In an unusual qualitative study, healthcare workers revealed a variety of attitudes about respiratory protection equipment, including motivations and suspicions that could improve or undermine compliance.1

“My background is in anthropology, so I think about the [work] culture of these different parts of the hospital. You want to have a safety culture that highly aligns with the protocols,” says Gemmae Fix, PhD, lead author and a researcher at the Center for Healthcare Organization and Implementation Research in Bedford, MA.

Fix and colleagues conducted 12 focus groups with nurses and nursing assistants at four medical centers. They analyzed the themes and content of the “stories” told by focus group nurses. The researchers sought to characterize perceptions of respiratory protection equipment (RPE), and assess how work factors may encourage or undermine use. They focused on registered nurses and nursing assistants, using a qualitative approach that solicited comments from these frontline workers.

The main themes that emerged included:

• policies are known and seen during work routines;

• during protocol lapses, use is reinforced through social norms;

• clinical experiences sometimes supersede protocol adherence;

• when risk perception was high, there was concern about accessing supplies;

• ED workers were seen as ignoring protocol because risk was ever-present.

Generally, healthcare workers were aware of the importance of respiratory equipment and following protocols, researchers found. However, compliance could be undermined by inaccessible equipment, diagnostic confusion and distrust, and observing ED staff not wearing masks routinely.

“Some of the stories we heard were specifically about the emergency department,” Fix says. “It was felt that the reason that people in the ED didn’t wear their masks as they should is that they just didn’t know [patient status]. They had all of these patients coming in without a diagnosis. By the time they were given a diagnosis, the perception was it was too late; they had already been exposed. People from the ED work all the time without masks, and when they go to other floors to bring patients, they still are not wearing masks.”

The primary focus of the group discussions was N95 respirators, which generally are recommended for airborne isolation precautions for pathogens like tuberculosis and measles. N95s also are commonly recommended for novel respiratory viruses like SARS and pandemic flu, as well as emerging infections like Ebola and MERS.

“Participants’ stories included a variety of cues prompting RPE use, including door signs on patient rooms, personal protective equipment carts in front of patient rooms, documentation in the electronic medical record, and patients being in a negative air pressure room,” the authors reported.

Wearing RPE was consistently recognized as “one of the things that you have to do,” although some complained the masks were “suffocating” and “claustrophobic,” Fix and colleagues reported.

Despite the discomfort, a common perception was that RPE was protective against occupational airborne infections. “I wouldn’t want to wear [RPE] all the time,” a nurse in a focus group said. “But they’re manageable, and I’d rather have them on than have them off.”

Stories underscored that it was socially acceptable among workers to identify RPE compliance lapses. For example, when a disoriented patient with TB unexpectedly walked out of his isolation room, coughing up blood and sputum, some nurses rushed to help. “Others told them to put on a mask,” Fix says.

In another focus group story, a food service worker entered a clearly designated airborne precautions negative pressure room without donning a respirator. “After informing this individual, the nursing staff reported the event to supervisors, who helped organize a respiratory precaution training for food service staff,” the authors reported.

Clinical Experience in Favor of Protocols

Beyond protocols, participants evaluated patient behaviors and symptoms to determine whether to wear RPE. This meant they might decide to use RPE even if protocol specified only droplet precautions or no precautions.

“Several healthcare workers we spoke with talked about wearing N95s when the protocol specified a surgical mask,” the researchers found. “This was because they suspected, based on their clinical experience, that the patient might later be diagnosed with a respiratory infection.”

One nurse stated, “I’m not going to make that mistake again.” In addition, some nurses wore RPE based on patient symptoms like coughing, regardless of diagnosis and isolation level.

“It’s not just Ebola anymore,” one nurse said in focus group. “There are a lot more viruses coming down the pike. We could end up wearing masks all the time at work.”

When nurses did not trust the working diagnosis, they relied on their own clinical judgment, which often led them to use a higher level of RPE, the study revealed. Inappropriate overuse can raise confusion and alarm in others, while depleting supplies of N95s for nonclinical reasons.

“The important thing here from a patient safety perspective is that they are not following the hospital protocol,” Fix says. “You can imagine if you work in a hospital — you know what the protocol is, and you see your colleague doing something different. Other colleagues in the emergency department may be doing what they want. This breaks the social norms, and disrupts the safety culture.”

The researchers found a relationship between risk perceptions, perceived access to equipment, and local context. For example, nurses working in rural sites reported easily available equipment, a perceived lower risk of exposures, and fewer patients in airborne isolation. In contrast, nurses in urban settings perceived a greater risk of exposure, more patients in airborne isolation, and respiratory equipment that was not easily available.

“They keep them [in another area] because they know how expensive they are,’’ a nurse told the researchers. “[Because] some people go to grab the yellow masks for droplet precautions, and they might put on the N95 respirator for a droplet [by mistake].”

These perceptions and suspicions that costs trump worker protection can contribute to a toxic work culture. “People talked about the hospital trying to save money,” Fix says. “They thought they were at risk, and wanted to get a mask, but the [PPE] was all the way down at the end of the hall. Or, they were locked away, or they didn’t have masks in the appropriate size. That undermines the worker’s trust in that healthcare system.”

Given these many variables that may influence respiratory use, Fix and colleagues recommended “team huddles” to review RPE issues when a patient is placed in airborne isolation. A review of the basics could open the huddles for other concerns about the use and availability of respiratory equipment.

“You have to be able to have conversations and address these concerns out front for your patient safety culture,” Fix says. “Not if, but when, the next [infectious agent] comes around, the system has that strong safety culture, and is ready for these events. People want to do their jobs, and they want to be safe. It’s not so much an education problem. I would say it’s a communication and perception problem.”


  1. Fix GM, Reisinger HS, Etchin A, et al. Health care workers’ perceptions and reported use of respiratory protective equipment: A qualitative analysis. Am J Infect Control 2019;47:1162-1166.