. The burden of personal protective equipment and its effect on the work efficiency in health-care workers. J Clin Sci 2023;20:30-4

How to cite this URL:
Vaidiyanathan B, Amalanathan S, Chokalingam SK, Colbert KR, Joseph IR, Kishore P. The burden of personal protective equipment and its effect on the work efficiency in health-care workers. J Clin Sci [serial online] 2023 [cited 2023 Jun 9];20:30-4. Available from: https://www.jcsjournal.org/text.asp?2023/20/1/30/372689

Introduction

The COVID-19 pandemic is not over yet; people still need hospital/Intensive care unit (ICU) care, and deaths are being reported in the western countries, while India is still awaiting the fourth wave.^[1] The contribution of the health-care workers during this pandemic is immense if not for the personal protective equipment (PPE) that has kept them working from the very beginning of this pandemic. The PPEs have undoubtedly become the protective shield against the virus spread among the health-care workers; however, they are not without adverse effects on the user.^[2],[3] The surgical/N95 face masks cover all gowns, gloves, and face shields that are being used as PPE as recommended in the guidelines by Ministry of Health and Family Welfare, India.^[1] Many studies have documented and reported the harmful effects of PPE, mainly due to heat stress and detrimental to the user.^[4],[5] Many studies have come out with possible explanations for its various adverse effects, such as mental, psychological, respiratory, and cardiovascular symptoms.^[6],[7],[8] It is imperative to know the adverse effects of PPE for documentation purposes and take measures to alleviate the symptoms in the future.

We studied the adverse effects of PPE by designing a cross-sectional survey on the health-care workers involved in COVID clinical care. In this article, we present the various effects of PPE and the same literature review.

Methods

We designed this study to be a single-center cross-sectional survey of the health-care workers involved in COVID clinical care. A semi-structured questionnaire was constructed containing questions regarding demographics and the effects of PPE on work efficiency and symptoms related to the cardiovascular, nervous, and musculoskeletal system. This questionnaire was peer validated before uploading on the Google platform for dissemination.

Inclusion criteria

All the faculty, residents, and intern trainees involved in COVID duties within the age limit of 20–60 years
All the nursing staff who were involved in COVID duties (casualty, operation theater, ICU, and COVID wards) within the age limit of 20–60 years
A minimum of 2 h of wearing PPE by the health-care workers.

Exclusion criteria

We excluded the health-care workers who were not involved in clinical COVID duties, multipurpose workers, technicians, etc.

This study was initiated after approval from the institute's ethics committee. The survey questionnaire was disseminated to all the health-care workers involved in COVID duties through their WhatsApp phone numbers. We received 384 responses that were found to be complete and were considered for the present study. The data were extracted in excel format from the Google survey platform. It was analyzed with Statistical Package for social sciences version 20 (Chicago). The Chi-square test was used to find the association of demographic factors to the objective variables. Shapiro–Wilk test was used to find the normality of the data. Mann–Whitney U-test was used to find the difference between quantitative variables. Spearman's Rho test was used to find the correlation between two variables.

Results

In our survey that included 384 participants, 73.4% (n = 282) were female and 26.9% (n = 102) males, with ages ranging from 23 to 57 years, and 53.1% (n = 204) were from the age group of 21–30 years. The study participants included nursing staff 50% (n = 192), intern trainees 14.3% (n = 55), resident doctors 24.2% (n = 93), and the faculties 11.5% (n = 44) of the institute. Health-care workers were posted in various clinical care areas, and 79.9% (n = 307) of participants worked in the ICU in rotations.

Our survey participants scored their work efficiency in PPE, 54% (n = 208) scored fair, 20% (n = 78) scored well, and 26% (n = 98) as poor.

Effects of personal protective equipment

59.9% (n = 230) of the study participants felt difficulty reading and writing in the PPE. This factor showed a significant association with their work efficiency (P = 0.019); 60.2% (n = 231) felt difficulty in intravenous cannulation and withdrawing blood samples, and 39.1% (n = 128) participants felt difficulty in adjusting the ventilator settings and infusion pumps during their working hours in PPE. The analytical data on univariate analysis did not show any significant association of these factors with work efficiency (P = 0.212, P = 0.125), respectively [Table 1].

Table 1: Effect of personal protective equipment on clinical work and work efficiency

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Effect of personal protective equipment on the cardiovascular symptoms

95.6% (n = 367) of the study participants had a feeling of thirst, 90.4% of (n = 347) had sweating, 31.3% (n = 120) participants experienced palpitations, 11.7% (n = 45) had chest pain, and 40.4% (n = 155) experienced dizziness during their working hours in PPE. However, these symptoms did not show any significant association with the work efficiency (P = 0.137, P = 0.096, P = 0.531, P = 0.130), respectively [Table 2] and [Table 3].

Table 2: Effect of personal protective equipment causing generalized symptoms and work efficiency

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Table 3: Effects of personal protective equipment on cardiovascular system and the work efficiency

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Effect of personal protective equipment on nervous and musculoskeletal symptoms

71.9% of the study participants (n = 276) had headaches and 80.5% (n = 309) experienced fatigue, 60.2% (n = 231) experienced generalized myalgia during their working hours, 43.8% (n = 168) of the study participants had mental clouding and 79.7% of study participants (n = 306) experienced irritability while working in their PPE. 85.7% (n = 329) of the study participants felt that they were being in a closed, tight environment that made them feel claustrophobic and isolated.

Our study revealed that the factor irritability significantly affected their work efficiency (P = 0.031); however, the other factors such as headache, fatigue, mental clouding, myalgia, and closed environment did not have significant association with work efficiency (P = 0.612), (P = 0.487), (P = 0.199), (P = 0.675), and (P = 0.107), respectively [Table 4].

Table 4: Effect of personal protective equipment on nervous and musculoskeletal system and the work efficiency

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Discussion

Many scoping reviews, cross-sectional surveys, blogs, personal narratives newspaper articles have been published regarding the adverse effects of PPE since the beginning of the Covid pandemic in different parts of the world.^{[9],[10],[11]} Studies from India in this regard are important since the working conditions in India, such as the weather, patient population, availability, and the type of PPE, are different.^[2],[4],[11] This study is a descriptive cross-sectional survey of 384 healthcare workers (HCWs); we analyzed the various factors that affected their work efficiency.

Age and comorbidities

Our survey had majority of health-care workers, 53.1% (n = 203) were below the age of 30 years and only 53 participants had comorbidities, and therefore were able to withstand the ill effects of the PPE without affecting their work efficiency (P = 0.381) and (P = 0.838), respectively.

Thirst and headaches

These two factors seem to be interrelated; thirst and headaches have been documented by the majority of the studies as well as also in our study.^[8],[12] 95.6% (n = 367) of the participants reported that they had a feeling of thirst, and 71.9% (n = 276) reported headaches. PPE restricts the intake of fluids, and this can lead to dehydration; combined with heat stress and physical exertion can lead to variable levels of ill effects that can further affect other related systems. However, in our study, these two factors did not affect their work efficiency (P = 0.280, P = 0.612), respectively. A randomized clinical trial by Loibner et al. showed that the heat stress and liquid loss were perceived to be restrictive at 28°C but not at 22°C.^[13] We stress that this factor has to be considered in working conditions in countries such as India and other Asian countries where the temperature is very high. In our study, both factors did not show a positive association with the number of hours donned (P = 0.808, P = 0.078) and their work efficiency.

Headaches

Headaches were a prominent symptom in our study 71.9% (n = 276) of the study participants reported headaches, similar to other studies such as Choudhury (90.67%), Swaminathan (61.4%), Tabah (28%), Ong et al. (80%).^{[2],[6],[12],[14]} Headaches are thought to be de novo that last for a few hours after donning. However, many factors influence headaches such as the duration and frequency of wearing PPE, reduced sleep, physical and mental stress, irregular mealtimes, and inadequate hydration.^[15],[16] Headaches did affect the work efficiency in the study by Ong et al.^[14] In our study, the headaches did not affect the work efficiency (P = 0.612), neither it was associated with the number of hours donned (P = 0.078).

Cardiovascular symptoms

A cross-sectional study from China by Xia et al. reported dizziness, palpitations, chest distress, dyspnea, thirst, and retro auricular pain in HCWs in PPE.^[7] Our study participants also experienced similar symptoms, such as chest pain, dyspnea, and palpitations, as reported by Choudhury et al., Moradi M, and Calgar et al.^{[2],[16],[17]} Roberge et al. have documented in their study that HCWs who are working for longer hours wearing an N95 Fractional flow reserve, blood CO₂ levels may rise, which could have a significant physiological effect on the wearer and that could cause diminished cardiac contractility, vasodilation of peripheral blood vessel.^[18] Authors Khoo et al., in their study, have documented that dyspnea may be secondary to the use of an N 95 mask or facepiece respirator compounded by anxiety and stress among HCWs.^[19] Although in our study, only a minority of HCWs reported these symptoms and yet did not affect their work efficiency, still it cannot be ignored.

Musculoskeletal

Fatigue (80%) and generalized myalgia (60.2%) are other prominent symptoms reported by our study participants, as also reported by Choudhury et al., Jose et al.^[2],[20] Shutting down central air conditioning systems in the hospitals to prevent the spread of droplets, heat and moisture generated inside coverall gowns, and prolonged wearing of PPE resulting in profuse sweating and dehydration can cause extreme fatiguability, weakness, and myalgia were the other plausible reasons as mentioned in the study by Jose et al.^[20]

Healthcare workers in the intensive care unit

In our survey, 307 participants (79.9%) had posted in ICU in rotation, and the majority have suffered the adverse effects of PPE while posted in ICU; Choudary et al.^[2] in their study have documented that HCWs while working in this physically demanding and mentally draining environment experience discomfort, fatigue, dizziness, headache, shortness of breath, muscular weakness, and drowsiness similar to our study^[3] [Table 5].

Table 5: Adverse effects of PPE in HCW's in clinical areas

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Effect on clinical work

Very few studies have documented the effect of PPE on clinical work and their work efficiency in PPE. 60.2% of our study participants had difficulty in intravenous cannulation and withdrawal of blood samples, and 39.8% (n = 128) had difficulty in adjusting the ventilatory settings and infusion pumps, and 59.9% (n = 230) had reported difficulty in reading and writing. This factor had a significant association with work efficiency (P = 0.019), and the other factors did show a significant association with work efficiency (P = 0212, P = 0.125), respectively. Although these factors did not show significant association, still they cannot be ignored because these activities are important for patient care and safety and delay in delivering adequate clinical care. Authors Choudhury et al., Farronato et al., Vidua et al. and Yánez Benítez et al. have also documented the effect of PPE on their work efficiency.^{[2],[5],[11],[21]}

Claustrophobia and mental clouding

85.7% of our study participants reported having feelings of being in a closed, tight environment and other studies.^{[11],[15],[21]} This adverse effect has not been documented or well-studied among HCWs. In our study, this factor did not affect the work efficiency; this creates an anxious state that may affect the mental status. claustrophobia is due to isolation or distancing the health-care worker from the patients, which is a cause of anxiety when PPEs are worn for the long term.^[22] 43.8% (n = 168) reported mental clouding; this symptom cannot be ignored since working in a critical area that needs accurate calculations can delay or hamper carrying out correct orders or limit decision-making. However, in our study, both these factors did not affect work efficiency (P = 0.107) (P = 0.199). This indicates that although our participants felt these symptoms majority continued to work.

Irritability

In our study, irritability was experienced by 79.7% (n = 306) of participants, and this factor significantly affected their work efficiency (P = 0.031). Hoernke et al., in their qualitative analysis, have documented that this factor is a limitation in delivering adequate clinical care due to the tight-fitting face masks, headaches, and skin reactions.

However, this factor was not associated with the number of hours donned and their work efficiency.^[23]

Limitations

Our study was done among the health-care workers in a tertiary care center during the COVID pandemic, the results cannot be generalized to other health-care centers
The results also depend on several other factors such as the geographical area, the ambient temperature in the area of work, material, and availability of the PPE so our survey results may not be comparable with other studies.

Conclusion

All the adverse effects reported by the health-care workers in our survey are like the other studies from other parts of the world. They need to be analyzed and addressed to alleviate or minimize the adverse effects. The work-rest ratio must be optimized, keeping in mind factors such as age, comorbidities, and physical and mental status of the health-care workers. The health-care workers need to be taught and encouraged to report the effects of PPE so that more user-friendly and better protective PPE kits can be devised and employed. The future of this pandemic awaits in formulating better and ideal PPE keeping in mind a balance between the comfort and security of the health-care workers.

Acknowledgment

We would like to thank Dr. Prakash Mathiyalagen MD (Community Medicine) for his valuable assistance in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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