INTRODUCTION

COVID-19 is a respiratory disease caused by SARS-CoV-2, a highly infective virus that is transmitted by the respiratory route (secretions, droplets or aerosols) and by direct or indirect contact, causing mild to severe respiratory disease. In more severe cases, there is respiratory discomfort, such as shortness of breath and pain, which can lead to death⁽¹⁾. Due to respiratory insufficiency, a greater use of mechanical ventilation and the admission of patients with severe conditions to ICUs (Intensive Care Units)⁽²⁾ were observed. On March 11, 2020, during a speech given by the director general of the World Health Organization, the impacts and global proportions of COVID-19 were characterized as a pandemic⁽³⁾. Until May 5, 2022, there were, in the world, 512,607,587 confirmed cases and 6,243,038 deaths reported, with Brazil, in the same period, being the third country with the most confirmed cases (30,460,997) and 663,602 deaths⁽⁴⁾.

During the pandemic, it was necessary to adopt safety protocols that would guarantee the protection of health professionals and patients, considering the form of transmission of the disease. The pandemic period was characterized by new discoveries and shortages of Personal Protective Equipment (PPE)⁽⁵⁾,⁽⁶⁾. The nursing team was more exposed for also acting in direct assistance in the Intensive Care Unit (ICU), as well as in potentially aerosol-generating procedures, such as intubation, tracheostomy and bronchoscopy⁽⁷⁾. It is worth remembering that nurses are competent to aspirate secretions through the tracheal tube. This procedure assists in the Mechanical Ventilation (MV) of patients who depend on artificial respiration to perform gas exchange⁽⁸⁾. During the pandemic, aspiration was changed to a closed and vacuum system in order to reduce contamination by aerosols⁽⁹⁾. In Brazil, of the 63,836 thousand accumulated cases of COVID-19 in nursing professionals, 872 died, and the mortality rate among these professionals is 2.33%⁽¹⁰⁾. Positive impacts on the knowledge of safety protocols by nursing professionals are observed. The risk of infection between professionals and patients is reduced when there is compliance with safety protocols^{(6) (11) (12)}. Hand washing, social distancing, environmental hygiene (objects and surfaces), as well as favoring air circulation, sun exposure and correct use of PPE, were very important strategies for reducing infection by covid-19^{(7 13 14)}.

The dressing and undressing of PPE is an essential safety protocol for reducing the transmission and speed of contamination of SARS-CoV-2⁽¹⁴⁾. It is noteworthy that the nursing team was in evidence during the pandemic period, as it is a protagonist in strategies to reduce the transmission of the virus⁽¹¹⁾. It should be noted that wearing PPE must follow the sequence of dressing and undressing and be performed before and after contact with the patient⁽⁷⁾. It should take place in a separate, ventilated place, with the correct cleaning of the equipment, in addition to being reinforced in situations of greater risk of infection, such as in procedures that generate aerosols, to guarantee the safety of the health professional⁽¹⁵⁾.

It was possible to observe in the literature challenges for its realization, since nursing professionals, when dressed correctly, feel more discomfort, pain and difficulty in performing routine procedures to maintain the patient's condition. This is because there were significant changes in the sequence to reduce the risk of infection within the treatment centers⁽⁹⁾. Additionally, another difficulty found is that the sequence presents complex, repetitive movements that require an essential condition: the availability of PPE⁽¹⁶⁾. Therefore, this study is justified considering the need to evaluate the knowledge of nursing professionals about the sequence of dressing and undressing, in order to also contribute to the post-pandemic period. Deepening knowledge about safety protocols - which contribute to good management of the nursing team - is and will be an essential tool for controlling and overcoming future health crises^{(6 12 17)}.

In this sense, the objectives of this study are: a) To assess knowledge about the sequence of dressing and undressing by nursing professionals who worked in care during the covid-19 pandemic in the five regions of Brazil; b) Verify the association between knowledge about dressing and undressing and sociodemographic and occupational variables of the participants.

MATERIALS AND METHODS

Cross-sectional observational study: data collected at a given point in time, testing a given hypothesis⁽¹⁸⁾. The study followed the Reporting of Observational Studies in Epidemiology (STROBE) checklist for its presentation. This research was approved by the Ethics and Research Committee of the University of São Paulo at Ribeirão Preto School of Nursing (CEP-EERP/USP), in accordance with CAAE n° 38623520.6.0000.5393, and followed the guidelines that regulate research involving Human Beings, in accordance with Resolution CNS 466/12 of the National Health Council.

The sample consisted of nursing professionals (assistants, nursing technicians and nurses) working in nursing care in five different regions of Brazil (South, Southeast, Midwest, North and Northeast). The recruitment and data collection of the participants took place between November 2020 and December 2021 and was carried out online using the social networks Facebook®, Instagram®, Linkedin® and WhatsApp®. The researcher made weekly posts on social networks, sent invitations to participate, identified himself and presented details of the research, making a brief report of the objectives, risks and contributions to the performance of nursing practice. The sample size was defined by convenience, being the maximum number of participants who agreed to participate in the research within the 13 months of recruitment. The inclusion criteria for participation in this research were: Nursing professionals aged ≥ 18 years, who provide assistance in different places of work. The exclusion criterion was the decline of the Nursing professional to participate in the study. The free tool Google forms® was used by the researcher, where a planned form was created so that all mandatory questions were answered. To answer the questionnaires, the participants informed their e-mail, avoiding duplicate answers.

Participants were asked to provide sociodemographic information (sex, age, level of education and profession) and occupational information (type and nature of the institution where they work, and length of time performing nursing services). In addition, they were asked to answer the questionnaire to evaluate the dressing and undressing of the Nursing professionals who worked in the assistance, built for this study, considering the information contained in the Technical Note GVIMS/GGTES/ANVISA No. 04/2020. Initially, the researchers designed a pilot version of the questionnaire based on the research objectives of the study. Then, the questionnaire was sent to a committee of judges, composed of three nursing professionals, who were familiar with the research objectives of the study. For each question, the expert answered "I strongly disagree", or "I disagree" or "Indifferent/neutral", or "I agree" or "I strongly agree". In addition, it was necessary to answer the question: "Do you suggest any changes to this question?". Each answer was analyzed by the study researchers, and when two or more experts marked the same alternative, it was accepted by the researchers. The suggestion of some changes to the question was also taken into account. This approach is consistent with recommended approaches for establishing the content validity of questionnaire surveys^{(19) (20)}. The content of the questions refers to the type of mask that should be used during the service, the type of precaution, whether or not there is a need for distancing, hand hygiene, as well as the description of the sequence for dressing and undressing PPE. The validated instrument is titled “SUPPLEMENTAL DOCUMENT” and can be found attached at the end of this file.

The questionnaire has 10 objective questions, on a Likert scale, ranging from 0 to 10 points, with five possible answers: I totally agree; I agree; indifferent/neutral; I disagree; and I totally disagree. Each possibility adds up to 10, 7.5, 5, 2.5 and 0 points, respectively. The closer the result obtained by the participant to the maximum score (100 points), it indicates that the nursing professional has adequate knowledge of the recommendations proposed by Anvisa during the COVID-19 pandemic. Arbitrarily for this study, the cutoff point ≥ 75 points and < 74 points were established to indicate sufficient knowledge (SK) and insufficient knowledge (IK), respectively.

The results were verified from the Google Forms® response item, analyzed using descriptive statistics and presented through absolute and relative frequency. Pearson's chi-square test (X²) was used to verify the association between sex (male and female), age group (18 to 24; 25 to 29; 30 to 39; 40 to 49; 50 to 59), level of education (complete Elementary School; High School or complete secondary education; Higher Education; Graduate), profession (Nurse; Nursing technician; Nursing assistant), in how many workplaces you work in nursing, type of institution (General ; University; District; Emergency Room; Long Stay Institution; Basic Health Unit; Home care; Obstetrics; Pediatrics; Surgical Clinic; Ambulatory), nature of the institution (public; private, public and private), and time of performance in the services of nursing (years), and professionals who scored ≥ 75 points for knowledge about dressing and undressing. All analysis was performed using SPSS version 23, with a significance level set at α = 5%.

RESULTS

Of the 493 nursing professionals, 157 (31.8%) were aged between 30 and 39 years, 374 (75.9%) were female, 358 (72.6%) worked as nurses, 392 (79.4%) worked in a workplace, with 219 (44.3%) in a general institution, with a predominance of 245 (49.6%) of a private nature table 1.

Table 1. Distribution of research participants (total and by region) according to sociodemographic and occupational variables. Brazil, 2020-2021. 

In table 2, we observe the total and regional data of the evaluation of knowledge about dressing and undressing of Nursing professionals. For a better interpretation of the results, they will be described according to the stage/theme of each question present in the questionnaire.

Table 2. Assessment of nursing professionals' knowledge about dressing and undressing (total and by region). Brazil, 2020-2021. 

Mask use in patient care: a total of 340 (68.97%) professionals use surgical masks, N95/PFF2 or equivalent for the correct purposes. However, there are professionals who do not agree with the statements in questions 1, 3 and 5. This is because 49 (9.9%) disagree (n=34) and completely disagree (n=15) that one should use surgical mask in patient care and N95/PFF2 for potentially aerosol-generating procedures. In addition, 17 (3.4%) professionals consider the fabric mask to be PPE for health care.

Precautions: regarding distancing, one of the droplet precaution measures, 69 (13.9%) professionals disagree (n=58) and completely disagree (n=11) that it is necessary to avoid direct contact of less than 1 m with the patients. Additionally, 48 (9.7%) do not follow standard precautions when providing patient care.

Dressing and undressing sequence: regarding the dressing sequence in question 9, 379 (76.8%) demonstrated knowledge about its steps, however, 78 (15.8%) did not perform the dressing sequence correctly. As for the sequence of undressing PPE, referring to question 6, 194 (39.35%) professionals do not follow the observation contained in technical note ANVISA nº 04/2020. In terms of knowledge about dressing and undressing, most had SK, with a score ≥75. From a regional perspective, proportionally, the Northeast had the highest frequency of CS (83.78%), followed by the Midwest (75%), Southeast (74.87%), South (64%), and North (60%).

Graph 1: Sufficient (SK) and insufficient (IK) knowledge about dressing and undressing in the total sample (n=493). 

Graph 2: Sufficient (SK) and insufficient (IK) knowledge about dressing and undressing in the five regions of Brazil. 

The Chi-square Test (X²) indicated that there is no association between the CS of dressing and undressing, and variables such as sex, age, education, profession, which workplaces, institution, nature of the institution and how long they have worked in the nursing services, in the total sample and by regions (p>0.05).

DISCUSSION

In the literature, it is observed that most health professionals working in the care of patients affected by covid-19 are female⁽²¹⁾. Our finding confirmed that the profile of nursing professionals also has a predominance of females, aged less than 50 years and mostly nurses⁽²²,²³⁾.

Although most of the professionals who participated in the study had adequate knowledge about the use of masks, 49 (9.9%) of the participants did not know which mask was suiTable for potentially aerosol-generating procedures. In addition, 17 (3.4%) consider the fabric mask to be PPE in the context of health care. The use of an N95 mask or equivalent is essential for reducing contamination, as it not only protects from droplets like commonly used masks (fabric or surgical), but also protects from smaller particles (aerosols), in addition to being better adjusTable, contributing to sealing⁽²⁴⁾. In view of this, it can be stated that the use of fabric masks by health professionals is inappropriate, in addition to providing a greater risk of contamination due to the penetration capacity of SARS-CoV-2.

As for the precautions to be taken in health care, 48 (9.7%) demonstrated that they did not know the need to continue standard precautions, in addition to droplet precautions. During any health care, in addition to standard precautions (such as hand hygiene), precautions for contact, droplets and aerosols should be taken⁽²⁵⁾. Therefore, nursing professionals who have discontinued standard precautions in the workplace because they are carrying out droplet precautions may be more exposed to contamination by covid-19, as they fail to carry out important steps in dressing and undressing.

Regarding the sequence of dressing, 78 (15.8%) participants are unaware of the sequence described in questions 8 and 9 as correct. This implies a greater risk for these professionals because they fail to perform some or all of the gowning steps. It was found in the literature that health professionals who work in places considered to be at low risk of contamination (such as general wards or in primary care) have less access to dressing and undressing training⁽²⁶⁾. Considering this gap, the present study evaluated the knowledge of nursing professionals working in any type of institution during the covid-19 pandemic. This means that we consider that nursing professionals who have a lower risk of contamination, due to their occupational condition, should also know and be evaluated regarding the stages of dressing and undressing, since asymptomatic and pre-symptomatic people can also transmit SARS-CoV- 2⁽²⁷⁾.

As for the disposal of PPE - one of the stages of the undressing sequence - it is observed that the pandemic scenario was characterized by a lack of inputs and high demands⁽²⁴⁾,⁽²⁸⁾. Therefore, attention should be paid to the 194 (39.35%) nursing professionals who are unaware of the observation in the technical note from ANVISA nº 04/2020, which appears in question 2. This observation is important because it explains how the professional's conduct should be during undressing in the context of follow-up assistance to suspected or symptomatic patients for covid-19. She details that there is no need to change a cap, glasses/face shield and mask, only an apron and gloves in the context described⁽²⁴⁾. In view of this, one should consider the possibility that these 194 nursing professionals who responded to the questionnaire would waste PPE, as they could discard these items unnecessarily (cap, glasses/face shield and mask). One of the solutions for the waste of PPE is its good management⁽²⁸⁾. This also depends on the professionals' knowledge of dressing and undressing according to the risk assessment, made by the team, of each health care. The lack of PPE is related to the low adherence of professionals to health protocols⁽²⁹⁾. Inadequate dressing of PPE, in addition to contributing to a greater risk of contamination, also contributes to the depletion of these supplies⁽³⁰⁾. Furthermore, reducing the unnecessary use and disposal of PPE can reduce financial costs and environmental impacts⁽³¹⁾. Therefore, knowledge about safety protocols is essential, especially in a scenario of high demands and stock limitations, such as the COVID-19 pandemic.

There are side effects related to wearing PPE and they can range from facial pain, difficulty breathing, headaches, overheating and dehydration, which contributes to greater discomfort and irritability during consultations⁽²⁶⁾. It is worth remembering that the more advanced the level of attire, the greater the chances of the appearance of skin lesions and itching⁽²¹⁾.

No association was found between the sociodemographic and occupational variables of nursing professionals and the percentage of knowledge about dressing and undressing. Although the sample is not representative, it should be noted that the scope of the research was nationwide, allowing a regional analysis of the profile and conduct of the nursing team as a whole. In addition, the knowledge assessment included nursing professionals working in all types of institutions, which differed from most studies that focus on hospitals, covid-19 posts and ICUs. One of the limitations of the study refers to the marital status of the participants. This is because there is an association of low adherence to safety protocols in single/separated/divorced health professionals⁽³⁰⁾. Furthermore, it should be considered that due to the need to collect data at a distance, there is a possibility that participants have accessed manuals and references to answer the questions correctly, which may compromise the veracity of the answers.

CONCLUSIONS

The present study was able to assess the knowledge about dressing and undressing of nursing professionals working in health care during the covid-19 pandemic in all regions of Brazil. Although we did not find an association between the level of knowledge and variables (sociodemographic and occupational), it was possible to identify and develop the possible impacts of the participants' conduct, such as: a higher risk of exposure to the new coronavirus and waste of PPE. Most participants achieved adequate scores and knowledge. Attention should be paid to the training gap, especially those aimed at nursing professionals working in institutions considered to have low risk of infection. Therefore, assessing the knowledge of nursing professionals can contribute to better training and management of future crises.