COVID-19: nurses say they are not getting adequate PPE
Exclusive research by Nursing Standard finds front-line staff are fearful for their own safety
- Two thirds of nurses say they do not have sufficient access to personal protective equipment (PPE)
- One third have used their own money and one tenth have tried to make their own
- RCN says nurses ‘must feel safe and need action rather than assurances’
Two thirds (67%) of nurses do not have access to sufficient personal protective equipment (PPE) as the COVID-19 pandemic continues, an exclusive Nursing Standard survey suggests.
Almost 3,500 UK nurses responded to our survey on the availability of PPE where they work.
Terrified front-line staff told how they fear for their health because of a lack of PPE such as face masks, goggles and visors.
‘I feel frightened for my life and in a situation out of my control,’ one nurse said.
Nursing Standard conducted an online survey open to all UK nurses and nursing students 3-6 April 2020, and received 3,438 responses.
Almost one third (31%) have used their own money to buy PPE and one in ten has resorted to making their own, our survey found.
‘I will be the next victim of COVID-19’
While some nurses said they had adequate supplies at work, most said PPE is scarce, rationed and often of poor quality.
31 December 2019
The World Health Organization was informed of a cluster of cases of pneumonia of unknown cause in Wuhan, China
‘Shocking,’ one nurse said about PPE provision. ‘Inadequate. Unsafe. I feel I am risking my life to care for these patients. And I feel I will be the next victim of COVID-19 if it carries on.’
Masks, when available, are frequently poorly fitting and out of date, some by years.
‘The surgical masks do not fit the faces of over half the nursing staff and, as most people say on the ward, [you] could fit your shopping in the sides where it bags so much’, one nurse said.
‘The flimsiest masks I've ever seen in eight years of hospital work are the only ones we have access to,’ another added.
One nurse said she was told to put a panty liner inside a used mask to extend its lifespan.
‘It is unacceptable that nurses are being forced to spend their own money to buy what would be considered the bare minimum to protect themselves’
Susan Masters, RCN
Getting a mask fit test and the correct size of filtering face piece respirator mask remains challenging, respondents suggest.
‘Only one type of FFP3 mask available which does not fit many people [but] no other option,’ a comment said.
‘The trust won’t mask fit test bank staff but allows them to work in the highest risk areas of respiratory, ITU, combined assessment and A&E,’ one nurse said. ‘There are many contracted staff that haven’t been mask fit tested too.’
What protective equipment should nurses have?
The government sets out different levels of PPE depending on where nurses are working.
Nurses working in inpatient settings, including wards, emergency departments and maternity units, with possible or confirmed cases, should wear disposable gloves, apron, a fluid-resistant surgical mask and eye or face protection, according to Public Health England.
Those in affected higher risk areas, which include ICU and emergency department resuscitation areas, should wear gloves, apron, a fluid-resistant gown, a filtering face piece respirator and eye or face protection.
In primary and community care, when carrying out direct patient care for someone with suspected or confirmed COVID-19, or in the community, where someone else in the same household has symptoms, nurses should wear disposable gloves, apron, fluid-resistant surgical mask and risk assess whether to use eye or face protection. They should wear disposable gloves, apron and a surgical mask when they visit a house with any member who is in the extremely vulnerable group.
Many nurses are deeply concerned that guidance for UK nurses differs slightly from that from the World Health Organization (WHO). ‘We have the "correct" PPE according to government guidance. However, we all feel that this is inadequate when caring for patients positive with COVID-19,’ one nurse said.
The WHO says that those providing direct care for people with or suspected of having COVID-19 in acute care and the community should wear eye protection, gloves and medical masks. It also specifies a gown, something only set out for those in higher risk areas in the NHS.
Different staff reuse and share visors
Limited supplies of basic PPE equipment are kept locked in a sister's or matron’s office, making it deliberately difficult to access.
‘It's given as if we are receiving ration on a case-by-case basis,’ one respondent said. ‘It's been locked away in cupboards and [we] have to ask matron or coordinators to issue it for individuals.’
Visors and goggles seem to be in particularly low supply, with equipment that should be disposable being repeatedly washed and reused by different staff.
One nurse said: ‘We share disposable visors, cleaning them after each use. We have three to share, there are 20 staff who come into contact with them every 24 hours, who wear them and clean them after they have worn them.’
‘We have to wipe over our visor and put it back in a bucket for others to use,’ a nurse said.
Concern about supplies reaching staff
The government has been dogged by criticism since the pandemic hit UK shores that not enough PPE was available for healthcare staff.
In March, NHS England said the military would help deliver supplies, including millions more PPE items to hospitals, ambulance trusts, GP practices, pharmacists, care homes and hospices.
Health and social care secretary Matt Hancocok told Downing Street press conference on 10 April that more than 742 million pieces of PPE have been delivered so far during the outbreak.
But the findings of the Nursing Standard online survey, which was carried out 3-6 April, suggest this is not yet enough to make a difference to supplies available to many front-line nurses.
Home secretary Priti Patel, fielding questions at a Downing Street briefing on 11 April, said she was 'sorry' if people felt there had been failings regarding the supply of PPE.
After being asked twice if she would apologise to NHS staff and their families over supplies of PPE, Ms Patel said: 'I'm sorry if people feel that there have been failings. I will be very, very clear about that.'
'But at the same time, we are in an unprecedented global health pandemic right now.
'It is inevitable that the demand and the pressures on PPE and demand for PPE are going to be exponential.'
At the start of April, the RCN wrote to the government about the ongoing shortage of PPE and has pressed the government to provide the right PPE to all health care staff, whatever the setting.
Commenting on the findings of our survey, RCN director of nursing, policy and practice Susan Masters says nursing staff must feel safe.
‘It is simply unacceptable that nurses are being forced to spend their own money to buy even what would be considered to be the bare minimum to protect themselves.
'We keep hearing that millions of pieces of equipment are being delivered but words are not enough. All nursing staff, no matter where they work, must feel safe and need action rather than assurances if they are to be able to do their jobs.’
Not meeting PHE guidelines
Public Health England (PHE) guidance sets out gloves, apron, surgical mask and eye protection as the basic kit required by healthcare staff going within two metres of someone with or suspected of having COVID-19 (see box, below).
Almost all staff told Nursing Standard they have access to disposable gowns (96%) and gloves (98%).
But only 27% reported access to fluid-resistant surgical masks and 42% reported they had eye protection through a visor or goggles.
Almost one third (31%) said they were buying their own equipment, including masks, hand sanitizer and eye protection.
Nurses providing their own equipment
One said their ward manager had bought goggles from eBay, someone else had bought respirator masks from DIY company Screwfix and another had purchased eye protection from Amazon.
Some people said they had to buy their own masks or goggles as the equipment they were provided with did not fit properly.
A number of nurses commented they had tried to buy equipment but could not find any available, such is the demand. A number said they would like to buy PPE but could not afford the cost.
Many people also spoke about buying equipment that is not recommended PPE by Public Health England, such as hair covers and shoe covers. A couple of respondents were buying shoes that they could leave at work.
A number of nurses reported they were not allowed to use the items they had purchased themselves.
‘We provided our own face shields. But then, they are advising us not to use it. Because it’s not from hospital resources,’ a nurse said.
Hazards of homemade protective equipment
One in ten nurses responding to the Nursing Standard survey said they have made their own PPE due to shortages.
Masks and scrubs are being sewn by nurses, managers and friends, the survey heard.
Nurses reported using snorkelling and cycling goggles, and wearing plastic bags on their feet.
Some reported making visors in a variety of ways, including using acetate sheets and 3D printers. ‘Made own visor from hairband and plastic A4 pocket,’ a comment said.
Before gowns arrived, a nurse said she and colleagues used disposable aprons to cover their arms.
‘Homemade forms of PPE are not likely to provide the correct level of protection’
Jennie Wilson, University of West London
A member of staff in a nursing home with cases of COVID-19 said: ‘The manager spent last night sewing improvised masks. She has ordered supplies and tried desperately to source proper PPE but with no luck.’
The dangers of home-made PPE were pointed out by some nurses. Some comments said they had been banned from wearing homemade creations at work, as they did not meet regulations.
‘I’m wary of home-made PPE owing to a question over its compliance,’ one comment said.
‘I have seen some FB [Facebook] articles suggesting that replacement filters can be made with charcoal, which is dangerous as this will not filter out viruses,’ one comment said.
Professor of healthcare epidemiology at the University of West London and vice president of the Infection Prevention Society Jennie Wilson agrees that people shouldn’t be making their own PPE: ‘I can understand nurses' concerns, but these home-made forms of PPE are not likely to provide the correct level of protection. We understand that some staff feel they need to wear a mask all the time, but World Health Organization and PHE guidance is consistent in saying that there is no evidence that wearing masks routinely confers any benefit.
’What is essential is encouraging cough etiquette, adherence to standard practice in relation to hand hygiene, and being extremely careful not to touch mucous membranes (eyes, nose, mouth) with hands or gloves whilst at work.’
Donated PPE from unexpected sources
More than one in five respondents said their employer had received donations of PPE equipment from other organisations, including from schools, building companies, Nando's restaurant chain, local dentists and vets, and other local businesses.
Goggles and eye protection appeared to be the most frequently donated items, although nurses said not all of it could be used as it did not pass infection prevention control standards.
Some local companies, including breweries and gin distilleries, have made alcohol hand rub, some nurses said.
Equipment that would have gone to the now-cancelled Glastonbury music festival is being distributed across the south west of England, according to one comment.
Donations of visors made by the Royal Mint factory, which usually produces coins and medals, were mentioned several times.
Lack of equipment and suitable guidance
Several respondents said they felt doctors were receiving a higher standard of PPE than other staff.
‘The consultant in charge of our team told us to think carefully about which PPE we chose as there won’t be enough for next week,’ a nurse said. ‘He was stood fully gowned.’
Confusion over what PPE should be available appears to be widespread, with nurses confused about when they should be wearing masks and wanting to wear them even when not covered by guidance.
A nurse pointed out that many nurses are not clear on what they should wear due to complex guidance.
2 April 2020
‘[A] lack of clarity in what is required for each patient setting has led to confusion and under or overuse of appropriate PPE. We have also been told to ration our use of PPE at times, which shows that we do not have enough.’
This lack of clarity and concerns about shortages are causing a climate of fear in healthcare settings, many respondents suggested.
‘Manager shouted at me for asking for PPE,’ said one nurse. ‘Matron stated masks were for patients and not for staff, which caused much animosity and fear,’ said another.
Government handling is life-threatening for nurses
Nurses generally condemned the government’s handling of the supply of PPE equipment to front-line staff during the pandemic, describing it as shameful, dishonest and life-threatening.
‘We had time to prepare for this. Health is the most important thing for all of us. I have been a nurse for 30 years and now I am frightened of going to work. It’s disappointing.’
Some said the government is doing its best in difficult circumstances, and others said the PPE situation is improving, and they had enough.
‘I risk my life to save others and the government can’t even provide the resources to lessen the risk’
But another respondent said nurses are not being told the truth.
‘They’re lying about what they’re actually doing. They’re saying there are tests for staff that aren’t available and they’re sending PPE which isn’t getting further than the ICUs because there isn’t enough,’ they said.
‘Disgusting’ situation in community and care home settings
The situation is ‘disgusting’, a community nurse said.
‘We are going into patients' homes that have symptoms and are positive with COVID-19 and we only have plastic aprons, short disposable gloves and surgical masks. We have to share one tub of chlorine wipes between the whole team and have to keep topping up our small hand gel bottles from bigger bottles. I’m not surprised staff are getting the virus.’
A number of staff from care homes also reported that they felt forgotten when it comes to PPE.
Nurses reported widespread anger at the lack of pandemic planning, and the impact it is having on them and their families.
‘I am a nurse but I am also a mother, daughter, sister, auntie and a niece,’ one said. ‘I risk my life to save others and the government can’t even provide the resources to lessen the risk that I do not become infected or that I am spreading it.’