Barriers and Facilitators to the Use of Personal Protective Equipment in Long-Term Care: A Scoping Review

A scoping review of the published literature of PPE use in LTC settings was conducted to address the following question: what barriers and facilitators exist to the uptake and appropriate use of PPE by health care workers in LTC facilities? The research question was guided by the PCC (population, concept, and context) framework. The population of interest was registered nurses, licensed practical nurses, and health care aides. The concept of interest was determining the barriers and facilitators to uptake and appropriate use of PPE within the context of LTC facilities. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was followed. The protocol for this scoping review was preregistered on Open Science Framework (Registration DOI: 10.17605/OSF.IO/SEZDP, Center for Open Science).

Online databases were searched from database origin to November 4, 2021, including Medline (Ovid), Embase, CINAHL, medRxiv, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (Supplementary Table 1). A gray literature search was conducted between January 7, 2022, and January 25, 2022, using the Canadian Agency for Drugs and Technologies in Health (CADTH) Grey Matters tool and the University of Toronto's guide to searching gray literature. The search strategies used a combination of controlled vocabulary (eg, “Health Personnel,” “Personal Protective Equipment,” and “Long-term Care”) and keywords (eg, “nurse,” “mask,” “nursing home”) (Supplementary Table 1). Vocabulary and syntax were adjusted across the databases. No language or date limits were applied. The reference lists of all included articles were searched for additional studies. All study designs were considered for inclusion. Only literature that used human participants was included. One reviewer conducted the searches for the scoping review. Covidence (Veritas Health Innovation) was used to manage identified articles and reports throughout the scoping review.

Abstracts identified through database searching were screened in duplicate independently by 2 reviewers, and all abstracts included at this stage by either reviewer proceeded to full-text review. Included were abstracts that were set in nursing homes or LTC settings or focused on LTC health care workers as the study population and discussed PPE use or infection prevention and control strategies. The uptake and appropriate use of PPE may be included as part of a broader infection prevention and control strategy, and so it was decided to broaden the inclusion at the abstract review stage. No language restrictions were applied to the abstracts. Results were downloaded from the databases and uploaded into Covidence, which removed the duplicates.

Full-text screening was performed independently by 2 reviewers. Discrepancies in screening were resolved through discussion until consensus was reached. Studies were excluded if they only included physicians in their study population or if relevant data about barriers or facilitators to PPE use in LTC could not be extracted. The full-text review was not restricted by language. If relevant abstracts written in English were identified but the full-text article was not written in English, Google Translate was used. Google Translate has been suggested to be a viable, accurate tool for translating non–English-language research for the purpose of conducting reviews.

All data extraction was conducted by 1 reviewer and reviewed by a second reviewer. A standardized data extraction tool was used to systematically extract data on study characteristics, study participants, intervention, implementation approaches and evaluation, and barriers and facilitators.

The Theoretical Domains Framework (TDF) was used to code the barriers and facilitators.^{,  ,}  Barriers and facilitators could be coded to more than 1 TDF domain if relevant. Coding was discussed and agreed on by the entire study team. Frequencies of coded TDF domains and themes were reported. Text evidence from the included articles to support thematic analysis was included in the text. Extracted data are summarized in tables.

From the published and pre-print databases, 3459 citations were retrieved, 36 full-text articles were reviewed, and 7 were included^{,  ,  ,  ,  ,  ,}  (Figure 1). From the citation searching of reference lists and the gray literature search, 2123 records were retrieved, 16 full-text articles were reviewed, and 3 were included.^{,  ,}  The primary reasons for exclusion at full-text screening were that the records did not include information on barriers or facilitators to the appropriate use and selection of PPE, the records were not collected in a LTC setting, and the records did not collect data on health care workers.

Summary characteristics, such as the studies’ main objectives, place of origin, participant characteristics, type of PPE investigated, and data collection methods of included records are presented in Table 1. The included studies were conducted between February 2017 and December 2021, with 8 of the 10 conducted during the COVID-19 pandemic. Studies originated from the United States (n = 5),^,,,, United Kingdom (n = 3),^,, Ireland (n = 1), and Australia (n = 1). Six studies recruited health care workers from LTC settings^{,  ,  ,,,} and 4 recruited health care workers from both LTC settings and acute care settings^,,, but reported their findings for LTC separately. Four studies used surveys to collect data about barriers and facilitators to PPE use,^{,,  ,}  4 used interviews and/or focus groups,^,,, 1 used a scoping review, and 1 used both a survey and interviews.

Of the 10 eligible studies included in this review, the most common TDF domain identified was environmental context and resources, which was observed in 9 of the included studies^{,  ,  ,  ,,  ,  ,  ,}  (Table 2). The definitions of each domain can be found in Table 2. Of the 9 papers found to reference this domain, 7 stated that the availability of PPE was a barrier to the appropriate use and selection of PPE.^{,,,  ,  ,  ,}  Five of these papers stated that PPE overall was not readily available,^{,  ,  ,,} 3 stated that masks or N95 masks were unavailable,^,, 2 stated face shields were unavailable,^, and 1 stated that gowns were not available. Without PPE being available, health care workers were unable to properly protect themselves and risk transmitting infection among themselves as well as with LTC residents.

“Nearly all the research participants in this study reported a severe shortage of PPE in their workplaces. This exposed the [health care workers] in many health and social care settings to possible infection of COVID-19. The shortage of PPE undoubtedly brought fear and anxiety among [health care workers].” (Nyashanu et al.)

During the pandemic, the price of PPE increased substantially. As a result, the financial cost of PPE was also cited as a barrier to its procurement and therefore its use.^,, The costs associated with different components of PPE were not specified.

“Some LTC facilities could find PPE, but the price was incredibly high. Despite this, they reported still purchasing the expensive PPE. As one infection preventionist explained, ‘I think I spent $46,000 yesterday on PPE, but I had to. We finally found supplies and you can't wait.’” (Rebmann et al.)

Other themes that were coded as barriers into the environmental context and resources domain included that additional staffing was required to manage the PPE and ensure that it was distributed properly, that PPE was being prioritized for acute care settings leading to LTC facilities lacking an appropriate number of PPE, and that the PPE that was supplied to LTC facilities was not fit for purpose and inappropriate for preventing COVID-19 transmission. However, some themes were coded as facilitators into the “environmental context and resources” domain. Placing gowns and gloves outside resident rooms was seen as a visual cue for its use, and having an inventory of PPE^, encouraged PPE use. TDF domains and extracted themes for each included study can be viewed in Tables 3 and 4.

The beliefs about the consequences domain was referred to in 2 references.^, The fear of spreading pathogens facilitated glove use. If health care workers understood that a resident had a transmissible disease, they would be more inclined to select PPE appropriately to prevent its spread. However, some health care workers were anxious that using PPE would frighten their residents and distress them.^, It is unclear which components of PPE contributes to the stress.

“Resident distress was particularly apparent for those living with dementia, who were disturbed by social distancing and the visual appearance and impaired communication associated with staff PPE use, although some interviewees reported a degree of accustomisation amongst residents.” (Bunn et al.)

The TDF domain knowledge was found in 2 references.^, Knowledge of appropriate PPE selection, specifically the appropriate use of gloves, was coded as a facilitator, because knowing when to use PPE encouraged its use when it should be used. Health care workers also felt that unclear guidelines around PPE use hindered them from using it and selecting it appropriately.^, They felt that guidelines were too ambiguous, were updated too frequently, or lacked consistency or clarity about PPE use in LTC facilities. This barrier applied to the use of overall PPE in both studies, but 1 study also reported that ambiguous guidelines on glove use resulted in health care workers not using gloves when they were supposed to.

“There are so many changes that are coming every day, today is one thing tomorrow is another one what are the guidance really? It really confuses and panics me” (Nyashanu et al.)

Health care workers felt that using PPE interfered with their ability to provide care to LTC residents, including affecting their ability to communicate, causing them difficulty in giving physical care, or preventing them from providing care efficiently and quickly.^, This barrier applied specifically to masks in both studies, and also applied to general PPE, goggles and face shields, and aprons in one of the studies.

“You can't go straight up to them anymore like you used to be able to. […] Having to go get the PPE and then go back, so you're effectively leaving people, which is a challenge […] because it's not in our nature to leave people” (Bunn et al.)

A lack of optimism about PPE was a barrier to its use, as some health care workers believed that specifically gowns were ineffective in preventing methicillin-resistant Staphylococcus aureus (MRSA) transmission. Some health care workers perceived that their LTC facility did not support or reinforce the use of gowns for medically isolated patients. The intention to protect oneself facilitated the use of PPE, as some health care workers used gowns and gloves to protect themselves or their clothing from bodily fluids, rather than to prevent infection transmission. The memory, attention, and decision processes domain of prioritizing resident care was a barrier to PPE use. Health care workers felt that if there was a resident who required their immediate attention, they would prioritize the resident's care over appropriately selecting and using general PPE and gloves.“If you see someone falling or fallen, you can’t go, ‘Hold on a minute, let me get my PPE on’ and then help them. […] So it is literally you just have to help them” (Bunn et al.

³⁷

• Bunn D.
• Brainard J.
• Lane K.
• et al.

The lived experience of implementing infection control measures in Care homes during two waves of the COVID-19 pandemic. A Mixed-Methods Study.

J Long-Term Care. 2021; 2021: 386-400

• Crossref
• Scopus (5)
• Google Scholar

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The TDF domains of skills, social/professional role and identity, goals, social influences, emotion, and behavioral regulation were not identified in any of the included studies.

Our findings provided an overview of the research identifying the barriers and facilitators to PPE use by health care workers in LTC settings identified in the gray and published literature without any restrictions on when the literature was written. It was not within the scope of this review to assess the methodological quality of the individual references included in the analysis, as its purpose was to be exploratory and describe existing literature from a wide range of study designs and methods using a broad lens. A total of 5216 references were identified by the gray and published literature search and 10 studies were included in the review. Most (80%) were conducted during the COVID-19 pandemic. Seven of the 10 studies highlighted barriers or facilitators to specific components of PPE (eg, masks, gloves, gowns).

Of the 10 eligible studies included in this review, the most common TDF domain identified was environmental context and resources, which was observed in 9 of the included pieces of literature.^{,  ,  ,  ,,  ,  ,  ,}  Lack of availability was the most common barrier to PPE use within LTC. Other barriers that were identified within the environmental context and resources domain were staffing requirements, prioritization of acute care, PPE not being fit to purpose, and the cost of PPE. Availability of PPE and appropriate placement of PPE were identified as facilitators to appropriate PPE use. Shortages of PPE leave health care workers dangerously ill-equipped to care for patients safely and also endanger health care workers. Many countries have struggled to protect their health care workers during the COVID-19 pandemic, where shortages of adequate PPE was a daily concern. As of May 2020, as many as 87% of nurses reported that they had to reuse a single-use disposable mask or N95 respirator, and 27% of nurses reported that, while not wearing appropriate PPE, they were exposed to patients who were confirmed to have COVID-19. As of January 2022, at least 46 health care workers have died from COVID-19 in Canada alone. These data are indicative of health care worker exposure to the virus and of the critical role of PPE in LTC.

The remaining TDF domains were identified in only 2 or fewer references, with the domains of skills, social/professional role and identity, goals, social influences, emotion, and behavioral regulation not being identified in any of the included studies. Additional research is necessary to assess the barriers and facilitators to the appropriate use and selection of PPE comprehensively using the TDF, and whether barriers or facilitators to PPE use exist in the TDF domains that were not sufficiently captured in existing literature. According to previous literature conducted in acute care settings,^{,  ,  ,  ,  ,}  barriers and facilitators exist in the domains of social influences, social/professional role and identity, and emotion; however, it is unclear if these barriers and facilitators to PPE use also exist in LTC settings.

To our knowledge, this review is the first aimed at determining the barriers and facilitators to PPE use by health care workers in LTC settings. There are other reviews that evaluated the barriers and facilitators to general infection prevention and control strategies, such as hand hygiene, isolation practices, and infection prevention and control measures used against specific infectious diseases, but did not focus on the barriers and facilitators to the appropriate use and selection of PPE itself.^{,  ,  ,  ,}  Other reviews investigated the barriers and facilitators to PPE use in acute care settings, but not if those barriers and facilitators exist in the context of LTC.^{,  ,  ,  ,  ,}  LTC is unique from acute care, given the chronic nature of the physical and cognitive challenges facing the residents and the longer-term nature of their residency.

At the time when this scoping review was done, 8 of the 10 included research articles were conducted and published during the COVID-19 pandemic.^{,  ,  ,,  ,  ,  ,}  The recent appearance of these studies may have influenced the findings of this review. For example, during the beginning of the pandemic, severe PPE supply issues were widespread among LTC facilities and other health care facilities. This may have influenced the reporting that PPE was unavailable or that acquiring PPE was challenging because of the supply issues, thus increasing the number of times that the environmental context and resources domain arose from the included literature. As a result, the findings of this scoping review may overrepresent the severity of the barriers to the appropriate use and selection of PPE associated with the environmental context and resources domain of the TDF and may not be widely generalizable outside of the context of the COVID-19 pandemic. Additional research is required to determine if this continues to be an issue or whether other barriers exists outside the context of the COVID-19 pandemic.

Different types of infections require different types of PPE in order to best prevent health care workers from being exposed. Eight of the 10 included studies were conducted during the COVID-19 pandemic, and the barriers and facilitators to the use of PPE were investigated in the context of the pandemic.^{,  ,  ,,  ,  ,  ,}  These studies identified that masks were more likely to not be an available component of PPE, but did not identify any other barriers and facilitators that were particularly more frequent in one component of PPE over another. One study was conducted to explore the barriers and facilitators to glove and gown use to prevent MRSA transmission. This study only investigated glove and gown use, as MRSA only requires contact precautions. The final study was conducted in the context of preventing respiratory viral transmission and thus only investigated barriers and facilitators to mask use. This study, in addition to 1 other, identified that masks in particular made communicating with LTC residents more difficult, especially among those with hearing difficulties and those living with dementia in whom the nonverbal communication that typically aids verbal communication was hindered by wearing masks. Some of the studies included descriptions of the PPE they were assessing, whereas others did not. However, none of the studies conducted a comparative analysis of all the barriers and/or facilitators to the different components of PPE. Further research is required to determine how and why different barriers and facilitators differ by the type of PPE.