Lockdowns, hand washing, social distancing and face masks were some of the restrictions imposed from spring of 2020 to help reduce the spread of a newly emerged virus, SARS-CoV-2, which causes COVID-19. The global pandemic of COVID-19 brought huge strain and change to the ways of working in the veterinary industry. New working bubbles, furloughing schemes, teleconsults and extra personal protective equipment (PPE) — a handful of examples of the adaptation across veterinary practices. Detrimental effects to social and in-person contact, although necessary to reduce the spread of the disease, have unknown long-term effects on mental health and wellbeing, and the veterinary industry is working hard to recover from the change and stress.
There have been government reports that highlighted significant harms to the education of children when required to wear face coverings in classrooms (Department of Education, 2022). Aside from the significant impacts on learning and communication, mask wearing is also linked to various other social and psychological harms. This article will discuss five key areas associated with mask wearing in the veterinary practice and the impacts on staff, patients and clients.
Face masks in reducing transmission of COVID-19
PPE places a barrier between staff and exposure risk and with appropriate use, helps prevent the spread of pathogens between animals and within the practice (Stull et al, 2018). Person-to-person transmission of COVID-19 can occur by direct transmission of droplets by airborne transmission of aerosols, or by touching the eyes, nose or mouth after direct contact with contaminated surfaces (Department of Education, 2022).
During the early stages of the pandemic, unless medically exempt, face masks were made compulsory across the UK. Veterinary practices, with staff and public safety as a priority, urgently brought in COVID-19 face mask protection policies to help minimise the risk of transmission. Veterinary professionals instantly adjusted their ways of working with face masks, wearing them in all areas at all times. While this was difficult, high levels of client and patient care were maintained.
The different stages of the pandemic, however, brought changes to the government's approach to face mask wearing and rules changed depending on COVID-19 transmission concern.
Published analyses from the UK Health Security Agency suggested the dominant variant Omicron strain of SARS-CoV-2 causing COVID-19 was unlikely to lead to a major surge in severe disease in care home populations. In December 2021 updated analysis was also showing significantly less severe illness and reduced hospitalisation than the previous Delta variant (UK Health Security Agency, 2022). In light of the significant improvement in the COV-ID-19 pandemic, January 2022 brought change to the UK's approach to controlling the spread of the virus. An an-nouncement made by the Prime Minister on the living with COVID-19 plan confirmed that:
- In England, face coverings are no longer required by law
- The government suggests that you continue to wear a face covering in crowded and enclosed spaces (Department of Health and Social Care, 2020).
Despite the change in stance made by the Prime Minister, veterinary practices still insist that face coverings are to be worn in the workplace. This is as result of evidence suggesting that face coverings, to some extent, can be effective in reducing transmission of the virus, although few studies have assessed their real-world effectiveness in preventing acquisition of COVID-19 infection (Andrejko et al, 2022).
It is important for staff members to be educated in effective face mask wearing as poor use can reduce levels of protection. Education and training in the type of masks are also necessary as only fully fitted, sealed and filtered face masks to at least FFP2/N95 standards will protect the wearer against COVID-19 infection (Health and Safety Executive (HSE), 2020). Face masks provide some protection to others but higher quality, better fitting face coverings are more likely to be effective (Environmental Modelling Group (EMG) and Scientific Pandemic Insights Group on Behaviors (SPI-B), 2021). A paper prepared by the Environmental Modelling Group conveyed the importance of specifying the use of well-fitting masks, as the fit is essential for effective source control and protection (EMG and SPI-B, 2021).
Homemade, reusable, non-medical masks made from household fabrics should ideally have a three-layer structure, with each layer providing a function and only have a five wash cycle threshold (World Health Organization, 2021)(Figure 1). The World Health Organization provides advice on mask use in the community setting.
Infection control and biosecurity are important to maintain practice hygiene standards. Numerous studies have demonstrated decreases in hospital acquired infections after some form of educational or training programme (Lobo et al, 2005), so educating staff on effective ways of wearing face masks could help improve COVID-19 infection risks. By having a dedicated infection control officer in practice to carry out such training would be beneficial to maintain staff understanding and compliance. However, with limitations on face mask compliance, education and training, other measures can be looked at to improve COVID-19 transmission risk.
A paper prepared from the Scientific Advisory Group for Emergencies in December 2021, stated effective ventilation has increased in importance in controlling the spread of the Omicron SARS-CoV-2 variant (EMG and SPI-B, 2021). This means practices would benefit from ensuring they understand the type of ventilation system in place for their setting and prioritise the improvement of ventilation in high risk or poorly ventilated spaces.
It is recommended that between 5–8 air exchanges per hour is crucial for good ventilation (Stull et al, 2018). This is the rate at which the complete volume of air inside a room is replaced with fresh outside air. Regardless of the type of ventilation system, filters must be cleaned or changed frequently to prevent infectious build up.
A way of protecting workers from occupational hazards is by controlling the exposures and looking at control methods on a hierarchy. The hierarchy of controls has been used as a means of determining how to implement feasible and effective control solutions (Centers for Disease Control and Prevention, The National Institute for Occupational Safety and Health (CDC NIOSH), 2015).
Figure 2 provides examples of hierarchy of control measures that can be applied to disrupt pathogen transmission and provide infection control for a variety of microorganisms, including that causing COVID-19. The use of PPE is considered a relatively less effective means of controlling exposures because it relies on human factors such as appropriate compliance, education and training. Although face masks are categorised in the lower tier, they are still critical for effective infection control, which is why many settings are still advocating the use of them.
Face mask policies and impacts to staff
On a 1–5 scale from a recent survey conducted by the Royal College of Veterinary Surgeons (RCVS), veterinary nurses reported an average score of 4.2 agreeing strongly that it was not easy to work while wearing PPE (RCVS, 2021). This was a similar result to that of veterinary surgeons. Daily, many staff can experience claustrophobia, dizziness, overheating and anxiety because of wearing face masks, especially in a busy and stressful environment. There are many exemptions from wearing a face mask, which include hidden disabilities including, but not limited to:
- Any physical or mental illness or impairment, or disability (within the meaning of section 6 of the Equality Act 201(1)
- The person is unable to wear a mask without severe distress (The Health Protection Regulations, 2020).
If someone does not wear a mask because they are exempt, they might feel anxious about being judged, shamed or stigmatised by co-workers. This may feel especially hard if the reason they cannot wear a mask is linked to mental health.
The benefits of source control when wearing masks are favourable to those with particular concern of contracting COVID-19. A person may have vulnerable family members or friends that they live with or have their own particular health concern. Wearing a face mask can help reduce the anxiety associated with contracting the infection and make someone feel safer. Face masks have also been beneficial to avoid unnecessary self-isolation, especially when staffing levels were strained. During the period when government rules allowed it, 9% of veterinary nurses had been able to avoid self-isolation as a result of being able to explain they were wearing appropriate PPE at the time of the contact (RCVS, 2021).
In a survey conducted by the RCVS, on a scale of 1–5, veterinary nurses reported an average score of 3.7 strongly agreeing they have experienced anxiety about COVID-19. It is not clear if the anxiety experienced was related to contracting the virus, but it shows many veterinary nurses have felt anxiety during that time.
The prevalence of COVID-19-related anxiety, and the extent to which it will last beyond the removal or relaxation of face mask policies, remains unknown. The charity Mind has great support and resources for COVID-19-related wellbeing (https://www.mind.org.uk/information-support/coronavirus/).
The University of Birmingham conducted a study that explored the perceptions of NHS employees working within a UK mental health trust in relation to the social impacts of the COVID-19 pandemic. In the study, 62% of colleagues felt face masks could negatively impact interaction with colleagues and people using the service. It also showed 77% off staff felt they made communication more difficult with service users and most believed that the potential benefits of face masks tended to outweigh the costs (62%; 21% undecided) (Eddy, 2021).
Effective and clear communication between co-workers is key to avoid misunderstanding and enhances patient safety. The importance of speech understanding in achieving success on shared missions has been extensively researched in military and industrial settings (Le Prell and Clavier, 2017). A study conducted by Hampton looked at the negative impacts of wearing PPE on communication during COVID-19. It concluded there was a significant difference in speech discrimination scores between normal and PPE wearing subjects (Hampton et al, 2020). With face masks potentially leading to voice strain, frustration or miscommunication, it may be beneficial for practices to use the pilot, repeat back communication style. This type of communication, also known as closed loop communication, is used strictly in the aviation industry to ensure that the message received from the sender was the intended message, by the responder repeating the message back to the speaker before completing the task (Salik, 2021).
This type of communication is often used with patient safety check lists prior to surgery to help avoid any potential errors (Ebeck, 2022), but it may be beneficial to communicate this way if face masks carry communication barriers across all areas of the practice.
Face masks and communication with clients
A successful and positive veterinarian-client interaction is crucial to providing excellent client and patient care. One research article conducted by Wong et al (2013) showed a significant negative effect found in a patient's perception of a doctor's empathy while wearing a face mask. Other human studies have also shown that clinician facial expressions can influence service user understanding, engagement, and treatment success (Ambady et al, 2002). By wearing face masks during consultations social interaction, client understanding and experience may be detrimentally affected by the use of face masks.
One way a practice could improve staff identity, is by introducing pictures on name badges so that staff and clients are able to see the ‘faces behind the masks’ in order to improve social bonds.
Veterinary nurses assist with and support clients during their beloved pet's euthanasia or during times of difficult news. Their empathy is crucial to be able to support clients during bereavement and potentially life changing events. If the importance of social interaction relies a lot on facial recognition, maybe disputes or complaints could also be defused more quickly if higher levels of trust and empathy could be visually demonstrated to clients.
Box 1 provides a personal example of an interaction involving the author. Anxious animals, upset children and misheard speech in a consultation room add time and pressure, therefore impacting client waiting times and experience. Veterinary nurses aim to communicate effectively to make an animal and owner feel at ease as soon as possible. Face masks could pose a hindrance to this.
Box 1.A personal interactionAs an experienced consulting nurse I held a routine postoperative check on a cat dental patient called Leo. I greeted my client with her approximately 2-year-old girl, who instantly became fearful and began crying when she saw me. As much as I tried to talk calmly and softly to the upset child, she continued to be upset. With permission from her mother, I took off my mask and there was an instant change in the child's behaviour. I smiled and reassured her and she smiled back, happily enjoying the rest of the consultation while I talked to her and her little cat, Leo. This demonstrated the impacts of social connection, trust and communication when it comes to face mask wearing. Not only did not wearing my mask reduce fear for the little girl, but Leo would have felt more relaxed after her 2-year-old owner/companion stopped crying. Animals pick up on many fears and anxieties especially from those they love and according to research from Nottingham Trent University, cats can notice when a person is stressed out or anxious, and can be less healthy as a result (Finka et al 2019).
It is important to consider client safety and ensure they feel safe when entering the practice. Public perception on how a practice is managing COVID-19 is important to demonstrate how a practice is managing transmission risks. However, if in line with government guidelines, both clients and staff should feel comfortable on their personal choice of wearing a face mask and not just wearing out of a sign of virtue.
Animals born during the pandemic
In a survey conducted in August 2020, The Dog's Trust asked over 6000 owners about their dog's behaviour during lockdown. More than a quarter said their dog had shown at least one new problem behaviour. One statistic showed a 54% rise in the number of people saying their dog hides or moves away when approached (Dogs Trust, 2020).
It is evident that in practice there has been a noticeable increase in nervous and anxious animals. A recent survey conducted by the RCVS stated a large majority of respondents had also personally seen an increase in caseload as a result of new animal ownership (RCVS, 2021). During the early stages of the pandemic, veterinary practices were not permitting owners into consulting rooms or offering euthanasia of patients at the owner's home, unless too unwell to travel to the practice. When taken away from their owners in order to be examined, although safer for employees, this may have affected the experience of patients visiting the practice. Being in an unfamiliar environment when not used to social interaction, with the added face mask communication barrier, may have contributed further fear and uncertainty when trying to socialise.
Most cats with normal domestic upbringing, are confident enough to explore and face different social situations. However, if a cat is not exposed to a full range of normal domestic living at an early age, such as in lockdown situations, it will potentially be scared of most things (Hargrave, 2020). Some cats are also born with a predisposition to anxious behaviour and even if socialised at a young age, they fail to learn that domestic life is free from danger, let alone the unfamiliar veterinary setting (International Cat Care, 2018).
Puppies born during lockdown were unable to socialise and attend puppy training classes and often they experience high levels of separation anxiety and mistrust in practice. A COVID-19 lockdown restrictions survey from the Dogs Trust revealed only 4% of puppies had visited a house other than the one they lived in and 42% of puppies had seen someone with their face covered (Dogs Trust, 2020).
The increase in puppies and other animal ownership through a time of isolation and separation is still affecting the ways in which practices work today. It will take some time for these animals to have better confidence when attending their veterinary appointments, so it is important that veterinary nurses take their time with these animals, especially if wearing facial coverings. Correct training in approaching nervous animals, particularly those born during the pandemic, will help create a better experience for patients and enhance their wellbeing.
With extra care and attention it should be possible to turn around the effects of poor social interaction, and for these specific patients, it may be worth assessing the risks versus benefits of wearing a face mask.
Face masks and communication with patients
Dogs are very social animals and they have many visual communication methods in common with wolves, including postures and facial expressions, which indicate aggression and fear (Bradshaw and Nott, 1995). They are visually orientated animals and recent research has discovered that dogs produce facial expressions as an active attempt to communicate with others (Siniscalchi et al, 2018).
When dogs pay particular attention to eyes and mouth in communicating, face masks pose a risk to communication breakdown. A lot of emphasis is placed on direct eye contact when partially showing your face, so it is no wonder an animal may perceive veterinary professionals as a threat.
A study conducted by Nagasawa et al (2011), showed dogs that live closely with humans are able to recognise positive facial expressions. When an animal cannot see that a veterinary professional is smiling under their mask, they will be unsure of their intent and will rely only on body language and eye contact.
Often, there are inexperienced or untrained members of staff, who are learning how to handle animals safely and effectively. Without the correct handling, training and awareness, there is a higher risk for animals to show unpredictable and protective behaviour if veterinary professionals are not demonstrating that they mean no harm.
Figure 3 is a step-by-step guide on how owners can introduce face masks to their dogs. In order to reduce nervous, aggressive behaviour, it could be useful for practices to create a similar guide or standard operating procedure (SOP) on how to approach and handle animals when wearing a face mask.
When face masks create empathy barriers human to human, and when dogs can recognise positive facial expressions with a smile, face masks could be hugely impacting patient and owner experience during difficult times such as euthanasias. The benefits of removing a face mask during emotional burdened events could be argued to out weigh the risks of COVID-19 transmission.
The government guidelines state that you are not required to wear a face mask if ‘speaking to or providing assistance to someone who relies on lip reading, clear sound or facial expressions to communicate’. Nurses, veterinary surgeons, assistants, receptionists, and anyone else working with animals, could argue that they are constantly communicating with animals that do in fact rely on facial expression for communication.
Conclusion
While there may be pressure to continue face coverings in the veterinary practice, there should be open discussions about the risks versus benefits of doing so. There is huge anxiety towards contracting COVID-19 and face masks act as an easy solution to make a person feel safer and more at ease, however at present, there is only limited scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including COVID-19 (World Health Organization, 2021).
Investigations on the social and psychological impacts of masks in the veterinary setting are likely non existent, and there is a need for research in this area. It may be beneficial to explore what further surveys a veterinary practice could do for staff and clients in order to gauge how they experience the impacts of social distancing and PPE attire. This could help educate practices on the way staff, clients and their animals are perceiving a service under pandemic infection control measures and their views on continued face mask wearing.
It is worth highlighting that the adverse impact on mental health was mentioned frequently in the RCVS impact of COVID-19 report. On a 1–5 scale from a recent survey conducted by the RCVS, veterinary nurses reported an average low of 2.7 on their overall feeling of positivity during the pandemic (RCVS, 2021). This should not be ignored and support for wellbeing during COVID-19 recovery is paramount. COVID-19-related depression and anxiety, and the extent to which it will last beyond the removal or relaxation of social distancing policies, remains unknown. So, better ways to support each other through the frequent changes in restrictions will help reduce stress and anxiety related to change. The power of a smile and visually seeing colleague's faces may be underestimated, and knowing the veterinary industry is moving forward along with the government plan on living with COVID-19, may lift spirits in looking ahead to a positive future.
It can be argued that we are at a point in the pandemic where the risk versus benefits of removing face masks could be re-evaluated in the veterinary setting. The RCVS report showed over two-thirds of respondents working as a veterinary nurse during the pandemic had received their first and second COVID-19 vaccination doses (69.1%), and a notably higher percentage of veterinary surgeons (81.2%). (RCVS, 2021). With that said, a number of vaccinated people will still get infected known as breakthrough infection (WHO, 2022) and research is still ongoing to understand the extent to which being vaccinated stops you from becoming infected and passing the virus on to others. Either way, having natural or vaccine-induced antibodies, along with a healthy lifestyle will aid recovery after contracting COVID-19 and help prevent re-infection (Kojima et al, 2022).
KEY POINTS
- It is important to consider that under Health and Safety legislation, a veterinary practice has ‘absolute duty’ to protect staff and face masks may help reduce COVID-19 transmission rates.
- Effective ventilation systems and maintenance routines have increased in importance for controlling the spread of the Omicron SARS-Cov-2 variant causing COVID-19.
- The increase in puppies and other animal ownership through a time of isolation and separation is still affecting ways of work today. It is important to take time with these animals if wearing face coverings and have correct training in approaching nervous animals, especially those born during the pandemic.
- Feelings on relaxed face mask restrictions can be difficult to navigate. Being around people without masks might make a person feel less safe from the spread of COVID-19, in contrast, people with masks may make a person feel uneasy and give them a visual reminder of danger. It is important to support everyone in practice when restrictions change to ensure they have the correct support when trying to process anxious feelings.
- Faces provide key information about identity and enhance socially important information such as trust. Face masks carry empathy and communication barriers and could be negatively affecting staff and client interaction.
- ‘Mask manners’ are important in order to help everyone feel comfortable. To keep in line with the living with COVID-19 plan, practices could consider a policy on managing face coverings on an individual basis and agreeing whether a face mask is to be worn when working in close contact with someone.