Lessons From a Personal Protective Equipment Champion on a COVID-19 Unit (2025)

Key Points

• PPE champions should have strong educator skills and understand the local context of a healthcare environment.

• Transparency and the use of humor by a PPE champion positively engaged the healthcare staff during PPE donning and doffing assessments during a tenuous time.

• Immediate feedback and ongoing communication with healthcare providers is essential to be an effective PPE champion.

In April 2020, shortly after the pandemic was declared in March 2020, a 42-bed inpatient surgical unit became one of two corona virus infectious disease 2019 (COVID-19) units at a large academic hospital in Canada. Roles of the unit nurse educator (NE) were to provide education and support to front line healthcare staff and to ensure they were practicing in a safe manner during this unparalleled time. The first line of defense against exposure to COVID-19 for healthcare providers (HCPs) is personal protective equipment (PPE). HCPs need to properly don and doff PPE without contaminating themselves or the environment they work in. At this hospital, nurses receive a review of donning and doffing PPE techniques including practice sessions at their initial orientation. Ongoing review of PPE practice is left to the discretion of each unit leadership team. Over time, practice drift creeps in, leading to breaks in protocol. A “PPE champion” model was created in a collaboration between the infection prevention and control department and the quality improvement department to provide on-the-spot audits ensuring staff were using PPE appropriately during this challenging and unprecedented time.

Like numerous organizations throughout North America, this hospital has been using the champion model for hand hygiene audits for many years. Some staff viewed these champions as the “hand hygiene police” as the audits were done incognito and immediate feedback was rarely given to the staff. The hand hygiene auditors’ goal was not to be the “hand hygiene police,” they lacked teaching abilities and an understanding of the unit’s context. An integrative review by Miech et al. (2018) of champion models used in health care listed characteristics of effective champions as having enthusiasm, maintaining a positive focus, showing strong educator skills while being credible, and understanding the local context. As the unit NE had established a positive and supportive learning environment within the surgical inpatient unit, the leadership team felt to best support the healthcare staff during this tumultuous time, the NE would be the most appropriate person to become the PPE champion. The NE decided to frame the audits as assessments with the HCPs to avoid the negative association of audits previously done by the hand hygiene champions.

At the end of April 2020, the PPE assessments began. The NE was completely transparent about what they were doing with the healthcare staff. For the nursing staff normally assigned to the unit, the NE would ask their permission to observe and assess them donning and doffing PPE. It was described as an opportunity to receive real-time feedback to ensure their safety. For other HCPs who would come and go on the unit such as physicians, residents, radiology technicians, and environmental services staff, the NE would first introduce themselves as the PPE champion and then seek the HCP’s permission to complete the assessments. Of the 293 individuals with 2,428 observation points conducted over an 11-month period, only one HCP said “no.” Many times, nursing staff would seek the NE out in the hall before donning or briefly wait before doffing to ensure the NE was available to assess. This transparent approach seemed to create a constructive environment and more engagement from the staff.

The quality improvement department supplied the NE with a tablet to collect donning and doffing data that loaded into a central repository. This data could be trended at the local and corporate levels. In April 2020, the assessments were conducted 5 days per week between 8 a.m. and 9 a.m. because this was the busiest time on the unit where the most assessments could be done. The PPE safety observation rating for the unit started out at 90% completed the week of April 26, 2020, and continued to climb to 100% the week of June 28, 2020. During this same time frame, the organizational average was 68.1%–91.2%. The Hawthorne effect likely contributed to the high safety ratings of the unit because of the transparency of doing the assessments. In a study conducted by Goedken et al. (2019) of hand hygiene champions in the Veterans’ Health Administration across the United States, some of the champions who were a peer on the units conducting audits felt conflicted and may have reported some data in a more positive light. It is unclear if the NE had this bias as the unit PPE champion, but they tried to be aware of it and report what was observed. It was the primary objective of the NE to keep the staff and patients safe; collection of the data was secondary.

Through the assessments, some key learning points emerged that required in-the-moment coaching and follow-up education and reminders (see Table 1). These points were corrected in real time with the HCPs, along with being included in the daily unit huddle and weekly COVID-19 education newsletter. The education newsletter also included the unit and corporate PPE safety ratings. These key learning points have since been incorporated into other orientation programs at the hospital.

When HCPs were doffing their face visors, the NE started calling it the “doffing yoga move” among the staff, where one would lean forward and keep their chin up to avoid contamination of their scrubs. Staff would smile under their masks each time the NE said this. The use of humor and enthusiasm by champions has been shown to improve implementation of champion models (Miech et al., 2018). Over the course of the 11 months the PPE assessments were conducted, general improvements were noted in the nurses who had multiple assessments. Some examples of improvements included consistently tying the waist strap when donning a gown and keeping their chins up when doffing face visors to avoid contamination of their scrubs.

Toward the middle of June 2020, two thirds of the 42-bed unit started receiving postoperative patients again. The COVID-19 section of the unit was decreased to 14 beds. The nursing staff continued to work both areas of the unit, but when on the COVID-19 side, they were dedicated there for 2 days. The assessments continued to be done one to two times per week, with increases in frequency as needed during peak admission times until March 31, 2021, when the COVID-19 unit was moved to another inpatient unit at the hospital as the staff on the current unit were getting burnt out. From July 2020 to March 2021, the unit PPE safety ratings fluctuated from 87.09% to 100%. with an average of 93.1% over the 8-month period. The organizational PPE safety rating average for the same time was 88.7%. Over the course of the entire 11 months, there was not one COVID-19 outbreak among the unit staff or patients in the COVID-19 unit, nor the related inpatient surgery unit. This is due largely to the staffs’ diligence and dedication to providing high-quality, safe patient care. The use of transparency, humor, real-time feedback, and on-going communication by the unit NE as the PPE champion likely contributed to this success as well.

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