Introduction

This essay is the critical evaluation of the compliance of the practice of Personal Protective

Equipment (PPE) by the staff during the pre- and the post- lockdown at a residential aged care

facility. The staff was unsure and apprehensive about use of PPEs during the lockdown even

after the initial mandatory education on infection control and PPE. Due to this apprehension the

following of standard practice and proper use of PPE is longer being followed. The members of

the staff feel that the PPE do not provide them with proper protection, and they feel that PPE are

not crucial for their safety and the safety of the resident. Due to this the PPEs are often being

ignored by the staff members as they are unsure but the level of protection it provides against

infection (Torjesen, 2020). Thus, it is very important that the faith in the protection provided by

the PPEs can be reinstalled. This essay consists of strategies which can be used to improve the

compliance and adherence with the best use of PPEs.

Background and Context

 COVID 19 is spread by the corona virus which a highly infectious microorganism. This virus

can spread by the respiratory droplets from person to person who are in close proximity.

Activities like speaking, coughing, sneezing, singing, etc. can acts as cause for the spread of this

virus. These respiratory droplets can also drop on the surface and contaminate them and when

some other person touches that surface and ingest the virus accidentally then they might get

infected as well. In this case Personal Protection Equipment’s PPEs prove to be an essential form

of protection against the infection. In the healthcare setting the proper and effective use of PPEs

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is essential to minimize the spread of the infection. An audit was conducted recently by the

COVID- nurses. During the audit it was observed that the staff members were not wearing PPEs

on several occasions even after previous education about the strict use of PPEs during the

lockdown. Donning and doffing of PPE refers to the proper procedures to put on and take off the

PPEs. The COVID Nurses checked the knowledge of the staff members about the proper

guidelines to use to PPEs and found that the understanding about it was very poor. The

healthcare staffs did not follow the proper rules when putting on PPEs which could lead to cross-

contamination and infection. PPEs provide and excellent way for protection against

contamination by the virus. (Tabah et al., 2020) As the healthcare workers are on the forefront in

our efforts to deal with this pandemic it is of prime importance to maintain the well- being of the

same. The healthcare workers are at the most risk to get contaminated and if it happens then

there will be no workforce to treat the common people. Also the healthcare staff come in contact

with infected people as well as the non- infected ones so can acts as a source for infection for the

non- infected people. The Aged Care facility has 108 staff, 120 Beds zoned in eight wings and

four nurse stations. In each wing, there are 4-5 hand washing basins only and 4-5 PPE stations

where staff can change their PPE. The large number of staff and risk of non-compliance to the

residents pose a challenge to implementing an effective strategy to improve compliance. This is

fast spreading infection and if staff does not comply to the rules then infection of one staff

member can quickly spread to the others and in no time the whole workforce would collapse.

This can prove to be fatal not only for the infected staff members but also for the patients that

depend on them for their treatment. The need was felt to develop strategies which can bring

about changes in the mindset of the staffs and make them aware of the importance of wearing

PPEs in the working environment.

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STRATEGY

The following strategies are planned to influence and improve compliance with PPE by staff

EDUCATION AND TRAINING

Educating and training the staffs about PPE is one the most important task towards getting the

staff members to use them. The training plan focuses on building skills and confidence amongst

staff in the donning and doffing of PPEs for a few weeks to all the staff. There is the re-

introduction of donning and doffing education program. This is done by playing the Department

of Health’s 6 minutes videos on Donning and Doffing and allowing them to practice following

the correct steps and sequence. Feedback will be given to each staff member to reinforce good

practice and provide an opportunity to improve. There will be registration of the advantage

in finishing the Monash University PPE Project Facility Booking form for more information for

staff members. The 1.5 hour training program by Monash University can be of great help. The

program utilises a Train the Trainer model, giving 2-4 heroes in the Aged care with instruction

assets to keep preparing the staff members after the training too, all the staff members interested

could take part among them. There are 3 RN's as Trainers and 4 EN and 2 PCA's. Train the

trainer helps to assist the staffs to watch Department video on donning and doffing before and

after each shift and assess staffs while doing it. The Training tool for using of Personal

Protective Equipment (PPE) means to give data concerning preparing in the utilisation of PPE.

Preparing staff in the right utilisation of PPE assists with limiting the potential for transmission

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of COVID-19 inside RACF amongst workers. The refreshment of PPE donning and doffing and

hand washing was done by sending out email, video's 1:1 with staff who needed more hand's and

assist them, 5 staff’s hand hygiene audit and PPE stock and staff 's compliance audit carried out

every week. There should be work done on education of the staffs which need to be structured

and linked to risk assessments and related control measures which include procedures.

There should be refresher education for infrequent, complicated or safety vital tasks and this can

also encompass appropriate reassessment.

SUPPORT AND RESOURCES 

The provision of support resources and equipment are enables good practice. The introduction of

the proper type, size and shape of PPE is important as in absence of these proper protection

cannot be maintained. The PPEs cannot be used for a long time so they must me supplied

regularly as without this the PPEs are of not much efficacy. The staff members need to be

provided with enough stock of PPE equipment’s like a mask, gown, face shield, goggles, gloves,

in each PPE station and it should be restocked every day by COVID Nurses to make sure that the

amount of these equipment’s is not running low. There should be a stocktaking procedure every

day by COVID Nurses to check and order PPE when the stock is running low, which maintains

the provision of enough stock every day. Out PPE Bay should be checked and maintained once a

day and there should be a stock take on PPE equipment’s, hand sanitizer and disinfected wipes.

Disinfected wipes are mostly used to wipes all the computers, keyboards, phones, medication

trolleys, surfaces etc. before and after each shift to maintain the hygiene. The creation of new

PPE bays and hand hygiene basins on different wings should be done so that staffs have more

access to PPE stations near by and hand washing basins around the facility. PPE bays should be

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set up on entrance of door and exit where staffs need to use PPE before entering to the building

and dispose the PPE and sanitise their hand after finishing work. 

IMPROVING CULTURE AND ENGAGING STAFF

By encouraging and motivating the staff members the culture and compliance can be improved.

The staffs should be praised and encouraged on their good work. The members of the staffs

should be able to give their input about the issues concerning PPEs. Their security concerns and

general queries should be listened to and resolved so that they can focus just on their work

without any other thoughts in their minds. As the staffs are on the forefront, they are the first

people to recognize any danger or risk, if any. Their concerns should not be neglected but

investigated and the conclusions should be briefed so that there are no doubts left residing in

their minds. The people who are regularly following the procedures and guidelines pertaining to

PPEs should be rewarded. This would encourage others to also follow in the footsteps of them.

These steps would ultimately lead to a harmonious and congenial environment to work in. Also

when the minds of the staff is free of doubt then they can work freely and to their full potential.

EVALUATE

Competency Assessment 

Competency is decided through a worker’s grasp of education given, and while under

supervision, show a capacity to safely function tasks and function plant. Both training and

coaching are a vital section of understanding the risks that can also demonstrate competency. It

is imperative to make sure workers can perform the work safely. First there should be a checking

of one to one donning and doffing competency of all the staff where staff have to show how they

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are going to properly be donning and removing the PPE in sequence without missing any steps,

and secondly, there should be check of hand washing and hand rub with alcohol based sanitizer,

where IPC lead monitor either they follow 5 moment of hand hygiene and when they wash their

hand correctly. 95% of the staff did very well with the competency assessment. (Jessop et al.,
2020)

 Environmental Audit

 An Environmental audit and infection control spot checklist should be done every week which is

aligned with the Commission's self-monitoring checklist. PPE Compliance audit including Hand

hygiene audit and feedback from different shifts help to find out where we can improve and

where the staff lacking on, give them feedback and opportunity to improve, reporting their

compliance and take them seriously. Checking all the sign and banners around the facility, signs

for hand wash are how to wash your hand near to hand washing basin, how to hand rub signage

near to all PPE bays, how to donning and doffing signage next to all the PPE bays and

maintaining physical distance signage around the facility for e.g., lift, dining room, nurse

stations, Staff rooms, communal area. Checking staff how often they washing hands, audit on

environmental tidiness and cleanliness of the facility, auditing on cleaning staff. Enchanted

cleaning of frequently touched surfaces is carried out with disinfectant bleach twice a day. We

have implemented bags on each lifter with disinfectant alcohol wipes so staff have easy access to

wipe over when used. The equipment’s and accessories which are used by residents and come in

contact with the patient should be properly disinfected by the staff members who is responsible

for the transfer of these equipment’s.

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Staff Feedback 

Improving culture by a feedback system, reporting their compliance, staffs who are

noncompliance by allowing them to participate in infection control for example: the staff

members were allowed to do an audit within the facility by giving them opportunity to choose

one of the wings so that they are aware of how the audit has been conducted, also they were

provided with monitor signage and poster about infection control which will encourage and

engage them in infection control audit and made them aware of the policy and procedure of the

workplace. (Loibner et al., 2019) Staff gained positive knowledge and attitudes towards PPE and

more compliance using PPE on day-to-day basis. This will help in determination and can be

completed through introducing approved fashions into of job for trials in which employees have

the possibility to evaluate a variety of models. In this way, a lot facts related to fit, comfort, and

employee acceptability will be gained. Gathering feedback from representatives will uncover

workers' opinion about the organisation they address.

Donning and Doffing

The process of safely putting on (don) the Personal Protective Equipment’s or PPEs is called

donning and the removal (doff) of the PPEs correctly and safely and also its safe disposal so that

there is no cross contamination to the environment and the healthcare workers. PPEs are crucial

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in case of infections which are transmitted easily. Only those clinical staffs which are properly

trained and are competent in use of the PPEs should have the access to the patient room.

Donning and doffing should be done in safe areas and all the proper guidelines should be

followed.

The standard recommended PPE components include a fluid resistant long sleeved gown, alcohol

hand rub, correct sized gloves, a disposable full face visor, goggles and a fit tested FFP3

respirator. First of all the pre donning instructions should be taken are of. This includes proper

hydration of the healthcare worker, tying of the hair, removal of all the jeweler and checking if

PPE is available in correct size. Then the healthcare worker should clean his/her hands with an

alcohol hand gel or rub. After this the rear fastening fluid resistant and long-sleeved disposable

gown should be put on and the neck tie and waist ties should be fastened. Then the FFP3 face fit

respirator should be put on, the upper strap on the crown of the head and the lower strap on the

nape of the neck. When done it should be checked that there is no leakage of air from the

respirator. It can be done by exhaling sharply, if air flows around the nose, then the nose piece

should be adjusted and if air flows around the edges of the respirator, then the head bands should

be adjusted. Then a disposable full-face visor should be put on. If visor is not available then

goggles may also be used. After this a pair of non- sterile nitrile gloves should be put on. It

should be made sure that the gloves are of the correct size and that the gloves cover the cuffs of

the gown completely. In the end a final check should be made to ensure that all procedures have

been followed and all the components of the PPE are in correct position.

The correct procedure of removal and disposal of PPE is called Doffing. If possible, there should

be presence of a buddy who is the member of the staff and is trained and competent in the use of

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PPE to assist the healthcare worker in doffing of the PPE. This greatly reduces the risk of cross

contamination and self-contamination by the healthcare worker while removing the PPE. The

healthcare worker should not enter a clean wearing contaminated PPE. And the buddy should be

informed before removing the PPE if the healthcare worker fears that the PPE has been

compromised. (Amon,2020) As the outside of the gloves are contaminated the healthcare worker

should use his one gloved hand to grasp the outside of the other glove and peel it off. The

removed glove should be held in the gloved hand. Now the fingers of the ungloved hand should

be slid under the other glove from the wrist and then peel it of as well. The gloves should then be

disposed off in clinical waste bin. After this the hands should be sterilized with alcohol hand gel.

Then there should be removal of the gown, it should be done slowly and should be given proper

care. First the neck tie should be untied then the comes the waist tie. The gown should pull away

from neck and shoulders making sure that only the inside of the gown is touched. It is necessary

because outside of the gown is contaminated. Then the gown should turn inside out and should

be folded into a bundle and be disposed in the clinical waste bin. To remove the visor the

healthcare worker should be standing straight and should not bend forwards as it can lead to

contamination. The elastic strap present at the back of the head should be held and after closing

the eyes it should be lifted upwards using both the hands. After this the visor should be discarded

to the clinical waste bin. Then the healthcare worker should leave the patient room with still

wearing the respirator. Outside the worker should again clean the hands using the alcohol hand

gel. Finally the FFP3 respirator should be removed carefully without touching the contaminated

outside part of the respirator and disposed off in the clinical waste bin. In the end the healthcare

worker should wash their hands with soap and water.

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CONCLUSION

We have discussed about the negligence of the staffs of the healthcare environment and how it

can be of grave consequences. Improper use of PPEs can be cause of infection of not only the

staffs but also the people that come to them for their treatment. In order to tackle this issue we

talked about various steps which we can follow to instigate the confidence of the healthcare care

staff in the protection PPEs provides. Also plans were discussed which can positively influence

the mindset and attitude of the staffs towards PPEs and make them confident in its use. Providing

education about the PPEs and skills on how to use them properly is of the utmost essence. If the

staffs are not aware of the PPEs effectiveness then they will be suspicious about its use they

would feel like they are being forced to use them. And if they are not skilled in its use then they

would not be able use it efficiently. Also there should be enough support and resources so that

equipments with right size are available for the staff. In the end we discussed about the proper

guidelines about Donning and Doffing of the PPEs.

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References:

Torjesen, I. (2020). Covid-19: Appropriate PPE prevents infections in doctors in frontline roles,

study shows. BMJ, m2330.

Loibner, M., Hagauer, S., Schwantzer, G., Berghold, A., & Zatloukal, K. (2019). Limiting

factors for wearing personal protective equipment (PPE) in a health care environment evaluated

in a randomised study.

Amon JJ: Human rights protections are needed alongside PPE for health-care workers

responding to COVID-19. Lancet Glob Health. 2020.

Tabah, A., Ramanan, M., Laupland, K., & Buetti, N. (2020). Personal protective equipment and

intensive care unit healthcare worker safety in the COVID-19 era (PPE-SAFE): An international

survey. Journal Of Critical Care, 59, 70-75.

Jessop, Z., Dobbs, T., Ali, S., & Combellack, E. (2020). Personal protective equipment for

surgeons during COVID-19 pandemic: systematic review of availability, usage and

rationing. British Journal of Surgery, 107(10), 1262-1280.

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