Background: Studies have provided strong evidence that personal protective equipment (PPE) effectively reduces the risk of transmitting highly infectious emerging diseases among healthcare providers (HCPs). However, literature examining this phenomenon specifically within the context of the COVID-19 pandemic remains limited. This study explored the behaviours and contributing factors influencing HCPs’ use of PPE, as well as how they established a sense of safety while caring for patients with COVID-19.
Diandra Mark, BSc, BSN, RN1*, Prachi Khanna, BSc1
1 Vancouver Coastal Health, Infection Prevention and Control, British Columbia, Canada.
*Corresponding Author:
Diandra Mark
Infection Control Practitioner
Infection Prevention and Control
Vancouver Coastal Health
899 West 12th Ave
Vancouver, B.C., V5Z 1N1
Email: diandra.mark@phsa.ca
ABSTRACT
Background: Studies have provided strong evidence that personal protective equipment (PPE) effectively reduces the risk of transmitting highly infectious emerging diseases among healthcare providers (HCPs). However, literature examining this phenomenon specifically within the context of the COVID-19 pandemic remains limited. This study explored the behaviours and contributing factors influencing HCPs’ use of PPE, as well as how they established a sense of safety while caring for patients with COVID-19.
Methods: We conducted 22 semi-structured interviews with HCPs who provided direct care to patients with COVID-19 in the medical and critical care units of a large urban hospital in Vancouver, British Columbia. An interpretive description approach was used to understand staff narratives and identify key themes.
Results: Staff reported high confidence in their PPE practices, citing factors such as emerging evidence and guidance, infection prevention and control (IPAC) protocols, occupational experience, specific PPE workflows, and point-of-care risk assessments. Within the broader context of the COVID-19 pandemic in British Columbia, staff identified several factors that influenced their PPE behaviours: PPE accessibility and availability, staff education, environmental reminders, staffing levels, environmental cleaning, physical space, time constraints, patient acuity and workload, PPE fatigue, the evolution of SARS-CoV-2 variants, vaccination status, occupational culture, and systemic trust.
Conclusions: Overall, our findings highlight the importance of a relational approach in supporting HCPs to keep both patients and colleagues safe during the pandemic. By fostering trust and open communication, infection control practitioners (ICPs) can help HCPs navigate the challenges of misinformation and psychological stress. Identifying the factors that shape PPE behaviour enables ICPs to design targeted interventions that address frontline staff needs and promote effective PPE practices. Ultimately, the development of realistic, context-sensitive guidelines — along with addressing the mental and informational challenges faced by HCPs – is crucial to enhancing safety and adherence to infection control practices in future public health emergencies.
KEYWORDS
COVID-19, personal protective equipment, healthcare providers
INTRODUCTION
Personal protective equipment (PPE) plays a critical role in interrupting the transmission chain of SARS-CoV-2 within acute care facilities. Proper use of PPE reduces the risk of healthcare-acquired infections among healthcare providers (HCPs) when treating highly infectious emerging diseases, including Ebola (Shenoy & Weber, 2021; Suen et al., 2018), Middle East Respiratory Syndrome (MERS), and Severe Acute Respiratory Syndrome (SARS) coronaviruses (Gamage et al., 2005; Occupational Safety and Health Administration, n.d.). Evidence on the effectiveness of PPE in reducing SARS-CoV-2 transmission among HCPs began to emerge during the early stages of the COVID-19 pandemic (Algado-Selles et al., 2020; Griswold et al., 2021). Guided by standards established by the World Health Organization (WHO, 2020) and the Centers for Disease Control and Prevention (CDC, 2024), acute care facilities worldwide implemented PPE protocols to protect HCPs from contracting COVID-19.
Prior to the COVID-19 pandemic, research emphasized the role of individual, organizational, and contextual factors in shaping how HCPs carried out PPE practices (Baloh, 2019; DuBose et al., 2018; Fan et al., 2020; Gurses et al., 2018; Ruskin et al., 2021). During the pandemic, mandatory PPE use imposed significant physical and mental strain on the health and well-being of HCPs. HCPs faced an increased risk of physical adverse effects, including headaches (Galanis et al., 2021; Hajjij et al., 2020), breathing difficulties (Galanis et al., 2021; Battista et al., 2021), skin reactions (Galanis et al., 2021; Battista et al., 2021; Singh et al., 2020), and heat stress, all of which negatively affected their physical and mental performance (Davey et al., 2021; Hajjij et al., 2020). In Canada, 95.0% of HCPs reported psychological impacts, with 86.5% experiencing elevated work-related stress (Statistics Canada, 2022). This level of occupational stress underscored the need for strategic interventions to enhance the sense of safety across all levels of healthcare organizations (Abbas et al., 2021).
In this study, “PPE practices” refers to the specific actions, protocols, and routines followed by HCPs to ensure the proper use, maintenance, and disposal of PPE. “PPE behaviours” describe how HCPs engage with or respond to PPE for its use and adherence. Understanding HCP perspectives is particularly valuable in light of the increasing prevalence of misinformation and disinformation. While some studies have employed survey methodologies to examine PPE behaviours among HCPs, few have explored their experiences through narrative-based approaches. This study had three primary objectives: (i) to understand the narratives of HCPs who worked in COVID-19-specific units during the pandemic and how they established a sense of safety through PPE use; (ii) to explore the individual, organizational, and contextual factors that influenced effective PPE practices, along with recommendations to address identified gaps; and, (iii) to assess how PPE practices contributed to HCPs’ sense of safety for themselves, their colleagues, and the patients in their care.
METHODS
Study design
We conducted a qualitative semi-structured interview study.
Setting
The study was conducted in the COVID-19 medical-surgical and critical care in-patient units of the Vancouver General Hospital from January to June 2022.
Participants
A total of 22 HCPs who delivered direct care to patients with COVID-19 were recruited using a convenience sampling strategy, including email invitations, posters, and communication through departmental leadership. This was followed by snowball sampling to expand participation. The sample was comprised of registered nurses, physicians, allied health professionals (physiotherapists and occupational therapists), radiology technicians, respiratory therapists, porters, social workers, and dietitians (Appendix A – see online edition). Targeted recruitment strategies were later employed to ensure representation across a diverse range of healthcare professions.
Data collection
We developed a semi-structured interview guide based on the research aims (Appendix B – see online edition). Participants provided informed consent before completing a 1:1 interview. All interviews were audio-recorded via Zoom. Interviews were then auto-transcribed using the speech-to-text function and cleaned up in Microsoft Word. Transcripts were stored in secured private cloud storage only accessible to the investigators. All participant identifying information was anonymized using a participant code. Transcripts were proofread and checked for accuracy before analyzing them using NVivo 12 software.
Data analysis
Interview data was analyzed concurrently with data collection using an interpretive description approach. We analyzed interviews from various health professional groups for narrative triangulation. The first transcripts were randomly selected and thematically coded using Microsoft Word. Preliminary themes and sub-categories were identified to create a draft codebook, which was then refined with subsequent transcripts coded. Once finalized, the remaining transcripts were coded using this guide. After independent coding, the authors held reflexive discussions to verify emerging concepts and theoretical links before coding in NVivo software. Finally, the quotes for each code were summarized to extract narratives before reaching a consensus on these narratives.
Ethics
The University of British Columbia Behavioural Research Ethics Board approved this study (H21-03077). Vancouver Coastal Health gave this study operational approval (V21-03077).
RESULTS
1. Confidence in the use of personal protective equipment in patient care areas and non-patient care areas.
Generally, staff reported that PPE guidelines were more explicit in patient care areas than the non-patient care areas given the greater risk of patient-derived transmission (Figure 1). Because guidelines in these areas were straightforward and familiar, staff’s confidence in their PPE practices was consistently rated high. In non-patient care areas, staff admitted to being more relaxed with their PPE practices given the lower risk of patient-derived transmission. However, when more colleagues began falling ill with COVID-19 from spending time in the same common areas, respondents reported being more careful with their PPE practices to avoid transmission amongst themselves.
2. Determinants of confidence in personal protective equipment
The factors below affected staff’s confidence levels in their PPE practices and the PPE that they utilized. Table 1 provides supporting quotes.
2.1. Current, emerging evidence
Staff’s confidence in their PPE practices was shaped by the
constant stream of current and newly emerging evidence reported by global, national and provincial public health organizations (e.g., WHO, Public Health Agency of Canada, British Columbia Centre for Disease Control). Participants repeatedly mentioned the mixed messaging presented to them on COVID-19 precautionary guidelines and PPE recommendations for the direct care of COVID-19 patients.
2.2. Point-of-care risk assessment
Staff’s confidence in their PPE practices was greatly influenced by their process of performing point-of-care risk assessment (PCRA). PCRA is an assessment conducted by HCPs to guide themselves in selecting appropriate PPE to minimize the risk of exposure to infectious body fluids by taking into consideration the patient, the care task, and the environment (Provincial Infection Control Network of BC, 2023). Participants reported a connection between their PCRAs and individual risk tolerance to contracting SARS-CoV-2. Staff factored in the prevalence of COVID-19 within their community e.g., the prevalence of close coworkers contracting COVID-19 during a specific time period to determine their level of risk in the workplace. The PCRA promoted their confidence in subsequent PPE choices they made as well as in justifying their PPE behaviours in COVID-19 units. Staff also applied the risk assessment to non-patient care areas such as break rooms.
2.3 Particularity in PPE workflow
In light of conflicting information surrounding COVID-19 transmission and PPE recommendations, staff developed habits in their PPE workflow. What staff wore, how much they wore, when they wore it and what they preferred were all dependent on the situation and individual. At baseline, staff followed the instructions of the isolation precaution signage guidelines on the patient doors. However, there were deviations as participants reported feeling more confident and comfortable when they were able to choose between wearing a surgical mask or an N95 respirator. Developing PPE workflow helped staff maintain consistency in their PPE practices. It established itself as a natural habit which built confidence and a sense of safety among staff.
2.4. Infection prevention and control guidelines
There were contrasting perspectives on how IPAC guidelines within acute care facilities impacted staff’s confidence in their PPE practices. Some participants initially felt apprehensive about PPE guidelines but deemed them adequate over time as they followed them. In contrast, others noted much unclarity and confusion across the pandemic’s course due to constant changes in guidelines with the different SARS-CoV-2 variant waves, PPE supply constraints and emerging evidence on the virus. Several participants reported feeling that local PPE guidelines were inadequate in protecting them. Based on the discordance between the IPAC guidance and their PCRAs, staff resorted to doing their own research to guide their practices. Observing variations in colleagues’ PPE practices decreased confidence levels in their individual PPE practices.
2.5. Occupational experience
An aspect unique in daily practice during the pandemic was the frequency of donning and doffing PPE for such a large volume of patient encounters. Educational refreshers for staff helped instill and maintain their confidence levels in PPE practices. Participants reported carrying out PPE practices so often that “it felt like second nature.” When they provided care for acutely ill patients and did not contract the virus, they were reassured that their PPE practices were accurate and effective in preventing transmission.