How do we ensure the responsible and practical use of PPE?

As an occupational psychologist and assessor of safety cultures across multinationals in mining, oil and gas and chemical processing, I have facilitated many groups of frontline operators discussing their use of Personal Protective Equipment (PPE) at work. From aluminium mines in Siberia to oil and gas plants in Abu Dhabi and utility companies in the UK, I would hear: 

"There is a PPE policy, but it isn't applied consistently..." 

"We're told to wear PPE, but don't…" 

"If someone sees you without a hard hat, you can be thrown off-site..." 

"I've cut corners to get an emergency situation sorted faster." 

"We're not asking why enough – when someone's not wearing their gas monitor…" 

In nearly every assessment I've carried out, PPE is problematic. 

Having an available protective kit that is accessible and fit for purpose is one of my mantras when I'm working in safety-critical environments. I'm often to be found rummaging through operating procedures with process controllers, inspecting computer interfaces in site control rooms, observing safety-critical tasks in air traffic control towers and the like. Across all safety-critical sectors, workers are required to use personal protective equipment (PPE) and follow rules to protect their and their co-workers' health and safety. As psychologists, we can draw upon research that influences safe working practices, such as the theories of motivation, learning and social cognition (Fiske & Taylor, 1991), and gives workers empowerment in the safety agenda (Geller, 2002).

Across industrial settings, PPE includes gloves, respirators, fire-resistant coveralls, hard hats, safety glasses, high-visibility clothing, and safety boots. And yet PPE is widely regarded as the least effective means of controlling hazards; hats and boots won't prevent you getting crushed by a forklift truck, a harness won't stop you falling to the ground if it's not tied on, gloves carry viruses from one surface to another. For this reason, workers must be trained in the function as well as the limitations of PPE (HSE, 2020). 

Nonetheless, despite the drawbacks, reliance upon PPE is commonplace in hazardous workplaces. So I find it startling that in a time of a bio-hazard pandemic we, in a country that is reputedly world-leading in safety, have struggled so hard to source PPE and to make it accessible to health workers, patients and the general public. I find it incredible that the far-off threat of asbestosis in the construction industry is better equipped than the imminent threat of death from Covid-19. I have been bewildered that the PPE, imported via lengthy logistics, has been late, scarce and not up to the required standard set down (HSE Rapid Evidence Review, 2020).

Workers are leading the charge

These are unusual times for the industrial safety psychologist, more used to operators, contractors, miners and makers avoiding PPE they can "do without." Health and social care staff have been crying out for protective kit. They have been threatening to refuse starting their shift without PPE and, when the kit is delivered, co-workers are cross-checking each other carefully and disposing of protective clothing meticulously. The workers are leading the charge whilst governments are falling short in coordinating the provision.

There are additional levels of safety controls to be considered, of course. The 'hierarchy of controls' (NIOSH, 2015) provides a strategy for reducing workplace hazards. Methods are Elimination, Substitution, Engineering, Administration and PPE. The hierarchy is typically expressed as an upside-down pyramid, where elimination is the most effective way to reduce hazards and takes pride of place at the top. At the bottom is PPE. And, until we have a vaccine or the virus has been eliminated, we have to rely on less effective safety controls.

There are any number of reasons why people typically don't use PPE reliably, from badly-designed clothing to a belief that it may do more harm than good. Just this week a homeless charity worker said to me: "I don't wear visors and masks because it means I can't do my job … my homeless community won't trust me wearing it and, besides, they have more important worries than getting a virus." This wasn't the first time that I've heard PPE obstructing someone's perceived ability to do their job. But it illustrates the ongoing battle we have with decisions to wear or not to wear, to scare or not to scare.

PPE and the public

Between 11 February and 24 April 2020, there were nine shifts in PPE guidance (Foster & Neville, 2020) amidst the government's continued struggle to reach required PPE stocks. Clarity and consistency are required: it is no wonder that health workers lost trust in the guidance and took measures into their own hands (Berry, 2020). 

For the public, non-surgical face masks were suggested, albeit with caveats about the efficacy of cloth masks (Dyer, 2020). Next, England mandated masks on trains, which could be discarded in transit through the Severn Tunnel, whilst Wales went mask-free. That is until the WHO recommended a three-layered mask and Wales promoted this. 

The guidance still appears to be less about efficacy and more about supply. In the same way that workers must be trained in the function and limitation of PPE, so must the public. Like other controls further up the pyramid, PPE is fraught with uncertainty around how the virus spreads, contamination of clothing, the additional risk of sanitiser-induced dry, cracked skin... the questions go on.

To what extent will the public follow suit in donning the right kind of masks and to what extent will the wearing of PPE affect other at-risk behaviours in the streets, shops, parks and eventually pubs? Optimistic bias (Kahneman, 2011) may reduce the likelihood of the general public wearing masks.

But, if the messaging focuses on protecting others, people might be more likely to wear masks. How does this play out if mask-wearing communicates (a shared belief) that you are a carrier of Covid-19? As, reportedly, the most anxious country in Europe (Radio 4, 2020), how we ensure a responsible and practical use of PPE in the 'new normal' will need strong and astute messaging.

Amidst our 'social reconnecting' behaviours post-lockdown, people need reassurance and clearer guidance on ways of navigating the PPE risk-benefit ratios.

Psychology at the forefront

Accounting for our cognitive distortions, the Government will need to communicate requirements clearly with lockdown-easing or hardening measures as we watch the R-rate change over the coming months. The Recovery Strategy (May 2020) sets out to provide population-wide public health education to help people take responsible risk judgements and act in ways that will avoid passing the virus to others.

In the daily government briefings, the deputy chief medical officer for England acknowledged that a combination of science, politics and practicality will inform the way forward (18 May 2020).

Together with emerging evidence about the virus spread, mortality rates, range of symptoms, vaccine development, mask-wearing efficacy, how we source and use good-quality, abundant supplies of personal protective equipment throughout the coming months is likely a continued challenge. 

Psychologists need to be at the forefront of the scientific community which advises the government. How we train and maintain its reliable use is going to require a good deal of applied behavioural, cognitive and social psychology in order to best protect our frontline staff, our backbone staff and our most vulnerable in society.

Sandra Lovell is a Chartered Psychologist, specialising in health, safety and wellbeing at work Independent

Lovell HF, Swansea

References

BBC (May 2020) Coronavirus PPE: Gowns ordered from Turkey fail to meet safety standards.

Berry Philip (2020) Illusions of Autonomy: Psychology and PPE

Dyer, J. (2020). When it comes to the COVID-19 fight, some problems can't be masked. Infection Control Today May 2020, 18-20.

Derek K Chu, Elie A Akl, Stephanie Duda, Karla Solo, Sally Yaacoub, Holger J Schüneman (2020). Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet Published Online June 1, 2020. https://doi.org/10.1016/ S0140-6736(20)31142-9

Fiske, Susan T. & Taylor, Shelly E. (1991) Social Cognition 2nd Ed. McGraw Hill. New York. ISBN 0-07- 100910-8

Foster, Peter & Neville, Sarah (2020) How poor planning left the UK without enough PPE, The Financial Times, London, May 1 2020. https://www.ft.com/content/9680c20f-7b71-4f65-9bec-0 e9554a8e0a7

Geller, E. Scott (2002) The Participation Factor; how to increase involvement in Occupational Safety. American Society of Safety Engineers. Illinois. ISBN 1-885581-37-8

Halpern, David (2016) Inside the Nudge Unit. WH Allen, London. ISBN 978-0-75355-655-9

HSE (2020) Management of risk when planning work: The right priorities, in Leadership and worker involvement toolkit. 

HSE (2020) RAPID EVIDENCE REVIEW DELIVERED BY HSE FOR THE GOVERNMENT CHIEF SCIENTIFIC ADVISER PART ONE: Equivalence of N95 and FFP2 masks PART TWO: Aprons, Gowns and eye protection.

Kahneman, Daniel (2011) Thinking fast and slow. Allen Lane. St Ives. ISBN 978-1-846-14055-6

NIOSH (2015) Hierarchy of Controls. National Institute for Occupational Safety and Health National Institute for Occupational Safety and Health.

OUR PLAN TO REBUILD: The UK Government's COVID-19 recovery strategy (May 2020). Presented to Parliament by the Prime Minister by Command of Her Majesty. ISBN 978-1-5286-1911-0

Radio 4 Today (2020) 18 May 2020