Initial themes categorised using the COM-B framework can be seen in Table 1.
Table 1. Themes matched to COM-B categories
- Skills in donning and doffing PPE
- Understanding PPE principles
- Knowledge of PPE protocols/processes
- Undergraduate learning about PPE
- Prior clinical teaching about PPE
- Unconscious habit – e.g. unconsciously doffing PPE as learned in operating theatre
- Beliefs about benefits of PPE for self-protection
- PPE availability/access
- Range of PPE sizes and different products
- Facility design
- Peer behaviour
- Clinical team norms
- Role models
- Time constraints to don and doff PPE
- Interference with clinical assessment
At the second stage of analysis, two overarching themes were developed to describe factors that were likely to impact on interns’ safe and correct PPE use in clinical practice. These were: a) adequacy of prior knowledge and skills for practice; and b) using PPE in the real world. Within the COM-B framework, theme A corresponded with capability/motivation, and theme B with opportunity. Below, we describe these themes in more detail.
Theme A: Adequacy of prior knowledge and skills for practice.
This theme describes participants comments on their PPE knowledge and education prior to the training received that day. All participants indicated that they had received basic education on the use of PPE at medical school, and some had received additional PPE education or training during clinical placement (e.g. several who had had placements in the operating theatres had been taught how to don sterile gloves and gown). This prior learning had provided some PPE knowledge and skills which, after their brief IPC/PPE orientation training, participants recognised had not necessarily been adequate for safe PPE use. They reported that preparation for medical school practical exams included an emphasis on hand hygiene before patient contact, so they automatically performed hand hygiene prior to donning PPE. However, although they were taught that PPE is important, correct methods of donning and doffing were not always demonstrated or explained. As one participant described it: “We get told what to put on, but no one's been, like, this is how you put it on...” (Participant 2 [P2], Focus Group 1 [FG1], emphasis added.)
Until then, many participants had been unaware of the risks of self-contamination during doffing or the rationale for the doffing steps that were taught. For example, most participants had been unaware that a critical step in doffing PPE safely was to perform hand hygiene after the removal of gloves (because of the potential to contaminate their hands (22)), as the following quotes suggest:
“I’ve never washed my hands right after taking off the gloves.” (P2, FG4)
“We didn’t wash our hands after we took our gloves off.” (P1, FG6)
Some participants had already developed incorrect and unsafe habits of PPE use. For example, some had previously tied their gowns at the front – where gown ties could become contaminated - and so risked contaminating their hands when doffing. One participant described his thoughts about the order of donning, during orientation PPE practice:
“I was much more conscious of what I was doing, because when you’re on the ward, you’re just like, yeah, yeah, yeah... You think you’re doing it automatically, but now you [need to] think in steps.” (P1, FG2)
Participants also recognised that their lack of understanding of correct donning and doffing of protective masks had led to unsafe mask use. For example, some had previously removed their masks upwards, over their face and hair, potentially contaminating themselves:
“But yes, I didn’t realise that it was much safer to pull [the mask] … downwards.” (P4, FG1)
There was also a notable knowledge gap in the use of eye protection, with many participants erroneously having believed that their own spectacles were an acceptable alternative to protective eyewear.
“I would have my glasses on as well, so I would be like, I’m good.” (P6, FG3)
For several participants, aspects of their PPE behaviour had been learnt in operating theatres, during surgical placements, which subsequently influenced their use of PPE in the wards. At orientation and during this study, PPE removal was taught according to current Australian guidelines (22), namely: remove gloves first, followed by hand hygiene, then remove eye protection, gown and mask (in that order). However, participants noted that, during the study, they had made a habit of removing their masks first, due to their experience in theatre:
“I think it’s just habitual [to remove the mask first]… when you’re going into theatre, you put the mask on then the scrubs…” (P4, FG5)
Also, many participants noted that they instinctively removed gown and gloves together in one motion as they had been taught to do in theatre:
“I’d actually take it […] off like in theatres. Like I’d pull the gown off and then take it off with the gloves and pull it off as one unit.” (P1, FG7)
Finally, participants demonstrated a mixed understanding of the items of PPE required for transmission-based precautions. Although some correctly identified the PPE required for contact, droplet and airborne modes of transmission, others expressed confusion about which type of mask to wear for various disease scenarios.
“And like I said, there's a lot of misunderstanding about what each mask is used for. They just think this [N95] is the better mask. Use this mask, rather than, like, what is its actually for”.(P1, FG8)
Theme B: Using PPE in the real world
Participants frequently referred to the differences between ‘real-life’ PPE use and how it was demonstrated at orientation. Factors contributing to these differences included the physical environment and resources, the behavioural norms of the clinical area where they worked and the expectations of their roles as junior doctors.
As taught in orientation training, the first step in donning PPE is to remove jewellery to allow for effective cleaning of hands and arms below the elbow. Participants described different approaches to this step across different clinical settings.
“Obviously in surgery, you don’t have [jewellery] in surgical scrubs, but on the ward, everyone wears their watches and rings and stuff.” (P5, FG2)
Conversley one participant described their experience working in a hospital where there was a strong emphasis on bare below the elbows.
“Because at my hospital, they’re very diligent in making sure that below the elbows had to be, like, nothing, literally, … so that’s why a lot of us now are used to not wearing watches.” (P4, FG3)
A commonly cited reason for non-compliance with removing jewellery on the ward was a requirement to use a watch for patient examination. There was also the practical barrier of finding a suitable, safe place for it when removed.
“I actually physically take everything off, you know, and sit it on the sink. And hope that it’s still there when I go back.” (P1, FG5)
“[Removing jewellery is] difficult on a ward where you're going to lose your watch, yeah.” (P2, FG5)
Another environmental barrier that impacted on PPE behaviour was the variability and availability of some PPE items in clinical areas. Different gowns and masks were available in different clinical settings, so could be unfamiliar. Participants particularly noted that goggles or protective eyewear were difficult to locate in wards and even when eye protection was available, it was not always suitable:
“None of these goggles fit over my glasses.” (P1, FG4)
One participant had addressed this problem by purchasing their own protective eyewear with prescriptive lenses. As medical students, participants had come to accept, as “normal”, that certain PPE items were never available on wards and, even if they were, they were rarely used anyway.
“I don’t … usually find [protective eyewear] on the wards and most times when we do, everyone just wears the mask and gloves and gown, no-one wears goggles.” (P6, FG7)
Participants identified that senior doctors are looked to as role models, but may not always model best practice, as described by the following participant:
“When you’re a student who’s a bit less experienced, you’re just following what the rest of the team is doing and basing it off that… [but] they’re not often the best models to follow.” (P1, FG1)
Frequently, as the most junior member of the team, the intern was often required to remain outside of the room during ward rounds, to write in the patient notes, which limited opportunities to practice donning and doffing skills. They also identified time pressure during ward rounds as a challenge to optimal PPE use, describing a lack of time for all team members to correctly don PPE.
“I was in a rush doing ward rounds, so I just follow suit.” (P1, FG3)
“When you're on wards you're definitely pressured to do it faster because you want to go in. Whereas today [during the training] I was like, oh, I've got all the time in the world to go in and do it correct.” (P3, FG6)