Ill-Fitting PPE Puts Women at Risk: Infection Prevention and Safety Gaps in Health Care Workforces

Personal protective equipment (PPE) is a cornerstone of infection prevention, yet for much of the health care workforce, it may not provide the protection it promises. In a field where women make up a large proportion of clinicians and support staff, ill-fitting PPE presents a persistent and often overlooked safety gap.

From compromised respiratory protection to reduced dexterity and increased injury risk, improper fit can undermine both worker safety and patient outcomes. In this Q&A, Wyatt Bradbury, MEng, CSP, CHST, CIT, TSSP, explores the clinical, regulatory, and cultural implications of PPE design and procurement, offering practical guidance for infection preventionists seeking to close this critical gap and strengthen frontline protection.

ICT: In health care settings, where women make up most of the workforce, how does ill-fitting PPE translate into measurable safety risks, particularly in high-exposure environments like the OR, isolation units, or emergency departments?

Wyatt Bradbury, MEng, CSP, CHST, CIT, TSSP: It’s important to start by identifying how much of the majority of women make up in health care settings. According to the US Census Bureau 2023 American Community Survey, women make up 75.3% of health care practitioners and technical operations and 84.2% of health care support operations.

Interestingly, these categories account for 15.8% of the total female workforce, with office and administrative support occupations as the sole category, at 15.7%, followed by management occupations at 10.48%. There are more than 80 million women workplace, making up 47.6% of the total workforce.

When talking about the use of PPE, it’s critical to remember that it’s a last line of defense. While it’s cheap, convenient, and tangible, the reality is that it’s more of a protective measure for the wearer than a true controller of the hazards. That doesn’t mean it isn’t still important. Quite the opposite; we just have to realize how critical it is to ensure PPE fits correctly, or risk it serving no benefit to the wearer.

Working in health care facilities necessitates frequent use of PPE. This includes gloves, bodywear, eye protection, and respiratory protection, along with footwear considerations that provide traction, comfort, and utility.

As referenced in ANSI/ASSP TR-Z590.6-23, during COVID-19, women experienced severe facial bruising and lacerations due to ill-fitting respiratory protection – often because there was only one mask option available. When a respirator doesn’t fit or doesn’t cover the airways as intended, it fails to capture the pathogens as designed. Poor fit negates any protection the respirator provides because it fails to seal against the wearer’s face. While the health care worker may have passed an annual fit test, any ongoing adjustments to support comfort or normal movement of their face, neck, head, or respirator during use could result in a lack of seal, simply because it was never designed to fit a woman’s facial structure.

In looking at other PPE, ANSI/ASSP TR-Z590.6-23 discusses the considerations surrounding gloves – probably the most common form of PPE used in a health care setting. Gloves that are designed solely based on a ratio of common measurements of hand length, breadth, and circumference do not consider proportions between measurements for different workers or the statistically smaller hand of a woman. Improperly fitting gloves make it difficult to conduct work that requires fine motor skills. It can also lead to a hand slipping within the glove itself, making it hard to grip, reducing grip strength, and impairing tactile tasks, while also increasing the risk of getting caught and ripped. There’s an inability to pick up and hold items, as well as a decrease in dexterity and reach, as the alignment of the digits in the digital folds of the glove is off.

Bodywear that does not adequately conform to the design of a woman’s body could be caught and ripped on snag hazards. It could also require frequent adjustment at inopportune times. The former negates the barrier the bodywear provides. The latter distracts from the task at hand and requires adjustment, pulling the healthcare worker away from their task.

ANSI/ASSP TR-Z590.6-23 also addresses eyewear, noting that safety glasses that do not fit put the wearer at increased risk of eye injuries. One-size-fits-all protection, like goggles and safety glasses, can leave gaps in protection due to a woman’s facial contours, cheekbone height, and other facial features that differ from the male facial structure. Failing to account for these increases the risk that a particulate could enter the eye despite wearing safety glasses or goggles.

Finally, footwear is a significant concern. Improperly sized footwear increases the potential for tripping and could lead to foot deformities or other foot-related problems for women who can’t get the proper safety footwear for their role.

Ultimately, if PPE doesn’t fit well, it’s not able to adequately perform its role as a last line of defense and is as if it were never there in the first place.

ICT: Many organizations treat PPE as an adherence checkbox. From a risk management perspective, what liability or regulatory exposure do employers face if they knowingly provide equipment that does not properly fit a significant portion of their workforce?

WB: 29 CFR 1910.132(d) is the section of OSHA General Industry Regulations that addresses PPE selection in the workplace. §1910.132(d) requires that employers “assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of Personal Protective Equipment.” If present or likely to be present, §(d)(1)(i) requires selection and use of PPE that will protect the affected employees, §(d)(1)(ii) requires communication of the selection decision, and §(d)(1)(iii) states that selected PPE shall properly fit each affected employee.

There is a great deal more required in this section of the regulation around training, how to conduct and certify a hazard assessment, and considerations for who is to provide and pay for PPE. Ultimately, employers have a responsibility to provide workers with PPE that fits female health care workers properly.

ICT: ASSP Z590.6 provides guidance for designing and procuring PPE for women. What practical steps should health care leaders and infection prevention teams take immediately to audit whether their current PPE stock truly meets workforce needs?

WB: There are a number of easy steps that can be taken.

Firstly, talk to the women in your organization who are using PPE Daily. Ask if it fits. Ask if it meets their needs. Ask if there is anything that can be done to make it easier to work safely while using PPE. The employees wearing PPE will know what works and what doesn’t. Ask whether there are situations or specific instances when adjustments are always needed, or when PPE becomes an inconvenience or ultimately fails.

Do this with genuine curiosity. Ensure, as much as practicable, you are engaging in an environment of psychological safety and identifying your intent – to drive real improvement and change where needed. Consider the avenues your organization has in place to receive feedback and leverage those channels, such as safety committees or team huddles. In all cases, be genuine, transparent, and seek to understand. If this is the first time your organization is undertaking continual improvement like this, it may be more difficult, but that is not a reason to stop – it just means the organization may have to be more persistent, transparent, and patient as you’re influencing the culture of the workplace at the same time you’re trying to address PPE fit.

A second step is to just observe how people are working in PPE in the workplace. Often, if the PPE doesn’t look like it fits, is constantly being adjusted, or doesn’t seem to be functioning properly, it isn’t. Look in a variety of situations and across all tasks to get an idea of where PPE may be missing (not identified) or is not being used. This also creates an opportunity to really explore why, including whether fit may be a factor. As with the first point, be genuinely curious and seek to learn. Even if you find nonadherence, don’t automatically default to discipline. Use it as a chance to engage with your healthcare workers and learn about their day-to-day and the challenges they face.

Finally, start to look through records, such as fit testing, to see where issues have arisen in the past. Review workers’ compensation records and injury reports to identify where improperly fitting PPE may have contributed to injury or illness. Use the lagging data to potentially tell you where issues exist and where you may need to begin focusing proactively to address hazards that PPE has been less effective at controlling – potentially due to the PPE itself. Work with employees who may, for example, repeatedly fail a fit test to obtain equipment that better suits their needs and body structure. Remember that PPE is ultimately about your workers’ protection. Ensure it suits them.

In all cases, bring in your manufacturers and distributors to have conversations with your procurement teams, operational leaders, risk management, and health and safety staff. Leverage them in learning about new products on the market and how you can get samples to distribute for feedback and testing among the workforce.

ICT: Beyond physical safety, you’ve mentioned psychological impact. In what ways does ill-fitting PPE affect confidence, authority, and belonging for women in high-risk clinical or industrial roles?

WB: Let’s take this fictional but realistic scenario as an example:

Imagine if you showed up to work each day in a uniform that didn’t fit quite right. You had to wear gloves, maybe even sleeves, that were too large and required constant adjustment at the most inconvenient times during an operation. You wear a respirator that passed the fit test that one time, but now it leaves gaps that let you inhale infectious pathogens. Your safety glasses are constantly fogging up or slipping. There are massive gaps through which debris can get in. You’re expected to go each day about your work, hiding these challenges and not calling attention to the extra burden you face while trying to do good work. As your body naturally changes, you have to keep wearing the same equipment so no one comments on you. Trying to work, trying to live, yet at the same time trying to blend in.

The reality for many women who raise a concern over PPE is that they’re at risk of distasteful remarks as a result of drawing attention to their specific needs. They may feel that they’re being perceived as receiving preferential treatment. Workplace harassment related to or resulting from unique PPE needs is a very real concern. A 2018 study by Curtis, Meischke, Stover, Simcox, and Seixas on Gendered Safety and Health Risks in Construction Trades found that 31% of tradeswomen reported high perceived stress compared to 18% of men.

Asking for equipment that fits is an opportunity for their employer to dismiss their concerns for simple reasons, such as budget constraints or the ease of restocking, which significantly affects engagement and job satisfaction. A worker’s protection is then simply dismissed. Research by Gallup shows that when employees strongly agree that they can give honest feedback, they’re 7.4 times as likely to have confidence in their leaders. Rejection of feedback erodes trust and morale in the organization, which has a direct psychological impact on belonging and satisfaction.

Workers ultimately want to accomplish their tasks successfully and feel like they’re contributing to their organizations. Ill-fitting PPE distracts from their ability to accomplish tasks as efficiently and safely, lessening their contribution. Having to knowingly forgo protection that doesn’t fit, or having protection that distracts from providing care efficiently, affects satisfaction and increases stress.

ICT: If this issue is solvable, why has it persisted for decades? Is the barrier cost, procurement inertia, design bias, or something deeper in workplace culture?

WB: From the stories I’ve heard and my conversations with ANSI/ASSP TR-590.6-23 teammates, doing nothing was really the easiest approach. It was an easy problem for employers to ignore, and an easy problem for female workers to simply bury themselves so as not to draw attention to themselves. In the report and in the prior question, we discussed how women didn’t want to receive distasteful remarks or be perceived as receiving preferential treatment. So, this problem persisted. Manufacturers didn’t adjust their products because the consumer – the organization – wasn’t considering the needs of the end user – female workers. And even where better-fitting equipment was available, not all women have had the means to procure it themselves. That last point should make any leader uncomfortable – female employees are having to spend their own earnings to protect themselves. Their alternative is using protection that may not be adequate.

Following NASA’s inability to conduct an all-female spacewalk in March of 2019 due to a lack of properly sized equipment ready for immediate use, this issue was brought into the public arena. ASSP’s Women in Safety Excellence (WISE) Group published a report shortly thereafter titled “Women and safety in the modern workplace,” which focused on ill-fitting PPE and workplace violence as the two primary issues. This report then led to the development of ANSI/ASSP TR-Z590.6-23, of which I was privileged to be a member.

Since then, we’ve seen manufacturers significantly expand their PPE product lines designed for, tested by, and tailored to the needs of women. Annually, the ASSP WISE hosts a fashion show of new and innovative products at its annual Professional Development Conference.

So, where the challenge was originally one of burying or ignoring the issue that led to a lack of product availability on the market, the reality today is that more equipment is available than ever before. Thus, now it’s a combination ignorance, lack of priority, or potential lack of motivation for any number of reasons that PPE for women is still not available and in use. And, in some cases, it’s the need for all parties in the workplace to realize that better fitting equipment is available and the reasons behind it – not all parties are even aware even today. This is why articles like this – even seven years into the improvement journey surrounding Women’s PPE – are still extremely valuable.

For me, even as a writer of the standard, I had to see how awful it was to fit a safety vest to a highly female-dominated department at a project site before I made a change. I was knowledgeable about the issue; we were providing a line of footwear specifically for women, and we were absolutely willing to evolve from “shrink it and pink it.” But it still took me seeing an employee wearing equipment that absolutely did not fit for me to engage the safety committee, multiple vendors and distributors, and drive through a significant change. And this led to a new set of conversations with our female employees about their needs in the workplace. The capital, shelf-space, and administrative need to essentially double our available safety vests became just a new normal we needed to adjust to based on our learning as an organization.

I think the more we can have discussions about the needs of women in the workplace and normalize those needs as we work to account for them, the more we can live the reality we need. We need to bring these conversations into the open so we can collectively work through these problems and make our workplaces healthy and safe for all who contribute to them.