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The COVID-19 pandemic has brought attention to the importance of correctly using personal protective equipment (PPE). Doffing is a critical phase that increases the risk of contamination of health care workers. Although a gamified electronic learning (e-learning) module has been shown to increase the adequate choice of PPE among prehospital personnel, it failed to enhance knowledge regarding donning and doffing sequences. Adding other training modalities such as face-to-face training to these e-learning tools is therefore necessary to increase prehospital staff proficiency and thus help reduce the risk of contamination.
The aim of this study is to assess the impact of the Peyton 4-step approach in addition to a gamified e-learning module for teaching the PPE doffing sequence to first-year paramedic students.
Participants will first follow a gamified e-learning module before being randomized into one of two groups. In the control group, participants will be asked to perform a PPE doffing sequence, which will be video-recorded to allow for subsequent assessment. In the experimental group, participants will first undergo face-to-face training performed by third-year students using the Peyton 4-step approach before performing the doffing sequence themselves, which will also be video-recorded. All participants will then be asked to reconstruct the doffing sequence on an online platform. The recorded sequences will be assessed independently by two investigators: a prehospital emergency medicine expert and an infection prevention and control specialist. The assessors will be blinded to group allocation. Four to eight weeks after this first intervention, all participants will be asked to record the doffing sequence once again for a subsequent skill retention assessment and to reconstruct the sequence on the same online platform to assess knowledge retention. Finally, participants belonging to the control group will follow face-to-face training.
The study protocol has been presented to the regional ethics committee (Req-2020-01340), which issued a declaration of no objection as such projects do not fall within the scope of the Swiss federal law on human research. Study sessions were performed in January and February 2021 in Geneva, and will be performed in April and June 2021 in Bern.
This study should help to determine whether face-to-face training using the Peyton 4-step approach improves the application and knowledge retention of a complex procedure when combined with an e-learning module.
PRR1-10.2196/26927
The emergence of COVID-19 has democratized the use of personal protective equipment (PPE) for all health care workers in and outside hospitals [
Although the donning phase is associated with a low risk of contamination, doffing is a critical phase and greatly increases the risk of contamination of caregivers [
Two previous studies have shown that training prehospital staff in using PPE through a gamified electronic learning (e-learning) module increases the proportion of making an adequate choice of PPE [
The primary aim of this study is to define whether the Peyton 4-step approach used in addition to our gamified e-learning module for teaching noncontaminant PPE removal increases the percentage of correct PPE doffing sequences performed by first-year paramedic students in comparison to e-learning alone.
We will carry out a parallel-group, randomized, quadruple-blind (participants, instructors, outcome assessors, and data analyst) controlled superiority trial designed following the SPIRIT statement (see
Study design.
All first-year students (N=62) from the Colleges of Higher Education in Ambulance Care located in Geneva and Bern, Switzerland, will be invited to take part in this study. To allow the first-year German-speaking students to participate in the study, the study material, including the e-learning module, will be translated into German. Participation will be on a voluntary basis during their school time as part of their curriculum. There will be no exclusion criteria.
The instructors who will be recruited to take part in this study are third-year paramedic students. Their participation will be on a voluntary basis. They will be specifically trained by two investigators in the noncontaminating removal of PPE (LC) and the Peyton teaching approach (L Stuby). These investigators will be accompanied by a bilingual teacher from the Bernese school to help with potential language issues. Peer teaching or near-peer teaching has been shown to have a positive influence on peer learners and to permit a deeper approach to learning [
An online platform [
An investigator (MS) who does not know the participants and will have no contact with them will randomly assign the participants into two groups according to a computer-generated list [
Participants will be divided between the instructors randomly by one of the investigators (L Stuby or LC) using an online team generator [
Prior to the beginning of the study, students will be sent emails containing general information about the study (
Participation will be free and each participant will be able to withdraw at any time without giving any justification. Participants will benefit from this study by acquiring knowledge regarding the safe doffing of PPE, which will be useful in their practice. There will be no financial compensation or incentive.
The data collected are encoded using the randomly assigned connection identifiers; thus, if a participant keeps their identifiers, it will be possible for them to request that the answers be deleted once the survey is completed.
French version of the platform welcome screen.
German version of the platform welcome screen.
After picking up an envelope, each participant will be asked to log into the platform with specific credentials. The welcome screen will be the same for both groups and, similar to the envelopes, will not contain any information regarding the study sequence to ensure that participants are adequately blinded.
After clicking the start button, a first questionnaire designed to collect demographic data will be displayed (
Both groups will then follow the e-learning module, the development of which has previously been described [
After completing the module, participants belonging to the control group will be asked to don the following PPE: protective glasses, FFP2 mask, coverall with hood, and gloves. They will then be asked to perform the doffing sequence individually, which will be recorded on video. After completing the doffing sequence, participants will be asked to go back to the online platform to electronically rebuild the doffing sequence.
Rather than immediately donning and doffing the PPE after completing the e-learning module, participants in the experimental group will be randomly allocated to the instructors to follow face-to-face learning according to the Peyton 4-step approach. After completing this workshop, these participants will resume the same path as their counterparts from the control group by moving on to the video recording of the doffing sequence and, finally, by being asked to rebuild the doffing sequence on the online platform.
Four to eight weeks later, depending on the schools’ schedules, participants will be asked to take part in a second session. This time interval is sufficient to reliably assess retention, which has been shown to be nonlinear. Out of the proportion of participants who display a significant decline in knowledge retention at 3 months, half will already present a significant decline in knowledge retention after 4 weeks [
Face-to-face teaching will proceed according to the following steps based on the Peyton approach [
Checklists and “buddy” systems have been used to improve the efficiency and security of doffing sequences [
The primary outcome will be the proportion of doffing sequences correctly performed after knowledge acquisition. Since practices differ from one center to another, we have developed an assessment grid validated by an IPC specialist for the assessment of this outcome (
Seven secondary outcomes will be assessed: time required to teach the technique, time required to perform the doffing procedure, learner satisfaction, proportion of correct computer sequences, confidence in using PPE, and knowledge and skill retention.
The time required to teach the technique using the Peyton approach will be recorded on a paper CRF (
The time required to perform the doffing sequence will be recorded (in seconds) by analyzing the recording (measured from the moment the first item is taken off until the moment the learner announces that the procedure has been completed).
Learner satisfaction will be measured using a 5-point Likert scale (not satisfied at all, not satisfied, neutral/undetermined, satisfied, very satisfied).
Computerized doffing sequence accuracy involves reordering the presented sequence in random order in two steps: first in the contaminated zone and then in the noncontaminated zone.
Confidence in the ability to use PPE will also be assessed using a 5-point Likert scale (not confident at all, not confident, neutral/undetermined, confident, very confident).
Knowledge retention will be assessed by reordering the computer sequence once again 4-8 weeks after the first acquisition intervention, whereas skill retention will be assessed in the same way as the primary outcome.
Some outcomes will be recorded electronically. This will allow for their assessment to be independent from subjective human evaluation. For all other outcomes, assessors will be blinded to participant allocation.
Electronic data will be recorded and securely stored in an encrypted MariaDB database (Version 5.5.5; MariaDB Foundation) hosted on a Swiss server.
At the end of the study, all electronic data will be extracted to a comma-separated value file by the only investigator who will have access to the dataset (L Suppan). No personal data (name, first name, date of birth, or IP address) will be collected.
An investigator (LC) will assign specific codes to the videotaped sequences of each participant. These codes will be created by concatenating the identifier used by the participant to log into the platform and the session number. These codes will be the only information sent to the blinded assessors apart from the recordings. All paper CRFs, including completed video assessment grids, will be sent to the investigator in charge of randomization (MS) for the constitution of the database. All electronically recorded data will then be imported to create the final version of the database. All data that could allow a data analyst to identify the group allocation will be deleted. The groups will be renamed otherwise (groups “Plutello” and “Plutinson”) and the curated database will be sent in Stata (Statacorp LLC) .dta file format to L Stuby for formal analysis. All investigators will be able to access the curated and coded dataset. The database will be deposited on Mendeley Data [
According to two previous studies [
We calculated that 46 participants would be needed to have a 90% chance of detecting, at the 5% significance level, an increase in the primary outcome from 10% in the control group to 50% in the experimental group; additional participants will be accepted as the training will be part of their curriculum.
Data analysis will be performed using Stata 15.1. Owing to the small sample size, only nonparametric tests will be used. Fisher exact test will be used for dichotomous variables and the Mann-Whitney
The study has been presented to our regional ethics committee (Req-2020-01340), which waived the need for further evaluation by issuing a declaration of “no objection” as such projects do not fall within the scope of the Swiss federal law on human research [
Once published, there will be no further modification to the study protocol. There is therefore no need to plan for communication of protocol amendments. This protocol version is 1.0 (January 11, 2021).
The online platform was finalized on January 15, 2021 [
Study sessions in Geneva were performed on January 25, 2021 for instructor formation, January 26, 2021 for the first session, and February 24, 2021 for the second session. Study sessions in Bern are scheduled for April 2021 for instructor formation and for the first sessions, and for June 2021 for the second sessions.
The results, whether positive or negative, will be submitted for publication. They will be reported according to the CONSORT-EHEALTH checklist [
This study should help determine whether face-to-face training using the Peyton 4-step approach in addition to the e-learning module can improve the application of a doffing procedure created by IPC specialists. It should also determine whether this approach improves knowledge and skill retention.
Four learning preference modalities have been previously described [
Concerning our target population, assessment with first-year students who are new to the field and who have not yet been exposed to PPE use will allow us to test our hypothesis on learners who are still naive regarding the doffing method. These students should not be prejudiced and should not have developed any particular habit, good or bad, regarding the use of PPE.
One of the strengths of our study is that the videotapes will be independently assessed by an IPC expert and a prehospital emergency medicine expert.
We chose to design this study to assess the impact of face-to-face learning added to the e-learning module. Another interesting design would be to assess the gain of adding the e-learning module to face-to-face learning with the control group following the face-to-face learning alone and to the experimental group following the face-to-face learning and e-learning module. Although we considered creating a third group to test this hypothesis, we finally decided on the use of two groups given the limited sample size.
Some limitations can already be anticipated. First, the specific population of the sample may limit the generalizability of the results.
Second, using third-year students as instructors allows us to blind instructors, but can limit the quality of teaching. Indeed, these students who will be trained as an instructor within the framework of the study have no expertise in either IPC or in teaching, and have no or little experience in their profession and as an instructor. When peer students or student tutors are used as teachers, the effectiveness of the Peyton teaching approach is less clear [
The aim is to teach the technique for the first time, and therefore it will not be integrated in a care simulation and will be performed in a classroom setting. Therefore, the environment will not be representative of the actual situations in which the participants will have to perform these actions. This implies that the mental load on the learners will be lower than when they will have to apply these techniques in the field or integrated into simulations. Therefore, it could be beneficial, after learning the procedure, to train for actual application during simulated care situations.
This study should help to determine whether face-to-face training in addition to an e-learning module can improve the application of a complex procedure and enhance its retention.
SPIRIT checklist.
PPE doffing procedure for instructors.
Peyton approach stages reminder sheet for instructors.
Copy of email to participants.
Questionnaire 1: demographic data.
VARK paper case report form (CRF).
SPIRIT diagram. Timeline of enrollment, interventions, and assessments.
Assessment grid.
Instructors paper case report form (CRF).
case report form
electronic learning
infection prevention and control
personal protective equipment
visual, aural, reading/writing, or kinesthetic
This study is supported by a grant from the Hans Wilsdorf Foundation for the payment of publications fees. Material costs (coveralls, FFP2 masks) will be paid by the Colleges of Higher Education in Ambulance Care. These funding sources had no role in the design of this study, and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results. The authors would like to thank Emmanuel Daniel, specialist nurse from the Infection Prevention and Control Division, Geneva University Hospital, for the validation of the steps (
LC initiated the study design. L Stuby conceived of the study and wrote the first draft of the present protocol. MS and L Suppan helped with implementation. MS, L Suppan, BG, and SH provided expertise in clinical trial design. SH provided expertise in the IPC domain. LC and MM are the local study coordinators. L Stuby will perform the primary statistical analysis. All authors critically revised the manuscript, contributed to the refinement of the study protocol, and approved the final manuscript.
L Stuby has received financial compensation when serving as an external teaching professional or exam expert for the Colleges of Higher Education in Ambulance Care in Geneva and Bern. MM is employed by the Center for Medical Education in Bern as a teacher. The other authors have no conflicts of interest to declare.