|Year : 2022 | Volume
| Issue : 3 | Page : 275-281
Skin problems among nurses due to personal protective equipment: A cross-sectional study from COVID-19 hospital
Suraj Chawla1, Shewtank Goel2, Abhishek Singh1, Vikas Gupta2
1 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
2 Department of Microbiology, Government Medical College, Shahdol, Madhya Pradesh, India
|Date of Submission||22-Nov-2021|
|Date of Acceptance||25-Apr-2022|
|Date of Web Publication||17-Sep-2022|
Dr. Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
BACKGROUND: Nursing staff are at much greater risk of infection due to the exposure to the highly infectious bodily fluids and droplet nuclei and needed the use of personal protective equipment (PPE) to reduce the transmission risk.
AIM: The present study was conducted to estimate the prevalence of skin injury and its type due to PPE usage nursing staff.
MATERIALS AND METHODS: This descriptive cross-sectional study was conducted after obtaining the institutional ethical approval in dedicated COVID-19 hospital for a period of 4 months among 144 nursing staff wearing Grade 2 and 3 PPE kit. Study subjects were approached through social networking websites and survey questionnaire (Google Forms) according to relevant guides; research literature was used for collecting the details regarding baseline, duty, and skin injury characterization. Chi-square analysis was used to find the association between dependent and independent variables and an association was significant for P < 0.05.
RESULTS: It was observed that 54.7% of nursing staff were working for 6 or more hours and 16.5% of subjects were wearing the PPE kit for 5 or more hours per day. 86.3% of subjects have suffered from skin injury after PPE usage. The most common symptoms/signs for the skin injury occurred were indentation and pain on back of ears (61.9%).
CONCLUSION: The skin injuries of PPE among the nursing staff may result in reduced morale for overloaded work and made them anxious, so an effective preventive measure should be adopted.
Keywords: Facial itching, facial rashes, mask, protective clothing, skin chapping
|How to cite this article:|
Chawla S, Goel S, Singh A, Gupta V. Skin problems among nurses due to personal protective equipment: A cross-sectional study from COVID-19 hospital. Indian J Health Sci Biomed Res 2022;15:275-81
|How to cite this URL:|
Chawla S, Goel S, Singh A, Gupta V. Skin problems among nurses due to personal protective equipment: A cross-sectional study from COVID-19 hospital. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 25];15:275-81. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/275/356274
| Introduction|| |
Personal protective equipment (PPE) refers to equipment used to avoid or reduce the accidental injuries and occupational hazards at work, and they are meant to protect against the physical, chemical, and biological factors encountered in the work environment. With the emergence of highly infectious epidemics, such as Ebola virus diseases and severe acute respiratory syndrome, nursing staff are at much greater risk of infection than the general population, due to the exposure to the highly infectious bodily fluids and droplet nuclei in the immediate patient environment. Hence, treating and caring for such patients need the contact precautions by means of PPE to reduce the transmission risk.,
The use of these protective equipment has again gained the attention among the health-care workers during the global public health emergency due to the coronavirus disease-2019 (COVID-19) appeared in December 2019. Nursing staff are highly at risk of contracting COVID-19 while caring for the patients, as they have prolonged duration of exposure performing many care interventions including aerosol-generating procedures. Furthermore, there is a common concern of infecting family and friends among nurses. Due to perceived risk of being infected, the nursing staff generally restricts their social contacts. Even there is a feeling of being isolated by their family members and friends among nurses because of their hospital work and which in turn pressurizes them to be absent from work.
Based on the precautionary protocols adopted by various agencies in controlling the infection, adequate use of PPE is reasonable based on the evidences, especially when aerosol-generating medical procedures are being performed. It is shown in literatures that the health-care workers who used mask, gown, and hand washing had less likely developed infection than who did not use them.
Since the mode of transmission of the disease is established to be respiratory droplet and indirect contact with fomites, the use of the PPEs is essential to prevent the cross-transmission of the infection. The PPEs comprise the equipment that protects the mouth, nose, eyes, ears, bare skin, and vulnerable parts, such as head and hands from the deadliest infectious secretions from the patients. Several skin damages have been reported due to PPE, such as pressure injury, contact dermatitis, pressure urticaria, and exacerbation of preexisting skin diseases, including seborrheic dermatitis and acne.,
The present institution was started 3 years back and process of recruitment of nursing staff is ongoing. The number of nursing staff ranged between 140 and 150. The college being in evolving phase has no nursing students, so nursing staff alone have to look after the patients in the COVID-19 wards besides doctors. Being limited number of nursing staff, the duties are less rotated and this makes more hours of working for providing nursing care to the patients and more hours of wearing of PPE kit while providing care to the patients. The documented skin injuries due to PPE kit including device-related pressure injury, moisture-associated skin damage, and skin tears are mostly for the patients, and no report of skin injuries among nursing staff wearing PPE has been seen, which needed to be addressed urgently, so we planned to conduct a descriptive study to estimate the prevalence of skin injury and its type, to find the association of related factors with the skin injuries, and to analyze the problems in the prevention and treatment of skin injuries among nursing staff during the COVID-19 pandemic, which will provide a basis for developing strategies for preventing and treating the skin injuries in upcoming third wave of pandemic.
| Materials and Methods|| |
Study setting and design
This descriptive cross-sectional study was conducted in dedicated COVID-19 hospital (DCH), Madhya Pradesh, for a period of 4 months (March 2021–June 2021). It was recognized official site as DCH for managing COVID-19 patients on March 27, 2020, when the disease started to occur in epidemic proportion in India.
Study population and sample size
The study subjects were nursing staff currently working at DCH, at the time of the study. The list of the study subjects was obtained from Medical Superintendent office along with their contact details (email and phone) and which counted to 144 eligible subjects.
The sample size was calculated (n = 97) considering the proportion of nursing staff having PPE related skin damages as 50% (studies not found in Madhya Pradesh) with confidence level of 95% and 10% absolute allowable error by applying the following formula: N = (Z1 − a/2)2 × p (1 − p)/d2, where Z = Standard normal variate for the level of significance (at 5% Type I error (P < 0.05), Z = 1.96 for two-sided test), a = Level of significance (0.05), P = Prevalence (proportion-50%), d = Absolute Allowable error (10%), n = Sample Size, so all eligible study participants which counted to be 144 were included in the study using convenient sampling method.
Study subject inclusion criteria were as follows: (1) those nursing staff who cared for the suspicious and positive COVID-19 cases in intensive care unit, high dependency unit, general wards, isolation wards, and private wards with moderate-to-severe risk exposure and were wearing surgical masks with goggles or protective face masks and protective gowns (called as Grade 2 PPE) or were wearing N95/KN95 respirators with goggles or protective face masks, protective gowns, latex gloves, and shoes (known as grade 3 PPE); (2) age ≥18 years, regardless of gender; (3) and voluntary participants.
Nursing staff who did not wear PPE or who did not contact the suspicious or confirmed COVID-19 patients were excluded from the study.
We designed a survey questionnaire according to relevant guides and research literature,, and reviewed and revised three times by consulting dermatologist, statistical experts, and nursing in-charges, and feedback was taken from some medical staff posted in DCH. It gathered general data (age, gender, marital status, current place of stay, having children in home, number of household members, and years of experience); PPE data (confidence in self-protection for COVID-19, how many days in a week you wear PPE kit, duration of PPE wearing while caring for patients); work absenteeism due to skin injuries; skin reaction related to mask (Surgical/N95), goggles/face shields, latex gloves (powdered/nonpowdered), and protective clothing; preventive measures taken to avoid skin injuries due to PPE; and treatment sought for the skin injury occurred.
Participation in this survey was voluntary and was not compensated. After obtaining approval to conduct this study from the Institutional Ethics and Review Board (IERB), study subjects were approached and recruited through social networking websites (Facebook, Twitter, and WhatsApp), and the password-protected survey links containing Google Forms were posted on the same which also included the contact details of the dermatologist (investigator). An introductory paragraph outlining the aims and objectives of the study as well as instructions to complete the questionnaire was explained in the survey link especially mentioning that if any of nursing staff having any kind of PPE-related skin injuries at present, please visit the dermatologist in the outpatient department hours or consult for any queries during suitable hours over the phone. All questions were mandatory. Informed consent was obtained from each subject before participation. Sufficient time was given to subjects to read, comprehend, and answer all the questions, and the subjects could not change the answers after submission of questionnaire. The subjects were given a week's time to voluntarily complete the questionnaire and those who did not responded back to the questionnaire with in defined time after three or more consecutive reminders were declared as nonrespondents and were excluded from the study. The questionnaire was checked for completeness by the investigator himself and incomplete questionnaires were excluded from the study. The subjects having skin injuries at present were examined by a dermatologist for the site, symptoms, signs, and systematic features of skin injury, and treatment was prescribed for them. The information pertaining to subjects was kept anonymous and confidential. The study was performed following the Checklist for Reporting Results of Internet E-Surveys guidelines.
Collected data were entered in the MS Excel spreadsheet, were coded appropriately, and werelater cleaned for any possible errors. Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, to facilitate the association of variables, more variables were created. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%) and quantitative data were presented as mean (standard deviation). The baseline and duty-related characteristics were considered the independent variables, and the presence of skin injuries was considered as the dependent variable. Chi-square analysis was used to find the association between dependent and independent variables. During Chi-square analysis, the cells having values <5 for any of independent variables were not considered for the analysis and were not shown in the results section. All tests (two tailed) were performed at a 5% level of significance; thus, an association was significant if P < 0.05.
All ethical issues were followed during the study. Participation was voluntary and participants were allowed to withdraw from the study at any moment. No personal data were recorded. Participants were assured that all data collected were used only for the current study. The study was initiated after obtaining approval from IERB (Project ID: IERC/21/07/001). In addition, before filling the questionnaire, participants were asked to give their consent to participate in the study.
| Results|| |
Out of total 144 study subjects, 139 subjects provided their responses for the questionnaire sent over social media. The mean age of study subjects was 27.2 ± 4.2 years. More than half of the study subjects had general nursing and midwifery as their qualification (53.2%, 74/139). Furthermore, more than half of nursing subjects were unmarried (57.6%, 80/139). Only 5% of nursing staff (7/139) had a total working of 5 or more years after passing their college and nearly one-fourth of subjects (23.7%, 33/139) were currently staying in campus hostel [Table 1].
During the amid of COVID-19 pandemic, the current institution was established as DCH, so most of the nursing subjects (95.7%, 133/139) were recruited on a contractual basis. More than half of nurses (54.7%, 76/139) were working for 6 or more hours during their routine shifts in DCH and more than one-fourth of subjects (28.1%, 39/139) had night shifts of more than 10 days in a month. More than one-tenth of nurses (16.5%, 23/139) were wearing the PPE kit for 5 or more hours per day during duty hours and 11.5% (16/139) of subjects reported absenteeism from duty hours due to PPE-induced skin injuries [Table 2].
More than four-fifth of subjects (86.3%, 120/139) reported that they have suffered from skin injury after PPE usage during duty hours [Table 3]. Skin injuries among subjects were mainly due to the use of masks and goggles/face shields (74.8%, 104/139), followed by the use of latex gloves (70.5%, 98/139) and protective clothing (32.4%, 45/139). Commonly reported symptoms/signs of skin injuries were indentation and pain on the back of ears (61.9%, 86/139); skin itching or rash (39.6%, 55/139); skin soaking in sweat (37.4%, 52/139); and dry skin (36.0%, 50/139).
|Table 3: Characterization of personal protective equipment induced skin injuries among study subjects (n=139)|
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When subjects were asked whether they opted for any preventive measures to avoid skin injury due to PPE kit, more than half subjects (60.4%, 84/139) denied such preventive measures being used. Subjects those who suffered from the skin injury (n = 120), only two-fifth of them (40%, 48/120) sought treatment for the same [Table 4].
|Table 4: Characterization of preventive and treatment modalities taken for skin injuries among study subjects (n=139)|
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To find the association of reported skin injuries with the subject's various characteristics, the Chi-square analysis was applied, and the cells with value <5 are not shown in [Table 5]. It was observed that skin injury was more frequent among subjects being married (89.2%, 66/74); staying at home (89.6%, 95/106); and having 2 or more members at their current place of stay (86.6%, 84/97). Furthermore, skin injury was frequent among subjects who were daily working for 6 or more hours (92.1%, 70/76); wearing PPE kits for 5 or more days in a week during duty hours (89.7%, 61/68); and wearing PPE kits for >2 h while on duty at DCH (89.9%, 80/89), but skin injuries were statistically significant with two variables only, i.e., current place of stay and daily duty hours (P < 0.05).
|Table 5: Association of skin injuries with the baseline and duty characteristics of study subjects (n=139)|
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| Discussion|| |
The present study made an attempt to find the skin injuries that occurred after PPE kit usage among nursing staff, and it was found that 86.3% of subjects have suffered from skin injury after PPE usage during duty hours. In a study by Lan et al., a similar prevalence of skin injury (97.0%) caused by infection-prevention measures among subjects was observed, whereas the study by Navarro-Triviño et al. showed a lower prevalence of skin injury (12.7%) among subjects.,
While analyzing more specifically about which content of PPE kit caused frequent skin injuries among nursing staff, it was revealed that masks and goggles/face shields caused skin injuries among 74.8% of nurses, followed by latex gloves and preventive clothing which caused skin injuries among 70.5% and 32.4% of nursing staff, respectively. In a study by Singh et al., goggles were the most common culprit agent among all PPE causing any one of the dermatoses (51.92%), followed by N95 masks (30.77%) and face shields (17.31%).
The commonly expressed symptoms/signs of the skin injury occurred were indentation and pain on the back of ears (61.9%) caused due to mask or goggles, followed by skin itching or rash (39.6%), skin soaking in sweat (37.4%), and dry skin (36.0%) caused due to latex gloves whether powdered or nonpowdered, and it was in coherence with findings from Agarwal et al. and Soraganvi et al. Studies., Similarly, a study by Hu et al. showed that the most common adverse skin reactions among health-care workers wearing N95 masks were nasal bridge scarring (68.9%) and facial itching (27.9%).
During to COVID-19 pandemic, the current institution was established as DCH, and most of nurses (95.7%) were recruited on contractual basis. The rapid rise of cases during the first and second waves of COVID-19 made nursing staff overburdened, which is reflected by the observation that 54.7% of subjects worked for 6 or more hours during their routine shifts and 28.1% of subjects had duties during night shifts for more than 10 days in a month. Due to overburdened state, 16.5% of nurses were wearing the PPE kit for 5 or more hours per day during duty hours, which was in coherence with the study by Singh et al., where 25% of nursing staff were wearing PPE for 6 or more hours, whereas study by Jiang et al. showed that 85.7% of subjects were wearing PPE for more than 4 h., Due to continuous wearing hours of PPE kit, it caused skin injuries among 86.3% of nurses, which made 11.5% of subjects absent from duty hours. A review by Cook also approves the present study's revelation. A study by Gheisari et al. has shown that skin irritations caused by PPE may cause discouragement of health workers from using it. Similarly, Vidua et al. expressed the concern of increasing numbers of health-care workers having discomfort while using PPE.
The Chi-square analysis showed that daily duty hours were significantly associated with the skin injury caused (P < 0.05). Similarly, the odds of skin injury were significantly associated with the daily wearing time of PPE kits in the Jiang et al. (95% confidence interval [CI] for odds ratio [OR] 1.61–3.21) and Lan et al. (95% CI for OR: 1.35–3.01) studies.,
The mean age of nursing staff was 27.2 ± 4.2 years, which reflects a quite young working health force in a present evolving institution due to which only 5% of nursing staff had the total working of 5 or more years after passing their college. Although the association was not found significant in Chi-square analysis, it was observed that skin injuries were quite frequent among subjects who were married (89.2%) and were not staying alone (86.6%), which shows that married and not staying alone nursing staff were more cautious about using PPE kit to prevent spreading COVID-19 to others. The study by Kumar et al. showed that 94.2% of subjects working in COVID-19 hospitals were concerned of infecting family members and the study by Alnazly et al. showed that fear of infecting family members was significantly higher among married subjects.,
According to studies by Bishopp et al., Yin, and Darlenski and Tsankov, prophylactic measures such as hydrocolloidal dressings and benzalkonium chloride patch could be considered to alleviate the PPE-induced skin injuries, but in the present study, a hesitancy was observed among subjects when it came to the application of preventive measures to avoid skin injury due to PPE kit, as 60.4% of subjects admitted that none of such preventive measures were considered by them.,, Even among those who had skin injury, 60% of them lagged to seek treatment which was a very similar pattern observed in the study by Jiang et al., where 82.7% and 55.0% of subjects did not take any preventive measures and treatment for skin injury respectively.
Although the minimal desired sample size was calculated in the present study, during Chi-square analysis, it was found that there were a few of cells where the value was <5, but the association was significant for the variables, so the author suggests to take a larger sample for such studies or to do multicentric study instead of single-centric study as the present one, to avoid such issues. Apart from limitations, the major strength of the study is that it revealed the skin injuries and its types among nursing staff in a tribal district of India. Along with that, subjects with skin injuries were treated by dermatologist during and after the study period. Apart from this, the investigator of the present study has planned for a prospective study where subjective examination will be conducted within 24 h of skin injury occurrence.
| Conclusion|| |
Hence, in this study, we explored the characteristics of the skin damage caused due to the PPE and corresponding care and preventive measures required among the health-care workers caring for COVID-19 patients. The skin adverse effects of PPE among the health-care workers may result in reduced morale for overloaded work and make them anxious. Hence, an appropriate monitoring of these adverse effects should be done and effective preventive measures should be adopted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]