Best N95 Training: Watch, Learn, Then Do While Being Watched

Probably the first thing that needs to be said about a study in the American Journal of Infection Control that looks at what might be the best method to train proper donning and doffing of N95 respirators is that it was conducted prior to the onslaught of coronavirus disease 2019 (COVID-19). The second thing that needs to be said is that that fact shouldn’t detract from what investigators with the University of Nebraska found out about N95 use. (The investigators’ backgrounds include industrial hygiene, infection control, and research design.)

“The lack of critical PPE supplies internationally presented unique challenges,” the study states. “Unexpected educational needs arose with the pandemic including the need for training on extended use and limited reuse of N95 respirators. While the content of instruction may be altered by this global experience, the educational strategies demonstrated in this study would likely remain effective.”

What exactly would remain effective, according to investigators, involved filming healthcare workers as they don and doff N95s, showing that video to participants (explaining where they got it right, and where they got it wrong), and then having the participants don and doff again with more input from trainers.

That’s what one of the groups of 24 healthcare workers did, which the investigators described as a reflective practice (RP) intervention. The other group of 24 workers did not undergo the final phase, the donning and doffing of the N95s while trainers watched and commented. This was the video alone (VA) group. The VA option took about 5 minutes, and the RP option took between 8 and 10 minutes.

“A critical safety behavior scoring tool (CSBST) was developed to compare the performance of the participants over time at pretest, post-test and 1 month later for follow-up,” the study states.

The study occurred in 2 locations between August 2018 and April 2019. One was a 700-bed tertiary care teaching hospital; the other a 100-bed hospital.

“The reflective practice intervention group was found to have significantly higher scores on the CSBST at post-test and follow-up than the video alone group,” the study states.

The 10-point CSBST for N95 test included 6 measures for donning and 4 for doffing.

“Hand hygiene was a critical component of both donning and doffing processes, accounting for 4 of the 10 total points,” the study states. “Correct strap placement and performing a proper seal check were key behaviors noted in donning. Doffing safety behaviors included limiting touch to the respirator straps for removal and gently moving the respirator from the face to the wastebasket.”

During the video assessments, the research team did not know whether the participant belonged to the RP or VA group. The participants returned a month later to see what they retained of their training and to repeat the video donning and doffing exercise.

“Both groups declined from post-test to follow-up, but the VA group at follow-up was not significantly higher than their pretest score [paired t(23) = 1.79, P = .088],” the study states. “The RP group was still significantly higher at the follow-up than they were at pretest [paired t(23) = 6.12, P < .001].”

The study concludes that “these practical interventions and tools to measure performance may substantially improve the safety of our health care workforce in the care of patients with infectious respiratory pathogens as well as other clinical tasks that require use of the N95 respirator.”