Medical interns' reflections on their training in use of personal protective equipment

A individually randomized controlled trial comparing Healer-led vs. clinician- led training to improve personal protective equipment use among traditional healers in South Africa

Like allopathic healthcare workers, healers are also exposed to patients' blood and body fluids. A widespread practice is the traditional "injection," in which the healer performs subcutaneous incisions to rub herbs directly into the bloodied skin, resulting in 1,500 blood exposures over their lifetime. We tested the impact of healer-led PPE training, staffed by trained traditional healers who reported using PPE during each risky clinical encounter vs. healthcare worker (HCW)-led PPE training sessions. We randomized 136 healers into one of the two study arms (67 in the healer-led group, 69 in the HCW-led group) and assessed the impact of trainer on PPE skills and use over a six-month period. All healers received one in-person day of didactic and practical training followed by three sessions at the healers' home. Participants were largely female (80%), averaged 51 years old, and practiced as a healer for an average of 17 years. Almost 44% either disclosed themselves as HIV+ or received a positive HIV test result at study initiation. Healers in the HCW arm showed equivalent PPE scores as those trained by traditional healers at baseline and at seven months. Healers in both arms self-reported high levels of glove use during"injections," with no statistical difference of use by study arm. When we assessed actual gloves and razor blades disposed of each month, a similar trend emerged. No one seroconverted during the study period. The need for PPE support among traditional healers cannot be ignored. Traditional healers can be trained to effectively disseminate PPE knowledge and skills to other traditional healers. With an estimated 200,000 traditional healers in South Africa, it is imperative that all of them have access to PPE training and supplies to prevent HIV, HCV, or HBV infections. Trial registration: ClinicalTrials.gov, NCT04440813. Registered 17 June 2020, https://clinicaltrials.gov/ct2/show/NCT04440813.

Using Video to Describe the Patient-Controlled Analgesia Pump Programming Process: A Qualitative Study

BACKGROUND

Patient-controlled analgesia (PCA) pumps are complex medical devices frequently used for postoperative pain control. Differences in how nurses program PCA pumps can lead to preventable medication errors.

PURPOSE

To describe similarities and differences in how surgical nurses program PCA pumps.

METHODS

We conducted a qualitative study using video reflexive ethnography (VRE) to film nurses as they programmed a PCA pump. We spliced and collated videos into separate clips and showed to nursing leaders for their deliberation and action.

RESULTS

We found nurses ignored or immediately silenced alarms, were uncertain about the correct programming sequence, and interpreted how to load a syringe in the pump in multiple ways; in addition, the PCA pump design did not align with nurses' workflow.

CONCLUSIONS

VRE was effective in visualizing common challenges nurses experienced during PCA pump programming. Nursing leaders are planning several nursing process changes due to these findings.

Video reflexive ethnography as an intervention to improve oral anti-cancer agent patient education: A pilot study

Objective

Oral anticancer agents (OAAs) are associated with side effects that interfere with medication adherence, despite patient education regarding side effect management. Video reflexive ethnography (VRE) captures care processes on video that allow participants to learn from videos. The purpose of this pilot study was to assess the usefulness and impact of VRE on improving OAA education.

Methods

This qualitative study was conducted in a pharmacist-managed OAA clinic: two pharmacists and four patients participated. We filmed each pharmacist providing education to two patients. We conducted patient interviews and one reflexivity session with both pharmacists to learn participants' perspectives. We used thematic content analysis to analyze data.

Results

Two themes emerged: what patients liked/helped, and things that were unclear. Patients liked instructions on temperature taking, directions to safely handle and store OAAs. Unclear areas included knowing the timing of the worst side effects.During the reflexivity session, pharmacists found patients' comments useful to improve their practice.

Conclusion

VRE was acceptable to pharmacists and patients. Pharmacists recognized VRE as a helpful technique to improve patient education on OAAs.

Innovation

The use of video enables participants to scrutinize and reshape their practices, making VRE a powerful innovation and adjunct to quality improvement initiatives.

Personal protective equipment and medical students in times of COVID-19: experiences and perspectives from the final clerkship year

BACKGROUND

The availability and correct use of personal protective equipment (PPE) to prevent and control infections plays a critical role in the safety of medical students in clinical placements. This study explored their experiences and perspectives in their final clerkship year with PPE during the COVID-19 pandemic.

METHODS

This qualitative study was based on social constructivism and was conducted in 2021 at the Charité - Universitätsmedizin Berlin. In three online focus group discussions, 15 medical students in their final clerkship year reported their experiences with PPE training and use during the COVID-19 pandemic. Data were recorded, transcribed and analysed based on Kuckartz's approach to content analysis. We drew upon the a priori dimensions of the capability, opportunity, motivation - behaviour (COM-B) model as main categories as well as emergent issues raised by the study participants (subcategories).

RESULTS

In addition to the three main categories of the COM-B model, eleven subcategories were identified through inductive analysis. The study participants reported several factors that hindered the correct use of PPE. In the area of capabilities, these factors were related to learning experience with PPE in terms of both theoretical and practical learning together with later supervision in practice. In the area of opportunities, these factors included the limited availability of some PPE components, a lack of time for PPE instruction and supervision and inappropriate role modelling due to the inconsistent use of PPE by physicians and nursing staff. The area of motivation to use PPE was characterized by an ambivalent fear of infection by the SARS-CoV-2 virus and the prioritization of patient safety, i.e., the need to prevent the transmission of the virus to patients.

CONCLUSIONS

Our study revealed several limitations pertaining to the enabling factors associated with the trainable behaviour "correct use of PPE". The concept of shared responsibility for student safety was used to derive recommendations for future improvement specifically for the medical school as an organization, the teachers and supervisors, and students themselves. This study may guide and stimulate other medical schools and faculties to explore and analyse components of student safety in clinical settings in times of infectious pandemics.

Organizational responses to the COVID-19 pandemic in Victoria, Australia: A qualitative study across four healthcare settings

Objective

Organizational responses that support healthcare workers (HCWs) and mitigate health risks are necessary to offset the impact of the COVID-19 pandemic. We aimed to understand how HCWs and key personnel working in healthcare settings in Melbourne, Australia perceived their employing organizations' responses to the COVID-19 pandemic.

Method

In this qualitative study, conducted May-July 2021 as part of the longitudinal Coronavirus in Victorian Healthcare and Aged Care Workers (COVIC-HA) study, we purposively sampled and interviewed HCWs and key personnel from healthcare organizations across hospital, ambulance, aged care and primary care (general practice) settings. We also examined HCWs' free-text responses to a question about organizational resources and/or supports from the COVIC-HA Study's baseline survey. We thematically analyzed data using an iterative process.

Results

We analyzed data from interviews with 28 HCWs and 21 key personnel and free-text responses from 365 HCWs, yielding three major themes: navigating a changing and uncertain environment, maintaining service delivery during a pandemic, and meeting the safety and psychological needs of staff . HCWs valued organizational efforts to engage openly and honesty with staff, and proactive responses such as strategies to enhance workplace safety (e.g., personal protective equipment spotters). Suggestions for improvement identified in the themes included streamlined information processes, greater involvement of HCWs in decision-making, increased investment in staff wellbeing initiatives and sustainable approaches to strengthen the healthcare workforce.

Conclusions

This study provides in-depth insights into the challenges and successes of organizational responses across four healthcare settings in the uncertain environment of a pandemic. Future efforts to mitigate the impact of acute stressors on HCWs should include a strong focus on bidirectional communication, effective and realistic strategies to strengthen and sustain the healthcare workforce, and greater investment in flexible and meaningful psychological support and wellbeing initiatives for HCWs.

'No-one else wears one:' Exploring farmer attitudes towards All-Terrain Vehicle helmets using the COM-B model

INTRODUCTION

All-Terrain Vehicles (ATV) are a popular piece of farming machinery but are linked to many fatalities and injuries every year. Despite evidence that ATV helmets reduce the risk of serious or fatal injury, research suggests that few farmers wear them. The aim of this study was to explore farmer attitudes toward ATV helmets, using the COM-B model as a framework to identify key barriers and enablers of helmet use and suggest potential interventions to increase helmet use in agriculture.

METHODS

A mixed-methods online survey featuring quantitative and qualitative questions was used to explore key attitudinal factors relevant to farmer helmet wearing. A total of 211 UK and Irish farmers were recruited, including farm owners, managers, workers, and contractors.

RESULTS

Personal exemption from risk, emotional benefits, cognitive barriers, and guideline prompts were all found to be significant predictors of farmer helmet wearing. Key categories within the qualitative data indicated that helmet properties, risk perception, farming culture, and the farming environment could all function as barriers to helmet wearing. Suggested enablers of helmet use included increasing helmet availability and enhancing awareness of the consequences of ATV accidents.

CONCLUSIONS

The key barriers and enablers presented within this paper highlight the relevance of capability (helmet design, time pressure), opportunity (social norms), and motivation (perceived control of risk) when considering farmer helmet wearing behaviors. In order to encourage farmers to wear helmets it will be necessary to design specific interventions using the behavior change wheel.

PRACTICAL APPLICATIONS

Key interventions to prompt helmet use include the inclusion of more cues to prompt helmet wearing (e.g., stickers on the ATV), enhanced training and education, and modelling (e.g., key farming figures shown to wear helmets in the media).

Rapid development and implementation of a behaviour change strategy to improve COVID-19 personal protective equipment use in a regional Australian emergency department

Objective

To identify barriers to, describe the development of and evaluate the implementation of a behavioural theory informed strategy to improve staff personal protective equipment (PPE) compliance during COVID-19 in a regional Australian Emergency Department.

Methods

Barriers to PPE use were identified through staff consultation then categorised using the Theoretical Domains Framework. The Behaviour Change Wheel was used to develop a strategy to address the barriers to PPE compliance. The strategy was refined and endorsed by the site COVID taskforce. Data were collected through direct observation. Descriptive statistics were used to summarise PPE compliance and inductive content analysis for free text data of staff behaviours.

Results

73 barriers were identified, mapped to 9 intervention functions and 42 behaviour change techniques. The predominant mechanisms were: (1) Executive communication reinforcing policy and consequences; (2) implementation of a PPE Marshal; (3) face to face reinforcement / modeling; (4) environmental restructuring including electronic medical record modifications. The PPE Marshal observed 281 PPE activities. PPE compliance varied between 47.9% (Buddy check) and 91.8% (Bare below elbow). The PPE Marshal intervened on 121 occasions, predominantly through buddying, explaining and demonstrating correct PPE use, most frequently with medical staff (72%).

Conclusion

We describe an evidence-based process to overcome barriers to PPE compliance that maximize safe work practice in a time critical situation. Staff require enabling, access to equipment and reinforcement to use PPE correctly.

Cohort profile: The UK COVID-19 Public Experiences (COPE) prospective longitudinal mixed-methods study of health and well-being during the SARSCoV2 coronavirus pandemic

Public perceptions of pandemic viral threats and government policies can influence adherence to containment, delay, and mitigation policies such as physical distancing, hygienic practices, use of physical barriers, uptake of testing, contact tracing, and vaccination programs. The UK COVID-19 Public Experiences (COPE) study aims to identify determinants of health behaviour using the Capability, Opportunity, Motivation (COM-B) model using a longitudinal mixed-methods approach. Here, we provide a detailed description of the demographic and self-reported health characteristics of the COPE cohort at baseline assessment, an overview of data collected, and plans for follow-up of the cohort. The COPE baseline survey was completed by 11,113 UK adult residents (18+ years of age). Baseline data collection started on the 13th of March 2020 (10-days before the introduction of the first national COVID-19 lockdown in the UK) and finished on the 13th of April 2020. Participants were recruited via the HealthWise Wales (HWW) research registry and through social media snowballing and advertising (Facebook®, Twitter®, Instagram®). Participants were predominantly female (69%), over 50 years of age (68%), identified as white (98%), and were living with their partner (68%). A large proportion (67%) had a college/university level education, and half reported a pre-existing health condition (50%). Initial follow-up plans for the cohort included in-depth surveys at 3-months and 12-months after the first UK national lockdown to assess short and medium-term effects of the pandemic on health behaviour and subjective health and well-being. Additional consent will be sought from participants at follow-up for data linkage and surveys at 18 and 24-months after the initial UK national lockdown. A large non-random sample was recruited to the COPE cohort during the early stages of the COVID-19 pandemic, which will enable longitudinal analysis of the determinants of health behaviour and changes in subjective health and well-being over the course of the pandemic.

Testing the efficacy and acceptability of video-reflexive methods in personal protective equipment training for medical interns: a mixed methods study

OBJECTIVES

To test the efficacy and acceptability of video-reflexive methods for training medical interns in the use of personal protective equipment (PPE).

DESIGN

Mixed methods study.

SETTING

A tertiary-care teaching hospital, Sydney, January 2018-February 2019.

PARTICIPANTS

72 of 90 medical interns consented to participate. Of these, 39 completed all three time points.

INTERVENTIONS

Participants received a standard infection prevention and control (IPC) education module during their hospital orientation. They were then allocated alternately to a control or video group. At three time points (TPs) over the year, participants were asked to don/doff PPE items based on hospital protocol. At the first two TPs, all participants also participated in a reflexive discussion. At the second and third TPs, all participants were audited on their performance. The only difference between groups was that the video group was videoed while donning/doffing PPE, and they watched this footage as a stimulus for reflexive discussion.

PRIMARY AND SECONDARY OUTCOME MEASURES

The efficacy and acceptability of the intervention were assessed using: (1) comparisons of audit performance between and within groups over time, (2) comparisons between groups on survey responses for evaluation of training and self-efficacy and (3) thematic analysis of reflexive discussions.

RESULTS

Both groups improved in their PPE competence over time, although there was no consistent pattern of significant differences within and between groups. No significant differences were found between groups on reported acceptability of training, or self-efficacy for PPE use. However, analysis of reflexive discussions shows that the effects of the video-reflexive intervention were tangible and different in important respects from standard training.

CONCLUSIONS

Video reflexivity in group-based training can assist new clinicians in engagement with, and better understanding of, IPC in their clinical practice. Our study also highlights the need for ongoing and targeted IPC training during medical undergraduate studies as well as regular workplace refresher training.

Does wearing personal protective equipment affect the performance and decision of physicians? A cross-sectional study during the COVID-19 pandemic

Background

The use of personal protective equipment (PPE) decreased the probability of viral transmission during the COVID-19 pandemic. However, some drawbacks have been observed with its extensive use, such as headaches, anxiety, and stress among physicians, which could affect decision-making processes, the performance of physicians, and consequently patients’ safety. Few articles have studied the impact of PPE on physicians from different specialties. This study assessed the effect of wearing PPE on the performance and decision-making of physicians during the COVID-19 pandemic and compared the effects of wearing PPE on physicians from different specialties.

Methods

A descriptive cross-sectional study was carried out through an anonymous 39-item online questionnaire. The physicians were divided according to the probability and frequency of performing invasive procedures. Group 1 included emergency medicine and critical care physicians, intensivists, and anesthetists, group 2 included physicians from different surgical subspecialties, and group 3 included physicians from different medical fields.

Results

This study included 272 physicians; group 1 included 54, group 2 included 120, and group 3 included 98 physicians. Approximately, 90.4% of the participants aged between 30 and -40 years, and 72.8% of the participants were specialists. Results indicated that the comfort, vision, and communication were significantly reduced in all groups (81.1%, 88.7%, and 75.5%, respectively). In contrast, the handling of instruments was not significantly affected in the second group only. In addition, the decision-making and the rate of complications were not significantly affected.

Conclusion

There was a negative impact of wearing PPE on the non-technical skills (vision, communication and overall comfort), and the technical skills of the physicians. The decision-making and patients’ safety were not significantly affected. Recommendations include additional improvement of the PPE design due to its crucial effect on both non-technical and technical skills of physicians.

•

The use of PPE decreases the rate of infection of healthcare providers.

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The use of PPE affected the physicians' performance (comfort, vision, and communication).

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The decision-making and patients' safety were not affected.

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Improvement of PPE design is important for better performance.

Attitudes towards COVID-19 precautionary measures and willingness to work during an outbreak among medical students in Singapore: a mixed-methods study

BACKGROUND

The COVID-19 pandemic has revealed challenges that medical students face when healthcare systems are under intense pressure. There is a need to assess medical students' education needs in pandemic preparedness. The objective of this mixed-methods study was threefold: (1) to assess COVID-19 perceived efficacy, susceptibility, and anxiety in relation to health literacy; (2) to describe attitudes towards a policy of precautionary measures against COVID-19 and willingness to work during an outbreak; and (3) to examine multilevel factors associated with willingness to work.

METHODS

An online survey was conducted among 263 medical students in Singapore during the lockdown period in July 2020. Participants were surveyed on COVID-19 related literacy, perceptions, anxiety, attitudes towards a policy of precautionary measures, and willingness to work during an outbreak. Bivariate and multivariate analyses were used to determine the factors associated with the key outcome variable of willingness to work. In addition, open-ended questions were used to assess medical education needs, which were reported using thematic analysis.

RESULTS

Perceived adequacy of COVID-19 information was associated with higher perceived efficacy, lower perceived susceptibility, and lower anxiety levels among the students. Medical students were mostly supportive of COVID-19 precautionary measures except for relatively intrusive measures like in-home surveillance. The degree of willingness to work during an outbreak varied based on certain conditions, in particular family's health and safety, and was associated with self-efficacy, perceived susceptibility, and hospital capacity of outbreak management.

CONCLUSIONS

Medical students' attitudes towards a policy of precautionary measures varied depending on legality, financial and psychological support, and privacy concerns. Health literacy played an important role in increasing the efficacy of protection against COVID-19 and reducing pandemic-related anxiety among medical students. Their willingness to work during an outbreak was increased by an effective policy of precautionary measures, hospital capacity to manage a pandemic, and assurance of family safety. Medical education should include pandemic preparedness to better prepare students to aid in pandemics, with emphasis on public health policy and ethics coupled with clinical training targeted to managing outbreaks.

Compliance to Screening Protocols for Multidrug-Resistant Microorganisms at the Emergency Departments of Two Academic Hospitals in the Dutch-German Cross-Border Region

Infections caused by multidrug-resistant organisms (MDROs) are associated with prolonged hospitalization and higher risk of mortality. Patients arriving in the hospital via the emergency department (ED) are screened for the presence of MDROs in compliance with the screening protocols in order to apply the correct isolation measures. In the Dutch–German border region, local hospitals apply their own screening protocols which are based upon national screening protocols. The contents of the national and local MDRO screening protocols were compared on vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing and carbapenem-resistant Enterobacteriaceae (CPE/CRE). The practicality of the screening protocols was evaluated by performing an audit. As a result, the content of the MDRO screening protocols differed regarding risk factors for MDRO carriage, swab site, personal protective equipment, and isolation measures. The observations and questionnaires showed that the practicality was sufficient; however, the responsibility was not designated clearly and education regarding the screening protocols was deemed inappropriate. The differences between the MDRO screening protocols complicate patient care in the Dutch–German border region. Arrangements have to be made about the responsibility of the MDRO screening, and improvements are necessary concerning education regarding the MDRO screening protocols.

Healer-led vs. clinician-led training to improve personal protective equipment use among traditional healers in South Africa: a randomized controlled trial protocol

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional 'injections', in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer's place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.