Table 3.

Summary of themes from all streams of data

Main themes	Subthemes	Policy review	Media analysis	Illustrative interview quotes
Theme 1: PPE guidance and training — ‘We weren’t prepared enough’	Inconsistent guidance	PHE guidance changed on March 6 2020 to advise FRSM masks be used instead of FFP3 respirators when assessing or caring for suspected patientswith COVID-19.29	Newspaper reports of HCWs expressing concerns about caring for suspected cases with FRSMs instead of FFP3 respirators.	What is really difficult for staff is that they’re being told to use a certain level of PPE for suspected patients but they might be watching the television and seeing, either from our country or other countries, people looking after patients wearing complete gear—total hazmat suits—covered from top to toe. Then they’re saying, ‘I’m being given much less than that to go see patients’.’ (Doctor, Consultant) Some staff felt messages of what PPE is required, in what situations, that there was a little bit of distrust…If the advice keeps changing, are we getting the right message? And is this message safe? Which caused a bit of worry and anxiety for some of the staff because at the same time they were hearing on the press that colleagues in other hospitals were getting sick. (Senior nurse) The guidelines are created within an emergency context…but I think that at local level, there should be an interest into tailoring those guidelines to needs. (General practitioner)
	The training gap	On 2 March 2020, all NHS organisations advised to provide HCWs with fit-testing and PPE training.34	Newspaper reports of HCWs working in PPE without having received training.	I haven’t had any training…some other nurses have been trained to use ventilators but there hasn’t been any PPE training or anything else at all. (Nurse) PPE training happened because of local engagement of clinicians rather than coming from the management…it is clinicians who have been coming knocking on the door saying we need to prepare and perform these trainings—that was strange, why didn’t that change come from the top? (Doctor, Consultant)
Theme 2: PPE supply— ‘If we’re not protected, we can’t protect the public’	Shortages	On 17 April 2020, PHE guidance changed to approve the reuse of PPE where there were acute shortages and it was safe to do so.33	Newspaper reports of inadequate access to PPE, especially for BAME, woman and community HCWs.	So, there were times, for instance, where you needed to go to the loo, but you didn’t want to waste PPE. (Doctor, Registrar) What I don't think was good was the PPE situation, begging for personal protective equipment, feeling guilty for asking for it, feeling guilty for raising our voices. (Medical associate professional) Some of the scrubs, there weren't enough small ones…and well, you wouldn't expect a six-foot man to wear something that would fit me.((Female) Doctor) We didn’t have family members coming in wearing PPE and seeing their relatives to say goodbye before they die, and we should have been able to facilitate that. (Doctor, Consultant)
	Procurement	In a letter to Trust chief executives on 17 March 2020, NHS England stated that there are local distribution issues despite an adequate national supply of PPE.37	HCWs using the ‘panorama’ hashtag on Twitter (n=2000 tweets), which referred to the BBC investigation on whether the government failed to purchase PPE for the national stockpile in 2009.	I think the one thing that’s probably been the biggest challenge has been sourcing PPE…That was probably the single biggest anxiety-inducing thing for staff on the ground. We never got to the point where we ran out but there was always this sense that we don’t know where next week’s is coming from. And the Trust always did manage to find it, but it was complex. (Doctor, Consultant) So there has been provision of PPE but not necessarily always PPE that is as secure as it could be. (Senior nurse)
	Risk of exposure	PHE guidance from 14 March 2020 advised HCWs who came into contact with a patientwith COVID-19 while not wearing PPE could remain at work unless they developed symptoms.39	News reports attributing a lack of PPE to frontline HCWs falling ill and dying.	They were saying that we were the ones that really should be using (PPE) and anyone who was in the room but is further away doesn't need it, because they're not at the mouth of the patient…you were begging to have more…you'd have to really make a stand and say well, ‘everybody in my team is wearing it.’ (Medical associate professional) The first thing to do is making sure the healthcare professional feels that they are not jeopardizing the life of their own families…don’t make them feel like a pawn in a bigger game, because sometimes we feel like we are obliged to do stuff to save the rest, but we are part of the rest too. (Doctor, Consultant) It was really scary because, it’s not just the patients…it’s the attitude towards the staff as well. They were treating anybody like you had it. I had an anaesthetist in the early days, when we weren't being given PPE, it was just like ‘don't come in, keep away from me’, and it was really difficult to work keeping apart from someone. It was like the way they treated you as well, as though you're infected so don't come near me. (Medical associate professional)
Theme 3: Challenges of delivering care in PPE—‘It’s necessary but it makes everything more difficult’	Physical effects	PHE guidance stated that HCWs should remain hydrated and be trained to recognise dehydration, fatigue and exhaustion while wearing PPE.33	Staff nurse in a news report describes taking minimal breaks during their 12-hour shift to avoid changing out of PPE to access water or toilets.	It’s hot, it’s sweaty, it’s inconvenient (Doctor, Consultant) The effort staff made for the patients, even though they were uncomfortable, overall was remarkable really. (Senior nurse)
	Practical problems	On 12 March 2020, PHE guidance stated that FFP3 respirator, long-sleeved disposable fluid-repellent gown, gloves and eye protection must be worn for AGPs.65	Consultant in a news report describes how PPE made treating patients significantly more difficult, obscuring their vision.	It makes it more difficult to go between patients. So, for example if there is an emergency in the non-coronavirus bay you can’t just leave. You have to take off all the PPE in a particular way to make sure you don’t contaminate yourself and then go to see what the emergency is. It causes a small delay that probably doesn’t make a difference, but psychologically it feels more stressful because you feel like it’s taking a lot longer. (Doctor, Registrar)
	Communication and connection	On 24 April 2020, PHE IPC guidance advised trusts that ‘visiting should be restricted to those assessed as able to wear PPE’.17	Positive news reports of HCWs using PPE portraits (disposable photos of their faces on top of PPE) to overcome rapport problems with patients.	I think it does make you feel very …dehumanized because you can’t recognize any of your colleagues. (Senior pharmacist) When you've got patients on the ward and they are stuck in a room on their own and everyone in the room is dressed in PPE and they can’t have their relatives visiting them that’s actually really frightening and stressful and will create problems for people. (Doctor, Consultant)

AGPs, aerosol generating procedures; BAME, Black, Asian and Minority Ethnic; FFP3, filtering facepiece 3; FRSM, Fluid-Resistant (Type IIR) Surgical Face Mask; HCW, healthcare worker; IPC, infection prevention and control; NHS, National Health Service; PHE, Public Health England; PPE, personal protective equipment.