key: cord-321584-4bu0lps0
authors: Mitchell, Brett G.; Russo, Philip L.; Kiernan, Martin; Curryer, Cassie
title: Nurses' and midwives’ cleaning knowledge, attitudes and practices: An Australian study
date: 2020-09-30
journal: Infect Dis Health
DOI: 10.1016/j.idh.2020.09.002
sha: 
doc_id: 321584
cord_uid: 4bu0lps0

BACKGROUND: As frontline providers of care, nurses and midwives play a critical role in controlling infections such as COVID-19, influenza, multi-drug resistant organisms and health care associated infections. Improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. As nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives’ knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments. METHODS: Cross-sectional online survey of 96 nurses (RN/EN) and midwives (RW) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in Australia. RESULTS: Nurses and midwives broadly stated that they understood the importance of cleaning. However, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. Most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism. CONCLUSION: Greater organisational support and improving applied knowledge about infection control procedures is needed. This includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

As frontline providers of care, nurses and midwives play a vital role in prevention and control of infections such as COVID19, influenza, multi-drug resistant organisms (MDROs) and health care associated infections (HCAIs) more broadly. However, nurses' and midwives' compliance with infection control policies can vary between settings and individual workers [1e3] . Subjective indicators such as visible dirt, personal appearance and whether a patient had been identified as being infectious, can inform nurses' decision-making regarding even basic standard precautions such as handwashing [1,3e6] . This reliance on personal judgement rather than consistent application of clinical standards for infection prevention and control could potentially lead to crosscontamination and subsequently, increase rates of infection. Experience, organisational structure (including staffing ratios and training), individual knowledge, and personal accountability may also impact on compliance with optimal infection control practice and governance [7e11] .

Beyond individual factors, the hospital environment has been shown to be a contributing factor in the spread of HCAIs and MDROs [12, 13] . Moreover, pathogens can survive for days or months on surfaces that have not been cleaned, posing an ongoing risk for transmission [14] . Consequently, there is a higher risk of a patient acquiring a pathogen from the previous room occupant [15, 16] . Improved cleaning can reduce the incidence of HCAIs and is cost effective [12, 17] , but relies on healthcare personnel to correctly and consistently apply cleaning measures. Nurses and midwives have the most contact with patients across healthcare settings. Therefore, they have a critical role in infection prevention and control. As an important first step in improving compliance and precursor to further work, this study sought to explore:

1. What are enrolled nurses, registered nurses and midwives' knowledge on the role of the environment in the infection prevention control, and 2. What are the barriers and challenges for nurses and midwives to maintaining a clean patient environment?

This paper reports findings from a cross-sectional, online survey of nurses and midwives employed in clinical roles.

Registered nurses (RN), enrolled nurses (EN) and registered midwives (RM) who are currently employed in clinical settings in Australia.

Participants were recruited via advertisements placed in written and electronic materials published by professional associations (such as the Australian College of Nursing and the Australian Nurses and Midwives Association), via workplace emails and newsletters, and through social media (Facebook, twitter) targeting nurses and midwives. The advertisements provided broad information about the survey, and included an online link to the study information, electronic consent form, and non-identifiable survey. Ten $20 gift cards were randomly allocated as a participation incentive. Participants who were not registered nurses, midwives or enrolled nurses were excluded from the study, in addition to those currently unemployed or not working in clinical roles (e.g. hospital, residential aged care facility, medical centre, or clinic).

The survey was open for responses between 1st December 2019 and 13th March 2020; at which time the survey was closed due to dwindling response rates. Interested participants accessed the online link as provided in the study invitation. Screening questions were used to exclude individuals who did not meet criteria for eligibility. Eligible participants then completed an online consent form before gaining access to the survey. 

Descriptive and exploratory analysis of survey results was performed. Qualitative (free-text) responses to open-ended questions were collated and each response read individually. Qualitative analysis (constant comparison, frequency counts/ranking) was used to identify and group responses into common themes.

Overview 132 participants accessed the online survey. Of these, 28 were subsequently excluded from the survey (n Z 19 not currently working in a clinical setting; n Z 6 not RN, EN or RM; and n Z 3 did not provide consent). Of the 104 eligible participants, 96 consented to participate and commenced the survey, representing our sample size. 79 participants completed the full survey. The use of IP address cross referenced against demographic information suggested there were no repeat responses from the same individual. Participant demographic data is presented in Table 1 . There was representation across all age groups, with diversity in the highest qualification obtained, the length of time at their current employer and the jurisdiction in which they worked. Most participants worked in a hospital setting.

Importance of cleaning Participants were asked to nominate the most important reasons for cleaning the environment in healthcare settings. Seventy-four (94%) participants indicated that the main reason for cleaning was to reduce the risk of infection transmission. Healthcare accreditation was found to be the least important reason for cleaning (n Z 35, 44%).

We asked participants to indicate who was responsible for cleaning four items, two frequently touched items (bed rails and nurse call bells) and two items of shared medical equipment (IV pole and IV pump). The majority of participants indicated that nursing/midwifery staff were responsible for cleaning the IV pole (73%, n Z 58) and pump (79%, n Z 62). There was less certainty about who was responsible for cleaning bed rails and nurse call bells. Fortypercent (40%, n Z 32) indicated it was a nursing/midwifery responsibility. Ten percent of participants did not know who was responsible for cleaning shared medical equipment (IV pole and pump). Participants were asked to nominate what method or product they would use to clean in various situations. Results are presented in Table 2 .

Using a Likert scale, participants were asked to indicate how much they agreed with four statements relating to the use and application of disinfectant products in clinical settings (Fig. 1) . While the effectiveness on patient safety was well understood, there was less certainty about disinfectants and their use. Participants were shown four visual representations of how to clean a surface, using different directional movements such as circular, up and down, one-directional or Sshaped (serpentine). Of those that answered, 61% (n Z 48) correctly identified the best way to clean a surface (i.e., answer Z C, serpentine). Regarding cleaning of shared medical equipment such as a blood pressure cuff, a small number reported 'probably don't clean' (14%, n Z 11) this equipment. The majority (81%, n Z 64) reported using wipes to clean shared medical equipment (supplementary material, Table S1 ).

Participants were shown pictures of three patient hospital rooms (Fig. 2) . Room A showed a patient lying present in the bed with various equipment. Room B appeared to be empty, with the bed looking slightly rumpled. Room C showed a patient lying in bed and was less cluttered in appearance than Room A. Participants were then asked to nominate which room presented the lowest risk of infection (A, B, C, or 'don't know'). The majority chose Room A, a cluttered room occupied by a patient.

Using a free text option, participants were asked what one item/piece of equipment they thought posed the greatest risk of infection transmission from the environment. The most common responses were hospital furniture 

The themes from participants around barriers to cleaning effectively were a lack of information and training, resources (cleaning products and equipment), lack of dedicated cleaning staff, and organisational structures. The free-text survey comments (supplementary material, SQ1-2) stressed the need for more readily accessible information including simple wall charts with information about which product to use and where and improved labelling on wipes and cleaning agents. More education was needed about which products were recommended for patients presenting with infections such as C. difficile or multi-drug resistant organism (MDRO). Product useability was important, with single-use disinfectant wipes preferred, especially where staff experienced competing time pressures. A lack of policies and guidelines to inform infection control practices and lack of clear role definitions and staff accountability were also identified. In contrast to most comments, seven participants perceived that 'nothing' impacted their ability to clean equipment between patients, i.e., cleaning always occurred even when staff were pressed for time.

Most participants reported having received information about cleaning importance, correct product usage and availability. Twenty-three percent (n Z 18) had received information within last 3 months, 19% (n Z 15) in the previous 3e12 months and 15% (n Z 12) reported having received information in the last 1e3 years. However, 32% (n Z 25) either 'do not recall' or have 'never' received any information about the importance of cleaning, product availability in their organisation, nor how to correctly apply products for infection control purposes. The majority of training received (25%, n Z 20) was provided by an Infection Control Team (Table S2) . Additionally, using a Likert scale, participants were asked to indicate level of agreement with four statements regarding cleaning effectiveness (Table S3) . Despite the majority indicating confidence in their cleaning ability (usually 46%, n Z 36; always 23%, n Z 18), most did not feel comfortable being admitted to a room where the previous patient had a multi-drug resistant organism (never 42%, n Z 33; only sometimes 34%, n Z 18).

It is well accepted that the clinical environment plays a role in the transmission of infections such as multi-drug resistant organisms (MDROs) and healthcare associated infections (HCAIs) [2,7,8,12,14,15,17e20] . Ineffective cleaning practices by nursing and midwifery staff may also contribute to a high pathogen-load being present within hospital settings [15, 19, 21] . As an important first step to improving environmental hygiene, this study found that nurses and midwives broadly stated that they understood the importance of cleaning, albeit, there is variation in cleaning responsibilities. Moreover, cleaning of shared medical equipment may pose current risk in terms of lack of cleaning. In keeping with Aiken et al. [22] , this study found that nursing and midwifery staff play a key role in cleaning duties as part of their working role. However, our findings suggest there was ambiguity about who was responsible for cleaning patient areas or certain items (such as IV pumps). There was also less certainty regarding how or when to use disinfectants and about the effectiveness of disinfectants on different groups of micro-organisms. These findings could be a result of any number of factors, including appropriateness of the product, lack of product information or of education. The implications of inappropriate product use may result in ineffective cleaning, thus increasing the risk of HCAIs. There are also health and safety implications for disinfectant use. In terms of the process of cleaning, 39% (n Z 31) of participants did not identify the correct way to clean (wipe) a surface (i.e. S-shaped or serpentine). Therefore, this finding, coupled with a lack of understanding about product (disinfectant) choice, will result in less effective cleaning and increase transmission risks.

As pathogens can survive on uncleaned or inappropriately cleaned surfaces for long periods of time, it is vital that shared medical equipment is consistently and correctly cleaned to reduce the risk of HCAIs. Genomic analyses by Lee et al. [23] of VRE transmission pathways within an intensive care unit identified the key role shared medical equipment has in ICU. Factors for suboptimal cleaning of shared equipment may include insufficient stocks of equipment to allow for cleaning and rotation between patients, lack of product at the point of use and perceived lack of time [1, 7, 19] . Understanding reasons for this are important and we will be following this up in future work. Survey participants called for more easily accessible information about the different types of cleaning products and what they were used for, greater accessibility to products, greater clarity around cleaning roles and who was responsible for maintaining particular items or patient areas, as well as increased accountability on the behalf of staff and hospital management.

Factors that may influence a decision for cleaning to take a secondary role include the perception of infection risk from the environment versus other competing patient care requirements, as well as understanding cleaning responsibilities. When we asked participants to identify which room posed the highest infection risk, the majority of participants chose the most cluttered room. This indicates good understanding among respondents that cluttered environments can hamper cleaning. However, the correct answer was 'don't know', i.e., while this room may reflect challenges undertaking cleaning, it does not necessarily relate to risk. Pathogens are invisible to the naked eye and any of the rooms may pose an infection risk [15] . Factors influencing risk would include the type of infection or pathogen from an unknown but colonised patient, as well as the effectiveness of cleaning. None of the provided images illustrated this. The subjectivity of choosing a room which is cluttered is consistent with other work, which found that compliance with even basic infection protocols such as handwashing and wearing gloves was individually and subjectively based [3e5] .

Variations in product use and cleaning practices [21, 24, 25] , information transfer and communication pathways [26e28], and organisational culture [20] , can all influence cleaning outcomes. Improving staff knowledge around product use, communication, training, audit and utilising an implementation framework have been shown to improve cleaning outcomes, reduce risks for patients and are costeffective [12, 17, 29] . In our study, most participants (68%, n Z 54) indicated that they had received information about the importance of cleaning, the types of products available in their organisation and product application. However, 11% (n Z 9) had last received that information more than 3 years prior and a further 32% (n Z 25) did not recall or had never received any cleaning information. Another key theme emerging from survey comments was the lack of simple information about particular cleaning products. Participants called for easy instructions to support correct product usage and application. These findings suggest the need for improved and structured education of nurses and midwives around cleaning on a regular basis, as well as improved communication. Education could be provided in any number of ways, including from nurse educators, online platforms or from representatives from industry supplying products and equipment. Of course, nurses are only one professional group in healthcare. Shared medical equipment is also used by medical and allied health. Potentially the same issues exist in these professional groups regarding knowledge of cleaning and responsibilities around who cleans equipment they use.

This study is limited by the use of a cross-sectional study design and the accuracy of self-report responses provided. The vast majority of surveys were undertaken prior to the COVID-19 pandemic taking hold in Australia, so biases associated with this are expected to be limited. The sample size, while not large is a further limitation. Nonetheless, this study provides a useful snapshot of nurses' and midwives' knowledge of infection control and cleaning processes, something that to our knowledge has not been undertaken before. We identified gaps in training and knowledge, as well as unclear responsibilities for cleaning certain objects. These findings can be used to inform workforce education and planning and hospital cleaning policies. Similarly, the findings lay the foundation for future research exploring solutions to try and improve the cleaning of shared medical equipment.

Greater organisational support, clear policies detailing cleaning responsibility, and improving the applied knowledge and personal efficacy of nurses and midwives regarding infection prevention and control is needed. This includes the correct use of disinfectants, which disinfectant to use for various situations, and how to clean effectively following discharge of a patient with a suspected or known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

Ethics approval for this study was granted by [blinded for review].

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Thank you to the participants in this survey.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.idh.2020.09.002.

BM, MK and PR designed the project. BM is the Chief Investigator for the project. BM and CC drafted the paper. All authors provided critical input into the paper. All authors approved the manuscript.

Two of the authors (BM and PLR) are editorial board members with the journal. All authors were blinded to this submission in the journal's electronic editorial management system and none of the authors played any editorial role in handling this paper whatsoever. One author (MK) has paid employment from a company which sells cleaning products, as well as university appointments. No company played no any role in the design, analysis, interpretation or presentation of this paper.

In kind support is provided by the higher education institutions with which the Chief Investigators are affiliated. PLR is supported by National Health and Medical Research Council Early Career Fellowships APP1156312.

Not commissioned; externally peer reviewed.