key: cord-0970975-sive1xl7
authors: O'Donohue, Laura S; Fletcher-Gutowski, Susan; Sidhu, Amreetpal; Verma, Aishwarya; Phillips, Tarin C.; Misra, Preeti G.
title: Mask Use Among Health Care Workers and Feelings of Safety at Work Pre- and Post- COVID-19 Vaccine
date: 2021-11-15
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2021.11.009
sha: d9dd857e53c2a21c43b502ae8ba4ac815813c6da
doc_id: 970975
cord_uid: sive1xl7

Background: Correct mask use can prevent the spread of COVID-19 and hospitals require correct mask use. Despite this, there is variation in mask use among health care workers (HCW). Incorrect mask use may lead to increased infections and decreased feelings of safety. The purpose of this study was to determine variation in mask use among HCW, as well as feelings of safety from exposure to COVID-19 when around colleagues before and after vaccine roll out. Methods: This study used direct observation to assess mask use in patient facing areas before and after COVID-19 vaccine. A staff survey was used to assess feelings of safety. Results: Over 1,600 mask observations showed increased compliance from 94.6% to 97.5% (p = 0.001). Three hundred survey responses showed significantly increased feelings of safety (p <0.001), and 203 free-text responses were categorized into six themes. Discussion: Understanding the behaviors and attitudes of HCW in patient facing areas compared to private workspaces can help improve policies and reduce HCW to HCW infections. Conclusions: Correct mask use was a highly adopted habit. The COVID-19 vaccine led to significantly increased feelings of safety, though diverging and often conflicting narratives seen in the survey should be considered when crafting future safety protocols.

The COVID-19 pandemic created an unprecedented challenge for health care. Correct mask use, defined as covering the nose and mouth, has been shown to help prevent the spread of COVID-19 1 and CDC continues to recommend mask use in health care facilities, including in staff break rooms. Despite continued education and signage about masking requirements, there is variation in mask use among health care workers (HCW). Incorrect mask use, even if rare, may lead to increased infections and decreased feelings of safety at work. All incoming staff and visitors at our 304-bed community teaching hospital in Michigan, USA, are given a mask but the rate of correct mask use is not known. Impact of incorrect mask use on HCW feelings of safety is also unknown.

The goal of this study is to determine the rate of correct mask use among HCW before and after COVID-19 vaccine roll out at our institution. A secondary aim is to determine how safe HCW felt from exposure to COVID-19 when around their colleagues before and after vaccine roll out and the factors that influenced their perceived safety.

The hospital received its first COVID-19 patient on March 14, 2020. The hospital serves an elderly population, and according to internal records, act as the primary emergency response hospital for approximately 141 facilities (skilled nursing, assisted living, independent living, and senior apartments) and 39 group homes. Data from our infection prevention team show that from March to June 2020 the hospital treated a total of 1,504 COVID-19 patients, with an average of 40-60 confirmed and suspected COVID-19 patients daily with a peak of 151 patients on April 9, 2020. During that time, 209 patients passed away from COVID-19, a case fatality rate of 13.8 per 100 hospitalized patients.

Caring for patients suspected or confirmed to have COVID-19 and the worry of spreading the virus to family and friends may manifest as emotional fatigue and anxiety in frontline staff 2 . While initial shortages of masks and isolation gowns were mitigated, changes in protocols, long hours spent in personal protective equipment (PPE), complex patient care, high mortality, and unknowns about transmission, has anecdotally contributed to fear and exhaustion among HCW at the hospital.

In the first months of the pandemic, education was disseminated electronically from twice daily COVID-19 huddles, followed by the addition of nursing educators and signage demonstrating correct mask use and donning and doffing procedures. The hospital continues to provide up-to-date guidance to staff on PPE and safe COVID-19 patient care.

Few studies have used direct observation to assess variation in mask use among HCW in the hospital setting since the start of the pandemic. One observational study from Uttarakhand, India 5 showed 54.1-75.6% correct mask use among HCW, where correct mask use was defined as wearing a medical, non-cloth, mask over the nose, mouth, and chin. A study from Zehejiang, China 6 showed 73.8% correct mask use, defined as a surgical mask "worn correctly" per their Infection Prevention Department. Incorrect mask use in this study was described as "pulled downwards." Another study from Canada 7 conducted after a facility-wide outbreak of COVID-19, showed that having an observer, or "dofficer," monitor PPE compliance and provide intervention resulted in a reduction of errors in donning and doffing from 9.81% to 2.88%.

Despite knowledge of masking efficacy in preventing the spread of COVID-19 1 there is still variation in compliance. One study of Americans and Canadians found that reported mask compliance among the general public was 84%. The 16% who did not wear masks did so because of beliefs that masks were ineffective and/or had an aversion to being forced to wear masks 8 .

In addition to masking as a means of COVID-19 prevention, many HCW have received COVID-19 vaccines. HCW were prioritized in the initial mRNA COVID-19 vaccine roll out in December 2020. One study of 609 HCW in California, USA, explored attitudes towards the upcoming COVID-19 vaccine 9 . They found that 46.9% of respondents felt that the vaccine would protect them from COVID-19, with 65.5% planning to delay vaccination after it became available. Those who planned to delay vaccination cited a desire to "wait and see" how the vaccine affected others (49.9%), and 1.30% indicated they never planned to receive the vaccine.

These studies demonstrate variation in mask use in the health care setting, variation in attitudes towards mask use and vaccination, as well as the emotional burden carried by HCW during the pandemic. Our study aims to explore objective mask use among HCW before and after vaccine roll out, as well as their subjective feelings of safety at work while around their colleagues.

This was a single center Institutional Review Board approved quality improvement study. The safety intervention was defined as the COVID-19 vaccine roll out at our institution, with pre-and post-assessment of HCW mask use and feelings of safety. Similar to how hand hygiene has been studied 10, 11, 12 , data was collected by non-intrusive, direct observation to assess variation in mask use among HCW. Observations occurred over two 5-day, Monday through Friday, periods. The first mask observation period was conducted in November 2020. The survey was sent to HCW on the main hospital campus by their department leaders.

Staff were given two weeks to complete the survey on our secure hospital network and all data was collected in REDCap. The survey asked respondents to rate their feelings of safety from exposure to COVID-19 when around their colleagues at work before and after COVID-19 vaccine roll out. Staff were given the option to share their role and primary work location from a dropdown menu, as well as an optional text box to explain why they rated their pre-vaccine feelings of safety as they did.

Descriptive statistics were used to analyze mask observation and survey data.

Distribution of mask use across time points and by role was analyzed as categorical and ordinal data using chi-square and Wilcoxon-Mann-Whitney tests respectively. Because survey data are paired data, feelings of safety across time points and by role was analyzed as categorical and ordinal data role using McNemar and Wilcoxon Signed Rank tests respectively. The free-text data from respondents explaining their pre-vaccine feelings of safety were scored into six categories . Categories were determined by a research team member, author LO, who reviewed all free-text responses and identified common sentiments. These common sentiments were coded with a number, 1 through 6, to represent each category. Comments that indicated no opinion or lacked reasoning, such as "N/A" or "no change" were excluded. (Table 1 ). There was significant (p=0.001) improvement in ordinal compliance across time points. This difference was driven mainly by the decrease in wearing masks below the nose (p=0.004) and increase in correct mask use (p=0.005) across time points (Table 1 ). Most groups maintained or improved their mask compliance, though the change was not statistically significant for any group ( Table 1) .

The distribution of observations by role was relatively consistent across time points (Table 2 ). The only group with significantly different representation between time points was patient care assistants who made up 11.71% in the pre-period and 6.73% in the post-period (p=0.002) ( Table 2 ). There was a significant difference in the distribution of observations from the General Medicine floors relative to the Atrium, with the proportion of Atrium observations making up a larger share of the sample in the post-period (83.5%) compared to the pre-period (62.7%) (p < 0.001) ( Table 2) . Figure 1 ). Response options consisted of a five-point Likert Scale ranging from 1 = very unsafe to 5 = very safe. There was a significant improvement in feelings of safety for all roles other than Administration and Clerk/Greeter, which showed non-significant improvements. Staff were given the option to share their primary role and primary work location (Table 4) . For the ordinal coding of safety data, a value of 1 is defined as "very unsafe" and a value of 5 is defined as "very safe."

Note. Distribution of responses to feelings of safety question by primary role in the pre-and post-period. Values of 1 and 2 are collapsed into a single "unsafe" category, and values of 4 and 5 are collapsed into a single "safe" category. Note: Staff were given the option to provide their primary role and work location from a dropdown menu.

The survey included the optional question: "Why did you rate your feelings of safety before vaccination started as you did?" The survey received 203 (67.7%) free-text responses that fell into six categories. Categories and representative examples are shown in Table 5a .

While a majority of responses (125/203, 61.6%) fell into a category that described feeling less safe prior to the vaccine, free-text responses helped highlight broad and often diverging safety narratives as highlighted in Table 5b . A theme that emerged across categories was "see something, say something." These responses were from HCW who took it upon themselves to "say something" to colleagues or bring up policy issues to hospital administration. Some responses made it apparent that they were tired of this role and felt they were not being heard. One representative response from a respiratory therapist who felt moderately safe before and after vaccination was: "I don't feel that we ALL took it seriously, therefore it required frequent reminders to staff to mask-up, wear proper PPE, etc. All of which gets tiring." Another response from a nurse who went from feeling very unsafe to moderately unsafe was: "I don't feel we are doing everything we can to protect ourselves or the patients. I have tried to bring attention to the fact that we are not enforcing many of the new COIVD policies that are in place. So far, the issues I have voiced concern about have not changed."

There The survey data showed a significant increase in feelings of safety after vaccine roll out, but respondents' free text explanations of their pre-vaccine feelings of safety showed a striking divergence in the lived experience of the pandemic and perceived risk of exposure from colleagues (Table 5b) . Notably, we did not conduct mask observations in private offices or break rooms where staff spend time eating and drinking together, activities where masks are typically off. This may help account for discrepancy between the high rates of mask use in patient-facing areas and relatively low feelings of safety among staff when around their colleagues.

Continued vaccination and easing of mask mandates are encouraging, but herd immunity appears less likely in the US due to vaccine hesitancy 14 . COVID-19 is likely to be with us for some time due to new mutations and possibly as an annual virus 15 . The health care community will have to continue improving and adapting safety measures and success will require buy in from HCW. For these reasons, it is important to understand these safety narratives and account for them in the design and implementation of safety interventions.

One way to interpret safety behaviors during the pandemic is through an understanding of attribution bias and naïve realism. Attribution bias is the tendency to attribute others' behaviors to their character rather than their circumstances 16, 17 . Attribution bias stems from naïve realism, which is a tendency to believe that we see the world rationally and objectively, and those who behave otherwise must be mis-informed or irrational 18 . Variation in a community's safety behaviors and an individual's interpretation of them exists because it is informed by that individual's personal experience and risk tolerance. Similar to how those driving slower on the freeway seem overly cautious and those driving faster seem reckless, those wearing a N95 at all times may seem overly cautious, while a colleague who pulls down their mask to speak can seem reckless.

This data shows that there is variation in how safe HCW felt while around their colleagues at work during the pandemic. Patient safety is a unifying goal which has motivated advances in infection control and quality improvement. COVID-19 has posed an additional unique challenge to HCW safety. Organizational awareness of these issues and a focus on "provider wellbeing" may go a long way to normalize these new concerns. Leadership's ability to reach out to hesitant or non-compliant sub-groups will also play a key role in continuing to provide a safe environment in health care.

There are many challenges in the pursuit of objective and subjective safety. One challenge is that behavior change is difficult, and its difficulty is exacerbated by the fact that HCW are mentally and emotionally fatigued 2 . In addition, when the pandemic began, masking was not as common of a habit in the US as it was in some countries, and faced the added handicap of mixed messaging early on about masking effectiveness 19, 20 .

One historic example that can be used to understand mask compliance is hand hygiene.

The benefits of hand washing for infection control have been known for hundreds of years, and yet, hospitals still require reminders and interventions in our effort to reach 100% compliance 21 . A common model is appointing a hand hygiene champion whose role it is to educate, encourage and monitor for proper hand hygiene 22 . Our survey demonstrates that staff have taken it upon themselves to point out lapses in masking and have grown fatigued.

Masking champions or "dofficers" 7 may be able to lift this burden from staff and provide regular and accurate feedback. Healthcare leadership may consider looking at models for hand hygiene and other infection control practices at their institution to draw inspiration for increasing mask compliance.

The challenges posed by the diverging narratives seen in the survey need to be explored in our current crisis, but also for reasons beyond the COVID-19 pandemic. There will be future challenges in health care that require a unified response from HCW. More importantly, it is always a good time to improve our culture of safety. HCW need to be able to respectfully point out lapses to a co-worker to keep our patients and each other safe. Implementing mask use and social distancing have put this practice to the test, in our communities and at work.

This study showed that mask use is a highly adopted practice among HCW in patientfacing areas, with correct mask use accounting for >94% of over 1,600 staff observations. HCW reported significant improvement in feelings of safety from exposure to COVID-19 when around their colleagues after vaccine roll out. Narrative reports of pre-vaccine feelings of safety exposed a divergent and conflicting experience of the pandemic. These narratives should be considered as COVID-19 safety protocols are crafted. The health care community has made tremendous progress in PPE availability and ubiquity, and we have seen its ability to keep HCW safe when used properly. This data can help build on the progress already made in patient and HCW safety during the COVID-19 pandemic. Better understanding of the lived experience of HCW during the pandemic can help to implement effective practices now, next season, and in the next safety challenge.

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Special acknowledgement to Methods Consultants for assistance with statistical analysis; LaurieMcHugh for assistance with project coordination; and Luna Nasry, Christina Lui, and Matthew Chuang for assistance with data collection.