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Addressing the Challenges of PPE Non-Compliance


By Kelly M. Pyrek

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

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

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

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

The Imperatives for PPE and the Challenges of Compliance

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

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

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

- Lack of time

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

- Physical discomfort/difficulty communicating when wearing masks

- PPE not available when needed

Boosting Compliance in a Culture of Safety

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

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

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

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

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

- Emphasize healthcare worker education and training

- Improve feedback and enforcement of PPE policies and use

- Clarify worksite practices and policies

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

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

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

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