By Cheryl Clark

Nurses are increasingly being forced to reuse N-95 masks, sometimes for five days or longer, and growing numbers of nurses said they feel unsafe reusing masks even after they were decontaminated, according to the latest in a series of nursing surveys.

That's the worrying message Tuesday of the latest results from 21,500 nurses responding between July 24 and Aug. 14. (The survey was sent to approximately 200,000 nurses.)

"It is troubling that six months -- six months -- into the COVID-19 pandemic, nurses continue to report that PPE [personal protective equipment] shortages persist, and reuse practices of single use PPE are on the rise, despite a lack of standard practices and evidence of safety," said Ernest Grant, PhD, RN, who represents some four million nurses.

The answers revealed that 68% of nurses said they were required to reuse N95 masks in the two weeks before taking the survey, compared with 62% who responded in the May survey, and 58% were reusing masks for five days or more compared with 43% in May.

Additionally, 62% felt unsafe with reusing masks and 55% felt unsafe using decontaminated masks, both similar to rates found in the May survey.

One nurse in a large hospital in Texas responded that her unit was given five N95 masks in March. She said that even "to this day we're still having to use these masks," according to Grant.

That, he said, gives a picture of the anxiety nurses are feeling.

Because of what they consider insufficient PPE, nurses struggle with anxiety, depression, and feelings of being overwhelmed. "We feel uncomfortable and unsafe that we're having to reuse these," said Grant, "because there's still no guarantee that -- yes they've undergone decontamination, but there's always the potential that as they are continually re-decontaminated, is there possibly a breakdown in the structure that may allow for the virus to penetrate?"

That is definitely a risk, said Tener Veenema, PhD, MPH, RN, of the Johns Hopkins Center for Health Security, during a webcast Tuesday to announce the survey results.

Decontamination procedures eventually will break down the integrity of the mask, she said. "The seal will no longer be a tight fit and the mask will lose its filtration efficiency, not only putting the nurse at risk but the patients and everyone else in that hospital or healthcare setting. This is why it's really critical to pay attention to the science behind the use of masks and respirators and the science behind decontamination."

Jennifer Gil, RN, who works in the emergency trauma department at Thomas Jefferson University Hospital in Philadelphia, said she and many of her nursing colleagues are operating "in crisis mode." The situation has had an "immense personal impact to our physical and mental health as we place ourselves and our families in harm's way."

Frequently, Gil said, she hears comments of desperation from her colleagues, as well as herself, with words like "I am not sure how I can do this much longer" and "I never thought I would consider leaving nursing."

Asked if he has heard of nurses receiving poor quality N95 masks or fake N95 masks, Grant responded that it's a "huge concern" that is putting lives in danger. He said he hopes the Trump administration and the Coronavirus Task Force will work hard to stop those sales.

The organization has heard from nurses complaining that the batches of masks they're provided said to be N95 are "are either counterfeit or that they're not true N95 masks," adding big concerns that breaks in the barrier will make it easy for the virus to enter "and infect the caregiver, and then subsequently they take it home to their loved ones, and worse yet, some of their colleagues, and some other patients that they may be caring for," Grant said.

Hospitals and other facilities spend a lot of money on these masks that they give to their nursing personnel, only to later learn they aren't what they thought they purchased, he said.

Veenema emphasized problems with reusing re-decontaminated N95 masks over time.

Survey data, she said, indicated nurses were being asked to reuse their N95 masks beyond the 5-day "contingency limit" specified by the CDC, which she called "very concerning."

"Masks may be contaminated with other things than SARS-CoV-2. MRSA is in hospitals. Clostridium difficile is in hospitals. Things splash up on masks: blood, saliva, fluids. All these things were the rationale behind the single time use."

There is no end in sight to these problems, said Grant, who predicted a mounting toll on the healthcare workforce for another six months to a year, with no reliable vaccine.

Veenema added that the problems nurses face with COVID-19 are compounded by wildfires in the West, hurricanes, and other disruptions with climate change. These "have rendered the United States vulnerable across a number of different levels," she said, adding that the PPE shortage, at least, is correctable.

In a news release, nurses have called for federal leaders to approve full use of the Defense Production Act to increase domestic production of PPE, pass the Medical Supply Chain Emergency Act of 2020 or other legislation that achieves the same goal, and expand investment in testing and public health infrastructure.