Discussion

Our survey of HCWs’ attitudes towards universal mask use and transmission-based precautions with glove and gown use, found that the majority of HCWs are in favor of PPE to prevent the transmission of pathogens in the healthcare setting, however support is not uniform across PPE type and attitudes have shifted during the course of the COVID-19 pandemic. Agreement with universal mask policy decreased from 84% early in the pandemic when vaccines were not available to 55% in 2023, and 90% of HCWs agreed with the use of gloves when caring for patients with antibiotic-resistant bacteria compared to 75% agreement with the use of gowns. Masks are valued by HCW for the protection they provide, but most respondents expressed some level of annoyance wearing them, and for a multitude of reasons. Some HCWs were broadly opposed to universal mask policies as well as gown and glove use for transmission-based precautions. As evidenced by correlation at the individual respondent level across different policy questions, there are may be more fundamental drivers of support for or against transmission-based precautions that impact their perceived value by HCWs.

Mask use during the COVID-19 pandemic has been a controversial topic both among hospital epidemiologists, HCWs, and the general public. ^{Reference Murray, Cowger and Hall12,Reference Ertem, Nelson and Schechter-Perkins13} Along with the debate about the optimal mask to prevent SARS-CoV-2 transmission, there is uncertainty about the appropriate timing for healthcare facilities to transition in and out of universal masking policies. ^{Reference Landelle, Birgand and Price4,Reference Loeb, Bartholomew and Hashmi14–Reference Klompas, Milton and Rhee16} In their review, Landelle, et al. ^{Reference Landelle, Birgand and Price4} discussed issues to be weighed when considering the de-escalation of universal masking policies including community prevalence of different respiratory viruses and outcomes of virus acquisition among patients and HCWs. Importantly, they acknowledge that adherence and compliance with masking should also be taken into account, as well as the physical discomfort and the potential negative impact that masking has on provider-patient relationships. Various experts and thought leaders have put forth contrasting viewpoints of the value and impact of universal masking at this stage of the pandemic, however, missing from these discussions are the contemporary opinions of front line health care workers. ^{Reference Shenoy, Babcock and Brust3,Reference Palmore and For Patient Safety17} To our knowledge, our study is the first survey to assess HCWs’ attitudes towards mask use early in the pandemic and evaluate how these attitudes have changed over time. Our survey findings echo many of the discussion points raised by others: HCWs valued the sense of self-protection that masks provide them but there are tradeoffs to their use including discomfort and challenges with workplace communication. The latter is an oft-cited counterargument to broad use of masking as disease outcomes improve and prevalence declines, and our survey provides additional validation of that claim. ^{Reference Shenoy, Babcock and Brust3,Reference Alzunitan, Perencevich and Edmond18}

Contact precautions with gowns and gloves are routinely used for the care of patients with antibiotic-resistant bacteria, though their value is more uncertain for endemic Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE). ^{Reference Popovich, Aureden and Ham19–Reference Bearman, Harris and Tacconelli22} To our knowledge, no studies have been done during the pandemic to assess HCW attitudes towards the use of glove and gowns for antibiotic-resistant bacteria, and very little data exist at all. ^{Reference Manian and Ponzillo23} Many authors outline the annoyance of donning and doffing gloves and gowns, but there are limited studies outlining US HCWs’ attitudes towards contact precautions, and none that we identified following the onset of the COVID-19 pandemic. ^{Reference Diekema, Nori and Stevens21–Reference Burkitt, Sinkowitz-Cochran and Obrosky25} Some studies have suggested that compliance with glove and gown use has been shown to decrease with increasing use of contact precautions, however, a 20 intensive care unit randomized trial comparing universal glove and gown use to glove and gown use for 10% of patients showed no difference in adherence. ^{Reference Manian and Ponzillo23,Reference Harris, Pineles and Belton26,Reference Dhar, Marchaim and Tansek27} In our survey, we found lower acceptance of gown use compared to gloves. Similar to considerations around universal masking, it is important for hospital epidemiologists, infection prevention programs, and others who develop PPE policies to consider the tradeoffs of a policy, balancing patient safety with any additional burden of work and acceptance by bedside staff. In particular, nurses and patient care technicians bear the greatest burden of work for donning and doffing during the course of routine patient care and notably expressed the lowest level of agreement with gown use in our survey. ^{Reference Roth, Hornung-Winter and Radicke28} Acknowledging current challenges with PPE compliance, further investigation into technology innovations such as antimicrobial impregnated fabrics could improve infection prevention without adding effort to the physical demands of patient care. ^{Reference Anderson, Addison and Lokhnygina29,Reference Bearman, Rosato and Elam30}

The limitations of this study include that it was performed at a single academic medical center. Despite numerous efforts to increase survey response rates, the survey response rate was still low. There are approximately 13,000 employees and staff at UMMC, however eligibility for the survey by having contact with patients as part of one’s role was self-reported, and the subset of staff who meet this criterion is not a defined quantity. Thus, we do not know whether HCWs who responded were representative of the entire eligible workforce. In addition, our survey did not inquire about attitudes regarding gown and glove use as they pertain to specific antibiotic-resistant bacteria (eg, MRSA), however it was intended for a multi-disciplinary audience including non-clinical staff members without expertise to discern the value of PPE for different pathogens. The timing of survey distribution was a strength of this study as it was administered immediately after a policy shift to de-implement universal masking, which allowed information to be gained about HCWs changes in attitudes towards universal mask use early in the pandemic versus late in the pandemic. It also must be acknowledged that the responses captured in this study regarding agreement with universal masking early in the pandemic are retrospective. Another important strength of our survey was our broad inclusion criteria, with responses from a large array of professional disciplines. The viewpoints of non-provider and non-nursing roles are often underrepresented and comprised 40% of our respondents with self-reported demographics. As indicated, despite the study being a single center study it is unique in assessing HCW attitudes towards different forms of PPE.

In conclusion, most HCWs are favorable towards mask use, glove use, and gown use for the prevention of pathogen transmission. However, some HCWs were not in favor of gown, glove, or mask use for patient care; these opinions appear to be driven by annoyance, impediment to work, or a combination of reasons including those not explored in this survey. More work is needed to help remedy the barriers towards the acceptability of these forms of PPE especially in light of the current HCW shortages in the United States and rising incidence of multi-drug resistant pathogens. More work is needed in the field of implementation science to educate HCWs and patients on the data supporting or refuting the use of precautions and other infection control interventions, and acknowledgement of the impact of different infection prevention strategies including the opportunity costs of time and effort, as well as contributions to fatigue and burnout. ^{Reference Silva, Galvao and Chapman31,Reference Trivedi, Schaffzin and Deloney32} As the science of transmission continues to evolve, we need to continue to assess HCW and patient attitudes towards transmission.