Interviews probed organizational and leadership practices used to support worker needs regarding respiratory protection. Several interactions and iterations are expected during the Delphi technique to identify policy needs or better predict and respond to future events. Specifically, research has indicated that three iterations are often sufficient to collect information and reach consensus.^11,17 Consequently, researchers developed three semi-structured interview guides that built on questions and responses from the previous interviews to enable a consensus-based approach. Literature reviews about EHMR implementation and maintenance, employee perceptions and reactions to EHMRs, implementation and communication about EHMRs, and questions about the organization’s culture toward respirators in general informed the interview guides.^18–20 POCs were presented with similar questions during follow-up interviews such as information that was useful for their organization, changes made to protocols, and then discussed what other organizations who were participating in the project found useful (anonymously). This series of interviews allowed researchers to reflect on others’ previous experiences, allowing POCs to reflect and determine what was useful and challenging for advancing EHMRs in their Respiratory Protection Program (RPP).¹¹

Organizational POCs voluntarily participated in virtual interviews between October 2021 and November 2022—once before or concurrent to EHMR distribution and then again in 3–4-month increments. Before each interview, researchers e-mailed and reviewed an informed consent document that outlined the purpose and voluntary nature of the study. The virtual meetings were not recorded to maintain confidentiality. One researcher facilitated the discussion while another took notes, numerically coding each file.

Participating organizations spanned 16 states and included 17 healthcare and 26 public safety settings. Researchers interviewed 73 unique individuals who identified as a POC for their organization. Interviews ranged from 20 to 65 minutes with an average time of 37 minutes. All organizations had POCs who participated in at least one interview and 65.8% of the sample had POCs who participated in two or three interviews. Table 2 shows a breakdown of POCs’ job roles.

Typically, data saturation informs the sample size because recruitment ends when redundancy in feedback occurs.²¹ Even though saturation was prevalent after the first round of interviews, the Delphi technique facilitated follow-up interviews to understand how initial barriers were overcome from a leadership perspective (if applicable), share how other leaders were overcoming these barriers, and provide lessons learnt to inform a consensus of practices around future respirator programming.¹¹ The second and in some cases, third interviews allowed POCs to formulate consensus opinions about best practices in leadership over a respiratory protection program.

Using NVivo software²² two researchers met to collaboratively discuss and code the data using deductive and inductive approaches offered by several scholars.^21,23,24 These steps included initial coding, focused coding, constant comparison, and negative case analysis. The codebook was finalized during the constant comparison and negative case analysis and transferred from NVivo to a Word document to ascertain the interview excerpts supporting each code more clearly. Researchers used the codebook to observe connections across participating organizations.

First, employee accountability for a reusable EHMR, including cleaning and proper storage, was often referenced. One POC for a long-term care facility explained:

Five of the organizations established a central location where employees could drop off their EHMR to be cleaned, disinfected, and stored during off shifts. However, due to lack of participation, four of them eventually suspended this service and employees became responsible for disinfecting their respirator. POCs reported employee dissatisfaction with being responsible for [another] piece of equipment. A POC within the emergency trauma unit of a participating hospital summarized these accountability barriers stating:

Although initial buy-in was difficult at some organizations, many POCs observed an increased sense of employee ownership and personal responsibility throughout the 1-year demonstration. One EMS ambulatory department stated:

In summary, even if EHMRs were not the norm as supply chains stabilized, POCs observed that employee maintenance of the respirators improved, noting a positive impact on the overall culture.

Feedback was shared regarding the role of peers in encouraging respirator use. To illustrate, one POC expressed that at first, fire-based paramedics kept the EHMRs on their belt but rarely donned them. However, during the second interview the same POC stated:

Similar feedback was shared from a long-term care setting, with the POC stating:

Several POCs noted challenges related to organizational buy-in and support at higher levels of their company. Some noted that their scheduled fit test training kept getting pushed back. Specifically, for participating organizations that were coordinating this program with several satellite locations, implementation took longer than they thought it would. One POC stated:

Challenges were also encountered when trying to partner with other organizational units. For example, a hospital trying to partner and expand the EHMR program with their local EMS or trauma unit sometimes faced resistance. To this end, holistic buy-in from all organizational units was regarded as important to many POCs. One POC said:

Some POCs expressed that they had been trying to make the case for EHMRs for years and receiving EHMRs from the SNS, in combination with pandemic-related supply shortages, was the only way to garner support at a higher level. Alternatively, some POCs described weekly, in-house education programs that provided EHMR training, noting the programmatic changes supported by the organization.

Points of contacts regularly said that leadership communication and engagement fostered more perceived trust and participation in the program. POCs indicated that trust was earned, in part, by modelling the behaviours they were promoting. As one POC stated:

Alternatively, it was important for the POCs involved to have trust in the individuals who were helping with the program, noting the important roles of those who did the scheduling, rescheduling, and fit testing.

Various forms of communication about EHMRs were often referenced as critical to program success. However, communication was also referenced as a pathway to improve trust and the overall culture of the organization. One POC reflected that their program was going well because of the holistic approach to tie EHMRs into overall health and safety programming, stating:

Another POC reflected on the success of their program, noting they had a new, proactive chief who wanted to make a lot of changes that would help EHMRs be more sustainable going forward.

Similarly, some POCs reflected that prominent leaders who were considered subject matter experts were imperative in promoting EHMRs. For example, one POC discussed that their training chief brought up EHMRs every few weeks and that, the more they talked about it, the more their employees talked about what the best uses of it were for them on the job. Similarly, another POC explained that their county medical director, who writes all the protocols, provided several informational meetings and webinars to employees about the purpose and protective utility of EHMRs. The POC observed this messenger as highly trusted among employees, which enhanced EHMR use at their department.

There has been a growing interest in the contribution of leadership practices to improve challenges in healthcare, with special emphasis in the Canadian health sector.^25,26 Within the Canadian health system, leadership has been cited as lacking during the implementation of major system reforms,²⁸ which occurred at the onset of the COVID-19 pandemic. To this end, arguments for collaborative engagement during the implementation of any procedural changes have been referenced as useful to the overall culture.²⁹

This study supported the concept of collaborative engagement with employees as many POCs correlated an increase in EHMR receptiveness and use with a positive change in their organizational culture. Collective experiences from POCs emphasized the value in peer support, employee engagement around EHMRs, and organizational flexibility to support worker well-being. For example, as other employees had positive or status quo experiences with EHMRs, POCs observed others using and requesting them, with some witnessing EHMRs becoming the preferred respirator type by the end of the demonstration period. The positive role of respirator champions has been observed and recommended in other documents,^3,4 so it is not surprising to hear the role of peer support in this study as well.

Engaging employees in EHMR selection, training, use, and maintenance is also important to sustain organizations’ inclusion of ‘new to them’ respirators. Along with a cultural shift toward reusable respirators, POCs discussed the importance of holistically supporting employees’ well-being and noted that this [EHMR distribution] program was a step in the right direction. Other research within this project found that the distribution of EHMRs was associated with higher perceptions of perceived safety climate,³⁰ indicating that organizations can consider what role or roles respirators have in employee well-being and perceptions of their organization’s safety culture.

Results also showed the importance of including realistic expectations and uses of EHMRs into dissemination plans. POCs noted the importance of openly communicating potential drawbacks that employees may experience (e.g., breathing resistance or moisture buildup) so they knew what to expect. Along these lines, the current study results have implications for improving policies and programs around respiratory protection. For example, in the United States, a mandated RPP is required but only includes technical information around respirator selection, use, and maintenance. These results support the need to also include aspects around leadership communication as it pertains to respirator use and support during routine and emergency scenarios. Other research has also noted the importance of policies that are flexible, adaptable, and resilient to uncertainties - all of which occurred during the COVID-19 pandemic, requiring leaders in health settings to support and model respirator use.³⁰ This same research has linked improvement in the availability of respirators, respirator training, and leadership practices with improvement safety climate, further supporting the need for effective leadership practices when introducing something new to the workforce.

Last, the way in which EHMRs are presented to employees and their purpose will likely need to evolve to support use. Several participating organizations eventually moved away from framing EHMRs as an emergency backup and started framing them as “PPE of the future.” To this end, future research should explore types of messaging around reusable respirators that can normalize use and the role that leaders can have in this process.

This study has limitations starting with the convenience sample of individuals that cannot be generalized to respective health delivery settings or other industries that were experiencing supply chain shortages during the COVID-19 pandemic. Further, the results cannot be generalized to Canadian healthcare settings given the US-based sample. Relatedly, because of a myriad of contextual factors, what works for some organizations may not work for others. Further, limitations of the Delphi technique specific to various healthcare settings include a potential lack of accountability due to the anonymity provided.³¹ Although criticism to the scientific rigour of the technique has emerged over the years, when it comes to using the Delphi approach in qualitative studies, the process has been deemed thoroughly scientific.³² Regardless, the judgement on consensus being reached in some qualitative Delphi studies will always be more subjective on the part of the researcher, and therefore potentially open to bias¹¹ and must be considered with these results. Even though the data were subjective observations from the POCs, the results produced saturated feedback and eventually, a consensus of experiences among the organizations across different organizational types.

Elastomeric half mask respirator research has focused on the perceptions and experiences of individual users^10,33 whereas experiences at the organizational level have not been studied. This perspective was necessary to identify leadership practices that can support other forms of respiratory protection during routine and emergency operations. Interviews helped recognize lesser-known areas of inquiry and in this case, were necessary to understand experiences, barriers, and perspectives over time.

This American study has leadership implications that can be considered by international healthcare entities. Specifically, the Canadian healthcare sector has been regarded as resistant to change, with a lack of leadership action.³⁴ This study illustrated tangible and intangible considerations for organizational leadership who are trying to support the integration of “new to them” respirators through consistent education, support, and communication. POCs were able to identify areas that can be proactively addressed whether that includes drafting respirator implementation plans or deploying practices and policies to better engage and communicate with employees about respiratory protection.

These findings complement previous recommendations to improve preparedness measures across organizations that rely on respirators to protect health workers. However, given that data collection reached a high level of saturation (ie, redundancy in feedback with little new information being shared among organizations) during each respective time—first, second, and third—across a range of occupations in healthcare and emergency response, there is an even bigger need to develop and support programs that allow for emergent and routine uses of EHMRs in the workplace. This study showed empirically driven leadership practices that can support these emergent and routine EHMR uses to protect workers.