COVID 19 was declared a pandemic by the World Health Organization on March 11, 2020, after causing 200,000 cases and 8,000 deaths in more than 160 countries. The virus's contagiousness is very high and 1,000 positive cases were detected two weeks after the first case was seen [1]. Thus, COVID 19 has become a major threat to life for healthcare workers who have made superhuman efforts throughout the pandemic. While nurses constitute approximately 60% of health professionals working in pandemic clinics, this number is followed by clinicians with about 30% [2].

Personal Protective Equipment (PPE) is the most crucial weapon of health workers against COVID 19, which is confirmed by reporting increased infection and death rates among health workers because they could not reach adequate PPE. It is also among what the COVID 19 pandemic has taught us that the correct use of PPE is as important as achieving sufficient PPE [3].

The authors found that PPE in clinics reduced communication, hearing and the ability to understand what one heard. This effect of PPEs has been increasingly mentioned both in social media and in the literature. Pure tone audiometry is the standard gold method for evaluating hearing sensitivity. However, pure tone audiometry results do not always correlate with functional hearing. Because useful hearing ability is faced with environmental factors affecting sound waves, such as background noise or pronunciation differences. The reliability of pure-tone audiometry in evaluating hearing is highly controversial, especially among healthcare workers working in places with a lot of background noise, such as İntensive Care Units (ICUs) [4]. Considering these conditions, to evaluate the hearing ability of healthcare workers working in COVID 19 intensive care units, either a test with actual sentences using a system that simulates ICU background noise or an evaluation should be made by directly referring to the experiences of these healthcare professionals.

In line with this information, we planned to conduct a questionnaire study toon the hearing and vision abilities of nurses, who make up the majority of nurses working in pandemic ICUs, due to the use of PPE. Their intervention evaluates the effects on patients. We hypothesize that we might obtain the qual of auditory and visual communication among nurses due to protective equipment during the COVID 19 pandemic.            

Participants

This study was conducted between September 2020 and December 2020, based in Konya Training and Research Hospital, by interviewing nurses working in the Covid-19 intensive care with protective overalls, masks and glasses. The study permission was granted by the Ethics Committee of Karatay University (41901325-050.99). Our criteria for the inclusion of participants were that they used the protective equipment we mentioned above, worked in the intensive care unit with Covid-19 patients and performed the duty of nursing in the intensive care unit where they worked.

Our exclusion criteria from the study are; that part had existing vision icipantand hearing-related diseases or disabilities.

Survey Questions and Answers

The data were obtained by applying a questionnaire consisting of 5 sections and nine questions. In the first part of the questionnaire, the participants agreed to participate in the study. Section 2 questions are not open to participants who do not agree to participate in the study. In the 2nd part, they were asked whether they use overalls, glasses and masks, which constitute the basis of our research. Those who answered yes in this section could move on to the 3rd Section questions. Participants’ demographic data such as gender and age were asked in the third part. In the 4th part, the participants were asked whether they had been diagnosed with hearing and vision loss while working with protective equipment. Finally, the 5th Chapter consisted of questions about whether the participants experienced hearing and vision loss caused by protective equipment and whether these losses disrupted their working order, communication and ability to respond in emergencies.

The answers to the questions are of three types; 1. The questions to be answered as yes/no, 2. The age range of the participants is 20 and 60 and under and over, the groups between the ages of 20 and 60 for ten years and finally, by the Likert scale; It was scored from 1 to 4 as did not affect, slightly affected, moderately affected, highly affected.

Data Collection

The survey questions prepared through the Google drive forms program were sent to the participants with the help of social media and they were asked to fill in. After the consent of the participants was obtained, the answers to the questionnaires they filled and completed were collected in the Google forms program.

Statistical Analysis

Before the study, based on similar studies, with the help of the G-Power analysis program, it was found that at least 100 participants should be in the 90% confidence interval, based on 0.4 standard deviations.

In the analysis of the data And descriptive statistics, the independent samples t-test was used for the parameters that usually fit and the Mann-Whitney test was used for those that did not include the normal distribution.

Of the 102 nurses who participated in the survey, 33 were male and 69 were female. Thirty-eight participants were 20-30 years old, 38 were 31-40 years old, 25 were 41-50 years old and 1 participant was over 50 years old (Table 1).

About 84.3% of the respondents stated that they had hearing difficulties while working in the covid-19 intensive care unit with overalls, goggles and N95 masks. The rate of those who noted that this hearing aid did not affect their communication with their colleagues was 19.9%, while those who stated that it disrupted their communication too much were 13.7%.

In the statistical analysis of hearing, a statistically significant difference was found between the communication difficulties of the nurses who thought that the hearing loss was caused by the protective equipment used and also due to the hearing loss (Figure 1A) (p<0.001).

About 100% of the nurses in the intensive care unit stated that they had visual difficulties while working in the covid-19 intensive care unit with overalls, goggles and N95 masks. While no nurse noted that this vision loss did not affect their communication with their colleagues, 56.9% of them stated that it disrupted their communication too much (Figure 1B).

About 6.9% of the nurses think that while working in the covid-19 intensive care unit with overalls, goggles and N95 masks, they believe it didn’t affect the quality of vital interventions such as CPR and airway 28.4% think that it affected them too much (Figure 2).

Table 1: Age Distribution of İntensive Care Nurses Participating in the Survey by Gender

Figure 1: (A) Figure 1A: The effect of hearing loss status of intensive care nurses participating in the survey and communication among themselves. Hearing Loss (HD); 1-Yes, 2-No. Hearing Loss and Communication (HDC) 1-did not affect, 2-Little Affected, 3-Moderately affected, 4-Impressed too much (B) The effect of vision loss status of intensive care nurses participating in the survey and working with themselves. Difficulty Seeing (DS); 1-Yes, 2-No. Difficulty to See when Working (DSW): 1-did not affect, 2-Little Affected, 3-Moderately affected, 4-Impressed too much

Figure 2: Difficulty working in cadiopulmonary arrest situation due to protective equipment of intensive care nurses participating in the survey.Cadiopulmonary Arrest (CPR): 1-did not affect, 2-Little Affected, 3-Moderately affected, 4-Impressed too much

As far as we know, our study is the first in terms of audio and visual communication related to Covid. When we look at the findings we obtained in our study among nurses in terms of auditory and visual communication, 84.3% of the 102 participants stated that they encountered the problem of not being able to hear or understand what is being said between them and their colleagues due to protective equipment such as masks and glasses used.

In the study of Smith et al. [5], 510 healthcare professionals were surveyed about the hearing problems they experienced while serving patients in palliative care. Ninety-one percent of healthcare workers reported that hearing loss significantly impacted the quality of care for older adults. Eighty-eight percent remembered a situation where hearing loss caused a communication problem with a patient and 56 percent said a communication problem had arisen.

Another study reported that people with hearing loss often complained that medical professionals lack understanding and empathy. They often complain that healthcare professionals ignore patient stress during healthcare. This problem is primarily due to hearing problems that prevent effective communication. The study stated that healthcare professionals could benefit from special training in dealing with the communication difficulties of patients with hearing loss [6].

Studies on hearing loss, communication, occupational hearing and hearing and communication problems arising from noisy environments were discussed [7-11]. Our study addressed the hearing difficulties experienced by the nurses working in the intensive care unit with the patients and among themselves due to the protective equipment they wear during the covid 19 pandemic process. Considering the answers to the questions asked about the subject, it was revealed that 13.7 percent of the nurses had severe communication problems. In the statistical analysis of these rates, it was found that hearing loss was effective in communication with a significant significance (p<0.001).

When questioned whether the nurses experienced vision loss while working in the intensive care unit with protective equipment during the pandemic, all respondents stated that they experienced severe vision loss, especially when using masks and glasses.

The closest and most recent study is the study b Gelardi et al. [12] and 116 healthcare professionals directly involved in the health services working in the pulmonology, intensive care and infectious diseases departments of Bari and Foggia Hospital were included in this study. Between May 1, 2020 and May 31, 2020, each participant filled out an online questionnaire to investigate the impact of the COVID-19 pandemic on employees' lifestyle changes and job performance. In addition, the results were compared according to the type of mask each participant used (surgical mask vs. N95). As a result, although the discomfort associated with mask use appeared earlier in subjects wearing N95, healthcare workers wearing surgical masks had a statistically higher mean score for a more significant number of disorders.

In another study [13] which can be evaluated in terms of affecting the visual function of healthcare professionals, 500 healthcare professionals of all ages and both genders who wear contact lenses were questioned about compliance with care recommendations and complications arising from inappropriate hygiene practices. As a result, 385 (77%) of the total contact lens wearers were women. Most (75%) wore contact lenses to correct myopia, while 54% said they occasionally wore them. Surprisingly, only 24% knew the cleaning protocol. Lens solution was changed daily by 33% of users and 42% after more than two weeks. While 412 (82%) participants practiced proper hand hygiene before wearing lenses, 88 (18%) did not. Infection and dry eye were statistically significantly (p<0.01) associated with gender, hand washing and frequency of contact lenses.

When we look at the studies on vision loss in health care workers, the disorders caused by the equipment used by the employees specific to their departments and the vision loss resulting from existing other diseases are discussed [14-16].

In our study, all nurses thought protective equipment caused vision loss and 56.9% believed these losses also disrupted communication with their colleagues. In this sense, as asked in the questionnaire, the participant considered that the steam from human breath might be the leading cause of vision loss, primarily when glasses are used together with a mask.

In the last part of the questionnaire, participants were asked whether they experienced any disruption in the procedures due to masks, glasses and other equipment used due to covid 19 in cardiopulmonary arrest and emergency intubation situations. 

A study [17] aimed to evaluate the challenges faced by healthcare professionals when using personal protective equipment in clinical practice during the COVID-19 outbreak in Wuhan, China. One hundred and twenty medical personnel from Chongqing Medical University First Affiliated Hospital applied to Wuhan First Hospital to provide medical assistance. Twenty volunteered to participate in a focus group discussion attended by infection control nurse leaders. Responses and conversations of the participants were recorded and the content was analyzed in terms of themes. Practical challenges included inappropriate dimensions, the complexity of design and use, doubts about its quality and effectiveness, potential risks during doffing and inadequate comfort regarding the use and layout of the space between the clean and contaminated area.

Another study [18] conducted a single-center, cross-sectional study among healthcare professionals using advanced protective equipment. A web-based questionnaire was distributed to assess the effects on individuals' physical and mental health. The physical and psychological impact was evaluated with a visual analog scale. Results A prospective analysis of the views of 72 participants is reported. The physical effect included fatigue, headache, skin changes, shortness of breath and adverse impact on vision. In addition, communication difficulties, somnolence, adverse effects on general performance and difficulties in using surgical instruments have been reported.

In general, protective equipment studies were related to adverse effects on health personnel, loss of comfort and equipment quality [19-21]. 

In our study, the last part of the questionnaire was mainly about functionality in emergencies. While 6.9% of the participants thought the equipment was an obstacle to them in emergencies, 28.4% stated that the equipment did not cause much negative impact in such cases.

As a limitation in our study, we could question the reason and get their opinions, especially in the nurses’ answers regarding adverse effects. However, especially in comfort-focused situations, reason-oriented inquiries could have contributed negatively to the statistical ability of the study as they could contain too much individuality. Another limitation was that we could expand the study to include the clinic. However, in this case, we hesitated to ignore the intensive care conditions we wanted to focus on and our field of work as an anesthesiologist.

As a result, in our study, protective equipment used in the Covid 19 process had adverse effects on the nurses working in the intensive care unit in terms of visual, auditory, communicative and, therefore, ability to work. We think that studies like ours can be valuable to make the protective equipment, which is an indispensable part of the pandemic process, more functional and comfortable. We think that healthcare workers who endure all kinds of difficulties during the pandemic process always deserve better.

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