Abstract
Aims
This study aimed to determine thermal comfort among nurses working with personal protective equipment in COVID‐19 clinic.
Methods
In this study, a descriptive design was carried out between June and September 2020. Sample of the study consisted of 246 nurses (77.6%) who worked in the COVID‐19 clinics with personal protective equipment. We used a questionnaire to determine thermal comfort of nurses; a follow‐up form to determine the factors affecting thermal comfort; and the ASHRAE Thermal Sensation Scale. Four measurements and follow‐ups were made three times.
Results
More than half of nurses complained of ambient temperature and ventilation, one‐third complained of humidity and nearly half complained of poor air quality. The mean thermal comfort score of nurses working in COVID‐19 clinics was 1.19 (SD = 0.75). The thermal comfort of the nurses was negatively affected in all measurements except before wearing personal protective equipment. The highest scores were measured leaving the patient room and before removing personal protective equipment (M = 2.65, SD = 0.58).
Conclusion
The thermal comfort, work performance and stress levels of the nurses were negatively affected by working with personal protective equipment. This study reveals the necessity of improving the working conditions of nurses, including working hours, environment and personal protective equipment.
Keywords: COVID‐19, nursing, personal protected equipment, thermal comfort, thermal sensation
Summary statement
What is already known about this topic?
Thermal comfort is one of the important factors affecting nurses' working performance.
The working conditions of the nurses affected their thermal comfort.
Due to the COVID‐19 pandemic, health‐care professionals had to work with personal protective equipment.
What this paper adds?
The thermal comfort of nurses working in patients' rooms with personal protective equipment was negatively affected in COVID‐19 clinics.
The temperature and stress levels of the nurses increased, and their performance decreased when working in the patients' rooms with personal protective equipment
The thermal comfort of nurses working in intensive care units was affected more negatively than nurses working in other services.
The implications of this paper:
The ventilation systems should be improved to provide thermal comfort for those working with personal protective equipment.
Working time and breaks should be organized accordingly considering the negative effects of working with personal protective equipment on nurses.
1. INTRODUCTION
Thermal comfort is a condition of mind that expresses satisfaction with the thermal environment (American National Standards Institute [ANSI], 2017). The perception of thermal comfort covers many inputs affected by physical, physiological, psychological and other factors (Djongyang et al., 2010). Satisfaction with thermal conditions occurs when the body temperature and skin moisture are within acceptable limits and when physiological regulatory mechanisms do not need to put in an extra effort for these variables (Djongyang et al., 2010). Thermal comfort components include the ambient temperature, radiant heat, relative humidity, air velocity, ventilation, activity type and level, metabolic rate, and clothing (Djongyang et al., 2010; Health & Safety Executive [HSE], 1999; Melhado et al., 2006). The factors affecting thermal comfort are individual factors such as age, gender, body surface area, body structure, ethnic structure, menstrual cycle, activity and posture; and external factors such as food consumed, the thermal resistance of clothing, ventilation conditions, colours, ambient temperature and changes in thermostat settings (Çetiner & Örkmez, 2012; Djongyang et al., 2010; HSE, 1999; Ulucan & Zeyrek, 2012).
Thermal comfort conditions in workplaces should not disturb employees or affect their physical and psychological conditions negatively (Official Gazette, 2013). Hospitals are special environments that require the protection of thermal comfort conditions at desired levels. Hospital staff may have to work with extra protective equipment in areas such as clinics that require isolation, operating rooms or imaging centres. This may negatively affect their thermal comfort (Bogdan et al., 2011; Khodakarami & Nasrollahi, 2012).
The sudden and unexpected emergence of the COVID‐19 pandemic has made it mandatory for health‐care workers (HCW) working with infected patients to wear personal protective equipment (PPE), and this has affected their comfort significantly. The SARS‐CoV‐2 virus is transmitted through behaviours such as when one's hands come into contact with the droplets emitted by infected people (while coughing or sneezing) and then touch the mucous membranes of the mouth, nose or eyes (Ministry of Health, 2020). The WHO emphasized that some measures should be taken to prevent the spread of the disease due to the rapid transmission of COVID‐19 from person to person (World Health Organization, 2020).
The SARS‐CoV‐2 virus can cause severe problems, including pneumonia, severe acute respiratory infection, kidney failure and death, and may require care and treatment of patients in the hospitals and even intensive care units (ICUs) (Ministry of Health, 2020; Wang et al., 2020). Therefore, HCW are at increased risk of SARS‐CoV‐2 infection. The study conducted by Barrett et al. (2020) with 546 HCW and 283 non‐HCW reported that the prevalence of SARS‐CoV‐2 infection was 7.3% among HCW and 0.4% in non‐HCW. Nurses have a higher risk of infection because they are in direct contact with patients diagnosed with SARS‐CoV‐2 infection. According to International Council of Nurses (ICN) report, ‘the cumulative number of reported COVID‐19 deaths of nurses in 59 countries was 2.710’ (International Council of Nurses, 2021). Since the infection is highly‐contagious, HCW, who come within 1 m of definitive or suspected cases of COVID‐19, are recommended to use the necessary PPE such as N95/FFP2 masks, face protection visors, goggles, overalls, cap and foot protectors for procedures that cause aerosolization in addition to gloves, liquid impermeable and long‐sleeved gowns and medical masks (Ministry of Health, 2020).
PPE is used by HCW to protect themselves, patients and others on a daily basis during health‐care delivery. PPE helps protect HCW from infected patients and materials, toxic drugs and other potentially hazardous substances used in health‐care delivery (Central for Disease Control and Prevention, 2020). PPE is a necessity for HCW, especially in cases such as the COVID‐19 pandemic. However, working with PPE negatively affects the thermal comfort and performance of HCW (Karahan et al., 2020). The human body generates heat during rest and movement. It must emit most of this heat to the environment through evaporation, convection, conduction, radiation and respiration to maintain homeostasis, (Oğulata, 2007; Parsons, 2020). However, PPE reduces the emittance of heat from the body to the environment by increasing its thermal resistance and vapour resistance. At that point, the body tries to reduce the heat by sweating. However, since the body heat does not decrease sufficiently in PPE, this can affect thermal comfort negatively and can create significant physiological and physical stresses (Potter et al., 2015). Besides, increased indoor and outdoor temperatures are reported to cause thermal stress and affect well‐being negatively (Mazzacanea et al., 2006).
All the above‐mentioned issues make it crucial to determine the factors affecting the thermal comfort of nurses, who provide care for the patients diagnosed with COVID‐19 and to understand the effect of those factors on nurses. In the studies conducted before COVID‐19 pandemic to determine the thermal comfort of nurses, it is emphasized that the working environment and clothing characteristics can affect the thermal comfort and work performance of the nurses (Derks et al., 2018; Karahan et al., 2020; Kim & Song, 2020). When we planned this study, there was no study in the literature on the thermal comfort of nurses working with PPE during the COVID‐19 pandemic. Since nurses particularly work with PPE, determining how this affects their thermal comfort and understanding the difficulties they have will contribute to the management of the process. Creating appropriate solutions for the factors that negatively affect thermal comfort considering the opinions and suggestions of nurses will contribute positively to the safety of nurses and patients.
1.1. Aim and research questions
The aim of this study was to determine thermal comfort among nurses working with PPE in COVID‐19 clinics during the COVID‐19 pandemic. We used the following questions to obtain a more detailed result for this purpose.
How does providing care with PPE affect the thermal comfort and performance of nurses?
Does the thermal comfort of nurses providing care with PPE differ according to their demographic characteristics?
What are the suggestions of nurses providing care with PPE to increase thermal comfort?
2. METHODS
2.1. Design and settings
This study, which aims to determine thermal comfort among nurses working with PPE in COVID‐19 clinics, has a descriptive design. In order to grant adequate and complete reporting of research, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.
This study was conducted in the COVID‐19 clinics of Cardiovascular and Neurology‐Orthopedic Hospitals within a public hospital complex in Ankara/Turkey between June and September 2020. These hospitals were selected because some of services were converted to COVID‐19 services and permission can be obtained. This hospital complex had eight hospital buildings and 3810 beds in total. The study was carried out in the COVID‐19 clinics of the 441‐bed Cardiovascular Hospital and the 506‐bed Neurology‐Orthopedic Hospital. There are a total of 12 COVID‐19 clinics (seven clinics and five ICUs) in the Cardiovascular Hospital and Neurology‐Orthopedics Hospital. There are 16 negative pressure chambers in the ICUs (suitable for patient monitoring via windows).
2.2. Sample
The study population consisted of 317 nurses working in COVID‐19 clinics at the time of the study. The number of nurses working in the COVID‐19 service was reported by the nurse managers. Convenience sampling was used to select the participants for the study. The study sample consisted of 246 nurses (77.6%), who worked in the COVID‐19 clinics of the Cardiovascular Hospital and Neurology‐Orthopedics Hospital wearing PPE (medical mask/N95 mask, gown, overalls, face shield and foot protector) and agreed to participate in the study. While the weekly working hours of nurses are 45 h, their daily working hours are 8 or 16 h.
2.3. Data collection tools
In this study, we used a questionnaire to determine the demographic characteristics of nurses and the factors affecting their thermal comfort; a follow‐up form to determine the factors affecting thermal comfort; and the ASHRAE Thermal Sensation Scale. The questionnaire and follow‐up form were developed by researchers.
2.3.1. Questionnaire on the demographic characteristics of nurses and the factors affecting their thermal comfort
The questionnaire was developed by examining the literature (Balaras et al., 2007; Çetiner & Örkmez, 2012; Djongyang et al., 2010; HSE, 1999; Melhado et al., 2006; Ulucan & Zeyrek, 2012) to determine the effects of PPE on nurses and factors affecting thermal comfort. It had 22 questions, including the descriptive characteristics of nurses (age, gender, education, body mass index [BMI], duration of work in the profession/clinic, etc.); complaints related to thermal comfort components such as ambient temperature, airflow, ventilation and humidity; variables that can affect thermal comfort (having a disease that affects the body temperature, duration of working with PPE, number of PPE changes, characteristics of the clinic they work in, etc.); the effects of working with PPE; and suggestions for increasing thermal comfort.
2.3.2. Follow‐up form on the factors affecting thermal comfort
This form includes the follow‐up of each participant to determine their perceptions of thermal comfort components (ambient temperature, humidity, airflow and ventilation) at the beginning, middle and end of their shifts:
before wearing the PPE,
before entering the patient room with PPE,
after leaving the patient room and before removing the PPE, and
after removing the PPE.
Body temperatures and performance levels of nurses were recorded in the same form. PPE and performance level were evaluated according to 0–10 Visual Analog Scale‐VAS. ‘0’ point indicated the lowest level of performance, whereas ‘10’ points indicated the highest level. In addition, the forms recorded the ambient temperature, humidity, airflow and the number of air change on the electronic panels of the clinics.
The questionnaire and follow‐up form were submitted to the expert opinion of one physician, two faculty members and four manager nurses in the hospitals. Two questions were revised, and one correction was made based on their suggestions to repeat the measurements three times, namely, at the beginning, middle and end of the nurses' shifts. A pilot study was carried out with 30 nurses, and no additional correction was required in the forms.
2.3.3. The ASHRAE thermal sensation scale
We used the ASHRAE thermal comfort tool to determine the thermal comfort of nurses. It was developed by Fanger (1970). Comparative studies were performed for validity and reliability of the scale (Piasecki et al., 2019; Schweiker et al., 2017). This scale aims to determine the participants' thermal sensation, defined as ‘+3: hot, +2: warm, +1: slightly warm, 0: neutral, −1: slightly cool, −2: cool, and −3: cold’ (Fanger, 1970). It rates the quantified thermal sensation of the participants, which is known as the actual mean vote (AMV). The participants mark anywhere on the seven‐point ASHRAE thermal sensation scale. The Predicted Percentage Dissatisfied (PPD) index is related to the predicted mean vote (PMV) model based on the voting on the thermal sensation scale. The PMV includes six parameters: ambient temperature, mean radiant temperature (°C), air velocity (m/s), relative humidity (%), clothing insulation and metabolic rate (Fanger, 1970; Parsons, 2020). It predicts the thermal sensation of participants on the ASHRAE thermal sensation scale. AMV is the value that the PMV equation is trying to predict. Recommended PMV limits are −0.5 < PMV < +0.5 (ANSI, 2017; Parsons, 2020).
2.4. Data collection
Researchers conducted daily clinical visits, spoke with the nurses and explained how body temperature measurements and other measurements should be made and recorded. The ‘Questionnaire on Demographic Characteristics and Factors Affecting Thermal Comfort’ was filled out by the participants. A nurse's body temperature was measured by another nurse at the times described above and recorded on the ‘Follow‐up Form on the Factors Affecting Thermal Comfort’ under the supervision of the researchers.
Similarly, parameters related to ambient temperature, humidity, airflow and ventilation on the electronic panels of the patient rooms and clinics were recorded in the follow‐up form.
2.5. Research procedure
The PPE worn by nurses include goggles, bonnets, N95 masks, visors, gloves, foot protectors and overalls. The overalls are disposable, hooded, covering the neck and chin, latex‐free, non‐translucent, non‐woven and do not contain any film, plastic or similar layer that makes breathing difficult. Body temperatures were measured with infrared thermometers of the same brand and features, following the instructions for use, from a distance of 5 cm from the middle of eyebrows without contact. Body temperature measurements were made after wearing and before removing the PPE, by opening the front of the visor. Nurses wore and removed PPE in the ‘equipment wearing area (dressing room)’ before entering and after leaving the patient rooms in the ICUs and clinics. The calibration of infrared thermometers was carried out regularly during the study.
The parameters (ambient temperature, humidity, airflow and ventilation) are adjusted automatically from a central system. HCW were unable to interfere with these parameters in their clinics. In the clinics where the study was conducted, mean ambient temperature (°C) was 24.52 (1.67); mean humidity (%) was 39.9 (9.02); mean air volume (m3/h) was 9085 (7141.99); and mean air change (pa) was 425.88 (348.74). The HVAC (Heating, Ventilating and Air Conditioning) Performance Qualification Test Report of the hospitals was prepared by the Accreditation Agency of Turkey. The test values complied with the standard at the time of the study. The mean air temperature was 21.2°C (Min = 12.4, Max = 29.9), and humidity was 40.75% (Min = 38%, Max = 46%) between June and September in the province where the study was conducted (Climate‐data.org, 2021).
2.6. Statistical analysis
The data were analysed using SPSS v.24 (The IBM SPSS Statistics, Chicago, Illinois, 2016). In terms of descriptive statistics, frequency and percentage were used for qualitative variables; mean and standard deviation were used for numerical variables. Kolmogorov–Smirnov test was used to determine the normal distribution of the data; p > 0.05 was obtained as a result of the analysis. According to this result, the data are normally distributed. Analysis of variance (ANOVA) was used in repeated measures to compare the groups (between groups), the change over time (within groups) and the group–time interaction. In groups with statistically significant differences, Bonferroni correction was used in multiple comparisons to determine which group caused the difference; p < 0.05 was considered statistically significant.
2.7. Ethical considerations
Written and verbal permits were received for this study from the Ministry of Health, Research Board and Clinical Research Ethics Committee, Hospital's Chief Physician and nurses. The researchers gave information on the purpose and application of the study to the participants. Their written and verbal consents were received, and then questionnaires were given. The study was conducted in accordance with the Ethical Principles of the Declaration of Helsinki.
3. RESULTS
Considering the results of the study, nurse's thermal comfort was significantly affected while working with PPE. The temperature and stress levels of the nurses increased, and their performance decreased when working with PPE. The nurses' performance decreased at the end of the shift compared to the beginning of the shift. The thermal comfort of nurses working in ICUs was affected more negatively than nurses working in other services.
While the study population consisted of 317 nurses, the final sample consisted of 246 nurses (77.6% response rate); 75.7% of the participants were female. Their mean age was 26.8 (SD = 5.5). The mean BMI was 23.1 (SD = 3.4) kg/m2; 87.8% were university graduates. Mean working years in the profession was 3.7 (SD = 5.4). The mean working time in the COVID‐19 clinic was 4.68 (SD = 2.0) months; 55.9% of nurses worked in the ICUs. The mean daily working time of nurses with PPE was 10.5 h (SD = 6.1), and the mean number of changes of PPE per shift was 4.5 (SD = 3.3) (Table 1).
TABLE 1.
Demographic and occupational information
| Baseline characteristic | n (%) | M (SD) |
|---|---|---|
| Gender | ||
| Male | 60 (24.3) | |
| Female | 187 (75.7) | |
| Age | ||
| <26 | 151 (61.1) | 26.8 (5.5) |
| ≥26 | 96 (38.9) | |
| BMI a | ||
| Underweight (<18.49) | 17 (6.9) | 23.1 (3.4) |
| Normal weight (18.5–24.99) | 165 (68.8) | |
| Overweight or obese (≥25) | 65 (26.3) | |
| Educational level | ||
| High school | 14 (5.7) | |
| Health vocational | 16 (6.5) | |
| Graduate and undergraduate degree | 217 (87.8) | |
| Years of nursing experience working years in the profession | ||
| <3 year | 172 (69.6) | 3.7 (5.4) |
| ≥3 year | 75 (30.4) | |
| Working time in the COVID‐19 clinic | ||
| <6 months | 151 (61.1) | 4.68 (2.0) |
| ≥6 months | 96 (38.9) | |
| Characteristic of the COVID‐19 clinic | ||
| In patient clinic | 109 (44.1) | |
| Intensive care unit | 138 (55.9) | |
| Working hours with PPE b | ||
| <8 h | 91 (36.8) | 10.5 (6.1) |
| ≥8 h | 156 (63.2) | |
| The number of changes of PPE | ||
| <5 | 162(65.6) | 4.48 (3.3) |
| ≥5 | 85 (34.4) | |
Body mass index.
Personal protective equipment.
More than half the nurses complained of ambient temperature and ventilation, one‐third complained of humidity and nearly half them complained of poor air quality. They stated that these problems were caused by inadequate ventilation and the difficulty of working with PPE. They reported that working with PPE mostly caused sweating, breathing difficulty, fatigue and thirst. In addition, they reported problems such as difficulty in moving with PPE, stress, skin problems, and the time spent wearing and removing the PPE. According to nurses' suggestions to increase thermal comfort, PPE should be designed ergonomically, the ventilation system and patient rooms should be adapted, working/break hours should be re‐arranged and the workload should be reduced (Table 2). Although it is not included in the table, 7.6% (n = 17) of nurses reported a disease that affected their body temperature as hypothyroidism (n = 13), hyperthyroidism (n = 2) and anaemia (n = 2).
TABLE 2.
Complaints related to thermal comfort components, effects on performance, suggestions and complaints
| Complaints and suggestions | n (%) |
|---|---|
| Complaints related to ambient temperature (°C) | 146 (59.1) |
| Feeling hot when working with PPE a and cool when removing it | 64 (25.9) |
| Inadequate air conditioning in rooms, hot rooms, unable to open windows | 54 (22.4) |
| Complaints related to humidity (%) | 71 (28.7) |
| Excessive sweating with PPE | 23 (9.3) |
| Dry/humid air | 16 (6.4) |
| Complaints related to air quality | 112 (45.3) |
| Unable to feel clean air due to ventilation problems | 62 (25.2) |
| Mask creates an obstacle | 4 (1.6) |
| Complaints related to ventilation | 133 (53.8) |
| Insufficient ventilation | 67 (27.2) |
| Bad smell in rooms | 10 (4.0) |
| Difficulty in breathing due to the mask | 9 (3.6) |
| Effects of working with PPE | |
| Sweating | 246 (99.6) |
| Dyspnoea, difficulty breathing | 228 (92.3) |
| Thirst | 210 (85.0) |
| Fatigue | 217 (87.9) |
| Nausea | 122 (49.4) |
| Difficulty in interventions in emergencies due to the limitation of movement | 53 (21.5) |
| Psychological fatigue, exhaustion, stress and fear of contagion and transmission | 59 (23.9) |
| Decreased hearing and vision | 20 (8.1) |
| Facial lesions and allergies, dermatitis on hands | 39 (15.8) |
| Wearing and removing PPE is time‐consuming and tiring | 20 (8.1) |
| Other (headache, dizziness, red eyes, syncope) | 50 (20.2) |
| Suggestions for increasing thermal comfort | |
| Suggestions related to PPE: PPE should be ergonomic/light, thin, breathable but protective, non‐sweating and sufficient in number; uniforms should be provided and washed by the hospital; non‐fogging glasses should be are designed | 110 (44.5) |
| Suggestions related to the environment: Ventilation system should become adequate, patient rooms should be single and have negative pressure | 47 (19.0) |
| Suggestions related to working conditions: Working time with PPE should be reduced, break hours should be increased, sufficient personnel should be provided | 27 (10.9) |
Personal protective equipment.
The mean thermal satisfaction/sensation of nurses working in COVID‐19 clinics was 1.19 (SD = 0.75). The mean thermal satisfaction of nurses was the lowest before wearing PPE (M = −0.04, SD = 0.97), and the highest after leaving the patient room and before removing PPE (M = 2.65, SD = 0.58). The body temperature measurements of nurses were the lowest (M = 36.4°C, SD = 0.22) before wearing the PPE, and the highest (M = 36.8°C, SD = 0.48) after leaving the patient room and before removing the PPE (Table 3).
TABLE 3.
Thermal comfort sensation and body temperature of nurses
| Measure | Time 1 | Time 2 | Time 3 | Time 4 | Total | Test |
|---|---|---|---|---|---|---|
| M (SD) | M (SD) | M (SD) | M (SD) | M (SD) | ||
| Thermal comfort | −0.04 (0.97)a | 1.27 (0.82)b | 2.65 (0.58)c | 0.85 (2.05)d | 1.19 (0.75) | F = 221.84*** |
| Body temperature (°C) | 36.4 (0.22)a | 36.6 (0.27)b | 36.8 (0.48)c | 36.7 (0.51)d | 36.6 (0.30) | F = 82.43*** |
Note: a, b, c, d There is a significant difference between the times marked with different letters (p < 0.05). Time 1 = before wearing the personal protective equipment (PPE). Time 2 = after wearing PPE and before entering the patient room. Time 3 = after leaving the patient room and before removing the PPE. Time 4 = immediately after removing the PPE.
p < 0.001.
The mean performance of nurses while working with PPE was 4.93 (SD = 1.71) according to VAS‐10. The performance scores of nurses while working with PPE were compared at the beginning (M = 7.28, SD = 2.20), middle (M = 5.04, SD = 1.81) and end of their shifts (M = 2.48, SD = 1.290) according to VAS‐10, and the difference was statistically significant (F = 957.387, p < 0.001) (Table 4). Although not illustrated in the table, 84.1% of nurses emphasized that working with PPE negatively affected their performance, and 87.6% (n = 212) reported that their performance declined in less than an hour while working with PPE. At the beginning of the shift, the highest stress level among nurses was measured after leaving the patient room and before removing the PPE; 55.1% (n = 136) of nurses described their stress level as high/quite high. Similarly, at the end of the shift, the highest stress level was measured after leaving the patient room and before removing the PPE; 79.6% of nurses (n = 172) described the stress level as high/quite high.
TABLE 4.
The performance levels of nurses with PPE
| Measure | At the beginning of the shift | At the middle of the shift | At the end of the shift | Total | Test |
|---|---|---|---|---|---|
| M (SD) | M (SD) | M (SD) | M (SD) | ||
| Performance level in the PPE | 7.28 (2.20)a | 5.04 (1.81)b | 2.48 (1.90)c | 4.93 (1.71) | F = 957.387*** |
Note: a, b, c = there is significant difference between the times marked with different letters (p < 0.05.).
Abbreviation: PPE, Personal protective equipment.
p < 0.001.
When we examined the mean thermal satisfaction of nurses according to their demographic characteristics, we found no statistically significant difference between the groups. However, we found a statistically significant difference in all measurements over time. There was a statistically significant difference in time and group interactions according to the unit/clinic where nurses worked (F = 5.499, p = 0.008). The thermal comfort levels of nurses working in the ICUs and clinics decreased over time (Table 5).
TABLE 5.
Thermal comfort sensation of nurses according to their descriptive characteristics
| Time 1 | Time 2 | Time 3 | Time 4 | Test | |||
|---|---|---|---|---|---|---|---|
| Descriptive characteristics | M (SD) | M (SD) | M (SD) | M (SD) | Group | Time a | Group × time |
| Age | |||||||
| <25 | −0.07 (0.99) | 1.21 (0.89) | 2.67 (0.63) | 0.84 (2.02) | F = 0.674 | F = 185.2*** | F = 0.926 |
| 25–34 | 0.06 (0.96) | 1.34 (0.79) | 2.65 (0.51) | 0.93 (2.08) | |||
| ≥35 | 0.04 (0.93) | 1.21 (66) | 2.56 (0.66) | 0.48 (2.08) | |||
| Gender | |||||||
| Female | −0.13 (0.87) | 1.16 (0.77) | 2.65 (0.58) | 1.11(1.94) | F = 0.087 | F = 148.8*** | F = 1.998 |
| Male | 0.04 (1.04) | 1.31 (0.84) | 2.65 (0.58) | 0.77 (2.08) | |||
| BMI | |||||||
| <18.49 | 0.43 (1.20) | 1.41(1.05) | 2.31 (0.84) | 1.08(1.67) | F = 0.928 | F = 76.97*** | F = 1.582 |
| 18.50–24.99 | −0.01 (0.99) | 1.28 (0.81) | 2.65 (0.57) | 0.77 (2.10) | |||
| ≥25 | −0.12 (0.81) | 1.24 (0.80) | 2.74 (0.49) | 0.99 (2.02) | |||
| Workplace | |||||||
| Patient room | 0.17 (0.85) | 1.32 (0.70) | 2.45 (0.69) | 0.75 (1.91) | F = 1.261 | F = 187.7*** | F = 5.499 b , ** |
| ICU | −0.13(1.04) | 1.24 (0.91) | 2.80 (0.41) | 0.93 (2.15) | |||
| Working hours with PPE | |||||||
| ≤8 h | 0.08 (0.90) | 1.23 (0.74) | 2.58 (0.67) | 0.77 (2.03) | F = 0.047 | F = 174.9*** | F = 0.745 |
| >8 h | −0.06(1.00) | 1.29 (0.87) | 2.69 (0.52) | 0.89 (2.06) | |||
| The number of changing PPE | |||||||
| <5 | 0.05 (0.98) | 1.24 (0.83) | 2.62 (0.59) | 0.84 (2.03) | F = 0.637 | F = 182.7*** | F = 0.943 |
| ≥5 | −0.08 (0.94) | 1.34 (0.82) | 2.70 (0.55) | 0.87 (2.08) | |||
Note: Time 1 = before wearing the PPE. Time 2 = after wearing PPE and before entering the patient room. Time 3 = after leaving the patient room and before removing the PPE. Time 4 = immediately after removing the PPE.
Abbreviations: BMI, Body mass index; ICU, Intensive care unit; PPE, Personal protective equipment.
No difference between the 2 and 4 measurements (p > 0.05).
Since the group × time interaction was significant, change over time was examined separately in each group.
p < 0.01.
p < 0.001.
4. DISCUSSION
The rapid spread of COVID‐19 in the world put a heavy burden on the health systems, whereas the working conditions, excessive workload, insufficient resources and excess stressors negatively affected the nurses (Mokhtari et al., 2020; Zhang et al., 2020). This study aimed to determine the thermal comfort level of nurses working in COVID‐19 clinics and wearing the PPE, the factors affecting their thermal comfort on nurses and the suggestions for increasing thermal comfort.
Many variables can affect people's thermal comfort, such as ambient temperature, relative humidity, air velocity, ventilation and clothing (Djongyang et al., 2010; HSE, 1999; Melhado et al., 2006). Working with PPE for extended periods negatively affects the thermal comfort of nurses (Lee et al., 2020). In our study, the mean working hours of nurses in a shift was 10 hours. Nurses reported that they mostly experienced problems with ambient temperature and ventilation while working with PPE. They emphasized that ventilation was insufficient while working with PPE.
Although it is emphasized that more studies are needed on the scope, features, how to wear or remove PPE, under current conditions PPE is one of the most effective initiatives for HCW to prevent COVID‐19 infection (Verbeek et al., 2020). On the other hand, the PPE's impermeability, evaporation and limitation of heat exchange can cause excessive sweating and the development of symptoms such as thirst and fatigue (Potter et al., 2015). Our study found that working with PPE caused physiological problems such as sweating, breathing difficulty and thirst, as well as movement limitation and dermatological problems. Lee et al. (2020) made a study to determine the heat stress and thermal perception among HCW consisting of nurses and physicians (n = 165) during the COVID‐19 pandemic in India and Singapore and, similar to our study, reported problems such as thirst (87%), excessive sweating (88%), exhaustion (78%) and desire to go to comfort zones (84%). The study by Tabah et al. (2020), which was conducted with 2711 HCW working in the ICUs during the COVID‐19 pandemic, reported that HCW experienced problems such as heat (51%), thirst (47%), pressure areas (44%), headache (28%) and exhaustion (20%) due to longer shift durations with PPE. In our study, nurses stated that PPE should be designed to provide thermal comfort, environmental arrangements should be made and working and resting hours should be re‐adjusted to solve their problems.
In our study, the mean thermal comfort of nurses was 1.19 (SD = 0.75). Thermal comfort was measured within the normal range before wearing PPE (M = −0.04, SD = 0.97). It was measured well above normal limits (M = 2.65, SD = 0.58) after wearing PPE and after leaving the patient room. The recommended thermal range on the scale of PMV is between −0.5 and +0.5 (ANSI, 2017). In parallel with this, the body temperature of nurses increased statistically significantly after wearing the PPE. There was no similar study in the literature, but the thermal comfort means were −1.18–1.5 in studies conducted in different clinics including operating rooms (Del Ferraro et al., 2015; Karahan et al., 2020; Pourshaghaghy & Omidvari, 2012; Van Gaever et al., 2014). Compared to other studies, our study shows that nurses had higher thermal sensation scores before leaving the patients' rooms and before removing the PPE, and their thermal comfort was significantly affected.
Our study examined how nurses' performance was affected during the time they worked with PPE and found that their performance decreased at a statistically significant level at the end of the shift compared to the beginning of the shift. The majority of nurses reported that their performance decreased in less than an hour after starting to work with PPE. Working with PPE can reduce performance by creating physiological and physical stress due to effects such as heat stress, difficulty in mobility and vision difficulty (Potter et al., 2015). Previous studies have also reported that the performance of HCW decreases when their thermal comfort is negatively affected (Derks et al., 2018; Karahan et al., 2020).
We could not find a statistically significant difference in thermal comfort according to the demographic characteristics of nurses. On the other hand, we found that working with PPE significantly reduced thermal comfort over time. This shows that working with PPE negatively affects the thermal comfort of nurses, regardless of age, gender or BMI. Human psycho‐physiological thermoregulation as a form of homeostasis involves continuous and harmonious interaction with environmental change. This is achieved by physiologic thermoregulatory responses and behavioural (adaptive) responses to maintain comfort with internal body temperature and thermal sensation (Parsons, 2020). However, when nurses work with PPE, their physiological regulatory mechanisms fall short, and they do not have any behavioural options such as reducing clothing. These conditions negatively affect the thermal comfort of nurses.
When we examined the time and group interactions, we found that there was a decrease in the thermal comfort levels of nurses working in the ICUs and clinics over time. Nurses working in the ICUs are exposed to intense stress. They have to provide long‐term and continuous care to patients with critical conditions under difficult working conditions (Mokhtari et al., 2020). Since ICU patients require closer monitoring and their dependence levels are higher than the patients in clinics, this may have caused ICU nurses to spend more time in PPE and their thermal comfort is more negatively affected.
4.1. Limitations of the study
The daily working hours of nurses varied such as 8–16 h. In addition, number and the time spent by the nurses in the patient room differed depending on the care needs of the patients. On the other hand, measurements were performed for each nurse at the beginning of the shift, in the middle of the shift and at the end of the shift. Body temperature measurements could not be made in the patients' rooms because nurses entered the patient room alone due to the risk of contamination. Measurements were made by removing the visor to determine the exact body temperature of nurses while working with PPE. The values set in the ventilation system for parameters such as ambient temperature and humidity were recorded, and no additional measurements were made for ambient temperature.
5. CONCLUSION
Our study found that the thermal comfort of nurses working in COVID‐19 clinics was negatively affected while working with PPE in the patients' rooms. Taking the suggestions of nurses into consideration, we recommend developing cost‐effective, time‐saving, easy‐to‐wear PPE that will increase thermal comfort; improving the ventilation systems to provide thermal comfort for those working with PPE; considering the negative effects of PPE while determining the number of nurses working in COVID‐19 clinics; organizing working time and breaks accordingly, considering the negative effects of working with PPE on nurses; and conducting further studies on this.
This study will contribute positively to the management of the process of understanding the difficulties they experience, and the creation of appropriate solutions to the safety of employees and patients, especially as nurses work at the closest distance for 24 h without interruption.
CONFLICT OF INTEREST
We have no conflict of interest to declare.
ETHICS STATEMENT
This study was approved by Ankara City Hospital No.1 Clinical Research Ethics Committee Presidency (Project No:820).
AUTHORSHIP STATEMENT
Conception and design, or analysis and interpretation of data: AK, SAI, FÇA, ABK, BÇ, EBE, BA, AA, ADG, YAB
Data collection: FÇA, ABK, BA, AA, ADG, AK, SAI, BÇ, EBE, YAB
Drafting the article or revising it critically for important intellectual content: AK, SAI, BÇ, EBE, FÇA, ABK, BA, AA, ADG, YAB
Final approval of the version to be published: AK, SAI, BÇ, EBE, FÇA, ABK, BA, AA, ADG, YAB
ACKNOWLEDGEMENTS
First of all, the authors would like to thank all nurses for helping us in conducting the study from Ankara City Hospital Cardiovascular and Neurology‐Orthopedic Hospitals. We would like to thank Prof. Dr. Erdem Karabulut for statistical analysis. We would also like to thank Ferişte Zaralı for professional translating and editing of the manuscript.
Karahan, A. , Avcı Işık, S. , Çevik, B. , Budak Ertürk, E. , Çevik Aydın, F. , Böke Kılıçlı, A. , Akçın, B. , Acar, A. , Dudu Gülkan, A. , & Aybar Bilir, Y. (2022). Determination of thermal comfort among nurses working with personal protective equipment in COVID‐19 clinics. International Journal of Nursing Practice, 28(6), e13112. 10.1111/ijn.13112
Funding information This study was not funded.
DATA AVAILABILITY STATEMENT
Data are available on request due to privacy/ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available on request due to privacy/ethical restrictions.