In the early days of our COVID-19 response we sometimes observed staff compromising their safety and that of others by using too much or too little PPE, or because of donning and doffing errors. Why was this happening? And how could we act at pace to support staff to use PPE in ways that could ensure the safety of staff and patients?

A blended behavioural science and learning mindset

Our starting point was that staff wanted to use PPE correctly, while recognising there can be many reasons why this may not happen all the time. A key realisation for me was that whilst donning and doffing PPE seems conceptually to be a straightforward task, to do so safely, each and every time, requires complex sequential learned behaviours.

Applying a behavioural lens allowed us to identify a range of challenges such as: lack of up-to-date knowledge and information; frequent changes to PPE guidance; lack of donning and doffing technique; skills and practice to safely use PPE; unfounded beliefs; heightened anxiety; forgetfulness in the moment; heuristics; and physical and environmental constraints.

This diagnostic made it clear to us that to support staff effectively we needed to ensure that any intervention enabled them to overcome these challenges so they could adopt safe behaviours. With support from the Medical Director’s Office and Infection Prevention and Control (IPC), a multi-disciplinary was brought together and rapidly implemented what we have been calling our PPE Helper Programme.

From the offset, our programme adopted and designed in an insight and learning mindset

From the offset, our programme adopted and designed in an insight and learning mindset, baking in improvement principles of real-time feedback, rapid iteration, metrics, and frequent sharing of learning. Our support and training to PPE Helpers included information on appropriate PPE use and best practice for donning and doffing, but we also placed importance on skills such as active listening and coaching, and the underpinning behavioural science knowledge of the programme.

At the heart of this programme were the PPE Helpers: a trained cohort of twenty redeployed staff – including educators, therapists and colleagues from nuclear medicine – who would visit wards regularly to promote best practice around the use of PPE. IPC training, support and shadowing were provided, and ward visits would often take place in pairs to encourage paired-learning and reflection. PPE Helpers focused on:

• supporting staff to don and doff safely
• providing knowledge, skills and signposting to up-to-date PPE information
• and ensuring that staff felt reassured, supported and listened to.

Oversight and operational stewardship came from a multidisciplinary team comprising the IPC general manager, IPC service manager, four senior nurses from IPC, lead PPE Helpers, and improvement leads.

A programme with impact

During our four-week evaluation period between 20 April – 15 May 2020, PPE Helpers conducted 268 visits to 30 wards across three hospital sites and engaged with hundreds of staff using PPE during the COVID-19 surge. Over this period, we witnessed a 23 percent increase in the mean proportion of times PPE Helpers reported that appropriate donning and doffing was observed ‘always’ or ‘mostly’ on their ward visit.

By building in improvement principles we were able to iterate the programme in real-time so that PPE Helpers were responsive to the immediate need of staff during their visits.

By building in improvement principles we were able to iterate the programme in real-time so that PPE Helpers were responsive to the immediate needs of staff during their visits. A good example of this was PPE Helpers assuming a role in providing specific information and reassurance to our BAME staff.

Staff who had encountered a PPE Helper were also more positive in responding to a range of statements about using PPE than those who had not. This included improved perceptions about PPE availability, training, donning and doffing, staff challenging one another about PPE, and reduced anxiety related to PPE.

But don’t just take our word for it. Our PPE Helper programme was recognised by the Care Quality Commission (CQC) in a recent visit, who highlighted it as outstanding practice.

As for the longer-term legacy we have used the rich learning generated to redesign and strengthen our Trust-wide hand hygiene safety programme. In August 2020 we began the roll-out of a longer-term embedded PPE and Hand Hygiene Helpers programme that is rooted in the core principles of the original programme.

A personal reflection

Continuous improvement is better than delayed perfection

– Mark Twain

By baking in improvement principles and ensuring regular after-action review we learnt through trial and error, allowing us to iterate in real-time. So, for example, the programme iterated by:

• providing greater focused support to BAME staff;
• switching the after-action review from paper to online;
• streamlining feedback captured to focus only on what was useful;
• adopting a site-based approach to sharing lessons;
• iterating core documentation and updating the FAQs; and
• surveying staff on perceptions about PPE and the PPE Helper Programme.

On a personal note, it felt rewarding to blend behavioural science and a learning mindset to the challenge of how to support our staff to use PPE safely. And, I also feel that a PPE Helper programme is a feasible and beneficial intervention for providing reassurance, support, advice and education to ward staff during infectious disease outbreaks. But, most of all I feel a sense of tremendous pride.

I feel proud that our Trust values shone through and guided us

I feel proud of every person that was part of the PPE Helper programme, and proud of all our staff that relied on PPE when caring for our sick patients. I feel proud that our Trust values shone through and guided us. I am proud that we were kind, lifting one another and expressing collective gratitude. I am proud that we were seamlessly able to bring differing expertise, and respecting and valuing that expertise. I am proud that we worked collaboratively, offering help and support, and fostering trust between staff using PPE and PPE Helpers. And, I am proud that we were aspirational, in our ambition and innovation for what we could do to make staff and patients safe, despite feeling scared, anxious and stressed ourselves.

I have come away from this experience with new friends and colleagues. And, although we did celebrate virtually, I am looking forward to the day we can all come together, face-to-face, to toast all the staff at the Trust that have and are continuing to work tirelessly in the face of a frightening global pandemic. But, until that time comes: “Cheers! And thank you PPE Helpers.”