Poor PPE use linked to weak training

Even OHNs lacked formal education

Nurses often don't know when or how to use respirators, and the fault may lie with their education — or the lack of it.

Basic nursing education contains little information on respiratory protection, other personal protective equipment (PPE), or occupational safety, an Institute of Medicine panel reported.1 Even occupational health nurses reported that they learned about respirators on the job, at professional conferences or from a special course rather than in their formal nursing education, according to a survey conducted through professional organizations.2

When health care workers have a lack of knowledge and a poor perception of risk of infection, they are more likely to have poor compliance with respiratory protection, says Debra Novak, RN, senior service fellow with the National Personal Protective Technology Laboratory (NPPTL) of the National Institute for Occupational Safety and Health (NIOSH).

"We've finding the infection control preparation is pretty weak in their educational programs," says Novak.

Respiratory protection will get a much-needed boost later this year when The Joint Commission accrediting agency issues a monograph on best practices. Novak advises employee health professionals to seize the limelight by creating a working group with infection preventionists, safety officers and risk managers to discuss how to improve the proper use of PPE.

"Daily PPE compliance is probably the best practice for emergency preparedness," says Novak. The challenge is "increasing awareness of proper use of respiratory PPE, working with health care workers in upgrading their knowledge base and risk perception, and teaching them about infection prevention practices," she says.

Gaps in knowledge add to risk

Health care workers are notoriously unprepared to use respirators. The Respirator Use Evaluation in Acute Care Hospitals (REACH) project, sponsored by NIOSH, revealed the gaps:

They receive little instruction during their annual fit-testing (40% of California nurses said their training lasted one minute to 15 minutes). They don't don or doff them properly (38% of North Carolina health care workers failed to remove the respirator properly and 32% failed to perform hand hygiene after removing them). They often didn't even know they were supposed to be fit-tested (15% of health care workers in Minnesota said they didn't need fit-testing before wearing an N95 respirator).3

A survey of 1,074 nurses in the Toronto area found that fewer than half regularly use the recommended PPE – despite the city's experience with SARS, in which 54 health care workers became ill and two nurses and a doctor died.

A culture of safety makes a difference. Nurses were twice as likely to wear the recommended PPE if they "perceived their organization supported the health and safety of employees," the authors found. Nurses who had received training and fit-testing in the last two years reported greater adherence to PPE use, and emergency department nurses reported less compliance.4

Too often, nurses and other health care workers don't understand why they need to wear respirators, says Novak. "Health care workers think you only wear respirators for TB," says Novak, who notes that NIOSH recently released an updated list of potentially life-threatening infectious diseases. (See box, below.)

Take steps to improve PPE use

Employee health professionals play an important role in promoting proper use of personal protective equipment (PPE) by health care workers. Here are some steps hospitals can take to improve respirator use, says Debra Novak, RN, senior service fellow with the National Personal Protective Technology Laboratory (NPPTL) of the National Institute for Occupational Safety and Health (NIOSH):

  • Make a commitment to organizational safety. PPE use is higher when the facility has an overall culture of safety, studies show. Seek best practices through collaboration between employee health, infection control, risk management and safety, Novak advises.
  • Place signs in a timely way to alert staff about the need for respiratory protection.
  • Update PPE education annually, including when to use PPE, what to use based on infection precautions, how to properly don and doff respiratory PPE and why PPE is an important last line of defense.
  • Develop a targeted, annual competency program on proper PPE use that reinforces infection control and occupational safety and health practices. CDC has developed an instructional program for the selection and use of PPE in healthcare settings that can be accessed at www.cdc.gov/HAI/prevent/ppe.html.
  • Monitor PPE compliance with unit-based routine observations and reinforce proper donning and doffing practices. An evaluation checklist and other resources are available from the toolkit provided by the California Department of Public Health at www.cdph.ca.gov/programs/ohb/Pages/RespToolkit.aspx.

She cites the case of an unconscious patient who was treated in the emergency department of Alta Bates Summit Medical Center in Oakland, CA, and later was determined to have meningitis. The EMTs who responded wore protection, but the police officer who first found the patient and a respiratory technician in the emergency department did not wear respirators and became severely ill.

A study of an early outbreak of 2009 H1N1 in New York City found almost five unprotected exposures by health care workers for every patient who presented with influenza-like symptoms. The authors noted "suboptimal adherence to recommended PPE" as one of the factors in the exposures.5

OHNs can boost respirator use

Occupational health nurses play an important role in educating health care workers about respiratory protection, according to an Institute of Medicine panel. The panel focused on how to improve the education and training of occupational health nurses so they can boost compliance.

"The goal is to look at how we educate nurses from the time they enter nursing up to and including when they would become an occupational health nurse," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, manager of Employee Health Services at Allegheny General Hospital and the Western Pennsylvania Hospital in Pittsburgh and association community liaison for the Association of Occupational Health Nurses in Healthcare (AOHP). "What competencies do they need to have? What are the best ways to enhance the knowledge?"

A survey of more than 2,000 occupational health nurses found that 83% said they were "competent, proficient or expert" in respiratory protection. Most (68%) had learned about respiratory protection on the job and about half (55%) had taken a spirometry class that was sponsored by the National Institute for Occupational Safety and Health.2

Occupational health nurses were more likely to feel competent if they had more experience, had certification (COHN), or if they were the person primarily responsible for the respiratory protection program.

The survey revealed one area of uncertainty: About one in four (28%) occupational health nurses said they weren't comfortable explaining the difference between a mask and a respirator, says Barbara J. Burgel, RN, PhD, FAAN, clinical professor and adult nurse practitioner in the University of California, San Francisco School of Nursing and an author of the study.

Employee health professionals need to help health care workers feel confident in using a respirator when they are potentially at risk, says Gruden. "We're constantly being proactive to teach staff they don't need to wait until there's a sign on the door that says 'airborne protections,'" she says.

Some occupational health nurses reinforce respiratory protection by including it in other wellness and safety initiatives, such as discussing respiratory health during a smoking cessation class, Burgel says.

"We take special pride in health coaching and tailoring programs for behavior change," she says. "We're trying to get individuals to change their behavior and wear respiratory protection correctly."


  1. Committee on the Respiratory Protection Curriculum for Occupational Health Nursing Programs, Institute of Medicine. "Letter Report." Occupational Health Nurses and Respiratory Protection: Improving Education and Training: Letter Report. Washington, DC: The National Academies Press, 2011.
  2. Burgel BJ, Carpenter H, Novak D, et al. Respiratory protection for occupational health nurses. Presented at the American Public Health Association meeting, October 28, 2012.
  3. NIOSH National Personal Protective Technology Laboratory. Presentations and posters from the personal protective equipment selection, use and expectations. March 20-21, 2012. Available at www.cdc.gov/niosh/npptl/resources/certpgmspt/meetings/03202012/PresentationsPosters03202012.html. Accessed on December 17, 2012.
  4. Nichol K, McGeer A, Bigelow P, et al. Behind the mask: Determinants of nurse's adherence to facial protective equipment. Am J Infect Control 2012; online publication in advance of press.
  5. Banach DB, Bielang R, Calfee DP. Factors associated with unprotected exposure to 2009 H1N1 influenza A among health care workers during the first wave of the pandemic. Infect Control Hosp Epidemiol 2011; 32:293-295.