Masks became a topic of discussion early in the 2020 COVID-19 crisis. The rapidly changing policies and recommendations by national and international agencies were confusing. Previously, not everyone in a setting needed to wear a mask. With the COVID-19 crisis, dialogues surrounding the types and hoarding of masks with high-price tags appeared in social media. Although nurses have used masks all through their careers, there is a new awareness and several confusing policies emerged on what type of mask to wear. That triggered a search for deepening our understanding of masks.
HISTORY OF MASKS
Masks for the prevention of the spread of infections were first introduced in the late 19th century and were composed of one layer of gauze and, later, two layers of gauze (Spooner, 1967). Spooner described a series of events that culminated in this including identification of the dangers of droplets and the use of two layers of gauze near the nose to collect moisture. Soon, researchers showed that “ordinary conversation could disseminate bacteria-laden droplets from the nose and mouth” and that prevention of droplets averts bacterial infections, specifically in surgical patients. The effectiveness of facial masks was verified by its use in the early 1900s by health care workers (HCWs) caring for patients with infantile paralysis and diphtheria. Spooner also discussed the value of replacing wet masks, sterilization before reuse, and the importance of hands not touching the mask. In 1918, Weaver, the first person to publish a study on masks, reported that HCWs who wore masks while working with patients with diphtheria showed a dramatic decrease in the disease from 23.5% to 5.2%. Spooner (1967) and Weaver (1919) described the effectiveness of masks in the prevention of the spread of scarlet fever, the Manchurian plague, and tuberculosis. After repeated washing, the masks were found to be more efficient as the spaces between threads narrowed (Weaver, 1919). On the basis of the effectiveness of masks in preventing transmission of microbes, masks were generally adopted in army and navy camps and many civil hospitals by 1918 (Weaver, 1919). Thereafter, much research was done at the beginning of the 20th century regarding masks, but with the emergence of antibiotics, the importance of masks was neglected (Rockwood & O'Donoghue, 1960). An interested reader can find the evolution of devices for respiratory protection that started in the mining industry, the Occupational Safety and Health Act of 1970, and the refining of products over time (Centers for Disease Control and Prevention [CDC], 2019b). A brief list can be found in Table 1.
Table 1 -
Timeline: History of Masks
as Reported by Spooner, 1967
and CDC (2019b)
||Milestones on the History of Masks
||Johann von Mikulicz Radecki reported on a surgical mask composed of one layer of gauze.
|Fluegge reported that ordinary conversation could disseminate bacteria-laden droplets from the nose and mouth.
|Researchers recognized the correlation of the dangers of exhalation as a cause of surgical wound infection.
||Huebner reported on masks made of two layers of gauze, worn at a distance from the nose, be used during operation.
Mask efficiency was improved by increasing the layers of gauze, and masks worn close to the nose collected moisture and decreased in efficiency.
||Scarlet fever was transmitted through droplet infection (Hamilton).
Recommended use of masks while handling sterile dressings
||Lord Moynihan advocated use of masks during operations.
||Meltzer: Use of masks by patients with infantile paralysis and their caregivers
||Weaver reported zero incidence of transmission of diphtheria with mask use.
Recommended sterilization of masks after each use
Replacing a mask with a sterile one when it became moist
Cautioned against hands being placed on the mask
||Capps confirmed efficacy of masks in military hospitals, in protecting patients from cross-infection, and use of gaze mask with three to four layers
|More research on efficacy of types of masks
Doust and Lyon tested three types of masks:
• Coarse gauze, medium gauze, and “butter” cloth
○ Each mask was 6 layers (XS) with hemmed edges
○ had four-cornered ties
○ covered from below the chin to above the nose
○ varied from two to 10 layers in thickness
Concluded that the coarse gauze was inefficient regardless of the thickness and that a finer gauze was more efficient.
||Weaver and Leete concurred with the finding that gauze was inefficient
• Mask efficiency was in a direct ratio with the closeness of the mesh and the number of thicknesses of gauze.
• Recommended a fine mesh gauze with 44 × 40 threads per inch.
• Wet mask is inefficient; therefore, change after wearing for a while.
||Widespread use of gauze masks
|Several publications in 1930, 1935, and 1937
||Variations of gauze masks
• Six-inch piece of rubber be placed between two layers of gauze to create a “germproof” mask.
• A 14-karat gold-filled wire frame, covered with waxed paper on both sides and extending below the chin (Melinger)
• Use of washed x-ray film as the deflector material
• Cellophane, gauze deflection mask is more effective (Blatt & Dale).
• Gel mask (a combination of gauze and filter)
• Alaska flannel placed between two layers of a 44 × 40 mesh gauze
• Paper mask consisting of a paper napkin, two small paper clips or safety pins, and two rubber bands
||Wearing masks just over the mouth only is entirely inadequate (Davis).
Longer wearing poses a greater risk of contamination.
||Newer masks and tested four types of masks
1. Absorbing gauze mask
2. Impervious mask that deflected expelled air behind the mask wearer
3. Paper masks
4. Filter mask (a compressed layer of cotton was placed between layers of absorbing gauze)
A filter type of mask proved to be the most effective for a longer period and effective after repeated washings
||Antibiotics introduced; decreased use of masks
||Renewed interest of mask in the operating room to prevent surgical wound sepsis
||Plastic mask with filter trapped organisms from the deflected breath.
Filter mask is better, retains efficiency for 3 hours.
Absorbing gauze masks are inefficient.
||Disposable fitted mask with bacterial filtration is effective.
Gauze mask of any variation is not useful.
||Partial powered air-purifying respirator invented by William Alfred Burgess
||The Occupational Safety and Health Act of 1970
||The Bureau of Mines and NIOSH developed standards for single-use respirators, and the first N95 respirator was developed by 3M and approved in 1972.
||CDC's “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities,” 1994
||The respirator certification regulation
||New York/September 11 attack
Development of a division in NIOSH for research of PPE and personal protective technologies
||NIOSH developed a standard for a full-facepiece, air-purifying respirator
||American National Standards Institute Standard Z88.2 updated the standard practice for respiratory protection.
CDC recommended the use of a NIOSH-approved N95 respirator, or a higher level of particulate filtration, or a powered air-purifying respirator when caring for a person under investigation
CDC = Centers for Disease Control and Prevention; NIOSH = National Institute for Occupational Safety and Health; PPE = personal protective equipment.
Types of Masks
Different types of masks emerged over time. Cloth masks were primarily used until the early 1950s and 1960s when disposable masks were introduced (Chughtai et al., 2013) but not recommended for professional use. Although more sophisticated masks have evolved, cloth masks continue to be utilized, especially in developing countries (Chughtai et al., 2013). Spooner described the emergence of a plastic shell mask that incorporated a filter and was designed for single use (Spooner, 1967). Since then, masks such as the N95 respirator and the powered air-purifying respirators (PAPRs) continued to evolve. As several types of masks came on the market, few common principles were identified by standard-setting agencies in different countries to establish their effectiveness. There was some but not extensive consensus, in terms of the material the masks are composed of, proper fitting, proper wearing, proper cleaning, proper disposal, and the pathogen virulence. The cloth mask is recommended for personal use at home/personal space, not in healthcare settings. During the COVID-19 pandemic, because of the scarcity of masks and based on the recommendations from organizations like CDC, people made cloth masks and used them. In addition, several people showed their altruism to others including HCWs by making masks and providing them.
A mask, also called respiratory equipment, is defined as a device that is worn over the nose and mouth, designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols; Gov.uk, 2020). Masks are used by workers in different types of environments. In the United States, the National Institute for Occupational Safety and Health specifies that the mask is required to protect the employees in their specific environment. The Food and Drug Administration (FDA) is the agency that approves the masks (CDC, 2020c), and the Occupational Safety and Health Administration (OSHA) regulates the standards for manufacturers and employer requirements (OSHA, 2020).
Masks required for HCWs, particularly in the hospital environment, will be discussed here. Dentistry has their specifications for masks based on the level of risk involved (PlastCareUSA, 2019; Sachdev et al., 2020). In health care, a mask is usually used to protect the mucous membranes of the nose and mouth when engaged in a procedure that is likely to generate splashes or sprays of body fluid or when the HCWs are within 2 meters of a person who coughs (Ontario, 2012). The most common types of masks used in health care are surgical, N95, and with a face shield. Table 2 gives a list of masks and their benefits and disadvantages.
Table 2 -
Respirators: A Comparison
||• Loose-fitting, disposable
||• Tight-fitting respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles (95%)
|Testing and approval
||• Cleared by the U.S. FDA
||• Evaluated, tested, and approved by NIOSH as per the requirements in 42 CFR Part 84
||• Respiratory and contact precaution
||• Intended for the health care setting only
||• Fluid resistant
||• Fluid resistant
||• Provides the wearer protection against large droplets, splashes, or sprays of bodily or other hazardous fluids
• Protects the patient from the wearer's respiratory emissions
|• Prevents exposure to particles including small-particle aerosols and large droplets (only nonoil aerosols)
||• Reduce exposure of saliva and respiratory secretions to others
• No protection against small airborne particles
• Not considered respiratory protection
|• Filters out at least 95% of airborne particles, both large and small particles.
• The higher the number, the better the filtration efficiency
|Fit test required
||• Yes. Beards must be removed before the fit test (at least where the rim fits).
• Must be tested every year or when the facial alteration happens subsequent to surgery or weight loss
|User seal check requirement
||• Yes, every time worn
||• Leakage occurs around the edge of the mask when a user inhales
||• Minimal leakage occurs around the edges of the respirator when a user inhales when properly fitted and donned.
||• During the COVID-19 crisis, the FDA approved reuse as an emergency amendment when not visibly contaminated.
||• After every use
||• Discard after each patient encounter and after aerosol-generating procedures (ideal)
• Discard when damaged or deformed
• Visibly dirty
• No longer seals well
• When breathing becomes difficult
• Contaminated by blood, respiratory or nasal secretions, or bodily fluid from patients
||• N95 respirators regulated under product code MSH Class II medical devices exempt from 510(k) premarket notification
|Use in children
||• Not designed for children
|Use by those with a beard
||• Not designed for those with a beard
NIOSH = National Institute for Occupational Safety and Health.
A surgical mask, also called facemask, is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. The edges of the masks are expected to create a seal around the nose and mouth (FDA, 2020b; Ontario, 2012).
An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles when there is a good seal. The edges of the respirator are designed to form a seal around the nose and mouth (FDA, 2020b; (Ontario, 2012); “N” means “not resistant” to oil, and the number refers to the filter's ability to remove the most penetrating particle size during “worst-case” testing (OSHA, 2020). Thus, N95 is not resistant to oil and filters out 95% of the particles. The higher the number, the better the filtering (OSHA, 2020). Whereas N95 provides a minimum level of protection, there are others with higher filtering power such as N99, N100, R95, P95, P99, and P100 respirators. Although N95 can be substituted with R or P types, N95 cannot substitute for R- or P-type requirements because R designation is for some resistance to oil and P designation is for strong resistance to oil (CDC, 2020b; Hendrick, 2020). All types, namely, N, R, and P, are available as a half-mask or full-mask types. These should be fit-tested before use to ensure there is no leak around the edges. The fit test must be repeated every 12 months or earlier if the face configuration changes because of oral/facial procedures (OSHA, 2020). Usually, the health employee maintains a list of masks that are fit-tested and updates it annually or with repeat fit tests.
Products labeled KN95 are not routinely approved for use by the U.S. FDA; however, during the COVID-19 pandemic, because of the shortage of N95 masks, FDA issued an Emergency Use Authorization Act, allowing the use of KN95 masks (“Difference Between Respirators and Surgical Masks,” 2018) if they meet certain standards; not all products labeled as KN95 respirators meet these standards (CDC, 2020a). The World Health Organization advises that 3M standard KN95 (or N95 equivalent certified by the National Institute for Occupational Safety and Health) can be worn by HCWs when performing any aerosol-generating procedures (CDC, 2020a). Masks labeled KN95 may be used as a substitute for N95s; however, procurers should verify that the specific product meets the standards. PAPRs are yet another alternative for N95 respirators (CDC, 2020b). These have a high-efficiency particulate air filter, which are available in different types as well (CDC, 2020b).
The British standards for masks are different from the U.S. standards for health care. The British Standards Institute regulates the quality and safety of their products. In the United Kingdom, there are two main types of masks: tight-fitting disposable filtering facepiece (FFP) respirators and loose-fitting powered hoods (TH2; Gov.uk, 2020). There are three categories of FFP respirators: FFP1, FFP2, and FFP3. The FFP3 and the loose-fitting powered hoods provide the highest level of protection and are therefore recommended for HCWs, particularly when caring for patients and while performing high-risk, aerosol-generating procedures. If FFP3 is not available, FFP2 can be used as an alternative. The N95 respirators used in the United States are tested against different standards but are broadly equivalent to an FFP2. The FFP3 respirators filter at least 99% of airborne particles, whereas FFP2 and N95 respirators filter at least 94% and 95% of airborne particles, respectively (“COVID-19 personal protective equipment (PPE),” 2020). The National Health Service provides a list of respiratory protective equipment to be used in general for any setting and in different clinical settings by different clinical personnel in table formats. Fit-testing guidelines are also given (“COVID-19 personal protective equipment (PPE),” 2020). For example, there are separate documents for HCWs in general when performing aerosol-generating procedures, in outpatient settings, community, and social work, for paramedics, transport, and pharmacists. These documents are similar to the infographics for respiratory protection provided by the CDC (2019a).
Mask selection is based on the type and length of procedure as well as the potential for droplet/aerosol contact. For a list of procedures that generate aerosols in a health care setting, see Box 1. The N95 respirator is used to prevent inhalation of small particles that may contain microbes spread by the airborne route or while performing aerosol-generating procedures (CDC, 2019a; Ontario, 2012). Eye protection, such as safety goggles, safety glasses, face shields, and visors attached to masks, are essential for procedures where a splash is anticipated. If the eye protector is reusable, it must be disinfected before and after use. Prescription eyeglasses are not considered a protective device.
Box 1 Procedures That Generate Droplets/Aerosols (Ontario, 2012).
|• ET intubation
|• Open airway suctioning
|• Endotracheal procedures such as bronchoscopy
|• Aerosol therapy such as nebulization
|• Linen handling
How to Wear, Check the Seal, and Remove Mask
It is important to select the right mask appropriate for the purpose. Images and a step-by-step demonstration of how to wear, check for seal, and remove N95 and surgical masks are available at the 3M site, which can be considered authentic, although several other manufacturers have similar posters and videos (3M, 1997, 2013). To wear, cup the respirator in your hand with the nosepiece at your fingertips and position it under the chin with the nosepiece up. While holding it in place over the nose and mouth with one hand, pull the top strap over the head and then the bottom strap over the head, and shape the nosepiece with both hands. Then, check for a seal by placing both hands completely over the respirator and exhale sharply (3M, 1997, 2013). If air leaks at respirator edges, adjust the straps back along the sides of your head and repeat the step. Correct placement of the straps is essential to maintain the seal (Beam et al., 2015).
To remove, slide the bottom strap up and over the head without touching the mask itself, then lift off the top band, and without touching the mask, store and then discard the mask based on the organizational infection control policy. The 3M document bears the warning “Misuse may result in sickness or death.” Similar posters on wearing, checking for seal, and removal can be found in the public health U.K. website as well.
Evidence on the Efficacy of Masks
Diverse types of masks provide different levels of protection, and the efficacy of different types has been examined by researchers. Researchers have compared the effectiveness of surgical and N95 masks (Beck et al., 2004; Patel et al., 2016) and nanofiber masks (Skaria & Smaldone, 2014) and found minimal difference, although the comfort may be better with the nanofiber mask. Beck et al. (2004) found that the surgical masks had an estimated efficacy within 1% of N95 respirators. Moisture retention, reuse of cloth masks, and poor filtration may result in an increased risk of infection (MacIntyre et al., 2015).
Systematic reviews and meta-analyses had varying conclusions on the effectiveness of masks or the superior benefit of one over the other. In a meta-analysis on the comparison of surgical and N95 masks, no significant difference in efficacy was found, although less filter penetration and less facial and inward leakage were noted with N95 respirators (Offeddu et al., 2017; Smith et al., 2016). However, for N95 to be effective and ensure optimum face seal, fit testing is essential. Offeddu et al. (2017) stated that the existing evidence is inconsistent within and across studies. They found that N95 respirators offer superior protection against clinical respiratory illness (Risk Ratio [RR] = 0.47, 95% CI [0.36, 0.62]) and laboratory-confirmed bacterial infections (RR = 0.46, 95% CI [0.34, 0.62]), but not viral infections or influenza-like illnesses.
A Cochrane review concluded that a simple surgical mask is an effective protection (Jefferson et al., 2011), although a Chinese Cochrane review found that there is a better protective effect of N95 respirator against laboratory-confirmed bacterial colonization (Long et al., 2020). The general public is not advised to wear the N95 masks (Jefferson et al., 2011), probably because, unlike for HCWs, the exposure to high-volume organisms in proximity is minimal and it is cost prohibitive. In addition, manufacturers may target production based on the HCWs' demand, not for public use.
Efficacy of different types of masks was investigated. Howard et al (2020) compared (a) a full-facepiece PAPR, (b) a full-facepiece PAPR with a shoulder-length hood, (c) a surgical mask, and no facial covering (for control). They found that PAPR are effective in reducing droplet contamination of the sterile field. However, PAPR configurations are not recommended near sterile fields for fear that any air blowing across a sterile field may be contaminating.
Mask can protect a person against exposure or coughs to others. During the earlier days of COVID-19, the World Health Organization recommended public use of masks, only for those with symptoms suggestive of the illness; however, this guidance was later updated to state that the protection offered by a mask to anyone may be beneficial in preventing transmission (Greenhalgh et al., 2020). The CDC also updated its recommendation regarding the public wearing masks (Greenhalgh et al., 2020).
Contamination of Masks
Although masks are expected to protect the HCWs, once used, the outer surface may be contaminated with microbes/viruses. Researchers have examined the contamination of masks in medical and dental settings (Chughtai et al., 2019). Chughtai et al. found respiratory pathogens on the outer surface of the mask after 6 hours of use (10%) and with higher rates of patient contact (n = 145). The surgical masks used by outpatient dental department personnel have relatively higher bacterial and fungal contamination than those used by the other dental departments (Sachdev et al., 2020). As this research involved a self-report of compliance with the recommended duration of use, the reported compliance may be higher than the actual duration of use (Chughtai et al., 2019). Duration for safe use of masks and an optimum number of clinical contacts have not been defined yet in the literature. Policies on this will help guide the HCWs on the safe use of masks and facilitate a healthy work environment.
Reprocessing, Decontamination and Reuse of Masks
With the surge in demand and shortage of supplies during the COVID-19 season, reuse of masks was considered and debated. Researchers tested different methods of decontamination of N95 masks using vaporized hydrogen peroxide, 70°C dry heat, ultraviolet light, and 70% ethanol spray (Fischer et al., 2020). These authors found that vaporized hydrogen peroxide was the most effective decontamination method because no virus could be detected after a 10-minute treatment, and therefore, the National Institutes of Health recommended that the masks could be reused twice (National Institutes of Health, 2020).
Is There an Expiration Date for Masks?
The FDA believes that, even after the expiration date, masks offer some protection; however, the FDA recommends that the user must inspect the product for any visible damage or change before use and, if visible tears or damage are observed, they should not be used (Nadeau, 2020).
Cost of Surgical Masks
Normally, the cost of surgical masks is minimal, less than 11 cents per mask (50-pack box for $2.28) and less than 1 dollar for the N95, but with the pandemic crisis, the prices have soared (3M, 2020; Nicas, 2020). At the time of this publication, regular surgical masks are costing 0.58 cents, and the N95 costs as much as $7 each (Nicas, 2020). The price then further escalated to $70 per pack of 50 surgical masks, and the price of N95 or other masks claimed to have a similar effect as price increases for N95 such as KN95 varies broadly (Nicas, 2020). 3M gives a listing of prices for all their masks based on model numbers, and the price range for all their products is 0.68–3.40 per piece (3M, 2020). Even with the rising cost, respiratory protection provided by the masks continues to be effective in decreasing infections (Khazeni et al., 2009; Mukerji et al., 2017). Nicas further adds that several fraudulent activities and hoarding have been identified and items have been confiscated.
CHALLENGES/PROBLEMS OF MASK USE
The health care system may experience challenges regarding the policy implementation on wearing masks, particularly in situations similar to the COVID-19 crisis. Because nurses are a major category of HCWs, the bulk of the masks are consumed by them. Nurses use masks for prolonged periods because they are usually at the bedside longer doing patient care and procedures. Therefore, it is essential to examine the experience of nurses, as well as the challenges in complying with the policy, and examine strategies to overcome those challenges.
Potential Challenges for Health Care Systems
Some of the potential challenges experienced by the health care system and strategies to address these are listed below. This may not be a comprehensive list of challenges.
- Compliance: Not all HCWs may comply with the guidelines to wear masks because of various reasons. Lack of knowledge about the effectiveness or inconvenience may be one of the reasons for noncompliance. To enhance compliance, a mask should be comfortable and effective.
- Improper wearing: People may not ensure the seal when wearing the mask, and they may wear it incorrectly by not covering the nose. The public and Health Care Provider should be taught how to wear masks properly while following other preventive measures (Greenhalgh et al., 2020).
- Ongoing change of policies: Educate the staff about policy changes promptly. Repeated reminders may help.
- Implementing the new policy is ongoing: There may be resistance from the staff. Education is the key to the successful implementation of a new policy.
- Cost: Mask reuse may reduce cost; however, if it is not safe, that cost indirectly will be higher.
- Lack of supply of the right masks and inadequacy of storage facilities to meet a higher need in crisis such as COVID-19: Recruiting qualified and experienced procurers and stocking an adequate supply may help meet ongoing needs and surges in need.
Problems Experienced by Mask Users
Lack of compliance by staff may be because of problems experienced by the wearer, resulting in a reluctance to wear masks. Some of these are listed below.
- Lack of availability: Sometimes, even when one wants to wear the mask, it may be unavailable. This leads to frustration, fear, and emotional trauma among HCWs, and some nurses who are afraid of infection may desire to leave the field.
- Removal of facial hair by men when using N95 masks to ensure adequate fit.
- Feeling of security: A mask may give a false sense of security to the wearer, and they may not adhere to other aspects of infection prevention, thereby failing to fulfill the whole purpose of masks.
- Those who wear glasses may experience clouding/fogging of the glasses and may avoid using a mask (Johnson, 2016). Dust, mist, smoke, condensation, or sweat flowing down over the facepiece lenses can reduce visual acuity (Johnson, 2016). Performance can be seriously degraded. Disorientation can result when vision is affected. Extra time and training under these conditions may help make changes.
- Mask reuse: Cloth masks can be washed and sterilized; the disposable ones, although safe, cannot be reused. Although several modifications in guidelines occurred during COVID-19 and ensured the safety of reuse, the efficacy is not yet established (FDA, 2020a). In addition, the right mode of decontamination is not known.
- Wearer discomfort: Perceived exertion; perceived shortness of air; and complaints of headache, lightheadedness, and difficulty communicating also increased over time (Rebmann et al., 2013). Discomfort accounted for 22% of removals; although compliance improved over time, touching under N95s and eye touches did not improve. Hung (2018) found a lack of social interaction (p = .003) as their expression of feelings is poorly perceived. Other researchers reported problems such as headache from CO2 to built-up (Gralton & McLaws, 2010) pressure on the face (16.9%, 25/148), breathing difficulty (12.2%, 18/148), discomfort (9.5%, 14/148), trouble communicating with the patient (7.4%, 11/148), and headache (6.1%; Chughtai et al., 2019).
- Skin breakdown (over the bridge of the nose and behind the ear).
- Impact on work performance because of changes in metabolism, thermal equilibrium, respiration, vision, and feelings of well-being (Johnson, 2016). Masks can also interfere with personal procedures such as eating and sneezing.
- Drawing negative attention to self (Hung, 2018); if the wearer is the patient, a sort of isolation discrimination can occur.
- Feeling hot, difficulty breathing, distraction, removal of cosmetics (Hung, 2018): Feeling hot is a commonly reported problem, especially if the whole personal protective equipment is required. Claustrophobic feelings also may be present (Gralton & McLaws, 2010; Johnson, 2016).
- Lack of recognition of the caregiver's face by the care recipient.
Special Consideration in Pediatric Settings
Nurses working in pediatric settings experience the same challenges as in any other setting. In addition, they may be concerned about the psychological impact when children may be afraid of people wearing masks. Lack of personal interaction or recognition of faces can increase the fear in children. The children may not be able to recognize the face of the person caring for them. Table 3 lists some of the challenges and strategies that can be used by HCWs to manage the challenges.
Table 3 -
Settings: Challenges and Strategies
||Effect on Children/Parents
||Strategy to Address/Comment
Social smile and expression of cordiality to build relationships cannot be displayed
|Child behavior Scared/afraid
Feelings of insecurity/loneliness
|• Display the ID card with photo and name
• Exaggerate the expressions of nodding, eye or brow movements
• Display pictures of the HCW with and without a mask in the work area
• Talk to them in simple appropriate language/words
• Answer their questions
If children need to cover their faces:
• Allow time to get used to the mask; do not hurry
• Decorate the mask
• Apply mask on a favorite stuffed animal
• Show pictures of other children wearing it
• Encourage/reward stickers, praise
• Make it fun, be playful, draw someone with a mask
|Teach parents on the following:
• Know the importance of masks
• Ask the parent to model the behavior
• Talk to the child in their language
• Wear it, stand in front of a mirror with the child to explain
• Practice wearing at home so that they get used to it
• Praise the child for wearing it
• Make it fun (e.g., who wears first, which color mask to choose)
||• Double-check if they understood
• Explain the rules more than once
• Show compassion
Beck et al. (2004)
described the psychosocial impact of masks
on children and families in pediatric
settings after the severe acute respiratory syndrome epidemic. They included the tips developed by the Departments of Social Work and Child Life, Hospital for Sick Children, Toronto, ON, Canada, in their publication. HCW = health care worker.
Beck et al. (2004) developed some practices and guidelines for those who need to wear a mask in pediatric settings to alleviate fear in children:
- Introduce self to identify the person behind the mask; display picture with and without a mask.
- Wear ID badges with pictures.
- Be sensitive to child/family reactions.
- Exaggerate head nodding and eyebrow movements to compensate for the hidden expression.
- Double-check to ensure that the child and family understood what you said, as masks make it hard to understand.
- Explain the importance of wearing masks.
- Let them verbalize their feelings.
- If it is required for the children to wear masks, offer incentives to keep it on. Reward for compliance.
Implications for Nursing
Nurses or HCWs should be trained to properly use the respirator and pass a fit test before using it in the workplace (Benson et al., 2013). Training is important to improve the wearer's ability to respond to work conditions but does not eliminate the basic physiological and psychological limits to performance (Johnson, 2016). A fit test must be performed by qualified and trained personnel for accuracy.
Research must be conducted on different aspects of mask use. Safe duration of use, contaminant load at different time intervals, comparison of different types of masks, mask reuse, safe decontamination procedures, the effectiveness of cloth mask with different materials, wearer experience on continuous use, the psychological impact of wearing a mask, and other aspects could be topics of research.
Nurses are on the front line of caring for patients during an epidemic or pandemic; this has been repeated throughout history. Nurses must be educated on the proper equipment to protect themselves and prevent the transmission of disease. The American Nurses Association (2020) states: “All nurses and the health care team must receive the highest level of protection to provide care for the individuals and communities in which they serve” (American Nurses Association, 2020, n.d.). It is essential to develop and educate all staff on preparedness plans that provide infection control procedures and protocols used within the health care facility. Nurses should be knowledgeable on the variety of masks and the benefits of each, and they should contribute to the future development of masks that are safe, cost-effective, and readily available during a health crisis.
3M. (1997). Wear it Right
. Health Care Particulate Respirator and Surgical Mask 1805/1805S. Accessed from www.3m.com/infectionprevention
3M. (2013). Wear it Right
. Health Care Particulate Respirator and Surgical Mask, 1860/1860S. Accessed from www.3m.com/infectionprevention
American Nurses Association. (2020). ANA response to coronavirus disease (COVID-19). Retrieved June 15, 2020, from https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/faqs/
Beck M., Antle B. J., Berlin D., Granger M., Meighan K., Neilson B. J., Shama W., Westland J., Kaufman M. (2004). Wearing masks
in a pediatric
hospital. Developing practical guidelines. Canadian Journal of Public Health
, 95(4), 256–257. https://doi.org/10.1007/BF03405126
Benson S. M., Novak D. A., Ogg M. J. (2013). Proper use of surgical N95
respirators and surgical masks
in the OR. AORN Journal
, 97(4), 457–470. https://doi.org/10.1016/j.aorn.2013.01.015
Centers for Disease Control and Prevention. (2019a). Respiratory protection infographics. https://www.cdc.gov/niosh/npptl/RespiratorInfographics.html
Centers for Disease Control and Prevention. (2019b). 100 years of respiratory protection history, Retrieved June 16, 2020, from https://www.cdc.gov/niosh/npptl/Respiratory-Protection-history.html
Centers for Disease Control and Prevention. (2020a). FAQs on shortages of surgical masks
and gowns. Retrieved April 2, 2020, from https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns#kn95
Centers for Disease Control and Prevention. (2020b). NIOSH approved respirators. Retrieved June 15, 2020, from https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource1quest3.html
Centers for Disease Control and Prevention. (2020c). Understanding the difference. Retrieved June 15, 2020, from https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf
Chughtai A. A., Seale H., MacIntyre C. R. (2013). Use of cloth masks
in the practice of infection control—Evidence and policy gaps. International Journal of Infection Control
, 9(3), 1–12. https://doi.org/10.3396/IJIC.v9i3.020.13
Chughtai A. A., Stelzer-Braid S., Rawlinson W., Pontivivo G., Wang Q., Pan Y., Zhang D., Zhang Y., Li L., MacIntyre C. R. (2019). Contamination by respiratory viruses on outer surface of medical masks
used by hospital healthcare workers. BMC Infectious Diseases
, 19(1), 491. https://doi.org/10.1186/s12879-019-4109-x
Food and Drug Administration. (2020a). Coronavirus (COVID-19) update: FDA issues second emergency use authorization to decontaminate N95
Fischer R. J., Morris D. H., Sarchette S., Matson J., Bushmaker T., Yinda C. K., Angeles L. (2020). Assessment of N95 respirator decontamination and re-use for SARS-CoV-2
Gralton J., McLaws M.-L. (2010). Protecting healthcare workers from pandemic influenza: N95
or surgical masks
?Critical Care Medicine
, 38(2), 657–667. https://doi.org/10.1097/CCM.0b013e3181b9e8b3
Greenhalgh T., Schmid M. B., Czypionka T., Bassler D., Gruer L. (2020). Face masks
for the public during the covid-19 crisis. BMJ
, 369, m1435. https://doi.org/10.1136/bmj.m1435
Howard R. A., Lathrop G. W., Powell N. (2020). Sterile field contamination from powered air-purifying respirators (PAPRs) versus contamination from surgical masks
. American Journal of Infection Control
, 48(2), 153–156. https://doi.org/10.1016/j.ajic.2019.08.009
Hung Y. (2018). A study of barriers to the wearing of face masks by adults in the US to prevent the spread of influenza
. Retrieved from https://repository.asu.edu/attachments/211332/content/Hung_asu_0010N_18395.pdf
Jefferson T., DelMar C, B., Dooley L., et al. (2011). Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev
Johnson A. T. (2016). Respirator masks
protect health but impact performance: A review. Journal of Biological Engineering
, 10(1), 4. https://doi.org/10.1186/s13036-016-0025-4
Khazeni N., Hutton D., Garber A., Owens D. (2009). Effectiveness and cost-effectiveness of surgical masks
and N-95 respirators for the next influenza pandemic. American Journal of Respiratory and Critical Care Medicine
, 179, A1636. https://doi.org/https://doi.org/10.1164/ajrccm- conference.2009.179.1_MeetingAbstracts.A1636
Long Y., Hu T., Liu L., Chen R., Guo Q., Yang L., Du L. (2020). Effectiveness of N95
respirators versus surgical masks
against influenza: A systematic review and meta‐analysis. Journal of Evidence-Based Medicine
MacIntyre C. R., Seale H., Dung T. C., Hien N. T., Nga P. T., Chughtai A. A., Rahman B., Dwyer D. E., Wang Q. (2015). A cluster randomised trial of cloth masks
compared with medical masks
in healthcare workers. BMJ Open
, 5(4), –e006577. https://doi.org/10.1136/bmjopen-2014-006577
Mukerji S., MacIntyre C. R., Seale H., Wang Q., Yang P., Wang X., Newall A. T. (2017). Cost-effectiveness analysis of N95
respirators and medical masks
to protect healthcare workers in China from respiratory infections. BMC Infectious Diseases
, 17(1), 464. https://doi.org/10.1186/s12879-017-2564-9
Nadeau K. (2020). Keeping on the cutting edge. Healthcare Purchasing News
Nicas J. (2020). It's bedlam in the mask market, as profiteers out-hustle good samaritans. New York Times
National Institutes of Health. (2020). NIH study validates decontamination methods for re-use of N95
Occupational Safety and Health Administration. (2020). Respirator types. Retrieved June 15, 2020, from https://www.osha.gov/video/respiratory_protection/resptypes_transcript.html
Offeddu V., Yung C. F., Low M. S. F., Tam C. C. (2017). Effectiveness of Masks
and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis. Clinical Infectious Diseases
, 65(11),1934–1942. https://doi.org/10.1093/cid/cix681
Ontario P. H. (2012). Routine practices and additional precautions in all health care settings
. (3rd edition; P. H. Ontario, Ed.). Retrieved from https://www.publichealthontario.ca/-/media/documents/bp-rpap-healthcare-settings.pdf?la=en
Patel R. B., Skaria S. D., Mansour M. M., Smaldone G. C. (2016). Respiratory source control using a surgical mask: An in vitro study. Journal of Occupational and Environmental Hygiene
, 13(7), 569–576. https://doi.org/10.1080/15459624.2015.1043050
PlastCareUSA. (2019). Differences between ASTM Level 1, Level 2, & Level 3 medical face masks
. Retrieved March 4, 2020, from https://plastcareusa.com/general/rules-history-of-bingo/
Rebmann T., Carrico R., Wang J. (2013). Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses. American Journal of Infection Control
, 41(12), 1218–1223. https://doi.org/10.1016/j.ajic.2013.02.017
Rockwood C. A. Jr., O'Donoghue D. H. (1960). The surgical mask: Its development, usage, and efficiency. A review of the literature, and new experimental studies. Archives of Surgery
, 80, 963–971. https://doi.org/10.1001/archsurg.1960.01290230081010
Sachdev R., Garg K., Singh G., Mehrotra V. (2020). Is safeguard compromised? Surgical mouth mask harboring hazardous microorganisms in dental practice. Journal of Family Medicine and Primary Care
, 9(2), 759–763. https://doi.org/DOI:10.4103/jfmpc.jfmpc_1039_19
Skaria S. D., Smaldone G. C. (2014). Respiratory Source Control Using Surgical Masks
With Nanofiber Media. The Annals of Occupational Hygiene
Smith J. D., MacDougall C. C., Johnstone J., Copes R. A., Schwartz B., Garber G. E. (2016). Effectiveness of N95
respirators versus surgical masks
in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis. Canadian Medical Association Journal
, 188(8), 567–574. https://doi.org/10.1503/cmaj.150835
Spooner J. L. (1967). History of surgical face masks
. AORN Journal
, 5(1), 76–80. https://doi.org/10.1016/s0001-2092(08)71359-0
Weaver G. H. (1919). Droplet infection and its prevention by the face mask Author (s): George H. Weaver Published by Oxford University Press. The Journal of Infectious Diseases
, 24(3), 218–230.