Discussion

Our study examines the postpandemic landscape of masking by exploring the beliefs, barriers, and perceptions surrounding mask usage among HCP involved in direct patient care. Overall, self-reported masking adherence rates remain low, highlighting a system wide gap in masking compliance. Although participants generally recognized that masking protects against respiratory infections, this belief did not consistently translate into practice. While 64.4% (n = 400) of participants recognized that masking protects others, suggesting confidence in its general effectiveness, this did not necessarily extend to a sense of social responsibility. Most disagreed with the statements that not wearing a mask endangered patients (n = 253, 40.5%), colleagues (n = 268, 42.9%), or family members (n = 269, 43%). This aligns with prior studies demonstrating a postpandemic decline in coronavirus risk perception and reduced protective behaviors.^{Reference Savadori and Lauriola17} Support for masking policies also varied with the majority (n = 347, 53.0%) endorsing visitor masking in hospitals. Only 42.1% (n = 276) of participants endorsed routine masking during clinical encounters with registered nurses, AHPs, and those part of ancillary staff being least supportive. Lower masking support among nurses may reflect pandemic-related fatigue and burnout. As frontline caregivers for respiratory patients, nurses faced sustained strain, with 91.1% reporting prolonged burnout and 61.0% low job satisfaction.²⁰ These factors likely contribute to resistance toward masking in non-mandated healthcare settings postpandemic and underscore a potential gap in understanding masking as a preventive infection control practice beyond symptomatic scenarios.

During the COVID-19 pandemic, HCP faced significant physical and psychological stressors.^{Reference Firew, Sano and Lee18} Most participants masked when entering patient rooms under droplet precautions but rarely during respiratory specimen collection, suggesting low perceived risk. Adherence was below 75% for all roles, except registered nurses, who may have higher compliance due to more patient contact, training or awareness of infection control protocols, and stronger accountability due to their frequent caregiving role. Other roles may perceive lower risk or face workflow constraints, reflecting a broader shift in HCP perceptions, with some clinical activities no longer seen as requiring consistent masking. In addition, because respiratory specimen collection often included testing asymptomatic patients as part of the hospital’s universal COVID-19 admission testing policy, some HCPs may have perceived themselves to be at lower risk of exposure.

Approximately half of participants in our study reported being up to date on COVID-19 vaccination. While prior studies have explored vaccine hesitancy—highlighting barriers such as safety concerns, mistrust of government, and perceived violations of autonomy—our focus was on the relationship between vaccination status and masking behaviors.^{Reference Peterson, Lee and Nugent19} While vaccination status (COVID-19 or influenza) and masking behavior differed between clinical scenarios, the absolute differences among vaccinated or not vaccinated were small. Consistent with prior studies examining infection prevention practices during the COVID-19 pandemic, masking behavior among HCPs did not differ meaningfully by vaccination status. This finding suggests that adherence to masking was primarily driven by institutional infection prevention policies and workplace norms rather than by individual vaccination decisions. Minor variations observed between groups may reflect contextual influences such as pandemic fatigue, perceived protection afforded by vaccination, and evolving public health messaging that, following vaccine rollout, shifted emphasis from universal precautions to individual responsibility. These factors may have contributed to subtle differences in masking behavior independent of vaccination status.^{20–Reference Betsch, Korn and Sprengholz22}

During the pandemic, HCP often masked in part due to social norms.^{Reference Carbon23} When asked who influenced their decision to mask, the most common response was “no one,” suggesting that masking decisions are now predominantly personal rather than guided by peers, friends, or family. This reflects a broader shift in postpandemic norms. Consistent with prior studies, our findings indicate that communication challenges, speech intelligibility issues, hearing impairment, and general discomfort remain common obstacles.^{Reference Esmaeilzadeh24–Reference Francis, Leavitt, McLelland and Hamilton26} Participants most frequently reported skin irritation, difficulty breathing, and vision interference, underscoring physical discomfort as a persistent deterrent. Open-ended responses revealed a wide spectrum of attitudes—ranging from “masks are helpful” to “masks are not important or helpful” and opposition to mask mandates—highlighting ongoing polarization around masking in clinical settings. A response highlighting opposition to mask mandates was “institutionwide mandatory masking is a net negative and interferes with important parts of the human experience.” These findings suggest that strategies to improve adherence must address both perceptual and practical barriers. Potential interventions include targeted education to reinforce the role of asymptomatic transmission, provision of masks with enhanced breathability and acoustic transparency, availability of communication aids, and reinforcement of risk-based masking guidance. Addressing these factors in tandem may help bridge the gap between knowledge, risk perception, barriers, and consistent protective behaviors in healthcare settings.

Our findings suggest declining trust in community-level transmission risk and reduced masking in clinical settings following the decline in COVID-19 cases. This behavior may be driven by a lower perceived threat of COVID-19 and pandemic fatigue. Education remains critical to reinforce that HARIs pose ongoing risks to both patients and HCP, emphasizing their continued prevalence and asymptomatic transmission. Masking should be promoted as one of several complementary strategies—alongside vaccination, ventilation, and hand hygiene—that together strengthen infection prevention and control efforts in healthcare environments.

Our study has several limitations. Vaccination status was self-reported and not validated against records, introducing potential misclassification. Participants may also have overreported vaccination due to social desirability, which could underestimate differences in masking behavior or inflate associations with vaccination. These factors should be considered when interpreting results. In addition, as a single-center study conducted at an academic medical center, our findings may have limited generalizability to other non-academic healthcare settings. The cross-sectional nature of the study precludes causal interference, and nonresponse bias may have affected sample representatives, as those with stronger views may have been more inclined to participate. Lastly, the timing of the survey—during peak respiratory virus season—may have affected participants’ attitudes and behaviors toward masking and vaccination.

In summary, we have shown that the overall perceived risk of acquiring a respiratory illness is low in the postpandemic era. There is a need to reinforce infection prevention as a shared responsibility, encompassing masking, vaccination, hand hygiene, and appropriate isolation practices. While masking remains an important component of this approach, educational efforts should also emphasize the broader set of measures that collectively reduce the transmission of HARIs.