Factors that affect the duration of wearing disposable personal protective equipment by healthcare professionals in Wuhan during treatment of COVID-19 patients: An epidemiological study.

The purpose of this study of healthcare workers who cared for COVID-19 patients was to identify factors that affected the duration of wearing personal protective equipment (PPE). The results of this study will provide initial guidance to practicing clinicians and a foundation for further research on this topic. This cross-sectional study examined 139 frontline healthcare professionals who worked at a single hospital in Wuhan, China, from March 16 to April 1, 2020. General and demographic data, physical and mental status, use of personal protective equipment, type of hospital work, and duration of wearing personal protective equipment were recorded. The mean duration of wearing personal protective equipment was 194.17 min (standard deviation: 3.71). Multiple linear regression analysis indicated that the duration of wearing personal protective equipment was significantly associated with the presence of a chronic disease, working hours when feeling discomfort, lack of patient cooperation and subsequent psychological pressure, prolonged continuous wearing of personal protective equipment, feeling anxious about physical strength, and the presence of fatigue when wearing personal protective equipment. These factors should be considered by practicing healthcare professionals and in future studies that examine the optimal duration of wearing personal protective equipment.

INTRODUCTION

Coronavirus disease 2019 (COVID‐19) is a newly identified infectious disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). COVID‐19 is highly contagious and is mostly spread through respiratory tract droplets and by direct contact, but transmission via the gastrointestinal tract is also possible (Rathore, Galhotra, Pal, & Sahu, 2020). Thus, people in the general population are susceptible to COVID‐19 (Li et al., 2020). The incubation period is longer than that of many other infectious respiratory diseases, and is generally 3 to 7 days but sometimes up to 14 days (Guo et al., 2020). Patients with severe disease can rapidly develop acute respiratory distress syndrome (ARDS) and septic shock, conditions associated with high mortality (Huang et al., 2020).

Since the beginning of March 2020, more than 3300 healthcare personnel in China had known SARS‐CoV‐2 infections (The Lancet, 2020). In Italy, 20% of medical and healthcare workers who were involved in responding to the COVID‐19 epidemic were infected, and some of them died (Guardian, 2020; World Health Organization, 2020). Thus, in addition to being physically and mentally exhausted and suffering from the long hours of working with patients and colleagues, these individuals also faced an increased risk of infection (The Lancet, 2020). It is essential to protect all healthcare professionals from COVID‐19. Thus, these individuals should wear a full set of disposable personal protective equipment (PPE) during their contact with patients (Huh, 2020). However, there are presently no uniform regulations regarding how long PPE should be worn by healthcare professionals when working in isolation wards.

To ensure the personal safety of healthcare staff, the PPE should provide “level 1 protection” and have a tight fit that prevents exposure (Ahmed et al., 2020). However, not all disposable PPE provides an appropriate balance of protection and comfort (Tabah et al., 2020). As the level of protection increases, overall breathability and wearing comfort decrease (Han, Ma, Hu, & Hao, 2020). Although wearing PPE probably provides healthcare professionals with a sense of security, those who wear PPE for a long time may experience blurred vision, shortness of breath, gasping, nausea, vomiting, diarrhea, skin damage (due to the high humidity), skin pressure damage, and even syncope (Tabah et al., 2020). In addition, long‐term use of disposable PPE reduces its protectiveness, and could seriously endanger the health of healthcare professionals (Han et al., 2020; Kantor, 2020). On the other hand, the use of disposable PPE for very short durations will lead to waste of medical resources and increase the tension associated with human resource deployment during an epidemic. Thus, from the perspective of the safety and comfort of the healthcare professionals, it is necessary to examine how long they should wear PPE when working in isolation areas, and how to best prevent the occurrence of adverse events.

No previous research examined the optimal duration for wearing disposable PPE by healthcare professionals during treatment of COVID‐19 patients. Thus, this study recorded the duration of wearing disposable PPE by healthcare professionals at a single hospital in Wuhan, China, and identified factors associated with the duration of wearing PPE. The long‐term purpose was to identify the optimal duration for wearing disposable PPE, based on avoidance of controllable risk factors, and to provide evidence‐based recommendations for optimizing the use of disposable PPE.

Many factors can affect the duration that a healthcare worker wears PPE, such as the individual's physical and mental condition, the characteristics of the PPE, and the nature of the hospital work being performed. Therefore, this research analyzed the factors that affected the duration of wearing disposable PPE by examining the internal and external environment of healthcare professionals. The results will provide the first data on factors that affect the duration of wearing PPE by healthcare professionals, and will also provide constructive suggestions for future clinical work and research on this topic. We hypothesized that multiple factors affect the duration of wearing disposable PPE by healthcare professionals in Wuhan when caring for COVID‐19 patients.

METHODS

Design

This cross‐sectional study used purposive sampling to study all 176 members of the healthcare staff of the First Affiliated Hospital of Dalian Medical University who participated in the prevention and control of the COVID‐19 epidemic from March 16, 2020 to April 1, 2020.

Participants and procedures

All included participants were healthcare professionals (doctors and nurses) who worked in the clinical frontline; had education, physical, and mental status that allowed independent completion of the questionnaire; and volunteered to participate in this study. Individuals were excluded if they had a previous mental illness based on a written questionnaire. A total of 176 healthcare professionals in the hospital wards met these criteria, provided informed consent, and received questionnaires. After exclusion of questionnaires that were incomplete or had unusable responses (such as lacking the times of entering or exiting the quarantine ward), 139 valid questionnaires were analyzed.

This study was approved by the Research Ethics Committee of the First Affiliated Hospital of Dalian Medical University (PJ‐KS‐KY‐2020‐53). Permission was provided to perform this study within the premises of the First Affiliated Hospital of Dalian Medical University and Wuhan LeiShenShan Hospital. After obtaining informed consent, uniform instructions were used to administer the questionnaires, which were completed and collected on the same day. Part of the questionnaire was completed in the isolation ward, so photocopies were taken for uploading and the paper version (which remained in the isolation ward) was destroyed. Participants were reminded to record their times of entering and leaving the isolation ward and times of putting on and taking off PPE. These times were recorded to determine “working time”. We defined “the time of wearing PPE” as the time the worker was wearing PPE for the specified work shift. But, if the worker had unbearable discomfort, he or she could take off the PPE at any time when not in the isolation area.

Measures

General data

Age, gender, education, professional title, marital status, and previous experience in caring for patients with other infectious diseases (SARS, avian flu, and others) were recorded. The presence of a chronic disease (hypertension, diabetes, etc.) was also recorded.

Physical and mental variables

Before taking off PPE, oxygen saturation and pulse were recorded. The amount of drinking water (ml; within 1 h before entering the isolation ward); volume of first urination (ml; after entering the isolation ward); and sweating during the shift (clothes dry, slightly damp, wet, or soaked) were recorded. In addition, each participant provided “yes” or “no” responses to the following questions: Were you sick during the recent support period? Are you worried about getting infected? Did lack of patient cooperation lead to psychological pressure? Did high work intensity cause psychological stress? Did you have blurred vision when wearing PPE? Did you feel dizzy while wearing PPE? Did you have a headache while wearing PPE? Did you have fatigue when wearing PPE? Did you have shortness of breath when wearing PPE? Did you feel “dull” when wearing PPE? Did you have nausea while wearing PPE? Did you vomit while wearing PPE? Did you have diarrhea while wearing PPE? Did you have a rash while wearing PPE? Did you feel irritable when your physical strength reached a limit? Did you feel anxious when your physical strength reached a limit? These questions were designed based on examination of the literature and consultation with experts.

Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). This study used the Chinese version of this scale (Liu et al., 1996), which is free to use without permission. This scale has 19 self‐assessment items that measure sleep quality in seven dimensions (sleep efficiency, sleep latency, subjective sleep quality, sleep duration, sleep disturbances, daytime dysfunction, use of sleeping medications). Each dimension was scored from 0 to 3, and the scores were added to calculate the total PSQI (range: 0 to 21). A higher total score corresponded to poorer sleep quality. Previous research indicated that this scale provided reliable assessments of sleep quality (Backhaus, Junghanns, Broocks, Riemann, & Hohagen, 2002; Liu et al., 1996).

The Self‐Rating Anxiety Scale (SAS) (Zung, 1971) was used to measure anxiety. This study used the revised version from the Chinese Scale Cooperation Group (Wang et al., 1999), which is free to use without permission. This scale has 20 items, each item was scored from 1 to 4, and the total score was obtained by adding the scores of each item. The total score was then multiplied by 1.25 so that the total standard score ranged from 0 to 100. The standard cut‐off value was 50, and a score above 50 points indicated the presence of anxiety symptoms. A standard score of 50 to 59 indicated mild anxiety, a score of 60 to 69 indicated moderate anxiety, and a score of 70 and above indicated severe anxiety.

The Self‐Rating Depression Scale (SDS) (Zung, 1965) was used to measure depression. This study used the revised version from the Chinese Scale Cooperation Group (Wang et al., 1999), which is free to use without permission. This scale has 20 items, each item was graded from 1 to 4, and the scores of all items were added to calculate the total score. As above, the total score was then multiplied by 1.25 so that the total ranged from 0 to 100. The standard cut‐off value was 53, and a score above 53 points indicated the presence of depressive symptoms. A score of 53 to 62 points indicated mild depression, a score of 63 to 72 indicated moderate depression, and a score above 72 indicated severe depression.

Types of PPE and related variables

The type of mask (N95 mask alone, N95 mask and a medical surgical mask, ordinary medical mask and a medical surgical mask, or others) and eye protection (goggles, face screen, goggles and face screen) used when working in the isolation ward, the duration of continuously wearing PPE, the maximum working hours when continuously wearing PPE, the hours working when feeling discomfort wearing PPE, the hours working when feeling tired after entering the isolation ward, and the hours working when at the limit of physical strength were recorded. For this last variable, this limit was defined by the time when a doctor or nurse wearing PPE felt that his or her physical strength did not allow further work. These variables were assessed based on examination of the literature and consultation with experts.

Types of hospital work

The timing of the work shift (day, before midnight, or after midnight), total number of patients cared for on a shift, number of patients 65 years‐old or more, total number of beds in the isolation ward, total number of doctors and nurses, current number of doctors and nurses per day shift, current number of doctors and nurses per night shift, and environment of the isolation ward (negative pressure ward or general ward) were recorded. These variables were assessed based examination of the literature and consultation with experts.

Statistical analysis

Two researchers entered all the data, and 10% of all entries were subjected to verification to ensure accuracy. SPSS 17.0 software was used for statistical analysis (SPSS Inc, Chicago, IL, USA). Descriptive methods were used for presentation of general information, physical and mental conditions, use of PPE, and type of hospital work. Count data were expressed as frequencies and percentages. Continuous data that had normal distributions were presented as means ± standard deviations (SDs), and data with non‐normal distributions as medians and inter‐quartile ranges (IQRs). For single factor analysis of continuous variables, Pearson or Spearman correlation analysis was used to analyze the correlation of different variables with the duration of wearing PPE. For categorical variables, a t‐test or a single factor analysis of variance was used. Stepwise multiple linear regression analysis was used to identify the independent effects of different variables on the duration of wearing PPE.

RESULTS

General characteristics of healthcare professionals

This study analyzed 139 healthcare professionals (nurses and doctors) who worked at LeiShenShan Hospital in Wuhan and cared for patients with COVID‐19 during March 2020 (Table 1). The overall mean duration of wearing PPE was 194.17 min (SD = 3.71) and the mean age was 31.49 years‐old (SD = 4.93; range: 22 to 43).

TABLE 1

Characteristics of study subjects (n = 139)

Label	x¯±s/n (%)	Label	x¯±s/n (%)
Age (years)	31.49 ± 4.93	Previous participation in caring for patients with other infectious diseases (SARS, avian flu, and others)
Gender		‐Yes	8 (5.8)
‐Male	9 (6.5)	‐No	131 (94.2)
‐Female	130 (93.5)	Education
Professional title		‐Master degree or above	2 (1.4)
‐Director physician or director nurse	0	‐Bachelor degree	121 (87.1)
‐Assistant director physician or assistant director nurse	8 (5.8)	‐College degree	13 (9.4)
‐Doctor‐in‐charge or nurse‐in‐charge	45 (32.4)	‐Technical secondary school education	3 (2.2)
‐Doctor or nurse practitioner	68 (48.9)	Marital status
‐Assistant doctor or nurse	18 (12.9)	‐Married	86 (61.9)
Do you have a chronic disease(hypertension, diabetes, etc.)?		‐Unmarried	52 (37.4)
‐Yes	53 (38.1)	‐Divorced	1 (0.7)
‐No	86 (61.9)	‐Widowed	0

Note: , means ± standard deviations.

Bivariate analysis of factors associated with duration of wearing PPE

Bivariate analysis (Table 2) indicated that the duration of wearing PPE had significant negative correlations with daytime dysfunction score on the PSQI (r = −0.167, P = 0.049) and the number of working doctors and nurses on the day shift (r = −0.193, P = 0.023). However, the duration of wearing PPE had significant positive correlations with maximum working hours while wearing PPE (r = 0.218, P = 0.010) and working hours when feeling discomfort (r = 0.218, P = 0.010).

TABLE 2

Bivariate analysis of the association of different variables with the duration of wearing PPE (n = 139)

Label	x¯±s/(md, IQR)	The duration of wearing PPE		Label	x¯±s/(md, IQR)	The duration of wearing PPE
		r	P			r	P
Age (years)	31.49 ± 4.93	0.090	0.293	SAS	43.11 ± 11.48	−0.043	0.615
Oxygen saturation before wearing PPE(%)	(98.00, 1)	−0.260	0.758	SDS	45.26 ± 12.02	−0.047	0.587
Pulse before wearing PPE (times / min)	88.02 ± 13.56	0.037	0.667	The maximum working hours when continuously wearing PPE(min)	358.06 ± 108.48	0.218	0.010
Oxygen saturation before taking off PPE(%)	(98.00, 1)	−0.043	0.617	The hours working when feeling discomfort wearing PPE(min)	127.71 ± 65.53	0.218	0.010
Pulse before taking off PPE(times/min)	91.82 ± 12.06	0.044	0.604	The hours working when feeling tired after entering the isolation ward(min)	193.24 ± 62.87	0.088	0.303
Water consumption (ml; within 1 h before entering the isolation ward)	(50, 100)	0.161	0.059	The hours working when at the limit of physical strength(min)	305.48 ± 90.01	0.025	0.772
Volume of first urination (ml; after entering the isolation ward)	(200, 200)	−0.084	0.328	Total number of patients cared for on a shift	(8,10)	−0.056	0.529
PSQI	9.94 ± 3.71	−0.035	0.683	Number of patients 65 years‐old or more	(4, 5)	−0.026	0.775
‐Sleep efficiency	1.09 ± 1.07	−0.002	0.978	Total number of beds in isolation ward	(48,10)	0.070	0.411
‐Sleep latency	2.11 ± 0.91	−0.024	0.782	Total number of doctors and nurses	(46, 5)	0.153	0.072
‐Subjective sleep quality	1.55 ± 0.77	0.003	0.971	Current number of doctors and nurses per day shift	(12,5)	−0.193	0.023
‐Sleep duration	1.59 ± 0.88	0.035	0.683	Current number of doctors and nurses per night shift	(7,0)	0.069	0.417
‐Sleep disturbances	1.29 ± 0.61	−0.056	0.515
‐Daytime dysfunction	1.90 ± 0.88	−0.167	0.049
‐Use of sleeping medications	0.42 ± 0.82	0.051	0.548

Abbreviations: , means ± standard deviations; Md, median; IQR, inter‐quartile ranges.

Univariate analysis of factors associated with duration of wearing PPE

Univariate analysis (Table 3) indicated that the duration of wearing PPE had significant positive associations with the presence of a chronic disease (t = 2.655, P = 0.009), lack of patient cooperation and subsequent psychological pressure (t = 2.271, P = 0.025), feeling “dull” when wearing PPE (t = 2.362, P = 0.020), feeling anxious because of limited physical strength (t = 2.226, P = 0.028), and work shift (t = 6.111, P = 0.003), but a significant negative association with the presence of fatigue when wearing PPE (t = −2.050, P = 0.042).

TABLE 3

Univariate analysis of the association of different variables with the duration of wearing PPE (n = 139)

Label	n (%)	The duration of wearing PPE (x¯±s)min	t/F	P	Label	n (%)	The duration of wearing PPE (x¯±s)min	t/F	P
Gender			−0.640	0.523	Did you have a headache while wearing PPE?			−0.905	0.367
‐Male	9 (6.5)	185.11 ± 42.43			‐Yes	45 (32.4)	199.02 ± 40.13
‐Female	130 (93.5)	194.79 ± 43.95			‐No	94 (67.6)	191.84 ± 45.43
Education			1.940	0.126	Did you have fatigue when wearing PPE?			−2.050	0.042
‐Master degree or above	2 (1.4)	223.00 ± 18.39			‐Yes	40 (28.8)	206.00 ± 39.73
‐Bachelor degree	121 (87.1)	196.67 ± 43.60			‐No	99 (71.2)	189.38 ± 44.60
‐College degree	13	169.31 ± 44.12			Did you have shortness of breath when wearing PPE?			1.795	0.075
‐Technical secondary school education	3 (2.2)	181.67 ± 28.43			‐Yes	68 (48.9)	187.41 ± 43.69
Professional title			0.069	0.977	‐No	71 (51.1)	200.63 ± 43.16
‐Director physician or director nurse	0				Did you feel “dull” when wearing PPE?			2.362	0.020
‐Assistant director physician or assistant director nurse	8 (5.8)	199.38 ± 46.17			‐Yes	95 (68.3)	188.29 ± 40.74
‐Doctor‐in‐charge or nurse‐in‐charge	45 (32.4)	195.36 ± 45.82			‐No	44 (31.7)	206.84 ± 47.74
‐Doctor or nurse practitioner	68 (48.9)	192.84 ± 43.01			Did you have nausea while wearing PPE?			0.254	0.800
‐Assistant doctor or nurse	18 (12.9)	193.89 ± 43.84			‐Yes	32 (23.0)	192.44 ± 44.91
Marital status			0.968	0.382	‐No	107 (77.0)	194.68 ± 43.62
‐Married	86 (61.9)	197.88 ± 43.71			Did you vomit while wearing PPE?			−1.432	0.154
‐Unmarried	52 (37.4)	188.60 ± 43.89			‐Yes	2 (1.4)	238.00 ± 2.828
‐Divorce	1 (0.7)	164.00			‐No	137 (98.6)	193.53 ± 43.76
‐Widowed	0	0			Did you have diarrhea while wearing PPE?			−0.565	0.573
Previous participation in caring for patients with other infectious diseases (SARS, avian flu, and others)			0.762	0.448	‐Yes	3 (2.2)	208.33 ± 35.47
‐Yes	8 (5.8)	205.03 ± 53.35			‐No	136 (97.8)	193.85 ± 43.99
‐No	131 (94.2)	193.47 ± 43.26			Did you have a rash while wearing PPE?			0.795	0.428
Do you have a chronic disease(hypertension, diabetes, etc.)?			2.655	0.009	‐Yes	11 (7.9)	184.09 ± 31.85
‐Yes	53 (38.1)	206.45 ± 43.56			‐No	128 (92.1)	195.03 ± 44.63
‐No	86 (61.9)	186.59 ± 42.39			Did you feel irritable when your physical strength reached a limit?			−0.379	0.705
Sweating during the shift			0.355	0.786	‐Yes	110 (79.1)	194.89 ± 42.16
‐Clothes dry	23 (16.5)	187.57 ± 60.25			‐No	29 (20.9)	191.41 ± 50.13
‐Slightly damp	63 (45.3)	192.97 ± 41.75			Did you feel anxious when your physical strength reached a limit?			2.226	0.028
‐Wet	45 (32.4)	198.53 ± 38.05			‐Yes	85 (61.2)	187.67 ± 42.92
‐Soaked	8 (5.8)	198.00 ± 38.96			‐No	54 (38.8)	204.39 ± 43.51
Were you sick during the recent support period?			1.175	0.242	The type of mask used when working in isolation ward			1.992	0.118
‐Yes	12 (8.6)	208.33 ± 27.00			‐N95 mask alone	14 (10.1)	203.57 ± 33.25
‐No	127 (91.4)	192.83 ± 44.87			‐N95 mask and a medical surgical mask	115 (82.7)	191.13 ± 44.73
Are you worried about getting infected			1.885	0.062	‐ordinary medical mask and a medical surgical mask	8 (5.8)	226.13 ± 36.75
‐Yes	116 (83.5)	191.08 ± 43.06			‐Others	2 (1.4)	175.00 ± 35.36
‐No	23 (16.5)	209.74 ± 44.95			The type of eye protection used when working in isolation ward			1.044	0.355
Did lack of patient cooperation lead to psychological pressure?			2.271	0.025	‐goggles	66 (47.5)	195.36 ± 40.87
‐Yes	51 (36.7)	183.25 ± 47.41			‐Face screen	2 (1.4)	150.00 ± 42.43
‐No	88 (63.3)	200.49 ± 40.45			‐Goggles + face screen	71 (51.1)	194.30 ± 46.29
Did high work intensity cause psychological stress?			0.072	0.942	The timing of the work shift			6.111	0.003
‐Yes	46 (33.1)	193.78 ± 45.21			‐Day	91 (65.5)	201.76 ± 42.52
‐No	93 (66.9)	194.35 ± 43.28			‐Before midnight	28 (20.1)	169.86 ± 33.21
Did you have blurred vision when wearing PPE?			0.363	0.717	‐after midnight	20 (14.4)	193.65 ± 51.32
‐Yes	64 (46.0)	192.70 ± 47.00			The environment of the isolation ward			−1.034	0.303
‐No	75 (54.0)	195.41 ± 41.08			‐Negative pressure Ward	136 (97.8)	193.60 ± 43.88
Did you feel dizzy while wearing PPE?			0.211	0.833	‐General ward	3 (2.2)	220.00 ± 34.64
‐Yes	49 (35.3)	193.10 ± 44.71
‐No	90 (64.7)	194.74 ± 43.49

Multivariate analysis of factors associated with duration of wearing PPE

All results in the univariate or bivariate analyses that had P‐values below 0.05 were entered into a multivariate analysis (Table 4). The results indicated that the duration of wearing PPE had significant positive associations with the presence of a chronic disease (t = 2.707, P = 0.008), working hours when feeling discomfort wearing PPE (t = 3.326, P = 0.001), longest continuous working time while wearing PPE (t = 2.395, P = 0.018), and the presence of fatigue when wearing PPE (t = 2.280, P = 0.024), but had significant negative associations with lack of patient cooperation and subsequent psychological pressure (t = −3.050, P = 0.003) and feeling anxious when physical strength reached a limit (t = −2.469, P = 0.015). .

TABLE 4

Multiple linear regression analysis of the association of different variables with the duration of wearing PPE (n = 139)

Label	B	SE	β	t	P
Constant	151.526	14.447	—	10.488	<0.001
Do you have a chronic disease(hypertension, diabetes, etc.)?(yes or no)	18.843	6.961	0.209	2.707	0.008
The hours working when feeling discomfort wearing PPE	0.170	0.051	0.254	3.326	0.001
Did lack of patient cooperation lead to psychological pressure? (yes or no)	−21.196	6.950	−0.233	−3.050	0.003
The maximum working hours when continuously wearing PPE	0.075	0.031	0.186	2.395	0.018
Did you feel anxious when your physical strength reached a limit? (yes or no)	−16.992	6.883	−0.189	−2.469	0.015
Did you have fatigue when wearing PPE? (yes or no)	16.802	7.368	0.174	2.280	0.024

Note: R = 0.503, R = 0.253, adjusted R = 0.219, F = 7.346, P < 0.001.

DISCUSSION

This cross‐sectional study examined healthcare professionals who cared for patients with COVID‐19 at a single hospital in Wuhan, recorded the durations of wearing disposable PPE, and identified factors that influenced this duration. The results showed that the mean duration of wearing PPE was 194.17 min (SD = 3.71). No previous studies examined this topic, so a comparison with previous research is not possible. Moreover, these results are from a purposive sample of care givers who were frontline healthcare professionals in China. Previous studies showed that wearing disposable PPE for too long led to discomfort, reduced protection, and increased the probability of infection (Ambigapathy et al., 2020). During the study period (March 2020), none of the healthcare professionals examined here developed symptoms of COVID‐19. Therefore, the durations of wearing PPE were apparently within the safe range. The data presented here thus provide a reference for subsequent studies of the effects of duration of wearing PPE by healthcare professionals, for subsequent research on the optimal duration for continuously wearing PPE, and for future development of relevant clinical standards or guidelines. In addition, the results presented here indicated that medical workers experienced discomfort when wearing disposable PPE after a mean duration of 127.71 min (SD = 65.53). This should be considered when formulating best practices for the duration of wearing PPE in clinical settings and in future studies.

This study showed that healthcare professionals with chronic diseases wore their PPE for longer periods than those without chronic diseases. The symptoms of chronic diseases are typically persistent, recurrent, and refractory (Han et al., 2020; Zhang et al., 2016). People with chronic diseases who continuously or intermittently experience symptoms of physical distress may have increased tolerance to wearing PPE because they have learned to adopt coping measures to manage physical discomfort. However, there is evidence that chronic diseases can reduce physical strength (Shen et al., 2019), and this would be expected to reduce the duration of wearing PPE. The present results are contrary to this expectation, possibly because this study examined subjects who were young (M = 31.49, SD = 4.93) and chronic diseases may not yet have led to significant negative effects, or because these healthcare professionals had certain personal characteristics that allowed them to overcome their limitations when responding to the COVID‐19 pandemic. Subsequent research should examine the unique qualities of healthcare professionals who have chronic diseases, and seek to identify the specific positive psychological features that provide them with increased resilience during disease outbreaks.

The results presented here showed that healthcare professionals who experienced discomfort soon after changing into their PPE wore their PPE for shorter durations. Although this is as expected, there are currently no clear regulations on the duration for wearing PPE. Instead, a healthcare professional who experiences unbearable symptoms or whose work schedule is ending simply removes the PPE at that time. In addition, the results presented here also showed that those with longer working hours wore their PPE for longer durations.

The results presented here showed that feeling anxious about reaching the limit of physical strength influenced the duration of wearing PPE. In other words, healthcare professionals who experienced anxiety were likely to wear PPE for shorter durations. Previous studies showed that the psychological state can directly affect physiological responses, and that unhealthy psychology adversely affects physical health (Salovey, Rothman, Detweiler, & Steward, 2000; Vander Zee, Buunk, & Sanderman, 1995). In addition, psychological pressure can adversely affect a healthcare professional's physiological status and ability to work (Roberts & Grubb, 2014). This suggests that clinical managers and researchers should pay close attention to the mental status of their staff, promptly identify problems, and provide guidance to affected workers. In addition, frontline healthcare professionals who are experiencing obvious psychological pressure may want to reduce their working hours and duration of wearing PPE. These individuals should seek prompt help or support, and should try to relax and improve their mental state to improve engagement in their clinical work.

However, some similar factors had opposite effects on PPE wearing times, such as fatigue, feeling dull, and feeling anxious. In particular, healthcare professionals who developed symptoms of fatigue wore their PPE longer than those who did not and feeling dull had no effect on the duration of wearing PPE. However, feeling anxious about reaching the limit of physical strength was associated with a reduced duration of wearing PPE. This may be because the symptoms of fatigue and feeling dull were mild, and these individuals simply decided to continue working. This study had a small sample size and used an evaluation tool that was subjective. These results thus require further examination in follow‐up research.

The results suggest that cooperation by patients affected the psychological status of healthcare professionals. More specifically, a lack of patient cooperation led to psychological pressure in healthcare professionals and reduced the duration of wearing PPE. Patients with COVID‐19 are generally more anxious (Chen, Wen, Zhou, & Xiao, 2020; Rajkumar, 2020). In particular, when faced with a sudden outbreak, patients may be psychologically traumatized, with manifestations of irritability, panic, and poor communication. Therefore, healthcare professionals should work with psychologists in these clinical settings. The psychological status of COVID‐19 patients is a very important consideration, and these patients should receive timely counseling and encouragement to establish confidence in recovery. These interventions will likely improve the coordination of treatment and nursing, and reduce the anxiety of healthcare professionals.

CONCLUSIONS

The mean duration of wearing PPE was 194.17 min (SD = 3.71) and the duration of wearing PPE was significantly associated with the presence of a chronic disease, working hours when feeling discomfort, patient cooperation, a long continuous time of wearing PPE, feeling anxious about physical strength, and the presence of fatigue when wearing PPE. These factors should be considered by practicing clinicians and in future studies that examine the duration of wearing PPE. These results provide the first data on factors that affect the duration of wearing PPE by healthcare professionals, and a basis for future research on this topic.

This study also had several limitations. First, the study participants were a small purposive sample of healthcare professionals from a single hospital in China. Second, this study was performed during the late stage of the COVID‐19 epidemic in Wuhan. During this period, there were fewer patients hospitalized with COVID‐19 than earlier during the epidemic. Thus, the healthcare professionals had a reduced workload and increased availability of human resources. These factors may have led to decreased durations of wearing PPE. Third, participants may have reported inaccurate times of entering and leaving the isolation ward and of putting on and taking off PPE, and inaccurate information regarding water consumption and urination. Fourth, although the study used “total number of patients cared for on a shift, number of patients 65 years‐old or more, and total number of beds in the isolation ward” to assess the workload, these factors may not accurately represent work quantity and quality, or even the ability to work. Finally, a major factor that determines the duration of wearing PPE is the manufacturer's suggestion. Therefore, the use of PPE should follow the guidelines of the manufacturer and other protocols established by healthcare institutions. Although a healthcare professional should not make arbitrary decisions regarding the duration of wearing PPE, the factors indentified here may cause deviations from proper and accepted use of PPE.

CONFLICT OF INTEREST

There are no conflicts of interest.

AUTHOR CONTRIBUTIONS

F.L., T.J., T.S., and Y.L. designed the study; Y.L., X.L., G.X. collected data; F.L., T.J., Y.L., and Y.S. organize the data; F.L., T.J. conducted the statistical analyses, drafted the manuscript; F.L., T.J., T.S., Y.L., X.L., G.X., Y.L., and Y.S. contributed to the discussion. All authors had read and approved the manuscript.