Experiences of personal protective equipment by Australian healthcare workers during the COVID-19 pandemic, 2020: A cross-sectional study

The aim of this study was to capture Australian frontline healthcare workers’ (HCWs) experiences with personal protective equipment (PPE) during the COVID-19 pandemic in 2020. This was a cross-sectional study using an online survey consisting of five domains: demographics; self-assessment of COVID risk; PPE access; PPE training and confidence; and anxiety. Participants were recruited from community and hospital healthcare settings in Australia, including doctors, nurses, allied health professionals, paramedics, and aged care and support staff. Data analysis was descriptive with free-text responses analysed using qualitative content analysis and multivariable analysis performed for predictors of confidence, bullying, staff furlough and anxiety. The 2258 respondents, comprised 80% women, 49% doctors and 40% nurses, based in hospital (39%) or community (57%) settings. Key findings indicated a lack of PPE training (20%), calls for fit testing, insufficient PPE (25%), reuse or extended use of PPE (47%); confusion about changing guidelines (48%) and workplace bullying over PPE (77%). An absence of in-person workplace PPE training was associated with lower confidence in using PPE (OR 0.21, 95%CI 0.12, 0.37) and a higher likelihood of workplace bullying (OR 1.43; 95% CI 1.00, 2.03) perhaps reflecting deficiencies in workplace culture. Deficiencies in PPE availability, access and training linking to workplace bullying, can have negative physical and psychological impacts on a female dominant workforce critical to business as usual operations and pandemic response.

Introduction and reviewed closely by the team. We piloted the survey with two general practitioners to ensure that all functionality was intact and to refine the wording of questions and response options. The final survey consisted of a combination of multiple response options and openended questions that covered six domains including the GAD-7 scale [14] as shown in Table 1. Skip logics were used to reduce survey burden and responses were not forced due to the sensitive nature of the questions.

Recruitment strategy
Convenience sampling techniques were used. The survey advertisement and link was sent to professional organisations: Royal College of General Practitioners, HealthEd Pty Ltd (a primary care education company); the Australasian College of Paramedicine, Occupational Therapy Australia, the Victorian Ambulance Union, and Health and Community Services Union, the NSW Nurses and Midwives Association, the Queensland Nurses and Midwives' Union, the Royal Australian and New Zealand College of Radiologists, the Victorian Perioperative Nursing Group and via social media channels including twitter and medical Facebook groups to capture a broad range of medical specialities from 1 July 2020 to 28 October 2020. As this study was exploratory in nature, a sample size calculation was not conducted. However, the sample size of previous cross-sectional studies amongst HCWs in China, Italy and Spain during the COVID-19 pandemic ranged from 59-5062 people [15]. As such, we anticipated that 2000 HCWs in Australia would participate in this survey.

Data analysis
Data analysis was performed using Stata/IC 15.1 (StataCorp College Station, Texas, USA). Descriptive statistics were used to summarise the characteristics of all respondents which were reported using frequencies, means/medians, standard deviations/interquartile ranges as appropriate. The characteristics of respondents associated with outcomes including anxiety, confidence with PPE, bullying over PPE and experiences with COVID-19 restrictions were examined using multivariable logistic regression analyses. All variables were entered simultaneously into the multivariable model, and highly correlated variables were identified using the variance inflation factor (VIF) where values >3 indicated the presence of collinearity. Model findings were reported as odds ratio (OR) with 95% confidence intervals (CIs) and p<0.05 was considered statistically significant. Free-text responses to survey items where there was the option for 'other' and the final question "Is there anything else that you would like to tell us about your experiences with PPE during COVID-19?" were analysed using qualitative content analysis techniques. Two researchers (DB and CP) created a coding guide by deductively coding 20 responses together. The remaining open-ended responses were divided in two and coded separately using the coding guide. The codes were clustered into categories and further refined into themes. DA and MAR reviewed all codes, categories and themes.

Ethics approval
Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID 26132).

Domain Questions/Variables
Anxiety Generalised Anxiety Disorder Scale (GAD-7). The GAD-7 is a brief measure for assessing symptoms of generalised anxiety disorder in the last two weeks. The response options for the 13 symptom items are "not at all," "several days," "more than half the days," and "nearly every day," scored as 0, 1, 2, and 3, respectively. The scale has been shown to have strong criterion, construct, factorial and procedural validity as well as good test-retest reliability. Scores of 5, 10 and 15 can be interpreted as mild, moderate and severe levels of anxiety [14]. https://doi.org/10.1371/journal.pone.0269484.t001

Perception of COVID risk
Perception of risk decreased over time with the 65.7% of 2248 respondents rating their risk of exposure to COVID-19 as 'some risk' or 'high risk' in March 2020 compared to 55.7% of 2224 respondents at the time of survey completion. The mean proportion of patients seen face to face in the last week of survey completion (n = 2168) dropped to 70% from 90% before the pandemic (n = 2204). Only 146 respondents of 2257 indicated that they had needed to quarantine with the average number of days of quarantine being nine (range 1-28). The majority of participants had been tested for COVID-19 (58.6%).

PPE training and confidence in use
Of 2197 respondents who responded to the questions relating to PPE training, 20% did not receive any form of PPE training (n = 442). Just under half of the respondents (49%; n = 1082) accessed formal workplace training with 36% (n = 784) being in-person and 14% (n = 298) online. The remaining respondents accessed online training by a recognised provider (19%; n = 410) with a minority accessing YouTube (8%; n = 175). Respondents cited the need for "more training early on and ongoing training" (Nurse, state unknown). The lack of training "fuelled anxiety" (Nurse, VIC). Training quality was characterised by an "inconsistent approach" (Doctor, QLD). Respondents stressed the importance of fit testing in protecting HCWs and were critical of the lack of interest shown by organisational leadership. Staff had "asked and been denied" fit tested respirators which had "contributed to staff worrying that if/when we have community transmission we will not be prepared or adequately protected." (Nurse, WA). Respondents were unequivocal "fit testing must become mandatory for nurses working on a covid ward" (Nurse, state unknown).

Use and access to PPE
With regards to accessing PPE, 251 of 2197 respondents were unable to access PPE, with the majority being community based HCWs. Barriers identified were supplier availability (53%; n = 133) and workplace rationing (53%; n = 135) followed by delivery delays (28%; n = 70), high costs (27%; n = 68), the workplace not supplying PPE (23%; n = 57) and denial of PPE based on a low perception of risk or inappropriateness by management (5%; n = 12). General practitioners (GPs) felt that they "have been largely ignored, everyone focuses on hospital workers as though we don't count as frontline" (Doctor, VIC). Many were "forced to buy products through alternative channels. . .and in some cases have paid up to triple the usual price" (Doctor, SA) including going to "Bunnings to get equipment for myself" (Doctor, QLD) or resorting to making their own "hand sewn gowns and head covers" (Doctor, VIC). Offerings from the national stockpile were "scandalous" (Doctor, NSW), with one QLD doctor reporting they received six N95 masks from the stockpile after a request for supply "one for each of our doctors-complete joke!" (Doctor, QLD). Of concern 12% (216/1790) of respondents were denied appropriate PPE when caring for suspected COVID-19 due to supply issues (59%), rationing (23%) and a low perception of risk by management (10%). Among 2131 respondents of 2197 responding to lack of access to PPE, 47% reported that they had to reuse or extend the life of their PPE with responses evenly spread between hospital and community settings at 47% and 46% respectively. "We were keeping used gowns, N95 masks, etc. and salvaging every drop of hand sanitiser from bottles." (Nurse, VIC). A variety of methods were used to extend the life of PPE including: wearing items longer than recommended (30%), reusing single use disposable items (25%), disinfecting items with liquid cleaner (21%), washing (15%), air drying, (6%) and using sunshine (4%). The majority of respondents (96%) who reported reuse and extended use of PPE were metropolitan-based.

Workplace safety and culture
Questions regarding workplace PPE policy were answered by 2084 participants of the 2258. About a third of these respondents (33%) were unable to follow workplace PPE guidelines due to a lack of a formal policy in 15%, with most of the latter being community based. Respondents complained about the frequent changes to PPE policy which contributed to bullying "Constantly changing guidelines has created confusion and anxiety amongst staff and contributes to bullying behaviour over the use of PPE." (Nurse, state unknown). The quality of advice was questioned as "workplace guidelines appear to constantly lag behind what should be standard" (Doctor, VIC) and inconsistency highlighted with "variations across healthcare networks which leads to staff working across networks implementing in Network X what Network Y are doing" (Nurse, state unknown). Respondents believed that the "delay in information from WHO regarding aerosol transmission was a huge fail" (Doctor, WA) which meant the influential state-based "DHHS guidelines have not kept up with growing evidence of airborne transmission". Precaution was emphasised because "there is no time to gather and study the evidence. Preventative and cautious guidelines need to be adopted. . .rather than the reactive policy that has resulted in such great numbers of HCW infections" (Nurse, state unknown).
Just over half (53%) the respondents answered questions about workplace bullying. Of the 1204 responses, 77% (n = 929) indicated that they had experienced bullying and harassment over PPE. "Bullying by the executive whenever PPE issues are raised is a huge problem" (Nurse, state unknown) with respondents told to "stop making trouble" (Nurse, VIC).
Seventy-eight percent of respondents completed the GAD-7 scale (n = 1753). Approximately 1 in 5 respondents (21.6%) showed moderate to severe anxiety in the past two weeks with almost half (48.5%) indicating some level of anxiety (mild, moderate or severe) in the past two weeks.

Factors associated with anxiety, confidence with PPE, workplace bullying and staff furlough
After adjusting for socio-demographic characteristics, respondents in Tasmania appeared to have higher odds of being anxious but uncertainty was great (OR 3.43; 95% CI 1.14, 10.37) ( Table 3). Those with less than 10 years of experience were more likely to report anxiety (OR 2.05; 95% CI 1.49, 2.82). Respondents in Western Australia (OR 0.38; 95% CI 0.21, 0.68) and those who did not receive in-person workplace PPE training were less likely to be confident with using PPE (OR 0.21; 95% CI 0.12, 0.37). In contrast, HCWs working in general practice (OR1.73, 95%CI 1.06, 2.84) and the community (OR 2.14; 95% CI 1.05, 4.36), as well as nurses (OR 2.10; 95% CI 1.23, 3.59) were more likely to report being confident with PPE use. HCWs who did not receive in-person workplace PPE training also had a higher likelihood of experiencing bullying over PPE use (OR 1.43; 95% CI 1.00, 2.03). However, allied health staff (OR 0.40; 95% CI 0.18, 0.90) and respondents in general practice (OR 0.22; 95% CI 0.13, 0.36) were less likely to experience bullying. A higher likelihood of being furloughed was associated with respondents in Victoria (OR 2.37; 95% CI 1.37, 4.10), those with less than 10 years' experience (OR 1.88; 95% CI 1.15, 3.07) and full-time employment (OR 1.57; 95% CI 1.02, 2.41). Of note, PPE training was not associated with reduced anxiety or furloughing. Table 4 details the adjusted analysis.

Discussion
This study provides insights from the experience of frontline HCWs during the height of the second wave in Victoria last year, and holds relevance for current outbreaks in NSW and Victoria.
The key findings reflected swiss cheese-like failures including inadequacies in PPE availability; training; fit testing of respirators; inconsistent guidelines and struggles with leadership which contributed to HCW infections. Strikingly, 80% of respondents were female reflecting the feminisation of the health workforce [16] where women have disproportionately borne the burden of COVID-19 both at home and at work [17]. Impacts included COVID-19 infections, discomfort, bullying, anxiety, financial costs, and a moral injury [18]. Inconsistent frequently changing guidelines that failed to recognise the airborne transmission of SARS-CoV-2, contributed to confusion and conflict with management, compromising care delivery under the added burden of PPE. The lack of bargaining power for many respondents limited their agency to resolve matters further exacerbating physical, psychological and financial impacts.
Despite the necessity of PPE training, a large proportion of respondents (47%) did not receive any formal training at work. This is in stark contrast to our Asian neighbours who have employed a variety of in-person training techniques including in-situ simulation, where high-stress clinical scenarios are role-played in order to improve real-world preparedness [19]. The provision of formal in-person training correlated with levels of confidence in respondents, while its absence correlated with workplace bullying perhaps reflecting broader deficiencies in workplace culture. The lack of in-person training was at odds with pre-pandemic national guidelines for infection control [20]. It is unclear why these guidelines were not enacted when the pandemic hit, especially when the consequences of incorrect PPE usage during a pandemic has increased significance. In fact, national infection control guidelines during the pandemic, downplayed fit testing because it "will be difficult due to limited supplies and range of types/ sizes available" [21] only to be reinstated in 2021 in the aftermath of HCW infections and hotel quarantine leaks [22]. Severe shortages in PPE lead to rationing, private purchase and its reuse/extension by a variety of non-standardised methods including UV/sun light, heat and disinfection potentially putting HCWs in harm's way [23].
The poor integration of modern work health and safety (WHS) principles in healthcare that was exposed nearly two decades ago by the Canadian SARS commission [24], remains pertinent today. Under Australian WHS legislation, an organisation is required to adopt reasonable and practicable controls such as the provision of fit tested respirators and appropriate parts of the PPE ensemble-when worker harm is likely, even when uncertainties around evidence prevail [7]. Although PPE is regarded as the least effective control, it must be strengthened especially when higher level controls (e.g. substitution, engineering, administrative) in healthcare settings are compromised or absent altogether [7]. Consultation between workers and management on matters relating to their safety is another legislative safeguard that was poorly executed as observed in other Australian [18] and international studies [25]. Notably, community-based respondents, more often lacking formal PPE policies, had a greater locus of control exhibiting decreased bullying and higher confidence. For example, general practitioners transformed their practice carparks into respiratory clinics [26] whereas hospital workers were bound by organisational policies and lacked agency to advocate for themselves. Junior HCWs were more likely to report anxiety or furlough reflecting their lower agency and higher risk of exposure in health care settings.
The occupational moral injury described by respondents echoed in an earlier study [18], could have far reaching effects. Moderate to severe anxiety was reported by more than one fifth (22%) of respondents, and several raised the prospect of leaving the healthcare sector. This threat should be taken seriously, as a health-care system cannot function in the long term by relying on the altruism and sense of duty in its workers [27]. A skilled workforce takes generations to develop and attrition of staff will have enduring effects.
A strength of this study is the high number of responses from community and hospital practice with the themes mirrored by another Australian study, providing external validity to our findings [11]. Limitations of this study include the lack of denominator data to gauge response to the survey. Specific groups like aged care workers and cleaners were under-represented but deserve targeted research given they comprised over 40% of HCW infections in Victoria [9]. Also underrepresented were nurses, allied health and people from culturally diverse backgrounds who may be less inclined to speak out about the issues explored in this study. To improve survey completion we used skip logics and did not force responses, however this led to changing denominators across questions, which may affect the generalisability and interpretation of the results.
Preventing infections in HCWs should be a national priority. They not only carry the burden of their personal health, but the potential to transmit COVID-19 to their co-workers, patients, family and the wider community. Apart from high quality PPE, in person training at work should be the minimum standard used for benchmarking because it correlates with greater confidence in using PPE and a better workplace culture.