This toolkit aims to help anyone working in health care and nursing to assess and manage the risks associated with respiratory infections, specifically COVID-19. It highlights the duties of nursing staff in specific roles (for example, employers, managers or health and safety reps) and provides the latest information on risk assessment.
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Note: Readers should use this toolkit with national or local policies/guidance, not as a replacement.
Employers have the legal duty and responsibility to ensure they provide a safe and healthy workplace so far as is reasonably practicable. Specific roles and responsibilities will differ depending on the positions within your organisation. Health and Safety legislation and regulations apply to all workplaces. These regulations include health and care settings where care is provided, such as people’s homes, prisons, and ambulances. For more information on health and safety, see the Health and Safety Executive Northern Ireland and Health and Safety Executive Great Britain websites.
Health care workers (HCWs) are at an increased risk of acquiring COVID-19 compared to the general population (Mutambudzi et al. 2021). Martin et al. (2021) highlights the following key predictors of SARs-CoV-2 infection:
- Working in nursing or midwifery roles;
- Occupational exposure to increasing numbers of patients with COVID-19;
- Lack of access to PPE;
- Cohabitating with another key worker;
- Working in a hospital inpatient or ambulance setting;
Considering this evidence, the RCN and partners have developed this online Infection Prevention and Control (IPC) risk assessment toolkit. We have created this toolkit to guide the mitigation of airborne transmission, which poses a significant risk to health care workers when working within 2m of a person known or suspected to have COVID-19.Increasing international evidence and consensus demonstrate that the failure to assess and mitigate the airborne transmission route may be detrimental to managing workplace infection risk. Failure to acknowledge the airborne transmission of respiratory illnesses like COVID-19 could affect the provision of suitable respiratory protective equipment. See the Respiratory Protective Equipment (RPE) section and further resources for more details.
The Scientific Advisory Group for Emergencies (SAGE) published a report on 8th December 2021 suggesting there is a greater danger with the airborne transmission route than has previously been the case. SAGE concluded that measures to reduce airborne spread, such as ventilation, well-fitting masks and distancing or reduced density of people in indoor environments, may be even more important, and the risk of nosocomial transmission is likely to be increased.
This toolkit has been produced collaboratively in association with the other professional organisations and associations as set out in the acknowledgement section.
This toolkit contains information, advice and guidance. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed.Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used.
Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this toolkit.
This toolkit aims to recognise risks when providing close proximity care for patients known or suspected to have COVID-19, and the increasing evidence base supporting this risk in enclosed spaces which can be applied to homes and health and care environments more generally. The UKHSA has confirmed the following regarding transmission of SARS-CoV-2, the virus that causes COVID-19:
- SARS-CoV-2 is primarily transmitted between people through respiratory particles (droplet and aerosol) and indirect contact through fomite transmission (contact with contaminated surfaces).
- When someone with COVID-19 breathes, speaks, coughs or sneezes, they release droplet or aerosol particles containing SARS-CoV-2.
- Aerosol particles can also be released when certain procedures or support treatments are performed in health and care settings.
- A person can be infected when these particles are inhaled, or come into contact with the eyes, nose or mouth.
- Transmission risk is highest where people are in close proximity (particularly within 2 metres) and/or in poorly ventilated indoor spaces, particularly if individuals are in the same room or ambulance together for an extended period of time”.
The information included within this toolkit does not represent alternative guidance to existing health and safety legislation, infection prevention and control guidance and employment law. It is intended to support health and care workers in all settings and managers to navigate existing guidance and support risk assessment in their workplace to reduce the transmission of infection. The principles included within this toolkit can be applied to respiratory infections other than COVID-19 if they represent a hazard to health.
Health care workers are at greater risk of being exposed to COVID-19, compared with the general working population, due to the undertaking of their duties whilst at work.
The SARS Cov-2 virus has been classified by the Advisory Committee on Dangerous Pathogens (ACDP) as a Hazard Group 3 biological agent. A group 3 biological agent is a substance which is hazardous to health. The evolution of SARS-CoV-2 variants of concern (VoC) associated with increased transmission of the virus and rapid rise in health care worker infections and sickness absence has raised many questions regarding the route and risk of transmission of the virus through the air and quality of ventilation to mitigate this where health and care is delivered for example care homes, patients own homes, prisons, and primary care/acute settings.
The toolkit recognises that health and care workers in contact with patients/clients who have or who may have the virus should be adequately protected under the legal duties placed on their employers under the Control of Substances Hazardous to Health (COSHH) Regulations 2002. In Northern Ireland this includes the Management of Health and Safety at Work Regulations (Northern Ireland) 2000 and The Control Of Substances Hazardous to Health Regulations (Northern Ireland) 2003.
COSHH Regulation 6 and Regulation 3 of the Management of Health and Safety at Work Regulations 1999 places a legal duty on employers to make a suitable and sufficient assessment of the risk of exposure to a substance hazardous to health and identify the steps that need to be taken to control the risk. If the risk of exposure cannot be prevented, adequate controls, in line with the principles of protection (outlined in Schedule 2A of COSHH) must be in place. Principle (e) in Schedule 2A requires the employer to provide employees with suitable personal protective equipment (PPE), e.g., respiratory protective equipment (RPE), in addition to all other control measures if the combination of those measures fails to achieve adequate control of exposure.
The employer must also provide employees who undertake work liable to expose them to COVID 19 with suitable and sufficient information, instruction and training provided in a manner appropriate to the level, type and duration of exposure identified by the risk assessment.
We know that in the face of this continuing crisis, our members want to deliver the best and safest care they can and deserve adequate and appropriate protection whilst working. Therefore, in collaboration with CAPA (COVID Airborne Protection Alliance group) and the British Occupational Hygiene Society (BOHS) the RCN has developed a risk assessment toolkit to support members working in all health and care settings.
It is the legal duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees. The current pandemic has shone a light on the risks faced by health professionals in all care settings and the need for rigorous and detailed health and safety procedures.
It is recognised that risk assessments can be complex, and duties outlined in legislation/regulation are sometimes difficult to navigate. At different levels within health and care organisations, the challenges in decision-making manifest themselves in different ways and hinge on different sets of duties and perspectives.
It is for this reason therefore that, working across a range of professional and scientific organisations, we have developed a toolkit that seeks to clarify the primary obligations of decision-makers at different levels across the health care sector to enable a consistent and systematic consideration of health and safety responsibilities in the context of COVID-19.
This toolkit aims to bring together all relevant duties, including IPC guidance (UK, national or local), health and safety legislation and employment law duties in a way that ensures that they work together in a complementary way from a health and safety perspective.
The toolkit aims to support relevant staff to solve practical problems and thinking through the considerations that employers and managers are legally obligated to consider when arriving at decisions which will determine the health of health care workers.
It should be highlighted that some of the information and detail in this toolkit might be new to health care workers who have not had to consider respiratory protection against biological hazards previously in their roles as employers, managers or individual workers. For more information on health and safety, see the Health and Safety Executive Northern Ireland and Health and Safety Executive Great Britain websites.
This toolkit should not be used in place of national or local guidance. It is designed to complement existing guidance as outlined in the introduction.
Toolkit users should select the appropriate section relevant to their role to review. You may also find it informative to review the roles and responsibilities of others to support your understanding of the management of risk where you work.
Also within this section is a guide to identifying potential control measures including the correct level of respiratory protection that may be required.