"One minute it's an airborne virus, then it's a droplet virus, and then it's like nobody really knows…": Experiences of pandemic PPE amongst Australian healthcare workers

Health and care workers' perceptions of PPE and physical distancing for COVID-19: A qualitative evidence synthesis

Background

Despite the effectiveness of personal protective equipment (PPE) and physical distancing interventions for COVID-19 infection prevention and control (IPC), low uptake among health and care workers persists.

Aim

To synthesise evidence from primary qualitative research exploring the perceptions and experiences of health and care workers on the use of PPE and physical distancing in the context of COVID-19.

Setting

Healthcare settings including care homes.

Method

An electronic database search was conducted using search terms based on the inclusion criteria, and the search strategy was peer-reviewed by a team of information scientists. Thirty qualitative studies were sampled after eligibility screening independently by two review authors. Synthesis was performed using the thematic synthesis approach. The confidence in each review finding was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations; Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.

Results

Fifteen analytical themes were identified. Health and care workers valued the use of PPE in patient care. The sense of value was heightened by perceived susceptibility to infection with COVID-19, the need to deliver optimal patient care and the desire to protect family members. Service delivery, clinical workflows, the absence of visual cues for spatial separation and physical infrastructure hindered adherence to physical distancing guidelines.

Conclusion

The gap between IPC guidelines and their implementation is an important health system barrier to PPE use and physical distancing in healthcare settings.

Contribution

This review provides useful insights on key considerations for planning and implementing IPC in healthcare settings.

Risk assessment and the use of personal protective equipment in an emergency department: Differing perspectives of emergency and infection control clinicians. A video-vignette survey

BACKGROUND

The use of personal protective equipment (PPE) in emergency departments (EDs) is an important defense during infectious disease emergencies. However, what counts as appropriate PPE in EDs is contentious and inconsistently implemented in practice.

METHODS

An online scenario-based video survey was distributed through purposive sampling, and completed by 270 ED and infection prevention and control clinicians in Australia. A descriptive content analysis was performed on the data, and differences between groups were tested using Fisher exact test.

RESULTS

Participants agreed that most items were required in both scenarios. Eye protection, mask use, and hand hygiene frequency were more contentious. Physicians were more likely than nurses, and ED clinicians more likely than infection prevention and control clinicians, to regard items or actions as optional rather than essential. Many ED clinicians, particularly physicians, regarded sequences as too time-consuming to be practical in a busy ED.

DISCUSSION

Our findings likely reflect differences in professional roles, competing priorities, and risks, and highlight important contextual characteristics of EDs, such as diagnostic uncertainty, equipment inaccessibility, and resource constraints.

CONCLUSIONS

To be feasible, practicable, and thereby effective, PPE guidance in the ED must be designed collaboratively with frontline ED staff, and reflects the complexities of their practice.

Radiographers and other radiology workers' education and training in infection prevention and control: A scoping review

INTRODUCTION

Infection prevention and control (IPC) is crucial in healthcare settings, particularly during pandemics like COVID-19. Radiographers play a vital role in maintaining patient safety by following IPC guidelines. However, there is concern that inadequate knowledge and practice of IPC among radiographers may compromise patient safety. Education and training programs can enhance radiographers' understanding of IPC to maintain safety in radiology departments. This scoping review aims to explore the literature on the knowledge of radiographers in IPC and the effectiveness of IPC education/training programs provided to radiographers and other healthcare workers (HCWs) in the radiology department, with a specific focus on the periods before, during, and after the COVID-19 pandemic.

METHODS

This scoping review followed the Joanna Briggs Institute's framework. The steps involved were: Define objectives and questions, align inclusion criteria with objectives, planning the evidence search and extraction, searching for evidence, selecting relevant evidence, extracting evidence, analysing evidence, presenting results, and summarising findings and noting implications.

RESULTS

Sixty-eight articles were included. Prior to the COVID-19 pandemic, practices among radiology HCWs were suboptimal, but improved significantly during the pandemic. During the pandemic, radiology departments implemented education programs to address inconsistence knowledge in IPC. Unfortunately, no studies explored IPC practices after the pandemic, leaving uncertainty about sustained improvements or potential regression.

CONCLUSION

The review highlights the limited assessment of IPC knowledge and practice among radiology HCWs, with most studies recommending further education and training programs.

IMPLICATIONS FOR PRACTICE

This scoping review explored IPC education and training among radiology HCWs, which is an important research topic after the COVID-19 pandemic to help reduce infection transmission in healthcare environments.

Factors influencing uptake of protective behaviours by healthcare workers in England during the COVID-19 pandemic: A theory-based mixed-methods study

BACKGROUND

Hospital infection control policies protect patients and healthcare workers (HCWs) and limit the spread of pathogens, but adherence to COVID-19 guidance varies. We examined hospital HCWs' enactment of social distancing and use of personal protective equipment (PPE) during the COVID-19 pandemic, factors influencing these behaviours, and acceptability and feasibility of strategies to increase social distancing.

METHODS

An online, cross-sectional survey (n = 86) and semi-structured interviews (n = 22) with HCWs in two English hospitals during the first wave of the COVID-19 pandemic (May-December 2020). The Capability, Opportunity, Motivation (COM-B) model of behaviour change underpinned survey and topic guide questions. Spearman Rho correlations examined associations between COM-B domains and behaviours. Interviews were analysed using inductive and deductive thematic analysis. Potential strategies to improve social distancing were selected using the Behaviour Change Wheel and discussed in a stakeholder workshop (n = 8 participants).

RESULTS

Social distancing enactment was low, with 85% of participants reporting very frequently or always being in close contact with others in communal areas. PPE use was high (88% very frequently or always using PPE in typical working day). Social distancing was associated with Physical Opportunity (e.g., size of physical space), Psychological Capability (e.g., clarity of guidance), and Social Opportunity (e.g., support from managers). Use of PPE was associated with Psychological Capability (e.g., training), Physical Opportunity (e.g., availability), Social Opportunity (e.g., impact on interactions with patients), and Reflective Motivation (e.g., beliefs that PPE is effective). Local champions and team competition were viewed as feasible strategies to improve social distancing.

CONCLUSIONS

It is valuable to understand and compare the drivers of individual protective behaviours; when faced with the same level of perceived threat, PPE use was high whereas social distancing was rarely enacted. Identified influences represent targets for intervention strategies in response to future infectious disease outbreaks.

Hospital health care workers' use of facial protective equipment before the COVID-19 pandemic, implications for future policy

BACKGROUND

Prepandemic routine use of facial (respiratory and eye) protective equipment (FPE) by health care workers was suboptimal. Understanding factors affecting routine use would facilitate escalation to high level use during infectious disease emergencies. This study explored health care workers FPE-related knowledge, attitudes and behaviors.

METHODS

Mixed methods were used in a respiratory ward and adult and pediatric emergency departments (EDs), prior to the COVID-19 pandemic. Study design and thematic analysis were based on the theoretical domains framework. Emergent themes were categorized, using the COM-B behavior model, into capability(C), opportunity(O) and motivation(M), which influence behavior(B).

RESULTS

22 emergent themes, representing factors influencing FPE use, were mapped to theoretical domains framework domains. Personal experience and departmental cultures influenced motivation. Compared with respiratory ward staff, ED clinicians were less knowledgeable about FPE; the unique ED environment and culture inhibited opportunities and motivation for FPE use. Eye protection was infrequently used.

DISCUSSION

Optimal FPE use is challenged by ED care models and settings. Changes are needed to translate pandemic-related improvements into routine care of other respiratory infections.

CONCLUSIONS

This study identified key determinants of FPE behavior. A review of context-specific FPE guidance for ED by infection prevention and control professionals would help to promote practicable, sustainable compliance.

Airborne infection prevention and control implementation: A positive deviant organisational case study of tuberculosis and COVID-19 at a South African rural district hospital

There are many examples of poor TB infection prevention and control (IPC) implementation in the academic literature, describing a high-risk environment for nosocomial spread of airborne diseases to patients and health workers. We developed a positive deviant organisational case study drawing on Weick's theory of organisational sensemaking. We focused on a district hospital in the rural Eastern Cape, South Africa and used four primary care clinics as comparator sites. We interviewed 18 health workers to understand TB IPC implementation over time. We included follow-up interviews on interactions between TB and COVID-19 IPC. We found that TB IPC implementation at the district hospital was strengthened by continually adapting strategies based on synergistic interventions (e.g. TB triage and staff health services), changes in what value health workers attached to TB IPC and establishing organisational TB IPC norms. The COVID-19 pandemic severely tested organisational resilience and COVID-19 IPC measures competed instead of acted synergistically with TB. Yet there is the opportunity for applying COVID-19 IPC organisational narratives to TB IPC to support its use. Based on this positive deviant case we recommend viewing TB IPC implementation as a social process where health workers contribute to how evidence is interpreted and applied.

Prevalence and associations between occupational diseases, emotional exhaustion, and dust mask anxiety among coal miners in Northern China

This study examined the prevalence and associations between occupational-related diseases, emotional exhaustion, and dust mask anxiety among coal miners in Northern China. The study sampled 506 miners from two coal mines in Northern China. Descriptive (frequency, percentages, and chi-square tests) and inferential (complementary log-log logistic regression) analyses were carried out to assess prevalence and associations. The prevalence of coal mining-related pulmonary diseases was 94%, with 40% and 37% reporting pneumoconiosis and bronchitis respectively. Emphysema and tuberculosis were less prevalent with a total prevalence of 5% while 12% of the miners reported two, three, or four of these diseases. For cardiovascular diseases, 66% of the miners reported 3H (hypertension, hyperlipemia, and hyperglycemia) while heart disease and cerebral infarction were reported by 6% and 2% of the miners respectively. Also, 5% and 2% of the miners reported two or all three of 3H, heart condition, and cerebral infarction. The overall prevalence of cardiovascular diseases was 81% while 82% and 63% of the miners reported experiencing some frequency of emotional exhaustion and dust mask anxiety respectively. The study also identified associations between mining-related diseases, emotional exhaustion, dust mask anxiety, and other demographic, personal habits and work-related factors. Miners with pulmonary diseases were more likely to experience emotional exhaustion and dust mask anxiety. Contrariwise, miners with cardiovascular diseases were less likely to experience dust mask anxiety. Factors such as age, engaging in physical exercises, rhinitis, source of pressure and shift system were also associated with emotional exhaustion and dust mask anxiety. These findings highlight the prevalence of occupational diseases, emotional exhaustion, and dust mask anxiety among coal miners in China. The study emphasizes the need for interventions to address health risks, improve work conditions, and support miners' well-being in the coal mining industry.

'You learn to smile with your eyes', exploring the impact of enhanced personal protective equipment on primary care dental practitioners in the UK: An interpretative phenomenological study

OBJECTIVE

The aim of the study was to explore how dental practitioners in primary care settings perceive the impact of enhanced personal protective equipment (PPE) upon patient communication and wider clinical practice.

METHODS

This study utilized a qualitative approach, rooted in critical realism. An interpretative phenomenological analysis (IPA) methodology was adopted as the study method. In accordance with IPA, in-depth semi-structured interviews were conducted. Eight dental practitioners were recruited, with data analysis conducted according to the principles of IPA.

RESULTS

Three themes were synthesized (related to communication and clinical practice): (1) Impaired communication and relationship building; (2) Physical impacts and required adjustments when wearing enhanced-PPE; and (3) Psychological stress of implementing enhanced-PPE. Theme one reflects changes to the dynamic of communication between patients and colleagues brought about by enhanced-PPE. Theme two describes the physical and psychological strains of providing care in enhanced-PPE and the ways through which practitioners tried to overcome these challenges. Theme three explores how the roll-out and guidance related to the use of enhanced-PPE affected clinical practice.

CONCLUSIONS

Dental Practitioners described several barriers to communication as well as physical and mental stressors caused by enhanced-PPE, all of which were perceived to impact upon the quality of care provided to patients. Further research is required to develop effective interventions to mitigate the impact of enhanced-PPE upon clinical practice and to explore the long-term impact of enhanced-PPE on clinical practice, post-COVID.

Pandemic preparedness of diagnostic radiographers during COVID-19: A scoping review

INTRODUCTION

As chest imaging is a tool for detecting coronavirus disease 2019 (COVID-19), diagnostic radiographers are a key component of the frontline workforce. Due to its unforeseen nature, COVID-19 has challenged radiographers' preparedness in combating its effects. Despite its importance, literature specifically investigating radiographers' readiness is limited. However, the documented experiences are prognostic of pandemic preparedness. Hence, this study aimed to map this literature by addressing the question: 'what does the existing literature reveal about the pandemic preparedness of diagnostic radiographers during COVID-19?'.

METHODS

Using Arksey and O'Malley's framework, this scoping review searched for empirical studies in MEDLINE, Embase, Scopus, and CINAHL. Consequently, 970 studies were yielded and underwent processes of deduplication, title and abstract screening, full-text screening, and backward citation searching. Forty-three articles were deemed eligible for data extraction and analysis.

RESULTS

Four themes that reflected pandemic preparedness were extrapolated: infection control and prevention, knowledge and education, clinical workflow, and mental health. Notably, the findings highlighted pronounced trends in adaptation of infection protocols, adequate infection knowledge, and pandemic-related fears. However, inconsistencies in the provision of personal protective equipment, training, and psychological support were revealed.

CONCLUSION

Literature suggests that radiographers are equipped with infection knowledge, but the changing work arrangements and varied availability of training and protective equipment weakens their preparedness. The disparate access to resources facilitated uncertainty, affecting radiographers' mental health.

IMPLICATIONS FOR PRACTICE

By reiterating the current strengths and weaknesses in pandemic preparedness, the findings can guide clinical practice and future research to correct inadequacies in infrastructure, education, and mental health support for radiographers in the current and future disease outbreaks.

The Enduring Effects of COVID for Cancer Care: Learning from Real-Life Clinical Practice

For three years, COVID-19 has circulated among our communities and around the world, fundamentally changing social interactions, health care systems, and service delivery. For people living with (and receiving treatment for) cancer, pandemic conditions presented significant additional hurdles in an already unstable and shifting environment, including disrupted personal contact with care providers, interrupted access to clinical trials, distanced therapeutic encounters, multiple immune vulnerabilities, and new forms of financial precarity. In a 2020 perspective in this journal, we examined how COVID-19 was reshaping cancer care in the early stages of the pandemic and how these changes might endure into the future. Three years later, and in light of a series of interviews with patients and their caregivers from the United States and Australia conducted during the pandemic, we return to consider the potential legacy effects of the pandemic on cancer care. While some challenges to care provision and survivorship were unforeseen, others accentuated and amplified existing problems experienced by patients, caregivers, and health care providers. Both are likely to have enduring effects in the "post-pandemic" world, raising the importance of focusing on lessons that can be learned for the future.

Paradoxes of pandemic infection control: Proximity, pace and care within and beyond SARS-CoV-2

From the adoption of mask-wearing in public settings to the omnipresence of hand-sanitising, the SARS-CoV-2 pandemic has brought unprecedented cultural attention to infection prevention and control (IPC) in everyday life. At the same time, the pandemic threat has enlivened and unsettled hospital IPC processes, fracturing confidence, demanding new forms of evidence, and ultimately involving a rapid reassembling of what constitutes safe care. Here, drawing on semi-structured interviews with 63 frontline healthcare workers from two states in Australia, interviewed between September 2020 and March 2021, we illuminate some of the affective dimensions of IPC at a time of rapid change and evolving uncertainty. We track how a collective sense of risk and safety is relationally produced, redefining attitudes and practices around infective risk, and transforming accepted paradigms of care and self-protection. Drawing on Puig de la Bellacasa's formulation, we propose the notion of IPC as a multidimensional matter of care. Highlighting the complex negotiation of space and time in relation to infection control and care illustrates a series of paradoxes, the understanding of which helps illuminate not only how IPC works, in practice, but also what it means to those working on the frontline of the pandemic.

Rapid qualitative analysis in a mixed-methods evaluation of an infection prevention intervention in a UK hospital setting during the COVID-19 pandemic: A discussion of the CLEAN study methodology

The COVID-19 pandemic created an urgent need for high-quality rapid research. One clinical challenge was how to minimise the risk of transmission in the hospital setting. The CLEAN study conducted a rapid evaluation of the potential utility of a spray-based disinfectant in a hospital setting. The study was undertaken between December 2020 and March 2021 and involved the implementation of the spray in 10 different clinical areas in one UK teaching hospital. A mixed-methods approach was adopted (including observations, surveys, and qualitative interviews) informed by the theories for understanding the implementation of new healthcare technologies. The evaluation found that while the spray had a number of perceived benefits when added to existing disinfection processes, other factors limited its potential utility. These findings informed a number of recommendations for future adoption within hospital settings. This paper describes and reflects on the rapid methodology that allowed us to undertake the study and deliver results in a short space of time. We experienced a number of pressures during set-up and fieldwork due to the challenging conditions caused by the pandemic, and the methodological approach had to evolve throughout the study because of the changing clinical context. The involvement of clinicians from the research setting as full members of the research team was key to the rapid delivery of the research. They provided an essential link to the implementation environment, and their experiential knowledge of the setting added an important perspective to the analysis. Balancing their involvement with their clinical roles was challenging, however, as was coordinating a large and diverse team of interviewers in such a short space of time. Overall, the study highlighted the value of rapid research to inform urgent healthcare decisions in a pandemic. Although our experience suggests that conducting such research requires some practical and methodological trade-offs, we found that there were also numerous benefits of using rapid methods and identified various opportunities to ensure their robustness.

'Like building a plane and flying it all in one go': an interview study of infection prevention and control in Australian general practice during the first 2 years of the SARS-CoV-2 pandemic

OBJECTIVES

General practitioners (GPs) and their staff have been at the frontline of the SARS-CoV-2 pandemic in Australia. However, their experiences of responding to and managing the risks of viral transmission within their facilities are poorly described. The aim of this study was to describe the experiences, and infection prevention and control (IPC) strategies adopted by general practices, including enablers of and challenges to implementation, to contribute to our understanding of the pandemic response in this critical sector.

DESIGN

Semistructured interviews were conducted in person, by telephone or online video conferencing software, between November 2020 and August 2021.

PARTICIPANTS

Twenty general practice personnel working in New South Wales, Australia, including nine GPs, one general practice registrar, four registered nurses, one nurse practitioner, two practice managers and two receptionists.

RESULTS

Participants described implementing wide-ranging repertoires of IPC strategies-including telehealth, screening of patients and staff, altered clinic layouts and portable outdoor shelters, in addition to appropriate use of personal protective equipment (PPE)-to manage the demands of the SARS-CoV-2 pandemic. Strategies were proactive, influenced by the varied contexts of different practices and the needs and preferences of individual GPs as well as responsive to local, state and national requirements, which changed frequently as the pandemic evolved.

CONCLUSIONS

Using the 'hierarchy of controls' as a framework for analysis, we found that the different strategies adopted in general practice often functioned in concert with one another. Most strategies, particularly administrative and PPE controls, were subjected to human variability and so were less reliable from a human factors perspective. However, our findings highlight the creativity, resilience and resourcefulness of general practice staff in developing, implementing and adapting their IPC strategies amidst constantly changing pandemic conditions.