The end of 2019 brought the spread of a novel coronavirus in Wuhan, Hubei Province, China. The novel coronavirus pneumonia was later named coronavirus disease 2019 (COVID-19), and the virus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), by the World Health Organization (WHO) (WHO, 2020a; 2020b). Following alarming levels of spread and severity, on 11 March 2020, COVID-19 was classed as a global pandemic by WHO. As of 12 December 2020, according to John Hopkins University in Baltimore, USA, there are over 71.4 million confirmed cases worldwide spanning 191 countries and regions, with over 1.6 million confirmed deaths. At time of writing, there were in excess of 1.8 million confirmed cases and 64 000 deaths in the UK (John Hopkins University, 2020).
Despite a spectrum in presentation, the principal symptoms of COVID-19 include anosmia, a dry continuous cough, shortness of breath, fatigue, and pyrexia (Centers for Disease Control and Prevention, 2020). Human transmission occurs through aerosols, respiratory secretions, and contaminated surfaces (Del Rio and Malani, 2020). Droplet transmission may occur at short distances through mucosal or conjunctival contact (WHO, 2020c). It has been well documented within the literature that aerosolisation of the virus is associated with increased transmission to and morbidity in healthcare staff (Tran et al, 2012).
Preliminary data from the initial outbreak in Wuhan suggested almost one-third of infected patients were health professionals (Li et al, 2020). Alongside sufficient provision of equipment and clear guidance, knowledge and adherence to appropriate use of personal protective equipment (PPE) among health professionals is required. A previous observational study performed in 2018 showed that in one tertiary care hospital the overall rate of adherence to appropriate PPE was 34.0% with the rate lower among nurses and nursing associates (27.9%) (Katanami et al, 2018). Adequate PPE is therefore of paramount importance in ensuring the safety of health professionals working on the frontline, particularly those participating in aerosol-generating procedures (AGPs).
Aim
This novel study, to our knowledge the first to be described within the literature, served to assess awareness, confidence levels and knowledge of current PPE and AGP guidance among UK nursing staff.
Methods
A nationwide 11-point confidential online survey (Figure 1) was compiled using the online Survey Monkey tool and disseminated to nurses across all specialties and grades over a 4-week capture period between May and June 2020. Dissemination platforms included social media, local and national trust-based internal mail, as well as regulatory bodies including the Nursing and Midwifery Council and Royal College of Nursing. Acquisition of demographic data was combined with questions relating to awareness of, knowledge relating to, and perception of education around PPE guidance published by Public Health England (PHE) (2020a). Official guidance as published by PHE was issued jointly by the Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland/National Services Scotland, PHE and NHS England and NHS Improvement.
Demographic data regarding experience level of participants was categorised according to banding, with band 5 nurses being qualified staff nurses, band 6 being junior sisters, specialist staff nurses or emergency nurse practitioners, band 7 nurses having a senior role including senior sisters, and finally band 8 nurses who include assistant directors of nursing, divisional nurses, matrons or senior nurse managers. Knowledge was assessed using multiple-choice questions, and perceived confidence using a self-administered 5-point Likert scale. Following the capture period, the data were downloaded and analysed using Microsoft Excel. Student nurses and healthcare assistants were not included within this study.
Ethical approval was not required for this observational study, which was assessing knowledge freely available in the public domain and all data were anonymised at point of collection.
Results
A total of 339 responses were collated within the predefined data-collection capture period. Of all respondents, medicine (generic inpatient wards and outpatient clinics) was the most represented specialty (n=102, 30%); followed by surgery (n=76, 22%); community (primary care) (n=57, 17%); emergency medicine (n=53, 16%); and intensive care (critical care) (n=45, 13%). Six respondents (2%) abstained from disclosing their specialty.
In terms of experience levels, the highest representation was from band 7 nurses (n=101, 30%); followed by band 6 nurses (n=99, 29%) and band 5 nurses (n=96, 28%), with the lowest representation from band 8 nurses (n=39, 12%). Four respondents (1%) failed to disclose their banding.
When questioned about their perceived confidence level, most respondents (n=105, 31%) felt ‘neutral’ (3/5 on Likert scale) about their awareness of the PHE PPE guidance across various settings (PHE, 2020a) (Figure 2). A further 127 respondents (37%) felt that they ‘agree’ or ‘strongly agree’ (either 3/5 or 4/5 on Likert scale) with regard to their confidence in knowledge of appropriate PPE in different scenarios, whereas 107 respondents (32%) felt they either ‘disagree’ or ‘strongly disagree’ (either 1/5 or 2/5 on Likert scale) with this statement.
The maximal attainable score on the knowledge-based questions was 10, spanning 6 questions. The mean score achieved was 5/10 (5.2 ± 2.1) with a normal distribution.
Of the surveyed cohort, 47% (n=159) cited insufficient education on PPE guidance, with further training warranted, whereas 17% of respondents (n=56) were satisfied with knowledge and training to date, with no educational intervention needed (Figure 3).
Subgroup analysis
Banding
Band 8 nurses were the highest performing group with an average score of 66%, followed by band 5 nurses (56%); band 7 nurses were the next highest performing group with 52%, with band 6 nurses the lowest performing group scoring 47% on average (Figure 4).
Perceived confidence levels were consistent among band 5, band 6 and band 7 nurses with a mode score of 3/5. Band 8 nurses had the highest levels of perceived confidence with a mode score of 4/5. Within each band, a higher proportion of those who were band 8 nurses (62%) stated that they were more confident by scoring either 4/5 or 5/5 on the Likert scale. Band 6 nurses reported lower confidence with higher proportions of this subgroup (42%) scoring either 1/5 or 2/5 on the Likert scale in comparison with their counterparts.
Speciality
Knowledge was highest among nurses working within intensive care, with an average score of 71% (7.1/10); followed by emergency medicine (54%); community (53%), medicine (51%); and finally those working in surgery (46%) (Figure 4).
Perceived confidence levels were consistent among those working in emergency medicine, intensive care, medicine, and surgery with a mode score of 3/5. Those working in the community had the lowest perceived confidence with a mode score of 1/5, with 47% of this subgroup selecting this score. Within each specialty, a higher proportion of those working in medicine (43%) and surgery (42%) stated that they were more confident by scoring either 4/5 or 5/5 on the Likert scale.
Aerosol-generating procedures
Respondents were asked to identify AGPs from a populated list according to the most recent PHE guidance at the time of the survey. Only 33% (n=113) of this surveyed cohort correctly identified that chest compressions and defibrillation during cardiopulmonary resuscitation (CPR) were classed as a non-AGP in accordance with PHE guidance. Nurses working in intensive care were the most successful among the different specialties in identifying the correct answer (84%).
High-risk environments
Respondents were asked to identify non-high-risk clinical environments according to the most current PHE guidance, again from a pre-populated list. The emergency department bays and acute assessment units were correctly identified by 34% of respondents (n=116).
Indications for FFP3 respirator mask use
Most respondents (54%, n=183) correctly identified the need for FFP3 respirator mask usage ‘during an AGP for a suspected or confirmed case’ and ‘whilst in a high-risk area with suspected or confirmed cases’.
Single versus sessional use of PPE
Of the five options provided, 19% (n=64) of respondents correctly identified ‘fluid resistant surgical masks, fluid repellent gown or overalls, filtering face piece (FFP) respirator and eye protection’ as PPE appropriate for sessional use.
PPE application
Respondents were questioned regarding the donning and doffing process of PPE for non-AGP procedures, coupled with their correct order of application. Of the entire cohort, 35% (n=118) correctly identified the donning process as ‘disposable apron application, appropriate mask, eye protection, disposable gloves’. With regard to the doffing process, 37% (n=127) correctly identified the process as ‘removal of gloves, hand hygiene, remove apron, remove eye protection, hand hygiene, remove mask, hand hygiene.’
Discussion
In the wake of this unanticipated global pandemic, fear, pressure, and anxiety among health professionals is at an all-time high. The Personal Protective Equipment at Work Regulations 1992 require an employer to provide suitable protection and training on the use of the equipment within its workplace—although these regulations were published 28 years previously, they have never been more relevant. The unprecedented nature of a global pandemic, combined with an evolving understanding of the pathogenesis of SARS-CoV-2, has meant a great deal of uncertainty has developed among health professionals.
A unified definition of an AGP is currently lacking, with variation in guidance published by two governing bodies WHO and PHE. AGPs can create a risk of airborne transmission of infections that are usually only spread by droplet transmission, and given the high risk posed to health professionals with AGPs, guidance states that the highest level of PPE is required for these procedures (PHE, 2020a). As described by Tran et al (2012), aerosolisation of the virus is associated with increased transmission and morbidity for health professionals. Akin to the surrounding uncertainty on the definition of an AGP, there is also discrepancy between the recommended guidance published by PHE and the WHO as to which activities constitute an AGP. The evolving nature of the disease has meant that PPE guidance is continuously under review, and subject to change. At time of writing, there have been three significant amendments to the PHE guidance (Table 1) (PHE, 2020b). The dynamic nature of this pandemic may not allow for a standardised training pathway to be established among all health professionals, which can subsequently lead to inconsistencies in support provided and knowledge acquired across different departments and specialties.
| Procedure | PHE guidance? | WHO guidance? |
|---|---|---|
| Bronchoscopy | ✓ | ✓ |
| Cardiopulmonary resuscitation (CPR) | ✓ | ✓ |
| Dental procedures involving high-speed devices | ✓ | ✓ |
| High-flow nasal oxygen (HFNO) | ✓ | ✓ |
| High-frequency oscillatory ventilation (HFOV) | ✓ | ✓ |
| High-speed cutting in surgery or post-mortem procedures involving respiratory tract or paranasal sinuses | ✓ | ✓ |
| Induction of sputum using nebulised saline | ✓ | ✓ |
| Manual ventilation | ✓ | ✓ |
| Non-invasive ventilation (NIV), bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP) | ✓ | ✓ |
| Tracheotomy or tracheotomy procedures | ✓ | ✓ |
| Upper ENT airway/GI endoscopy procedures involving respiratory tract suctioning | ✓ | ✓ |
Source: PHE, 2020a; WHO 2020c; WHO 2020d
Contrary to PHE guidance, chest compressions and defibrillation during CPR are classed as an AGP by WHO (Table 1) and the Resuscitation Council UK (2020). The PHE stance on CPR was based on a statement published by the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), stating that ‘it is biologically plausible that chest compressions could generate an aerosol, but only in the same way that an exhalation breath would do’ (PHE, 2020c). Discrepancies within the guidance can lead to confusion among health professionals with regard to the level of PPE required in various emergency situations, as reflected in the results among this cohort, with only 35% correctly identifying that chest compressions and defibrillation during CPR is not classed as an AGP by PHE. In contrast, there is a common misconception that application of high-flow nasal oxygen is not classed as an AGP, a finding corroborated by 46% of the surveyed cohort. There is a belief among health professionals that nebulisation of patients is deemed an AGP, however this has been clarified by NERVTAG, which advised that as the aerosol derives from a non-patient source, this does not carry patient-derived viral particles. If this particle coalesces with a contaminated mucous membrane it will cease to be airborne and therefore not part of an aerosol and not deemed an AGP (PHE, 2020c).
As non-invasive ventilation (NIV) is deemed an AGP, wards undertaking non-invasive ventilation are by definition classed as high-risk environments. The majority of this cohort (41%) failed to identify NIV as a high-risk procedure. Emergency department bays and acute assessment units are not classed as high-risk environments, contrary to the consensus found in this survey. Guidance is based on the understanding that high-risk patient flow is immediately diverted away from low-risk areas (hot and cold settings respectively), with AGPs also undertaken in dedicated areas, thus minimising risk to non-COVD-19 patients and health professionals.
According to standard infection control precautions (SICPs), different PPE can be subject to either single use or sessional use. A single session is classed as an interaction between a health professional and a patient in a specific clinical setting or exposure environment. This can take place over a varied amount of time during which multiple clinical activities can be completed, such as a ward round. The items of PPE that are recommended for sessional use are fluid-resistant surgical masks, fluid-repellent gowns or overalls, filtering face piece (FFP) respirators and eye protection. Single use requires the health professional to dispose of the equipment and maintain hand hygiene after each patient contact, such as with sterile nitrile gloves (PHE, 2020a). When questioned in this survey, only 19% of respondents correctly identified all PPE items that are appropriate for sessional use, highlighting a lack of awareness surrounding this topic.
An encouraging majority of this cohort were familiar with both the donning (35%) and doffing (38%) process with regard to PPE. It appears that widespread education highlighting the correct process, including tutorials and posters in donning and doffing areas, coupled with high-volume procedure repetition has consolidated health professional knowledge. Such an assumption could explain the higher knowledge-based scores among intensive care nurses compared with their counterparts (average score of 71%). Induction training on PPE received by intensive care nurses prior to the height of the pandemic will no doubt have also contributed to their overall knowledge and awareness of PPE.
It is concerning that 17% of the respondents reported deficiencies in training around PPE guidance, and the need for further educational intervention (47%). This may in part be attributed to the constantly evolving nature of both the understanding of COVID-19 and PPE guidance. Such deficiencies will no doubt have contributed to increased but potentially avoidable transmission rates between patients and health professionals, while simultaneously resulting in inappropriate PPE use during a period of global shortages and financial burden.
Although standardisation of guidance offers a potential solution when addressing knowledge deficits as well as perceived confidence levels on PPE use, in practical terms this is seldom a straightforward task. Variable consensus among specialist bodies will always result in variation from national guidance. It is for these reasons that local training measures/consolidation of approved guidance for each individual trust serves as a more sustainable solution long-term solution. Difficulties encountered in the delivery of lectures due to social distancing measures opens up the role of mandatory e-learning modules on a local or even regional level.
Conclusions
The unprecedented and constantly evolving nature of the COVID-19 pandemic stands to leave a lasting legacy within healthcare services worldwide. Although there has been positive news on the vaccine front, until these are distributed on a previously unwitnessed scale, the virulent threat to health professionals will continue to generate apprehension and clinical concern. A clear understanding of national guidance not only limits the inappropriate use of PPE during a period of unprecedented demand but serves to minimise the risk of morbidity and mortality among patients and health professionals. Unification of guidance across governing bodies and a global consensus, combined with educational tools provided on local and regional e-learning platforms, may serve as remedial tools in the global battle against COVID-19 in the coming times.