key: cord-0771712-ptyjxtk1 authors: Jordan, Sarah R.; Daddato, Andrea E.; Patel, Hemali P.; Jones, Christine D. title: Forgotten frontline workers: Environmental health service employees' perspectives on working during the COVID‐19 pandemic date: 2022-02-15 journal: J Hosp Med DOI: 10.1002/jhm.12781 sha: 45785e40772c691568429532e52050a7dba38618 doc_id: 771712 cord_uid: ptyjxtk1 BACKGROUND: Environmental Health Service employees (EVS) sanitize healthcare facilities and are critical to preventing infection, but are under‐resourced during the COVID‐19 pandemic and at risk of burnout. OBJECTIVE: Understand demands on EVS’ work and strain on resources during COVID‐19. DESIGN: Qualitative descriptive study conducted in winter 2020–2021. SETTING: One quaternary care academic medical center in Colorado. PARTICIPANTS: A convenience sample of 16 EVS out of 305 eligible at the medical center. Fifty percent identified as Black, 31% as Hispanic, 6% as Asian, and 6% as White (another 6% identified as mixed race). Sixty‐nine percent were female, and half were born in a country outside the United States. MEASURES: Semistructured telephone interviews. Interviews were audio‐recorded and transcribed, and thematic analysis was used to identify key themes. RESULTS: Four themes illustrate EVS experiences with job strain and support during COVID‐19: (1) Needs for ongoing training/education, (2) Emotional challenges of patient care, (3) Resource/staffing barriers, and (4) Lack of recognition as frontline responders. Despite feeling unrecognized during the pandemic, EVS identified structural supports with potential to mitigate job strain, including opportunities for increased communication with interdisciplinary colleagues, intentional acknowledgment, and education for those who speak languages other than English. Strategies that can increase physical and emotional resources and reduce job demands have potential to combat EVS burnout. CONCLUSIONS: As the surge of COVID‐19 cases continues to overwhelm healthcare facilities, healthcare systems and interdisciplinary colleagues can adopt policies and practices that ensure lower‐wage healthcare workers have access to resources, education, and emotional support. Environmental Health Service employees (EVS), or those in hospitals who clean and sanitize facilities and equipment, are essential in preventing hospital-based transmission of infectious disease, 1-3 yet up to two-thirds of EVS report working in chronically understaffed positions in the United States. 4 In addition, the average pay for the field is just $13 per hour in the United States. 5 Many also lack protections such as paid sick leave and health insurance. 4, 6, 7 Despite their critical role in preventing infection, EVS have also described feeling undervalued due to their perceived "low status" being positioned at the bottom of the hospital worker hierarchy in terms of education and pay (compared to nurses and doctors). 8, 9 The impact of social hierarchies and stereotyping lower-earning workers can lead to poor health outcomes such as mental health disorders. 10, 11 The ongoing COVID-19 pandemic has only exacerbated inequities and occupational health risks EVS already face. In the early months of the COVID-19 response in the United States, EVS were among the last to be supplied with masks in some instances, 12 all while performing added cleaning tasks under increased time constraints given pressures on hospital capacity. 13, 14 Although concerns during the COVID-19 response have been studied among other disciplines including physicians, nurses, advanced practice clinicians, and even home health aides, 15, 16 little is known about the experiences of EVS. As turnover in the profession continues to be a concern, 17 This study involved semi-structured interviews with EVS working at one quaternary care academic medical center in Colorado. Qualitative descriptive design allowed for data collection about EVS' real lived experiences, perceptions, and attitudes about their work. 19, 20 Interviews were conducted between November 2020 and January 2021. This study was approved by the Colorado Multiple Institutional Review Board and informed consent was required. This study is informed by the Job Demands-Resources Model, which we used as a lens to understand both demands on EVS as they worked through the COVID-19 response, and resources available to them (both physical and emotional). 21 The Job Demands-Resources model suggests that even when working in a high stress role (e.g., "high demand," in the form of workload or time pressure), workers who are provided physical, psychological, social, or organizational support (high resources) will experience less strain and burnout, regardless of occupation. This guiding framework provides the opportunity to identify structural factors that have potential to mitigate burnout for EVS. University of Colorado Health (UCHealth) is a quaternary care academic medical center located in Aurora, CO. Its urban location and catchment area of the surrounding tri-state region serves a wide range of patients across different regions and socioeconomic statuses. EVS at UCHealth are employed through an independent contractor and include 305 employees, all of whom were eligible to participate in this study. Translator services were offered for non-English speaking participants. The study team worked with EVS leadership at UCHealth to recruit employees and ensure their participation was voluntary and confidential. EVS leadership distributed information about the study in team meetings and posted flyers in common areas. EVS were invited to contact the research coordinator (S.R.J.) to arrange a time for a telephone interview. Interviews were conducted from November 2020 to January 2021 with a convenience sample of EVS who responded to participate; some participants also referred other EVS colleagues through snowball sampling. 22 The guiding research question in this study explored how EVS experienced working on the frontlines of the COVID-19 pandemic, specifically related to job strain and support (see Appendix A for interview guide). Interviews lasted up to 1 hour and were conducted by the research coordinator (S.R.J.), an experienced qualitative researcher who did not have a direct connection to patient care or hospital operations. Interviews were de-identified, audio-recorded, and transcribed. Interviewees also completed a short demographic survey. Participants were compensated with $25 gift cards. Interviews were conducted with all participants who volunteered (after multiple reminders were sent), at which point it was determined thematic saturation was achieved, where no significantly new information emerged. 23 We used thematic analysis and a team-based approach to interpret the data including our perspectives from sociology, gerontology, and hospital medicine. 24 Of the 305 EVS working at UCHealth at the time of this study, 16 responded for an interview (13 staff and three EVS supervisors). Of the 16 interviewees, 50% were born in a country other than the United States and the majority spoke multiple languages. One interview was conducted in Spanish with the help of an interpreter. Nearly 70% of participants identified as female and ages ranged from 33 to 69 years old. Fifty percent of interviewees identified as Black, 31% as Hispanic, 6% as Asian, 6% as White, and 6% as mixed race. Demographic data of participants are displayed in Table 1 . Table 2 displays themes and additional illustrative quotations from the four key themes below. The training EVS received from supervisors to prepare them to work during COVID-19 involved information on hospital protocols, personal protective equipment (PPE), and preventative behaviors like handwashing. EVS also received demonstrations from nurses on gowning up and down with PPE, which were highly valued. Some still desired more education on the disease and believed ongoing refresher sessions would be helpful, especially with fast-changing protocols. Others even took it upon themselves to stay abreast of the pandemic by subscribing to YouTube news channels or visiting libraries. One salient need that emerged was the need for training and education delivered in languages other than English. Half of participants were born in a country other than the United States and for many, English was a second language. One participant described how rooms, in place of their colleagues who declined. One supervisor described the strain from turnover: We did lose some housekeepers that had been here the longest-older people who, out of concern, decided, "This is no longer for me." The percentage of applicants who wanted to work here did go down drastically. And for some time, we did struggle with housekeepers who didn't wanna come into work, or they quit and we were having to scramble into, "Well, who's gonna do what?" (#2) Interviewees described feeling burnout from repeated high stress shifts with several patients passing away, limited resources, and high demands placed on all interdisciplinary colleagues. For EVS in this study, feeling a lack of recognition as frontline workers often manifested in two ways: feeling forgotten in mainstream media, and in their day-to-day interactions with interdisciplinary colleagues. One participant described: They would say in commercials to the frontline workers, "Thank you nurses, thank you doctors," but I A lot more education. Because since COVID, only one time I saw a lady come by and was talking about protecting yourself. But you need more people that can come to the huddle in the morning and really give some education. If they were seeing somebody from the nursing staff come down every other week or every Monday for instance-after the weekend you would come in and give them some more education on what is going on… give them some more encouragement, come and talk about the PPE, let them be aware more and understand more about COVID. #8 (Continued) It's a scary thing… I had one patient, and he just knew he wasn't gonna make it, y'know? And I was like, "You never know what God got in store for us. I don't know what your faith is," I said, "but keep it up." And he was like he just lost all of it. I'm like, "Just hold on, you'll be all right." And then he didn't make it. So that made me feel sad, too. #1 The hardest thing is when you see a person who is in a very serious condition, who is connected to all the machines, and all this equipment… it is hard seeing patients very sick. #5 You see them in the glass in the room… it's a tough feeling… there are always tubes, and they cannot talk, they cannot move. #14 Comparisons to working during past outbreaks Emotionally, COVID has hit me more than the exposure to HIV, because with COVID, you can be right there near 'em, and there you are, exposed to it, y'know? So emotionally I'm here, but I'm not. #1 We've been through the bird flu, H1N1… but none of us have been through what we're going through now because this is more devastating. This outbreak… I notice that people are a little more tired because this takes a lot out of you. This stuff spreads like a wildfire. I just think mentally and physically a lot of us are just tired but we're essential and we're needed at the hospital so we just keep chugging along. #10 There's a lot of nurses that help out the housekeepers, and they tell them, "Oh, don't go into that room. We'll pull out the trash for you, and we'll do everything." Most of the time they keep them informed of the precautions of going inside the room. And there was times that they provided our housekeepers with the face shields. #7 Limitations of not working directly for the hospital We've been brave to go into those rooms and clean them. We are front liners too. We don't feel that appreciated during this situation. We could have benefits… it would make a big difference. Figure A1 . The Job Demands-Resources Model. From Bakker et al. 30 Knowledge, attitudes, and practices regarding environmental cleaning among environmental service workers in Chinese hospitals Knowledge, attitudes, and practices of environmental service workers related to environmental cleaning and healthcare-associated infections (HAI). 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The Guardian Low-wage workers and health benefits use: are we missing an opportunity? The Invisible Staff": a qualitative analysis of environmental service workers' perceptions of the VA Clostridium difficile prevention bundle using a human factors engineering approach Keepers of the house: a documentary How job demands, resources, and burnout predict objective performance: a constructive replication Forgotten frontline workers: Environmental health service employees' perspectives on working during the COVID-19 pandemic What has it been like working in EVS during COVID-19? a. How did you feel when you were asked to care for patients with COVID-19? How has it felt to interact with/care for COVID-19 patients? c. What has been the hardest part about working during this time? Training and Education 1. How were you trained to work with COVID-19 positive patients/rooms? Or what did management do The authors would like to acknowledge and thank the editors at JHM for the inspiration that led to this study. We also wish to thank Erva The authors declare that there are no conflicts of interest.