Received: 22 March 2021 | Revised: 19 July 2021 | Accepted: 18 August 2021 DOI: 10.1111/jocn.16031 ORIGINAL ARTICLE Spanish nurses’ experiences with personal protective equipment and perceptions of risk of contagion from COVID-­19: A qualitative rapid appraisal Maria Romeu-­Labayen PhD, Assistant professor1,2 | Glòria Tort-­Nasarre Senior 1,3,4,5 1 Lecturer | Bruna Alvarez Assistant professor | Martí Subias-­Miquel RMHN, 1,6 Assistant professor | Eva Vázquez-­Segura RNM, MA, Assistant professor1,7,8 | Diana Marre Associate Professor1 | Paola Galbany-­Estragués Senior Lecturer1,9 1 AFIN Research Group and Outreach Centre, Autonomous University of Abstract Barcelona, Cerdanyola del Vallès, Spain Aims and Objetives: Explore nurses' experiences and perception of risk regarding the 2 Department of Public Health, Mental Health and Mother-­Infant Nursing, use of personal protective equipment during the first wave of the pandemic in Spain. Faculty of Medicine and Health Sciences, Background: The contribution of our study is to use qualitative methods to under- University of Barcelona, L’Hospitalet del Llobregat, Spain stand nurses' experiences and perceptions of the risk of the contagion linked to the 3 Department of Nursing, Faculty of shortage of PPE during the first wave of the pandemic, whose explosive start strained Nursing and Physiotherapy, University of health systems around the globe. Lleida, Lleida, Spain 4 Design: Qualitative descriptive design according to the Rapid Research Evaluation Health Education Research Group (GREpS), Faculty of Nursing and and Appraisal model. Physiotherapy, University of Lleida, Lleida, Methods: Semi-­structured videoconference interviews were conducted to explore Spain 5 Anoia Primary Care Service, Gerència the experiences of 29 nurses including staff nurses, nursing supervisors and nurs- Territorial Catalunya Central, Institut ing directors from hospital and community services of the Spanish health system. Català de la Salut (ICS), St. Fruitós del Bages, Spain Interviews lasted 30–­45 min and were conducted in May 2020. We carried out a 6 Parc Sanitari Sant Joan de Déu, Sant Boi thematic analysis using Dedoose. The COREQ checklist was used to report findings. de Llobregat, Spain Results: We identified the following themes and subthemes: 1. Experiences with per- 7 Department of Public Health, Mental Health and Mother-­Infant Nursing, sonal protective equipment: scarcity, inequality, reutilization, self-­protection, delega- Faculty of Medicine and Health Sciences, tion of responsibility, and gap between protocols and reality; 2. Perception of the risk University of Barcelona, Barcelona, Spain 8 of contagion: lack of credibility, lack of trust, lack of support, and meeting subjective Manso’s Sexual and Reproductive Healthcare Center, Gerència Territorial needs. Barcelona, Institut Català de la Salut (ICS), Conclusions: The scarcity of personal protective equipment and inequality in its dis- Barcelona, Spain 9 tribution led nurses to take initiatives to feel more protected. Mid-­ranking supervisors Research Group on Methodology, Methods, Models and Outcomes of Health were caught between the responsibility of monitoring and rationing personal protec- and Social Sciences (M3O), Faculty of tive equipment and providing the necessary protection to nurses. The disjuncture Health Science and Welfare, Centre for Health and Social Care Research (CESS), between protocols and the available supply of personal protective equipment caused University of Vic-­Central University of confusion. Lack of credibility, lack of trust and lack of support from management Catalonia (UVIC-­UCC), Vic, Spain This is an open access article under the terms of the Creat​ive Commo​ns Attri​bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2021 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd. J Clin Nurs. 2021;00:1–13.  wileyonlinelibrary.com/journal/jocn | 1 2 | ROMEU-­L ABAYEN et al. Correspondence Glòria Tort-­Nasarre, Department influenced participants' perception of the risk of contagion. Mid-­ranking supervisors of Nursing, Faculty of Nursing and were often responsible for trying to alleviate fear among nursing staff. Physiotherapy, University of Lleida, C/ Montserrat Roig, 25198 Lleida, Spain. Relevance to clinical practice: Understanding the factors involved in risk perception Emails: gloria.tort@udl.cat; gtort.cc.ics@ can be helpful to decision-­makers who help protect nurses in clinical practice. These gencat.cat results can help administrators and policymakers because they point to the need for nurses to feel that their departments and centers look after their safety at work. Transparent communication and emotional support may contribute to their well-­being in the face of risk. KEYWORDS crisis intervention, health risk, practice nursing, qualitative approaches 1 | I NTRO D U C TI O N What does this paper contribute to the wider The World Health Organization (WHO) declared the outbreak of global clinical community? COVID-­19 an international public health emergency on 30 January • The scarcity of personal protective equipment and in- 2020 (Mahase, 2020). After the disease spread rapidly around equality in its distribution led participants to take initia- the world, it was declared a pandemic on March 11, 2020 (WHO, tives such as reusing equipment and constructing their 2020). Through Royal Decree 463/2020 of March 14, 2020, the own with non-­approved materials. Participants who Spanish government declared a state of alarm that included a stay-­ were mid-­ranking supervisors monitored the use of per- at-­home order to prevent the spread of the disease (Ministerio de sonal protective equipment. la Presidencia & Relaciones con las Cortes y Memoria Democrática, • Supervisors were caught between the responsibility 2020). This was the start of an unprecedented public health crisis of rationing personal protective equipment and that of that has upset not only people’ lives but also the country’s social, providing the necessary protection to nurses. There was economic, political and health structure. a gap between the protocols surrounding the use of PPE and the reality of the available equipment. • Lack of credibility, lack of confidence and lack of support 2 | BAC KG RO U N D from management worsened the perception of risk of contagion of participants. Mid-­ranking supervisors be- The protection of health professionals during a pandemic is key to came responsible for managing fear and the perception preventing community transmission (WHO, 2018). Protection ma- of risk among their nursing staff. terials and protocols have evolved since the 1980s, when the HIV-­ AIDS pandemic began. In 1985, the Centers for Disease Control and Prevention introduced the ‘universal precautions’ to prevent contagion from bloodborne pathogens. In 1996, they were revised major concern for nurses who worked with HIV patients and that as the ‘standard precautions’, which defined protection against the health administrators must comprehend the great complexity of risk main transmission pathways for infectious disease: aerosols, drops perception in order to offer solutions. and contact (Wolf, 2005). The main measure is handwashing and the More recently, the world has witnessed several pandemics caused main physical barrier is personal protective equipment (PPE), which by respiratory illnesses with airborne transmission. Severe Acute protects skin, mucous membranes, the respiratory tract and cloth- Respiratory Syndrome (SARS) in 2002 and Middle East Respiratory ing. PPE includes gowns, gloves, masks, face shields and goggles Syndrome (MERS) in 2012 affected Asia, the Middle East, Europe (Wolf, 2005). and the Americas (Høiby, 2020). In 2007, the WHO recommended During the HIV-­AIDS pandemic, Gerbert et al. (1988) showed reinforcing handwashing and the use of masks, glasses and gloves that nurses’ perception of risk was linked, on the one hand, to the to prevent transmission between health professionals and patients fact that authority figures minimised the likelihood of infection and and established the relationship between erratic use of PPE the introduced protocols that didn't guarantee nurses’ safety and, on the transmission of nosocomial of avian flu virus (WHO, 2007). Corley other hand, to communication problems between nurses and health et al. (2010) provided a qualitative description of the experiences authorities, caused in part by nurses’ own subjective risk assess- of nurses who cared for people who were sick with or suspected of ment. The authors noted that mistrust is one of the main engines having H1N1 at a hospital in Queensland. Some participants felt un- of fear. Gallop et al. (1992) concluded that fear of contagion was a protected because the protocols surrounding PPE were unclear, and ROMEU-­L ABAYEN et al. | 3 sometimes they perceived that protocols were modified according Studies about experiences and perceptions of healthcare profes- to the availability of PPE instead of according to safety criteria. A sionals who care for COVID-­19 patients are beginning to emerge. In qualitative study about the MERS pandemic in Korea concluded that a qualitative study, Sun et al. (2020) finds that Chinese nurses who the experience of nurses should be taken as a starting point for de- cared for hospitalised COVID-­19 patients had both positive and neg- signing protection strategies for future epidemics or pandemics. The ative emotions surrounding this experience. Zheng et al. (2021) sug- authors showed that nurses felt unprotected, alone, tired, and stig- gest implementing mental health promotion programmes to improve matised. At the same time, feelings of comradery, the responsibil- the well-­being of nurses. Deliktas Demirci et al. (2021) qualitative ity of caring for others, and the social support they received helped study shows that staff shortages, scarce PPE and a lack of organi- them grow as nurses and maintain their commitment to provide care sational support resulted in stress for nurses working on COVID-­19 despite the adversity that they faced (Kim, 2018). wards. Tort-­Nasarre et al. (2021) show that nurses responded to The recent epidemics of Ebola virus disease (EVD) in Africa organisational during the COVID-­19 pandemic using improvisa- between 2014 and 2016 also provided a useful comparison to the tion, adaptation, and learning strategies. Pérez-­Raya et al. (2021) COVID-­19 pandemic because the high transmissibility of the virus offer a quantitative study of the impact of COVID-­19 on Spanish put health systems around the globe on alert. EVD’s transmission nurses, concluding that better planning is necessary to ensure safe pathway is direct contact with fluids: blood, secretions and organs care for patients and personal safety for nurses. The contribution of infected people as well as contact with contaminated materials. of our study is to use qualitative methods to understand nurses’ ex- Contact with persons with EVD carries a high risk of infection, which periences and perceptions of the risk of the contagion linked to the itself carries a high risk of death. Strict protocols for putting on and shortage of PPE during the first wave of the pandemic, whose explo- removing PPE were implemented. The lack of sufficient PPE and sive start strained health systems around the globe. the improper removal of PPE carried high risk of contagion (Adongo et al., 2017; Reidy et al., 2017). In the United States, nurses preparing for the arrival of patients with EVD noted that the lack of a specific 3 | TH E S T U DY treatment, the scarcity of PPE and the lack of training about how to use PPE with these patients caused them to fear contagion (Gabel 3.1 | Aim Speroni et al., 2015). In Australia, where nurses also prepared for pa- tients with EVD (although none arrived), they relied on their institu- Explore nurses’ experiences and perception of risk regarding the use tions’ good organisation and preparation to address a possible EVD of PPE during the first wave of the COVID-­19 pandemic in Spain. case. Under these circumstances, nurses’ perception of risk focused on the fear of infecting their families (Pincha Baduge et al., 2017). Historically, nurses have played an important role in infection pre- 3.2 | Design vention, the monitoring of isolated patients, containment and public health (Smith et al., 2020). During the COVID-­19 pandemic, nurses We conducted a qualitative interview-­based study, using Rapid have faced fear of contagion, an emotion shared by healthcare profes- Research Evaluation and Appraisal (RREAL, Vindrola-­Padros et al., sionals around the world (Liu et al., 2020). COVID-­19 contagion among 2020). RREAL makes it possible to obtain and analyse data in a short healthcare professionals has been linked to working at close range of time (Beebe, 1995; Green & Thorogood, 2013). We were able to patients without PPE and having had close contact with infected peo- begin data analysis 3 weeks after the first interview was conducted. ple (Jin et al., 2020). Infected healthcare professionals initially wore little protection because they were unaware of the transmission ca- pacity of the SARS-­CoV-­2 virus and they also lacked information about 3.3 | Participants whether their patients were infected (Wei et al., 2020). In Spain, healthcare professionals had insufficient access to PPE, The study population was nurses in Spain who were active during putting individual and collective health at risk (Lázaro-­Pérez et al., the first wave of the COVID-­19 pandemic, from 14 March to 4 May 2020). In the face of a shortage of protective gear, the Spanish gov- 2020. We used intentional sampling (Morse & Field, 1995) and iden- ernment purchased PPE from China for distribution throughout the tified potential participants using the snowball technique. The in- country (Ministerio de Sanidad, 2020). This strategy was modified clusion criterion was being a nurse, nursing supervisor or nursing due to distribution problems that left some geographic areas short-­ director during the first wave of the pandemic. Participants included handed and was ultimately delegated to the regional governments men and women between age 23 and age 61. We chose participants (García, 2020, March 24). The failure to supply PPE had direct con- from different areas of nursing and geographic areas to obtain as sequences for healthcare professionals, who faced the risk of con- diverse a sample as possible (Table 1). tagion whenever they came into direct contact with people with Authors MRL, GTN, MSM, EVS drew on their network of pro- COVID-­19 (Zhan et al., 2020). The shortage of PPE has been iden- fessional contacts to identify the initial participants, who were tified as a possible cause of contagion between healthcare profes- contacted by e-mail and invited to participate. Participants who re- sionals and patients (Suárez-­García et al., 2020). sponded and accepted our invitation received an information sheet 4 | ROMEU-­L ABAYEN et al. TA B L E 1 Sociodemographic characteristics of participants 30–­45 min and two questions were asked: What is your perception Nursing Nursing of the supply of protective equipment during the COVID-­19 pan- Nurse supervisor director demic? What was your experience of caring for patients during the Sex pandemic? Due to the sensitive nature of the questions asked in this Male/Female 19/5 2/1 2 study, survey respondents were assured that raw data would remain Age confidential and would not be shared. The interviews were audio 23 to 29 years old 8 0 0 recorded, and the interviewers took notes and wrote memos. Both 30 to 49 years old 10 2 1 the notes and the memos were used in the RREAL process. 50 to 62 years old 6 1 1 Region 3.5 | Ethical considerations Catalonia 15 3 2 Madrid 3 The study and the informed consent process were approved by the Basque Country 3 bioethics committee of the host university (Exp. 5184). The voice Extremadura 2 recordings and transcripts are stored in encrypted files to which only Cantabria 1 the principal investigator has access. We protected the confidential- Type of health centre ity of participants by substituting real names with codes. The confi- Hospital 15 3 2 dentiality protocol does not allow us to re-­contact participants, but Field hospital 1 the informed consent document they received contains a link where Home emergencies 1 they can find the study results. Primary care 5 Nursing home 2 3.6 | Data analysis and an informed consent document that include details about the The data were anonymised and transcribed. Guided by our research purpose design, expectations, risks, and benefits of the study. After questions, we analysed the most frequent topics that we identified participants signed the informed consent document, we arranged a in the interviews (see Gale et al., 2013; Smith & Firth, 2011). We fol- time for the interview. The interviews were conducted in May 2020 lowed Braun and Clarke's approach to thematic analysis (2014). We using videoconferencing, given the stay-­at-­home order. We used used the Dedoose® platform and we identified meaning units re- Skype or Zoom and recorded the interviews. lated to the research objectives and grouped them into sub-­themes and themes. We identified and reported patterns from the data and arranged them systematically to shed light on the research ques- 3.4 | Data collection tions, while remaining profoundly respectful with the perspective of the participants (Colorafi & Evans, 2016) (see Table 2). Three team researchers (MRL, GTN, EVS) conducted the interviews, We completed the Consolidated Criteria for Reporting until reaching data saturation with 29 interviews. We defined satu- Qualitative Research (COREQ), a 32-­item checklist for interviews ration as the point at which no new information was indentified from and focus groups used to verify the quality of a study’s methods interview responses (Fush & Ness, 2015). Interviews lasted between (Tong et al., 2007) (Appendix S1). TA B L E 2 Phases of thematic analysis according to Braun and Clarke (2014) Phases Description Collaborators 1 Familiarisation with the data: listened to recordings, transcribed recordings, MRL, GTN, BA, MSM, EVS, DM, PGE anonymisation and transcription and entering transcripts into Dedoose 2 Entering codes. Segmentation of meaning units within the transcribed MRL, GTN, BA, MSM, EVS interviews. Definition of sub-­themes and identification of relationships between sub-­themes 3 The inclusion of meaning units in each sub-­theme was discussed until a MRL, GTN, BA consensus was reached. Grouping of meaning units into sub-­themes 4 A glossary was created with the description of each sub-­theme MRL, GTN, BA, PGE 5 All sub-­themes were reviewed, relationships between sub-­themes were MRL, GTN, BA, DM, PGE identified, and they were grouped into two themes 6 The final report was written MRL, GTN, BA, DM, PGE ROMEU-­L ABAYEN et al. | 5 3.7 | Rigour Scarcity Credibility, transferability, dependability, and confirmability ensure Most participants faced a sudden need for PPE and experienced a the trustworthiness of qualitative research (Polit & Beck, 2016). shortage thereof. Some reported having access to expired, unused To ensure trustworthiness in the study, the data were discussed PPE that had been saved from the EVD pandemic. by MRL, GTN, BA, DM, and PGE until we reached consensus. The triangulation of observers ensures the consistency and strength of We didn’t have the necessary material, there weren’t the results and therefore their trustworthiness. The interviewers enough masks, we had PPE from Ebola that had been carefully recorded their impressions and perceptions during the in- stored for four or five years. It was all a little bit hand terviews and they shared these ideas with the rest of the team and to mouth. used them to reflect on the beliefs, values and personal interests (P11 nurse) that could influence the research (see The University of Auckland, 2020). Some nurses understood this as a consequence of the lack of fore- sight in the organisation. The sharp increase in demand for care for COVID-­19 patients and the logistical improvisation used to meet it ex- 3.8 | Research team and reflexivity plain the shortages. The research team was made up of nurses and anthropologists. I think that the political strategies and the manage- The anthropologists and three of the nurses hold Ph.Ds. and have ments of the centres have improvised because they experience with qualitative research. The external perspective had no other choice. […] We’ve had moments that of anthropologists in the health context has added strength to we’ve adapted to what we had, to go out to battle. the analysis. Reflexivity is important in ensuring that researchers (P1 nurse) reach an accurate interpretation of the data. In this sense, team members have been aware of the necessity of maintaining dis- Health centres improvised quickly to increase the number of beds, tance from their own nursing practice and have counted on the sometimes setting up field hospitals. perspective of the anthropologists, which has contributed to iden- tifying the influence of their own practice on nurses during the It’s logical that at first there was a lack of material because analysis process. Ward 7 opened overnight: soldiers assembling beds, we too, removing plastic wrap, organising the warehouse, volunteers helping: suddenly from one day to the next 4 | FI N D I N G S 500 beds were assembled. But of course, there were a lot of nursing stations, it was 10 I think, and it's normal that Two themes and 11 sub-­themes were identified related to the aim of material was missing, but it gradually came to us. the study (Table 3). (P18 nurse) 4.1 | Experiences related to personal Inequality protective equipment The distribution of PPE was not only insufficient, but also uneven. In the first wave of the pandemic, nurses had different experiences Differences in access to the equipment occurred between depart- related to PPE that were unprecedented. ments, between professional categories and even between shifts. TA B L E 3 Structure of themes and Themes Sub-­themes sub-­themes 1. Experiences with personal protective equipment 1.1 Scarcity 1.2 Inequality 1.3 Reutilisation 1.4 Self-­protection 1.5 Delegation of responsibility 1.6 Gap between protocols and reality 2. Perceptions of the risk of contagion 2.1 Lack of credibility 2.2 Lack of trust 2.3 Lack of support 2.4 Meeting subjective needs 6 | ROMEU-­L ABAYEN et al. Some participants who worked in areas where PPE was lacking ob- for suspected cases it was impossible. You couldn’t served that healthcare professionals from other areas had all the manage. material they needed. (P8 nurse) You see that they come from the health service to do The lack of PPE was so severe that the only possible way to avoid some tests in the nursing home or whatever and […] running out was to wash, disinfect, and reuse it. obviously, it’s nice to see how they dress, undress, all new, they take it off, they don’t touch anything. It’s a I mean, it's just that our case has been […] reusing little sad, in that sense, that some have so much and PPE. I understand it's done because there's no equip- others so little. ment, […] but I think they still don't really know the (P23 nurse) importance of having to change [your equipment]. I mean, I have to take off a coverall and I have to spray Some health centres differentiated between professional groups. it with a spray and pray it's clean, so that when I put it According to the participants, physicians had the necessary equip- on in 3 hours, I don’t get infected. ment, training, and information, but nurses did not. These resources (P23 nurse) came late, if at all. Some participants reported that nurses organised themselves to We have encountered the lack of organisation start- disinfect and reutilise PPE. ing from the top level. I mean higher up… doctors were trained and each one received protocols, but But we still have one [PPE] for you, for as long as it no one gave me anything. […] The only thing is that lasts. We have a dirty area. We put it in there, we someone came here to tell us how to remove our per- hang it up, we treat it with bleach diluted in water. We sonal protective equipment, but they came when we move it to an intermediate area, and we go over it with had been working in the unit for three weeks already. an ozone machine. And then we take it to a clean area, (P10 nurse) but it’s still the same [gear] with several disinfection processes. (P14 nurse) Reutilisation In non-­specialist areas of hospitals, primary care facilities and nurs- Self-­protection ing homes, PPE was reused more than in other areas. The life of masks was extended beyond manufacturers’ recommendations. The nurses felt unprotected, and fear of contagion led them to use materials they had within reach, without knowing whether it really I would sometimes go out sweaty, with my whole improved their safety. mask wet, dripping, and wanting to change my mask and they [the supervisor] would say, ‘No! It has to last We've suffered a lot over equipment. […] Looking for for a week’! And once a supervisor said, ‘If you all tutorials on how to make gowns out of garbage bags. keep going like this’, she said, ‘next week you’re going The cleaning woman giving us large garbage bags. A in with only a surgical mask and the week after you’re midwife who knows a lot about sewing, making tuto- going in with your hand here’ [makes the gesture of rials on how to do it. One [nurse] who has a neighbour covering her mouth with her hand] (silence). whose husband works in China giving her masks. We (P3 nurse) had one and we kept it. My mother making cloth hats for all my co-­workers. Participants who worked in units that had both patients with (P2 nurse) COVID-­19 and other patients faced an added difficulty. They were forced to keep track of which equipment they had used in which room, Participants also reported having to use expired masks, which was to avoid spreading the infection to patients who were not infected better than not having a mask at all, even though they didn't offer the with COVID-­19. same guarantees as unexpired masks. It was chaos because at night there are three of us: me We had to use plastic and make our own PPEs with and the two nurse’s aides. We had to reuse the equip- rain jackets, with diving goggles. The masks were not ment to go into the rooms. We had to be careful not FFP2. We had six for the whole nursing home and to go with the positive [gear] to the other rooms, but ROMEU-­L ABAYEN et al. | 7 they were the ones from H1N1, from 2012, I think, there. Everything disappears. […] Obviously, you have that were super out of date. to have enough for everyone, but not misuse it… (P14 nurse) (P21 nursing supervisor) Monitoring Gap between protocols and reality According to the participants, the scarcity of protective gear and Participants agreed that there was a gap between the protocols sur- some cases of misuse had implications for management. The supply rounding the use of PPE and the reality of the available equipment. of PPE had to be monitored, and nurses had to justify their need Some supervisors reported that they were unable to implement for it to be provisioned. Supervising nurses distributed equipment to protocols rigorously because of the lack of PPE. nurses according to the procedures they had to carry out. Because they can't say 50 protocols […] perfectly […] If I had to go inside a room, inside an operating room describing what to do with PPE, and then not have in this case, to do a pump that was beeping at me or PPE. […] I try to make people respect the protocol change an IV… I didn't need all the equipment—­the wa- as much as possible, I'll make use of what I have, terproof gown, the gloves […] I could go in with a double right? And I'll adapt according to the general condi- glove or a simpler gown and respiratory protection […] tions or common sense in many things. But if you're But if I have to go in and put in an IV, or manipulate the telling me to put on, to throw away the FFP2 every airway, obviously we are the first ones who know we time or the FFP3. […] Because protocol tells you that have to be protected. And the truth is, there are times you have to throw it away every time you go in, but when we didn’t manage to handle this. […] We had to if you don't have [enough], you can't throw it away ration them very well. There was even a kind of conflict. every time. (P21 nursing supervisor) (P21 nursing supervisor) Participants who no longer had direct access to PPE (as they had Several participants pointed out that even though they had re- enjoyed before the pandemic) had to request gear from their superiors. ceived training on the proper use of PPE, they didn't receive the equip- ment that had been used in the training sessions. In terms of the treatment that we [healthcare] profes- sionals received by the hospital administrators, well… During the month of February at the health department little [protective] equipment, you had to be asking for they were posting videos of how to put on and take the equipment. off a PPE. And when we needed them there weren’t (P12 nurse) any [roars with laughter]. It’s outrageous. We've been watching videos for three weeks, and now, where are they? I take it off like this [pantomimes the action of Delegation of responsibility taking off PPE], and now, where is it? There's nothing. (P2 nurse) Responsibility for rationing and monitoring the equipment lay mostly with mid-­ranking nursing supervisors. Centre administra- tors delegated this responsibility to nursing supervisors, who found 4.2 | Perceptions of the risk of contagion themselves in the difficult position of trying to protect their nurses while also minimising the risk of running out of PPE. During the first wave of the pandemic many participants were fully aware that they were working in conditions that did not guarantee On the one hand, protecting their staff and, on the other their personal safety from contagion. Four factors influenced par- hand, not running out of gear. And management has often ticipants’ perception of risk of contagion from SARS-­CoV-­2 during delegated that responsibility to mid-­ranking positions the first wave of the pandemic. (P25 nurse). Some participants who were supervisors reported that PPE was Lack of credibility used too quickly if they didn't administer it carefully. The lack of clear and truthful guidelines about the risk of SARS-­ First thing in the morning, I distribute the FFP2s. […] CoV-­2 contagion and how to protect oneself against the virus dis- Because if you leave a box out, in five minutes it’s not credited public management and hospital administrations. 8 | ROMEU-­L ABAYEN et al. I follow quite a few healthcare professionals on so- Some participants reported that the information that they re- cial media who talked about how odd the ministry's ceived was not reliable, and they feared that administrators were recommendations were on which equipment to use, withholding information about the risk of contagion to justify distrib- which seemed to be decreasing. At first, they would uting less PPE. tell us FFP3 masks and then they were going down. That is, because there wasn’t enough gear, they low- I understand it's a changing situation, but we could ered their PPE recommendations. This generated a have been more careful with information overload. bit of a lack of credibility. Then when equipment ar- Sometimes they would also try to take advantage of rived from China, it was written in Chinese so we un- new situations to avoid sending you more PPE be- derstood nothing, but the numbers written as FFP5. cause they said there was no danger anymore, etc. When more equipment started to arrive, we had to It’s much more difficult to work this way because we ask less, but of course, then comes the news of defec- were working from [a perspective of] generalised mis- tive equipment, etc. You're putting the [healthcare] trust, even among co-­workers. […] That makes people professionals you have to take care of at considerable think they're more worried about saving [equipment] risk. than about protecting people. (P12 nurse) (P16 nurse) The protocols of each centre also varied and often failed to cover all of the situations that nurses encountered. Lack of support They haven’t stipulated well what PPE we should Some participants felt a lack of support from their supervisors that wear when we go to work in a dirty area. It depends a added to their feelings of vulnerability and fear. bit on the judgement of the person and on the equip- ment that’s available that day. It depends on how the I haven’t been afraid, not personally afraid… I mean, wind blows. It’s very clear when you go to treat a re- it’s my job. I chose to be a nurse, and I’m here for spiratory patient how you should dress. Now if you’re whatever comes. But I have felt unprotected by the going to work in areas that are potentially contami- system and by my superiors. At no time have I heard nated, but you’re not going directly to a COVID-­19 that comfort of: ‘Let’s go girls, one day less! It’s okay, patient, there’s not a protocol for protecting yourself. we’re going to try to do it together! What do you Sometimes the recommendations are even contradic- need? What are you missing’? No, it was all fear, that tory: there are areas that are very well defined, others the gear shouldn’t be used up, that there aren’t masks, not at all… This generates confusion since in the end that there aren’t PPE. (P3 nurse) you don’t know what you should do in each case. (P29 nurse) Sometimes, the lack of support led nurses to question whether they wanted to continue in their jobs. Lack of trust There has been a lot of… a feeling, a perception of a lack of safety for the worker. And even at sometimes The scarcity of PPE led nurses to mistrust centre administrators and people have even been forced to wonder to what ex- even their peers. Participants interpreted administrators’ concern tent they wanted to keep providing that care, because about saving equipment as a lack of interest in their safety. This lack they haven’t felt supported or backed up. of trust appeared in some participants who perceived that the work- (P14 nurse) ers who were responsible for distributing PPE wore better quality equipment than that which they distributed. Meeting subjective needs It's true that we got a little angry because the people who handed out the equipment were the emergency Lack of knowledge about the virus and contagion pathways raised department people […]. It was therefore a little suspi- a lot of concern among nurses. Nursing supervisors had protocols cious that they brought us those hard masks, but they for distributing PPE according to objective criteria. However, the came wearing their 3M mask. At that moment, we nurses’ subjective perception of risk generated fear that needed to wondered why they had those and we were brought be managed. Mid-­ranking nursing surpervisors had to handle these the hard egg-­shaped masks. subjective emotional needs of their nurses, showing comprehension (P18 nurse). of their experiences and perceptions. ROMEU-­L ABAYEN et al. | 9 [A lack of PPE] hasn't occurred at the hospital. It was contributing to the fact that nurses are the healthcare professionals more [a question of] FFP2 or FFP3. ‘That one [nurse] that experienced the highest incidence of infection (Bandyopadhyay is wearing an FFPx. Why aren’t I’? And you had to et al., 2020). A scarcity of PPE also occurred during the EVD pan- be with them a little bit and explain the difference. demic in West Africa (Adongo et al., 2017). Additionally, Australian Taking protocols and keeping up to date with proto- nurses pointed to a lack of PPE to care for people infected with cols coming out of occupational health, so that people H1N1 influenza in 2009 (Corley et al., 2010). Our results show saw that we're already protected. And it depends on that, despite these recent experiences of PPE shortages around the type of patient you have. So, ‘She has to be pro- the world, shortages were not prevented at the beginning of the tected a little more, with a surgical gown’, and you had COVID-­19 pandemic. Moreover, we show how nurses experienced to be very on top of the situation. There was fear… these shortages. Notably, in many instances they reported that the It’s true that the needs and perceptions of the staff, unexpected explosion of the pandemic had prevented institutions be they COVID dirty rooms, COVID clean rooms. The from preparing. perception is that they were under-­protected, and Our finding that healthcare professionals had unequal access to they demanded this protection without having objec- PPE during the first wave of the pandemic is consistent with a study tive criteria. It was based more on subjective criteria. by Jia et al. (2020), which shows that hospital nurses in Shandong […] ‘Do you feel safer if you're wearing this? Well, were less protected than doctors. Different degrees of access to here, no problem’! They [supervisors] end up under- PPE among different health units have also been found in the UK standing that it’s not worth it to argue and continually (Hoernke et al., 2021). PPE shortages were most notable in care put the regulations on the table. But rather give more homes, community health facilities and general practice. The un- weight to people’s subjective judgement. ‘Do you feel availability of PPE at the onset of the pandemic had consequences better? Well, here, go ahead’! for the risk of contagion among healthcare professionals, with im- (P28 nursing supervisor). portant implications for their health and the risk of transmission to healthy patients (Suárez-­García et al., 2020). According to our study, The restrictions on PPE caused concern, tension, and fear among inequality in access to equipment produced differences between nurses, who in turn felt unable to make changes to ameliorate the departments and even between co-­workers, leading to discomfort situation. among co-­workers and increased perception of risk. Reusing PPE was also linked to the perception of risk, according On the one hand, you wanted to help, because your to our results. Non-­specialised services in hospitals, primary care fa- co-­worker comes to demand a series of protective cilities and nursing homes faced the most scarcity of PPE, and these items, which sometimes there weren’t any or we areas identified more initiatives by nurses to reutilise gear. This didn’t have approval from the administration to hand result is consistent with those of Hoernke et al. (2020), and there them out. Protocols are very restrictive for using PPE. are also precedents of reuse during the H1N1 influenza pandemic So, we’ve experienced a lot of tension, with a lot of in Australia, which led to increased perception of risk of contagion fear on the part of all [healthcare] professionals, and among nurses (Corley et al., 2010). The reutilisation of material we have found ourselves with little wiggle room for should be performed according to the manufacturer's instructions, improving this situation. but it is still unknown whether reuse is recommended in the case of (P25 nurse) COVID-­19 (Bessesen et al., 2015; De Perio et al., 2020). These reuse initiatives were taken without knowledge of the manufacturer's instructions, and they were attempts to improve protection, even 5 | DISCUSSION though efficacy was not guaranteed. These findings extend those by Liu et al. (2020), which show that doctors and nurses in China Our results reveal the participants’ experiences with PPE as well as reused PPE. At the same time, many participants engaged in self-­ the factors that influenced their perception of risk during the first protection using non-­approved do-­it-­yourself materials, as was com- wave of the COVID-­19 pandemic. mon throughout Spain. This result, consistent with Hoernke et al. (2020), shows that nurses took the initiative to protect themselves and continue caring for people who were sick with COVID-­19. These 5.1 | Experiences related to personal results indicate that when nurses felt vulnerable and lacked knowl- protective equipment edge about the risk of contagion, they sought out protective gear that could alleviate their sense of risk. These results show the severity of the shortage of PPE that affected Healthcare professionals knew that level 3 of biosecurity protec- nurses and other healthcare professionals during the first wave tion had been activated in China, following WHO recommendations of the pandemic in Spain (Suárez-­García et al., 2020). This short- (Zhan et al., 2020). Spanish health institutions had difficulty supply- age was experienced around the world (Iqbal & Chaudhuri, 2020), ing healthcare professionals with PPE (Suárez-­García et al., 2020). 10 | ROMEU-­L ABAYEN et al. This led to increased monitoring of PPE, which meant a change in the the department, nurses trusted their managers. Our results indicate typical working dynamics of resource managers and nurses. Many the importance of prioritising the care and protection of nurses to health centres administrations delegated to mid-­ranking nursing su- preserve their confidence in management. pervisors the management of PPE and limited the access of general During the first wave of the pandemic, nurses worked in pre- nursing staff. Mid-­ranking nurses rationed PPE to avoid running out. carious conditions, with few safety protections, resulting in anxiety. Our results indicate that, for mid-­level nursing supervisors, taking Mental health teams were deployed to provide support to health- responsibility for monitoring PPE was difficult to combine with en- care professionals, but this help was distributed unevenly across suring the protection of nurses, given the shortage of equipment. institutions and geographic areas (Lázaro-­Pérez et al., 2020). The Prior to the pandemic, nurses in Spain were entrusted with distribut- precedent of China revealed the emotional impact the pandemic had ing PPE among themselves as necessary to care for patients. During on healthcare professionals and the need for health institutions to the first wave, mid-­ranking supervisors became responsible for this support their well-­being (Liu et al., 2020). We stress that, although task, leading some participants to sense that supervisors were more our participants had access to psychologists, they missed the sup- concerned with maintaining stocks of PPE than with protecting port and care of their superiors during the workday. They felt vul- nurses’ health. nerable and reported that they needed their supervisors to support Protocols on the use of protective gear in Spain were updated them and recognise their effort. Support from management is key frequently, as information about SARS-­CoV-­2 and its transmission for increasing nurses’ sense of security and decreasing their percep- pathways became known. These results highlight that a gap devel- tion of risk. oped between safety protocols and the availability of PPE. A similar Lack of knowledge about how the virus spreads is an added stress gap between protocols and availability occurred during the H1N1 that substantially increases fear among healthcare professionals (Liu pandemic in Australia. The difference between protocols and clinical et al., 2020). Fear of contagion decreases when there is an adequate reality caused confusion and jeopardised the protection of nurses supply of adequate protective gear (Liu et al., 2020), which is the due to a lack of knowledge about the virus (Corley et al., 2010). We responsibility of institutions in pandemics (Lam & Hung, 2013). Fear highlight that the scarcity of PPE caused not only confusion, but also can be mitigated by providing training on prevention measures that fear, among our participants. provide greater safety and lessen psychological pressure (Mo et al., 2020). We have shown that meeting nurses’ subjective needs related to fear of contagion led to fewer disagreements among nurses over 5.2 | Perceptions of the risk of contagion the scarcity and distribution of protective gear. According to Watkins et al. (2006) to improve infection con- Our results indicate that the lack of credibility of health administra- trol strategies, consideration should be given to the influence of tors resulted from the lack of clarity in protocols and veracity about individual risk perception (see Gerbert et al., 1988, described in the risk of SARS-­CoV-­2 infection and how to prevent it. The lack of ‘Background’), as well as the culture of the organisation and infec- specific protocols and the existence of contradictions between dif- tion control policies involved in nursing practice. We have identified ferent protocols led to confusion and a feeling of insecurity among lack of credibility, lack of trust and lack of support as factors influ- the participants. Lázaro-­Pérez et al. (2020) remark that the lack of encing participants’ perception of risk. Meeting nurses’ subjective clarity affected the well-­being of healthcare professionals and pa- needs as they face the risk of contagion often lay with mid-­ranking tients. We see a precedent in the confusion that occurred among nursing supervisors. Awareness, acceptance, and comprehension of emergency room nurses in Hong Kong when faced with informa- the subjective experience of risk helped some nursing supervisors tion overload during the human swine influenza epidemic of 2009 alleviate nurses’ fear and discomfort. (Lam & Hung, 2013). Lam and Hung's study showed that, ironically, excess information led to confusion and increased risk of contagion. We have shown that, in addition to impairing the credibility of health 5.3 | Limitations and future directions administrators among the nurses they employ, confusing protocols accentuated the sense of risk among participants. The qualitative design has allowed us to explore the experiences Participants felt a lack of trust in management when it seemed and perceptions of nurses from different departments and different that management was more concerned about rationing gear than geographical areas but does not make it possible to generalise the about their safety. Mistrust also occurred among healthcare pro- results to all nurses. fessionals of the English National Health Service because of poor Another limitation is that it has been difficult to distance our- handling of the lack of PPE during the pandemic (Iqbal & Chaudhuri, selves from the health crisis we were studying because it is severely 2020). Pincha Baduge et al. (2017) have written about the perception affecting the entire population. All team members have been af- of risk among emergency nurses in Australia who were preparing for fected by the pandemic as users of health services, family members potential cases of EVD (which in fact never arrived). The authors of a person who has been sickened by or died from COVID-­19 and/or conclude that when the organisation provided the appropriate gear, nurses working in frontline health care in Spain. We have had to be with well-­defined processes and protocols tailored to the needs of conscious of the individual situation of each team member. ROMEU-­L ABAYEN et al. | 11 One possible line of future research would be to further investigate BA, MSM and EVS completed and transcribed the interviews, as well nurses’ perception of risk with respect to COVID-­19 and PPE at an- as initial analysis and coding of data. MRL, GTN, BA, DM and PGE other stage of the pandemic. The abruptness of the onset and the se- discussed the codings throughout the analysis, and were extensively verity of the pandemic decisively influenced the work of nurses, their involved in revising and finalising the themes. MRL wrote the paper protection at work and their perception of risk. It would therefore be and prepared the manuscript for journal submission; all authors con- interesting to know how experiences and perceptions change as the tributed substantially to editing the draft. All authors read and ap- pandemic progresses. This line of inquiry could also be extrapolated proved the final manuscript. to future health crises or epidemics that are foreseeable due to habitat loss among many animal species and global hyper-­connectivity. ORCID Maria Romeu-­Labayen https://orcid.org/0000-0001-9482-9474 Glòria Tort-­Nasarre https://orcid.org/0000-0001-5270-821X 6 | CO N C LU S I O N Bruna Alvarez https://orcid.org/0000-0002-9069-4573 Diana Marre https://orcid.org/0000-0003-2852-3762 The scarcity of PPE and inequality in their distribution led partici- Paola Galbany-­Estragués https://orcid. pants to take initiatives to feel more protected and maintain their org/0000-0003-3775-1695 commitment to care for people infected with COVID-­19. Participants who were mid-­ranking supervisors were caught between the re- REFERENCES sponsibility of monitoring and rationing PPE and providing the nec- Adongo, P. B., Tabong, P. T. N., Asampong, E., Ansong, J., Robalo, M., essary protection to nurses. 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