Staying cool and comfortable at work: the challenges of PPE

How design input from nursing staff is making the combination of uniforms and COVID-19 care requirements a bit more bearable

• Nursing Standard hears from nurses about their experience of wearing personal protective equipment over workwear
• Nurses explain the practical and cultural issues they face – and how they’re dealing with them
• Advice on how to stay cool under layers of uniform and PPE

COVID-19 has forced nurses to wear more personal protective equipment (PPE) than ever before in their professional lives.

‘Hot’, ‘sweaty’ and ‘smelly’ were some of the words used by respondents to a recent Nursing Standard survey to describe how wearing layers of aprons, gloves, masks and visors makes them feel. With warmer weather just around the corner, we look at the challenges PPE poses for nurses, the innovations in uniform design that have emerged from the pandemic, and advice on keeping cool.

Hot and sweaty – what staff told us about their experience of wearing PPE

Nursing Standard’s health and well-being at work survey asked how nurses cope with wearing PPE, and about the practicalities of wearing PPE over standard uniforms or workwear.

Of 1,415 people who responded to our anonymous online survey, 60% (851) said they were comfortable when wearing PPE, 40% (564) were not.

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One said: ‘The PPE makes my scrubs all sweaty and wet, making it uncomfortable.’

‘We are not provided anything to change into, so if we don’t bring any extra uniforms we’re wet, smelly and uncomfortable all day,’ another told us.

Worryingly, another wrote: ‘I've become too hot on some occasions, which has led to hypoglycaemia.’

Challenges community nurses have been facing

Nurses who work in the community report a varied experience.

‘We only have plastic pinnies and gloves. We do have ill-fitting fluid resistant masks and visors, which constantly steam up, preventing you from seeing properly and therefore endangering patient safety,’ one nurse said.

Senior specialist practitioner in end of life care Parveen Akhtar, who works in the community in London, said the introduction of PPE and uniforms has created a ‘distance’ from patients and families when going into their homes.

‘Wearing gloves and trying to comfort or stroke a patient, the gloves are sweaty – there was no sensitivity with that. That was hard for us and we still feel it. Families have fed back that they miss the personal touch,’ adds Ms Akhtar.

Due to PPE shortages early in the pandemic, Ms Akhtar and her team had to source their own forensic-style body suits to wear when visiting patients in care homes.

‘They came in so handy. We were hands-on when nobody else was touching these patients in care homes, but we felt protected with these body suits,’ she says.

Advanced nurse practitioner Peter Jones works in a GP practice in Worcestershire. Like other general practices, his workplace had to look at alternative ways of delivering services to comply with social distancing.

But the combination of PPE and the weather made an outdoor phlebotomy clinic, with patients remaining in their cars, unworkable. ‘As soon as it was windy, it was completely unsafe,’ says Mr Jones.

‘A patient is in their car, I have a phlebotomy needle in my hand and the wind is nipping my pinny up in my face. One day it was particularly windy, and my visor got blown straight off my face. We tried alternatives, but the PPE meant we couldn’t do outside clinics.’

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Community nurses have also shared with Nursing Standard on social media the challenges of donning and doffing PPE outdoors against the elements.

‘The snow, rain and wind… and trying to put PPE on at boot of car before going into a home,’ one district nurse working in the Highlands of Scotland told us.

Scrubs under PPE – sometimes one size does not fit all

Many survey respondents said their employers had allowed more staff to wear scrubs with PPE, describing them as a comfortable alternative to more restrictive and traditional tunics or dresses.

However, difficulties to do with availability and sizing of scrubs were highlighted.

‘Sizes aren’t always available’ said one nurse, while another said: ‘I was offered scrubs to wear, but they were three sizes too big’.

Others said their workplace would not sanction the wearing of scrubs. ‘The matron says they [scrubs] are not professional,’ one respondent said.

Making nurses’ uniforms more comfortable

Our survey also asked how staff would like to see uniforms or work clothing adapted or improved. The overwhelming answer was that lighter uniform materials would make work more comfortable.

Scrubs were popular, with some people calling for them to be introduced permanently across the board beyond the pandemic – with a few tweaks.

Many respondents suggested introducing pockets for pens and equipment. And one suggested that they should be made ‘easier to put on, without going over your head’.

However, one community nurse said they were concerned about the image scrubs present, saying: ‘I don't think these are appropriate for the community setting. It’s like wearing pyjamas in patients’ homes.’

Uniform adaptations reflecting cultural diversity

The challenges of the pandemic have led to some creative thinking when it comes to uniforms and PPE.

At Imperial College Healthcare NHS Trust in London, emergency medical admissions unit ward manager Noni Nyathi spearheaded the idea for head coverings to meet the needs of staff who have African-Caribbean heritage and those wishing to cover their heads for religious reasons.

Ms Nyathi’s idea came from her concerns about bringing the virus home from work. During the early weeks of the first wave, she was washing her hair every day, which meant it became dry and brittle.

‘African-Caribbean hair needs oils added rather than being removed’, says Ms Nyathi.

She asked a relative, who sews, to make a covering for her hair that matched her uniform, and after wearing the head covering to work, colleagues said they wanted the same. ‘Most of my team are from a black, Asian or minority ethnic background, so they were quite keen to have what I had,’ says Ms Nyathi.

The head coverings proved so popular that Ms Nyathi presented the idea to her line managers, and the design was approved for wider production.

The head coverings were formally introduced in January and are made of 100% cotton. They come in three sizes, according to length of hair and hair type. They can be washed at 60°C and are permitted to be worn anywhere in the trust except in theatre.

To date, 4,000 head coverings have been ordered and 1,200 have been distributed to staff.

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The success of the head coverings inspired other staff to think about how uniforms could be adapted for other staff groups.

‘We thought, “are there other groups of staff that perhaps have concerns that we don’t know about?”, says clinical procurement lead nurse Marcelle Tauber. ‘For Muslim staff, should we start thinking about providing hijabs for our female staff?’

The trust consulted some of its Muslim staff and one of its Muslim chaplains, who used contacts at her mosque to help find suitable fabric for hijabs that were light, comfortable and washable.

The hijab and head coverings have since been incorporated into the trust’s uniform policy.

Ms Nyathi says her experience shows the importance of staff involvement in making uniforms practical and comfortable.

‘I’m sure people have good ideas that they are keeping to themselves,’ she says.

‘If you have an idea, you should put it forward,’ she says.