Analysis

Staying cool and comfortable at work: the challenges of PPE

Innovations in uniform design are making COVID-19 care requirements a bit more bearable

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

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
A nurse in a hospital wearing full PPE
Picture: Alamy

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.

564

respondents to a Nursing Standard survey said they were not comfortable when wearing PPE
(Source: Nursing Standard health and well-being at work survey 2021)

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.

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.’

Advice for nurses on how to keep cool in PPE

Advice from Pat Cattini, lead infection prevention and control nurse at the Royal Marsden Hospital in London and past president of the Infection Prevention Society:

  • Have a drink before donning any PPE
  • Remove your mask when you can and take regular short breaks, even ten minutes will help. Find a quiet spot outside or socially distance in an office
  • Apply lip balm and face moisturiser frequently, and don’t forget to include your ears
  • Beware sore or red patches on the bridge of your nose or strap contact points behind the ears. Loosen your mask or protect your skin with a plaster
  • ‘Buddy-up’ – ask your colleague or teammate how they are managing with their mask and remind them of these tips

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.

A community nurse taking a patient's temperature in his home
Picture: iStock

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.

Community nurse Parveen Akhtar
Community nurse Parveen Akhtar

‘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.’

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.

Too hot at work? How one trust used feedback to keep staff cool

Illustration showing a female nurse in a short-sleeved uniform and a male nurse in shorts
Picture: iStock

Northern Devon Health NHS Trust used a staff survey to gauge views in the workforce, before updating its uniform policy.

‘Most of the feedback was about the uniform being too hot, particularly in the summer months,’ says trust associate director of nursing Charlotte Overney.

‘We did some investigating into uniforms with our procurement department, and we found some thinner uniforms that look the same as the thicker ones. So now, staff have the choice.’

The survey also highlighted issues about gender-based uniforms.

‘There was feedback such as, “why are [female] nurses allowed to wear dresses if we [men] can’t then wear shorts?”. Those discussions were really important to hear,’ says Ms Overney.

As a result of the feedback, the trust now allows knee-length, navy shorts to be worn by all members of staff in the event of a level-four heatwave, subject to the approval of the director of nursing.

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.

500%

year-on-year increase in workwear orders for the NHS in April 2020
(Source: NHS workwear supplier Alexandra)

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 redesigns address needs of nurses

Two nurses at a patient's bedside in hospital, both wearing PPE
Picture: Reuters/Toby Melville

As a supplier to acute and community organisations across the NHS, workwear firm Alexandra has had a busy year.

At the height of the pandemic’s first wave in April 2020, orders were up 500% on the same time the previous year.

Prior to the pandemic, the firm used material for uniforms weighing 195g, but switched to a thinner material weighing 145g to make uniforms more comfortable for staff when wearing PPE.

‘Nurses are in very hot environments and then you put PPE on top, it is very uncomfortable. So lightweight uniforms are where we have seen the trend,’ says head of UK sales Emma Moore.

The company worked with customers to make alterations suited to the needs of the healthcare workforce.

Ms Moore adds: ‘While orders of gowns were coming in en masse to cover and protect, the one-size-fits-all approach doesn’t work. Gowns could not be used in the right way. Plus, a lot of them were disposable, which wasn’t efficient economically.’

As a result, the company worked with a trust and its clinicians to create a gown that came in a range of sizes, from small to extra-large. The new gowns have different collar and cuff sizes and can be washed and reused up to 25 times.

While normal uniform guidelines dictate that clinical staff must be bare below the elbow, the pandemic changed all that.

The company received apron requests for full gowns that are fluid repellent.

Global sales and commercial director Rebecca Jones adds: ‘Normally you have a tunic on or a scrub with an apron over the top, but arms weren’t covered. Now, it is really important the arms are covered and totally protected.’

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.

Ward manager Noni Nyathi wearing the head covering she proposed as a uniform option for trust staff
Ward manager Noni Nyathi wearing the head covering she proposed as a uniform option for trust staff

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.

1,200

head coverings have so far been distributed to staff at Imperial College Healthcare NHS Trust as part of its staff uniforms
(Source: Imperial College Healthcare NHS Trust)

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.

How Nursing Standard conducted the survey

  • We asked nurses to share information about their health and well-being at work
  • The questions were asked using online tool Survey Monkey and the survey ran from 17-28 February 2021
  • It was promoted via email to registered users of RCNi.com, in our online news and on social media
  • We received 1,415 responses and the initial findings were analysed by Nursing Standard staff

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