Covid‐19 and personal protective equipment: The experience of nurses engaged in care of Sars‐Cov‐2 patients: A phenomenological study

Abstract

Aim

The study aims to explore the experiences of nurses who have worked in Covid‐19 wards providing care for Covid‐19 patients.

Background

During the Covid‐19 pandemic, personal protective equipment (PPE) was considered an effective and guaranteed protective measure.

Methods

This is a descriptive qualitative study with thematically analysed interviews. Twelve nurses working (specify context) were interviewed.

Result

Three themes emerged from interviews: (1) confidence with PPE used during the Covid‐19 crisis, (2) training in the use of PPE and (3) technical requirements for PPE.

Conclusions

This study clarified the importance of PPE quality and choice in establishing comfort for nurses and providing better patient care. These results could suggest useful elements to improve the PPE products by making them more comfortable for health care workers.

Implications for nursing management

Our results are important to promote and suggest prevention measures that are as comfortable and suitable as possible for health workers involved in the Covid‐19 emergency, and also for potential future similar crises.

1. BACKGROUND

In March 2020, the World Health Organization declared Covid‐19 a pandemic emergency (WHO, 2020). Italy is one of the European countries where the virus has spread fastest, especially in its northern regions, with 10,355 cases of infection in April 2022 (A.I.FI, 2022).

Strategic prevention measures, such as social distancing and the use of personal protective equipment (PPE), can reduce infection (WHO, 2020). The most at risk of Covid‐19 diseases are those who are in close contact with Covid‐19 patients, including health care workers providing direct care to positive patients and laboratory staff handling biological samples of Covid‐19 cases without the use of the recommended PPE or using inappropriate PPE (Houghton et al., 2020).

It is necessary to underline that PPE must be considered an effective and guaranteed measure for protecting health care workers (ISS, 2020) only if their use is under administrative, procedural, environmental, organizational and technical controls in the health care context that tests correct and appropriate use of PPE (Ezike et al., 2021).

Given the global shortage of PPE that occurred during the initial period of the pandemic management, it was essential to acknowledge the WHO recommendations regarding the necessity to optimize the use of PPE by deploying global strategies to ensure the widest possible availability to those most at risk of infection (Min et al., 2021). These strategies include ensuring the appropriate use of PPE, guaranteeing the availability of PPE necessary to protect health care workers, assisting individuals based on proper risk assessment and coordinating the management of PPE supply chain (Min et al., 2021).

Health care organizations had to redefine and plan new strategies for managing clinical and health care activities to reduce the inappropriate and excessive use of PPE and ensure constant availability. The overall aim is to minimize the number of admissions to wards and hospital rooms of Covid‐19 positive patients to avoid repeated actions of dressing and undressing, resulting in PPE overuse (Merchant et al., 2021; The Lancet, 2020; Wang et al., 2020).

This study focuses on the use of PPE as reported by the current legislation (European Regulation [EU] of 2016/425 of the European Parliament and Council of March 9, 2016, on personal protective equipment and repealing the Council Directive 89/686/EEC) and the impressions of health care professionals regarding their use and characteristics.

2. AIM

This study aims to explore the experiences of nurses with PPE working with infected Covid‐19 patients.

More specifically, this study aims to investigate the following:

• The technical characteristics as defined by the regulation and the level of comfort expressed by health care professionals when using PPE to prevent the transmission of the new Sars‐Cov‐2 virus.

• The compliance between the safety characteristics defined by regulation about the manufacturing production of PPE and the perception of safety expressed by the operator during the use of PPE.

3. METHODS

3.1. Design, setting and participants

This study applied a phenomenological design approach through semistructured interviews and descriptive analysis (Colaizzi, 1978; Mortari, 2007). According to Mortari, phenomenology applied to empirical research requires researchers to explore the empirical facts narrated by participants. The main aim of the thematic analysis is to identify in data collected similar concepts while exploring the significant correlations referred to the different PPE available. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines, a 32‐item checklist for interviews and focus group. The semistructured interviews were conducted face to face to understand more in‐depth their personal experiences during the care of Covid‐19 patients regarding PPE use and acknowledging the manufacturing characteristics stated by the current regulations.

3.2. Setting

Public and private Italian hospitals providing care to Covid‐19 patients in Piedmont, a region in northern Italy, were involved in this study.

3.3. Sample and participants

Convenience sampling was carried out to recruit nurses working in Piedmont hospitals taking care of Covid‐19 patients. Data collection went from December 2021 to February 2022,

The sample recruited was convenient to prompt experience of the phenomenon under investigation. The principle of data saturation defined the nurses' sample size, which were achieved with 22 participants.

The study participants were nurses working in Covid‐19 wards and who have used PPE to prevent the Covid‐19 risk of infection. Those who agreed to participate in the study expressed their consent and preferred times and places when they were available for an interview.

3.4. Data collection

The data were collected through face‐to‐face, semistructured open‐ended interviews; with this type of interview, the nurses were able to describe their experiences according to how and what they thought essential to share. The interviews were conducted by I. T. (male, MSN, RN), T. B. (female, PhD, MSN, RN) and R. D. (female RN MSN). For the face‐to‐face interviews, a room within the hospital facility was available to maintain the confidentiality and the serenity necessary to share their story. The interviews were audio recorded and verbatim transcribed by the interviewer. Face‐to‐face semistructured, open‐ended interviews were conducted by the researchers (Janghorban et al., 2014) in Italian and lasted approximately 30 min. Researchers also took field notes while conducting the interviews, including descriptions of the environment and context (Phillippi & Lauderdale, 2018). The interview began with some demographic questions to describe the study sample's characteristics (e.g., gender, age, degree year, working experience and working facility before the Covid‐19 emergency).

The interview questions were tailored according to the participants' answers to enable an in‐depth exploration of the participants' experiences.

Participants discussed and agreed on the interview location with the investigator.

3.5. Ethical considerations

According to the current Italian legislation on clinical trials (Legislative Decree 24.06.03, no. 211 and Ministerial Decree 17.12.2004), the study was conducted by European legislation and the Declaration of Helsinki.

Information sheets, informed consent forms and consent forms for data processing were delivered to the participants, as required by the current provisions. The Inter‐Company Ethics Committee approved the study.

The participants gave their informed consent only after receiving a complete and adequate explanation of the study protocol from the principal investigator and the opportunity to reflect on the study and ask questions. Subsequently, the researcher contacted the participants providing them with all the necessary additional information and explanations required.

4. RESULTS

A total of 22 nurses were interviewed: The majority were female and aged between 36 and 50 years. Below we report the demographic characteristics of study's participants.

Table 1 shows the gender data stratified by age group and educational qualification.

TABLE 1.

Participant demographics

Age groups	25–30		31–35		36–40		41–45		46–50
	N	%	N	%	N	%	N	%	N	%
Gender
Male	3	25	—	—	2	17	—	—	—	—
Female	—	—	1	8	—	—	2	17	4	33
Qualifications
Regional school diploma	—	—	—	—	1	8	2	17	4	33
Degree	2	17	2	17	1	8	—	—	—	—

Table 2 shows the study participants' wards.

TABLE 2.

Service wards pre Covid‐19

Service ward or department	Absolute value	%
Haemodynamics	1	8
Operating block	3	25
ICU	4	34
Hospice	1	8
Heart surgery	3	25
Total	12	100

Based on the analysis of interviews transcripts, the following themes were developed: (1) knowledge of PPE used during Covid‐19 emergency, (2) education and training on the PPE use, (3) PPE technical requirements.

4.1. Knowledge of PPE products used during Covid‐19 emergency

This theme describes nurses' knowledge of PPE while taking care of Covid‐19 patients during a change in PPE product provision, based on hospitals availability.

All 12 health care providers interviewed clearly remember and listed all the PPE provided reporting all the PPE established by the Istituto Superiore di Sanità document. It is necessary to point out that the PPE that has not been mentioned in all the answers is the Tyvek suit present in nine health care providers' answers. Likewise, as seen in each of the answers of these nine health care providers, they consistently report the use of water‐repellent gowns, as well. During the interview, an attempt was made to investigate why the two different PPEs were handed out, but the answers received were unclear and did not give reliable data. It is presumable that this was the result of the non‐constant presence of Tyvek overalls which, when absent, were replaced by water‐repellent gowns. In fact, during the interviews, it emerged that three operators reported the following sentence: ‘we started the Covid period wearing the Tyvek overalls, at a certain point these were replaced by water‐repellent gowns notifying that the overalls were assigned to the intensive care units as according to the Istituto Superiore di Sanità document the water‐repellent gown was sufficient to protect the operator’ [ID 20].

During the interview, a further investigation as to why two different PPEs were delivered, but the answers received were unclear and not deemed reliable. Three operators reported during the interviews:

We started the Covid‐19 period wearing the overalls; at a certain point, these were replaced by water‐repellent gowns. We were informed that the overalls were intended only for intensive care units because, according to the Istituto Superiore di Sanità document, the water‐repellent gowns were sufficient to protect the non‐intensive care unit operators [ID 3].

4.2. Education and training on the PPE use

This issue underlines the lack of training on PPE use given the sudden and rapid nature of the pandemic. The conversion to Covid‐19 units was sudden, and some operators started using PPE without receiving adequate education and training.

No education or training undertaken: Five operators reported they had not participated to any education or training, referring: ‘There was no time to be trained due to the ward conversions into Covid‐19 departments’ [ID 1].

It is essential to underline, in the category of no education or training, the five interviewed operators reported. However, in different ways, ‘There was no time to be trained because the conversion into Covid‐19 wards was sudden’ [ID 2]. ‘I was not trained because I was assigned to the Covid‐19 ward, the morning I entered my shift, without a minimum of notice due to the emergency occurring’ [ID 4].

The location where training took place: One interviewed nurse reported that they had searched online to understand how to put on, handle and remove PPE [ID 3]. Seven nurses reported that they had participated in workplace training.

Type of lessons undertaken: Seven nurses interviewed reported to have participated in frontal lessons with the help of audio‐visual material.

4.3. PPE technical requirements

PPE had advantages and disadvantages during use. PPE must have features that ensure comfort, including freedom of movement to perform procedures, thermal comfort (temperature and relative humidity) and breathability while avoiding reduced visibility and discomfort caused by prolonged wear such as neck pain, back pain and adverse skin reactions.

The following subcategories emerged from data collected.

4.4. Comfort

The most comfortable PPE were identified in disposable gloves (6 participants), water‐repellent gowns (5 participants), visors, FFP2 masks and headwear (3 participants); goggles, suits/coveralls and footwear (2 participants). One nurse answered that none of PPE worn was comfortable due to the 12 h of continuous use.

The reasons that determined a judgement of comfort, divided into different personal PPE categories are as follows:

• Visors/face shields: considered more head‐adaptable due to the possibility of adjusting the strap; they did not fog up while on duty and provided a sense of reassurance during work activities.

• Goggles/spectacles/glasses: The two operators that reported goggles/spectacles/glasses to be more comfortable than visors reported feeling them more comfortable and lighter to wear and easier to remove during breaks.

• Headcover: Due to its conformity, the protective cover was suitable for all operators.

• Facemasks: Three operators reported that they found the facemasks comfortable due to the adjustability capacities to their faces and the presence of elastic bands that did not constrain their heads too much while preserving an adherence to the face.

• Coveralls/one‐piece suits: The comfort was due to its breathable material and not stiff, leaving no problems when wearing the suit for extended hours and making it easy to put on at the beginning of the shift and remove at the end.

• Water repellent gowns: All the health care workers who reported that this PPE was more comfortable agreed on the aspects of freedom of movement.

• Disposable gloves: The comfort was due to the constant presence of correct‐sized gloves that granted greater freedom of movement and action despite using a double pair.

Skin‐friendliness:

• Visors/face shields and eyewear: The visor was unlikely to cause problems to the provider's skin when caring for Covid‐19 positive patients.

• Facemasks: Seven out of 12 care providers interviewed pointed out that the materials used were too heavy to bear and they often felt that they had a lot of resistance in breathing. Five out of the seven operators who reported poor quality of the materials recommended using more suitable and especially non‐irritating materials. They reported the following ‘the facemasks provided during the Covid‐19 emergency were not always made of suitable materials. Above all, I often had itching around my nose and chin after a few hours’ [respondent no. 7]. Furthermore, the five operators who recommended more suitable materials reported that after a few hours of wearing them during their shift, they had sores on their cheekbones, nose and chin with stinging and, in some cases, bleeding.

• The following was reported in relation to this claim: ‘the masks I wore during the covid emergency made marks on my face. I remember in one of the first shifts that after 6 hours of work, during a break after taking off the mask, I saw my face marked and in some places the skin started to lacerate. I finished my break and continued working until 10 p.m. At the end of my shift I went to the doffing area and I still remember that when I took off the mask I saw the edge of it stained with blood and I touched my cheekbones feeling a strong burning sensation, above all I saw slight traces of blood on my fingers’ [ID 13]. ‘I did not have lacerations on my face but I remember that many of my colleagues had irritations on their faces and I think this was due to the poor quality of the materials used’ [ID 15].

• Overalls/one‐piece suits: Seven out of 12 operators reported that the overalls were made of non‐breathable materials. As a result, they are often drenched in sweat with wet uniforms. In relation to this group of interviewees, they reported the following: ‘I often used the protective overalls, and I must say that, apart from the sizes not always being correct, they were comfortable and did not give me any problems. When they were unavailable, I wore the water‐repellent gowns and felt less safe.’ [ID 9] ‘The overalls I used during the covid emergency were often the wrong size for me and during my shift I often felt wet as the material was not breathable and caused profuse sweating so much so that my uniform underneath was wet. This made working hours much more exhausting as I was disturbed by feeling wet’ [ID 5].

• Water repellent gowns: None of the interviewed nurses reported any problems with skin‐friendliness.

• Disposable gloves: Only one health professional reported a problem with excessive sweating and subsequent discomfort during care activities. The interviewee stated the following:

The gloves used during care were those used during normal care activities, and I found my hands very sweaty as always. Only in this case, having to wear the double glove for many hours without the possibility of changing the ones in contact with the skin, the feeling of discomfort and itching was stronger than during normal working days [ID 8].

4.5. Fitting (dress‐ability)

Morphology:

• Visors/face shields and goggles/spectacles/glasses: Three interviewed nurses reported that they found visors more adaptable, while two respondents reported spectacles/glasses instead.

• Headcover: Four interviewed nurses reported this item as being more adaptable.

• Facemasks: Three out of 12 respondents reported this item as morphologically adaptable.

• Coverall/one‐piece suits: Five out of 12 operators reported that the one‐piece suits were more adaptable to their body shape, although some of them reported the following: ‘The overalls were the most adaptable equipment to suit the body even though the available sizes often did not correspond to the actual sizes needed. This resulted in a difficulty of movement as the baggy suit was a nuisance during certain care activities’ [ID 7].

• Water repellent gowns: In this case, 5 out of 12 operators reported that the water repellent gowns were more adaptable to their body shape. It is essential to mention that the same respondents, who positively evaluated the water‐repellent one‐piece suits, positively assessed the water‐repellent gowns used as an alternative when the one‐piece suit sizes were not available. It is also important to underline that these same nurses reported that they considered the water‐repellent gowns more comfortable between the coveralls and the gowns as they were more familiar with wearing them during their typical working day.

• Disposable gloves: Three operators reported the importance of having the right size gloves because those provided were often never appropriate in terms of personal size.

• One of the three operators also emphasized the importance of suitable gloves tailored for such emergencies in which it is necessary to cover every part of the body, as he had used short gloves that had to be attached to the skin by using paper tape: ‘During the Covid‐19 emergency the use of two pairs of gloves was not that traumatic although I must say that it was very uncomfortable because of the length of the glove in contact with the skin as once it was put on it did not reach beyond the wrist and therefore all my colleagues and I had to make do with using paper tape to secure them’ [ID 11].

4.6. Visual area

Regarding this subcategory, we investigated only PPE that had aspects that could have influenced an appropriate range of vision that would not have put the health care professionals in difficulty during their care activities:

• Visors/face shields and eyewear: Nine interviewed nurses reported that they never had problems with their range of vision when wearing a visor or eyewear. However, they recognized the visor as the best performing PPE when worn, even in the case of nurses wearing prescription spectacles. Three nurses reported problems of spectacles/glasses fogging up due to the simultaneous use of facemasks and spectacles/glasses. All three cases suggested the following indications: ‘It would be reasonable to consider the problem of spectacles fogging up with the simultaneous use of face masks, finding a solution to prevent the glasses from fogging up when the two personal protective equipment are worn together’ [interviewee n° 12].

4.7. Safety perception (total protective shielding)

Referring to this subcategory, we asked nurses a question to investigate how much the simultaneous use of all PPE made them feel safe while caring for Covid‐19 positive patients about a possible personal infection.

Eight out of 12 nurses reported that they always felt protected; the remaining four nurses reported that they did not feel sufficiently protected, giving the following reasons:

‘Often given the shortage, I thought they were not enough to protect me, and I got infected, so the fact that I did not feel safe was subsequently confirmed’ [interviewee n° 7].

‘No, I did not feel totally protected as we had to use the same personal protective equipment even for several shifts, and in fact, I became infected with Covid‐19’ [interviewee n° 9].

‘I did not feel protected because of the long twelve‐hour shifts, which increased my stress with the fear of making mistakes and removing my personal protective equipment wrongly, resulting in the possibility of my being infected’ [Interviewee n° 10].

‘I did not feel sufficiently protected as the personal protective equipment provided was not always the right size. Nevertheless, it was too tiring anyway as the shifts were raised to twelve hours.’ [Interviewee n° 11].

At the end of the interview, we made a good question to understand what suggestions the nurses felt like giving the manufacturers for PPE production that would actively respond to their needs for comfortable, safe and prolonged wear.

What was immediately noticeable was that the nurses only and exclusively made suggestions for facemasks and protective coveralls/one‐piece suits. Nine operators out of 12 reported that for facemasks, they would recommend using softer materials that had better adapt to face shape and, above all, the use of pads in the contours of the masks to avoid skin damage. As for the coveralls, the same nine operators reported that they would recommend a more breathable and softer material to make movements more accessible and more flexible.

The remaining three operators did not advise on what materials to use or how to improve PPE. Still, they reported that they would recommend involving nurses in the manufacturing process. This would be useful to gather crucial professional advice to produce PPE that responds to real needs and not only to technical standards that consider only health protection aspects and not comfort.

5. DISCUSSION

This study investigated the nurses' experiences working in Covid‐19 wards and whether they had received any education or training in PPE use with the perceived level of safety during their working activities.

Training has played a fundamental role for nurses, even if not all reported training in PPE use. Literature provides evidence of the importance of training to increase skills and a person's safety during highly contagious infectious diseases such as Covid‐19 (Barratt et al., 2020). According to some health care professionals interviewed, being trained gave more reassurance that they would start the pandemic with more confidence for themselves and their family members, whom they would see back home at the end of their shift.

Concerning perceptions on PPE, the nurses positively perceived the use of PPE to be crucial for protection from the Covid‐19 infection. However, at the same time, they expressed stress and discomfort regarding their use. The reports on facial masks as a cause of irritation and facial injuries due to the lack of adaptation of facial morphology and poor quality confirm the evidence present in the literature. The prolonged pressure on the skin and the hot and humid microclimate created in the area covered by the mask increase the probability of developing pressure injuries (Bambi et al., 2021).

This study reported the discomforts expressed by nurses, such as fatigue and tiredness, sweating, dizziness, dehydration, irritation and poor visibility due to eyewear fogging up. In a previous study (Min et al., 2021), more than half of the frontline nurses reported the discomfort of wearing glasses.

Several authors have considered appropriate size, fit and quality key factors in facilitating PPE use (Chapman et al., 2017; Kang et al., 2018).

Some nurses in the study reported insufficient quality of the PPE items. Such evidence in literature reports that the poor quality of PPE can prevent compliance with its use (Kang et al., 2018). Health care facilities should be aware of these discomforts, and options of different types of PPE should be available for health care operators, particularly facial protection equipment.

The contribution of the present study was to provide additional information about nurses' experiences with the use of PPE while working with Covid‐19 patients. This study has clarified the importance of PPE quality in establishing comfort for nurses and providing better patient care. These findings may suggest functional elements to produce more comfortable PPE for health care professionals.

The limitations of this study were the use of a convenience sample of nurses within an Italian region; the results may not reflect the experiences of all nurses assigned to Covid‐19 wards in different settings. The nurses interviewed were from other facilities with different organizational arrangements. In addition, the results of this study represent nurses' experiences at the time of the interviews; therefore, they cannot report the dynamic nature of the global pandemic.

The choice of PPEs should reflect the nurses' feedback to reduce discomfort and improve comfort.

6. CONCLUSION

In this pandemic, people most at risk of infection were those who cared for Covid‐19 patients and all international health care providers. In a very timely manner, it was necessary to implement measures to prevent the risk of Covid‐19 contamination both for health care providers and the community.

Starting from hygiene measures, health care providers needed to take additional precautions to protect themselves and prevent transmission in the health care setting. Safeguards involved the provision of appropriate PPE and targeted education and training on how to wear, remove and dispose this.

Therefore, health care institutions had to select appropriate PPE that complied with specific manufacturing and technical standards aimed at the safety of health care workers involved in a health care emergency.

For the reasons mentioned above, it is essential that industries, particularly health care organizations, consider the point of view of PPE users when managing any future emergencies.

Suppose industries and health care organizations move in this direction, in that case, the manufacturing and the adoption of new instruments that are more comfortable and suitable to use will positively affect the working conditions of nurses. Beyond that, on the way, they interact with their environment but primarily with the patients with whom they must communicate and interface to satisfy their needs.

7. IMPLICATIONS FOR NURSING MANAGEMENT

Our study underlines the importance of investing more in continuous education and training on infective risk and health emergency management and designing a PPE that is safe and comfortable and suitable for health care professionals for wearability and comfort.

It also underlines the importance of deploying resources for appropriate materials to protect against work‐related risks, but that is soft and, above all, skin friendly.

Our findings are important to promote and suggest prevention measures that are as comfortable and suitable as possible for health care workers involved in the Covid‐19 emergency and for potential future similar crises. For example, the adoption of company procedures to guide the employee in the donning and doffing of PPEs with designated areas for this purpose could have a positive impact on the management of the emergency; creating PPE manufacturing projects in collaboration with health care workers who use the equipment to increasingly improve the products are not very complex and costly solutions to implement.

CONFLICTS OF INTEREST

The authors state that they have no conflicts of interest.

ETHICS STATEMENT

The Institutional Board of the Intercompany Ethics Committee of the Public Hospital SS Antonio e Biagio e C. Arrigo, Alessandria, has granted ethical approval (Resolution n. 354).

AUTHOR CONTRIBUTION

Terranova, Bolgeo, Bagnasco and Zanini have made substantial contributions to the conception and design, acquisition of data, analysis and interpretation of data; Di Matteo, Gatti, Gambalunga and Maconi have made substantial contributions to acquisition of data, analysis and interpretation of data. All authors have been involved in drafting the manuscript, revising it critically for important intellectual content and given final approval of the version to be published. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Terranova, I. R. , Bolgeo, T. , Di Matteo, R. , Gatti, D. , Gambalunga, F. , Maconi, A. , Bagnasco, A. , & Zanini, M. (2022). Covid‐19 and personal protective equipment: The experience of nurses engaged in care of Sars‐Cov‐2 patients: A phenomenological study. Journal of Nursing Management, 30(8), 4034–4041. 10.1111/jonm.13837

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.