Creating a safe environment for care Defining the relationship between cleaning and

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Creating a safe environment
for care
Defining the relationship between cleaning and
nursing staff
Acknowledgements
The RCN would like to thank the following for their involvement in the development of this publication:
Tracey Gauci, Nursing Officer, Welsh Government, and Patron, Association of Healthcare Cleaning
Professionals
Liz Jones, Past President, Association of Healthcare Cleaning Professionals
Denise Foster, Past Chair, Association of Healthcare Cleaning Professionals
Members of the Association of Healthcare Cleaning Professionals
Members of the RCN Infection Prevention and Control Network
RCN contributor - Rose Gallagher, Adviser for Infection Prevention and Control
This publication is due for review in November 2015. To provide feedback on its contents or on your
experience of using the publication, please email publications.feedback@rcn.org.uk
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alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance.
Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN
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Contents
Introduction
Methodology
4
5
Key themes of the relationship 5
What do we mean by partnership working? 7
Attributes
8
Outcomes/consequences
Next steps
9
Recommendations
References
Further resources
9
9
10
10
3
Creating a safe environment for care
Introduction
The relationship between nursing and cleaning
professionals is central to the management
of the patient environment. This environment
is the interface between the patient and the
organisation and it provides both a practical
and safe area in which to provide patient care.
The setting should facilitate a patient’s privacy,
dignity and recovery. As such, any factors
that have a negative impact on the patient
environment risk affecting its functions and
the patient’s subsequent confidence in the
organisation providing care.
and that contract flexibility is prejudiced. Other
influences on management and the responsibility
for patient environments include:
• the introduction of modern matrons (England
only) with specific responsibilities for tackling
standards of cleanliness
• the introduction of PFI contracts and help
desks to manage issues or rectification of
problems
• an enhanced focus on responsibilities for
cleaning of low-risk commonly used patient
equipment as part of enhanced regulatory
assessment and infection prevention
strategies.
One of the most longstanding concerns
associated with the patient environment is its
potential role in the transmission of infection.
The association between contaminated surfaces/
equipment and the transfer of disease-causing
micro-organisms is well established and with
an ever increasing focus on its role with specific
infections caused by C. difficile, Norovirus and
multi-resistant organisms. The decontamination
of patient environments is central to the
provision of safe care due to the contact between
contaminated hands or equipment and vulnerable
patients. The relationship therefore between the
two main groups of hospital staff, nursing and
cleaning staff, who work in close association with
patient environments is crucial. Many different
perceptions exist with regard to this relationship,
often based on the history or current status of
cleaning service provision.
Despite the increased focus on the importance
of the environment, the relationship between
nursing and cleaning professionals, although
often referred to, has not been fully explored.
The opportunity to define this relationship
became available through joint working
opportunities between the Royal College of
Nursing (RCN) and the Association of Healthcare
Cleaning Professionals (AHCP) and is detailed in
this publication.
Current service provision falls into two areas,
inhouse cleaning services (employed by and
managed by each organisation) or contracted
cleaning services provided by a third party.
Historically, it has been perceived that inhouse
cleaning services provide a superior standard
of cleanliness; however, there is no evidence
to support this. Such perceptions may have
developed based on assumptions that cost,
as a major factor in the provision of cleaning
services, has led to the deterioration in standards
as cleaning posts are reduced with a focus on
efficiency rather than quality (Unison, 2009)
(Gallagher, 2013 in press). The focus on efficiency
has also caused concern amongst members
of the RCN and AHCP who report concerns that
contracted out services lack the flexibility of
inhouse services. Specific concerns relate
to contracted services not being receptive to
unexpected clinical events which require a
cleaning response, that cleaning contracts can
be cited as reasons not to meet specific requests
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Key themes of the
relationship
Methodology
In 2012, a number of workshops took place at RCN
and AHCP events in England, asking members
to describe how they felt nursing and cleaning
professionals could work together better. Ideas
generated at the workshops were analysed and
divided into three categories:
Enabling factors
Enabling factors are crucial for nursing and
cleaning professionals to understand as they
define their relationship in terms of how they
work together. Enabling factors are not about
what is right or wrong; they describe what
is required to support both parties with the
features identified acting as a useful barometer
for organisational culture and support. Although
the attributes of the relationship are useful for
recognising a good working relationship, the
enabling factors are critical for supporting the
success of the relationship. As such enabling
factors have been themed in the context of
organisational and local factors.
• enabling factors - those factors required to
enable a good working relationship between
nursing and cleaning staff
• attributes - the recognisable characteristics of
a good working relationship
• outcomes or consequences of a good working
relationship.
Table 1 (on page 6) describes the outcome of
the analysis. Further description is provided
in addition to consideration of its implications
following recommendations from the Report of
the Mid Staffordshire NHS Foundation Trust Public
Inquiry (Francis report, 2013), into poor standards
of care at Mid Staffordshire NHS Trust.
5
Creating a safe environment for care
Outcomes or consequences
of a good working relationship
Enabling factors
Attributes
Factors required to enable a good
working relationship between
nursing and cleaning staff
The recognisable characteristics
of a good working relationship.
A good relationship...
Organisational level
Enables effective communication For the organisation
on matters relating to cleanliness
• Retention of cleaning staff
of the patient environment:
and associated memory.
• provides a stimulus for
• Improved external review,
regular communication and
eg, regulatory assessments.
feedback on cleanliness
• Staff are respectful towards
• creates a culture for learning
each other.
from incidents/issues using a
For nursing staff
no blame approach
• Active, visible executive level
engagement and support is
present.
• Appropriate contract
negotiation takes place prior to
acceptance including clarity on
tasks and responsibilities.
• Cleaning professionals are
present at multi-professional
meetings.
• Training is provided and
undertaken.
• Good quality equipment and
products are provided.
• Role titles are consistent and
clearly understood.
• Core relationships exist
between cleaning services and
IPC and estates departments.
• Language associated with
cleanliness or contractual
requirements is consistent and
unambiguous.
• promotes awareness of roles
and responsibilities that is
not dependent on the ward/
department manager
• All levels of the nursing
hierarchy are aware of
expectations of their role in
relation to cleanliness.
• is visible to all staff, patients
and relatives.
For cleaning staff
Supports individuals to raise
concerns that impact on
cleanliness of the patient
environment:
• sharing and commending of
good practice takes place
• Cleaning staff are confident
to raise concerns.
For the workplace
• Patients and their carers/
visitors are confident to
speak to highlight concerns
or praise to staff.
• acknowledges changes in
• A culture for respectful
workload pressures intuitively
relationships is created.
and formally
• A comfortable work
• supports early recognition
relationship/atmosphere
• A stable, consistent workforce is
and management of issues.
is created.
present (cleaning and nursing).
Creates a culture of respect and
• A clean patient environment
Workplace level
value:
is created and maintained.
• Leadership and expectations of
• interaction between nursing
• Cleaning and nursing teams
nursing and cleaning staff are
and cleaning staff is present
are perceived as integrated
clear and complied with.
with one joint goal.
• provides the conditions for a
• Nursing staff clean and tidy up
team approach to cleanliness
in accordance with their role as
of the environment.
they work.
• Cleaning staff are integrated
into ward/department teams.
• Good work is acknowledged and
fed back.
• Cleaning workload is planned
and permits dedicated time for
cleaning.
• Adequate storage is available
for equipment and consumables.
Table 1 - A framework to describe the relationship between nursing and cleaning professionals
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responsibilities for cleaning and tidiness.
While the intention of this publication is not to
comment on nursing responsibilities for cleaning,
it is crucial to acknowledge the importance of
different attitudes (both personal and cultural)
that influence perceptions on the extent to which
nurses clean. Recent media reports (Calkin, 2012)
highlighted variations in cleaning practices,
regardless of whether these occur in line with
local/national practice, indicating that more work
is required on this issue as well as the implications
for relationships in the workplace.
As with any relationship or team development,
changes occur over time. The vision of the
organisation in relation to the patient environment
in its entirety is therefore important as it provides
a structure for developing opportunities for
long-term joint goals and aspirations. In
discussions with workshop participants, when
asked to describe partnership working, the theme
of team work and role clarification was very strong.
Phrases included one team not two, understanding
each other’s roles, talking to each other, having
the same goal and how you talk to each other.
Other recurrent phrases included respecting each
other and recognising that each other work hard.
It was interesting to note a preference for the use
of the word ‘team’ from cleaning professional
participants and ‘roles’ from nursing staff. We
currently have no way to understand whether
the two terms are used synonymously or reflect
underlying differences in how the relationship and
roles are viewed by each party.
When asked what was further required to improve
partnership working nursing staff identified
factors which focused on the importance of
leadership, communication, positive feedback
and a no-blame culture. Interestingly cleaning
professional’s responses focused on the practical
process for support such as clear systems to
support escalation of issues, protected cleaning
time, workload planning and responsiveness.
Both groups raised the need to be able to discuss
problems including consideration for the use of
advocates or mediators to resolve issues.
A further element that was identified was the
importance of role clarification. This included
reference to the use and interpretation of
job names/titles and references to nursing
What do we need to enable partnership working?
Nursing staff
Cleaning professionals
Talking to each other
Eliminate silo working
How you talk
Clarity of responsibility
Having the same goal
Do what the nurses ask you to!
Working as one team
Get other people out of trouble
Having a line management chain that makes sense Teamwork
Understanding each other’s roles (links to role
titles)
Seamless support
One team, not two
Having the intuition and flexibility to undertake
extra roles
Integrated as part of team
Level playing field – everyone able to participate
Having clear escalation and governance systems
Respecting each other
Recognising that each both work hard
Table 2 – The description of participant’s comments on the meaning of partnership working
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Creating a safe environment for care
What do we mean by partnership working?
Nursing staff
Cleaning professionals
• Appropriate contract negotiation (includes
breakdown of tasks and responsibilities).
• Try to maintain stability of staff.
• Group meetings.
• Multidisciplinary meetings include cleaners
where appropriate.
• Set and spread examples of good practice.
• Consider job descriptions and contracts.
• Provision of good quality equipment
(sign of respect).
• Training.
• Infection prevention and control team
engagement.
• Opportunity to escalate issues or adverse
reporting (use of advocate/mediator
– helps with language).
• Director-level input.
• Training and development.
• Incentivising/positive feedback.
• Email access/bulletins/alternative
communication.
• Messages/posters.
• Involvement of estates teams.
• Language.
Table 3 – The identifying factors needed to help partnership working
Attributes
The three central attributes identified that describe
a good relationship are effective communication
about the environment, support to raise concerns
and creating a culture of respect and value. These
reflect closely the recommendations from the
Francis report on:
important reflection can help ascertain the quality
of interaction between the two staff groups – from
the basic (knowing each other’s names and having
photos of cleaners present on team notice boards),
through the practical (working tidily and cleaning
as you go) to the more strategic (a shared goal
delivered by an integrated team).
• reporting concerns about patient safety
(recommendation 12)
This shared culture is something that workshop
participants felt could be observed when present.
As with the other attributes, it should therefore
be possible to describe and even to measure the
extent to which each attribute exists – either
at an organisational level or within individual
wards or departments. For instance, the support
to raise concerns attribute could be observed at
different levels in organisations from discussions
at ward/department level meetings (for example a
cleaner and a staff nurse jointly raising a concern
with the ward sister or domestic supervisor) to
formal discussion papers presented at board level
jointly by the directors of nursing and estates
and facilities management. Likewise, an absence
of joint working or evidence of conflict can also
be seen as useful in so far as such situations
could act as a prompt for further investigation or
evaluation into local/organisational culture.
• the need for effective teamwork
(recommendation 237)
• the contribution of cleaning and catering staff
(recommendation 237)
• the need for all staff to be vigilant about
hygiene requirements (recommendation 240).
The recognition of attributes is essential in
supporting the evaluation of services both
internally and externally. Without a framework,
such as that described in Table 1, the relationship
is open to unsystematic evaluation and the
influence of personal perceptions.
Within the key attributes of the relationship,
workshop participants described the importance
of developing a culture of respect and value. This
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Next steps
Outcomes/
consequences
The RCN and AHCP are committed to supporting
further work in this area and will look in more
depth at the analysis to see how it can be used
or replicated to raise awareness of this important
relationship and its impact. This work represents
a first step in starting to describe this relationship
in ways that have not been used before. Although
based on the experience of workshops undertaken
in England (workshops were open to UK-wide
membership) the principles of this work are
applicable to the four countries of the UK and all
care settings.
Both attributes and enabling factors are essential
in shaping and defining clear outcomes, such as
confident cleaning professionals and a sustainable
workforce which delivers high quality consistent
services. The consequences of a good relationship
may be both visible in the workplace and
commented on by external bodies. Ultimately
improved scores on assessments such as Patient
Led Assessment of the Care Environment (PLACE)
or regulatory inspections (eg, Healthcare
Environment Inspectorate (HEI), Regulation and
Quality Improvement Authority (RQIA), Care
Quality Commission (CQC) and Health Inspectorate
Wales (HEI) should be achieved. Other positive,
visible consequences include staff who report they
are happy to work together or instances where they
are observed to be looking out for each other’s
welfare and sharing good practice or improvement
ideas.The ultimate vision for both nursing and
cleaning professionals is the provision of a clean,
tidy and safe patient environment. Achievement of
this is dependent on organisations considering the
importance of the central relationship between
these two import staff groups and how it enables
this relationship above and beyond contractual
process driven structures.
Recommendations
• Individual organisations should assess their
own services against the framework and use it
to drive improvement.
• The framework should be used to inform
future standards impacting on patient care
environments and existing evaluations
such as Patient Led Assessment of the Care
Environment (PLACE) reviews (England).
• The RCN and AHCP should develop a
framework to support regulatory bodies
undertake consistent evaluation of
organisations compliance against regulatory
standards for adoption across the UK.
• Further work on understanding the relationship
between nursing and cleaning professionals
should be undertaken to better understand
its impact and factors contributing to its
ongoing development.
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Creating a safe environment for care
References
Calkin S, (2012) Lack of cleaning services sees
nurses disinfecting beds, Nursing Times, available
at: www.nursingtimes.net
(accessed 3 September 2013).
Gallagher R 2013 in: Walker J ed. Decontamination
in Hospitals and Healthcare. Woodhead Publishing
(in press).
The Mid Staffordshire NHS Foundation Trust Public
Inquiry (2013) Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry, London: Stationery
Office. (Chair: R Francis). Available at
www.midstaffspublicinquiry.com
Further resources
Patient Led Assessment of the Care Environment
(PLACE)
www.england.nhs.uk
Care Quality Commission
www.cqc.org.uk
Health Improvement Scotland
- Healthcare Environment Inspectorate
www.healthcareimprovementscotland.org
Health Inspectorate Wales
www.hiw.org.uk
Regulation and Quality Improvement Authority
(RQIA)
www.rqia.org.uk
10
The RCN represents nurses and nursing, promotes
excellence in practice and shapes health policies
November 2013
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