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

Transcription

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

2 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 To provide feedback on its contents or on your experience of using the publication, please publications.feedback@rcn.org.uk RCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or 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 2013 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.

3 Royal college of nursing Contents Introduction 4 Methodology 5 Key themes of the relationship 5 What do we mean by partnership working? 7 Attributes 8 Outcomes/consequences 9 Next steps 9 Recommendations 9 References 10 Further resources 10 3

4 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. 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. 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 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. 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. 4

5 Royal college of nursing 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 - 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. Key themes of the relationship 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. 5

6 Creating a safe environment for care Enabling factors Factors required to enable a good working relationship between nursing and cleaning staff Organisational level 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. A stable, consistent workforce is present (cleaning and nursing). Workplace level Leadership and expectations of nursing and cleaning staff are clear and complied with. Nursing staff clean and tidy up in accordance with their role as 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. Attributes The recognisable characteristics of a good working relationship. A good relationship... Enables effective communication on matters relating to cleanliness of the patient environment: provides a stimulus for regular communication and feedback on cleanliness creates a culture for learning from incidents/issues using a no blame approach promotes awareness of roles and responsibilities that is not dependent on the ward/ department manager is visible to all staff, patients and relatives. Supports individuals to raise concerns that impact on cleanliness of the patient environment: sharing and commending of good practice takes place acknowledges changes in workload pressures intuitively and formally supports early recognition and management of issues. Creates a culture of respect and value: interaction between nursing and cleaning staff is present provides the conditions for a team approach to cleanliness of the environment. Outcomes or consequences of a good working relationship For the organisation Retention of cleaning staff and associated memory. Improved external review, eg, regulatory assessments. Staff are respectful towards each other. For nursing staff All levels of the nursing hierarchy are aware of expectations of their role in relation to cleanliness. For cleaning staff 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. A culture for respectful relationships is created. A comfortable work relationship/atmosphere is created. A clean patient environment is created and maintained. Cleaning and nursing teams are perceived as integrated with one joint goal. Table 1 - A framework to describe the relationship between nursing and cleaning professionals 6

7 Royal college of nursing 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. 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 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. 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. What do we need to enable partnership working? Nursing staff Talking to each other How you talk Having the same goal Working as one team Having a line management chain that makes sense Understanding each other s roles (links to role titles) Having the intuition and flexibility to undertake extra roles Having clear escalation and governance systems Respecting each other Recognising that each both work hard Cleaning professionals Eliminate silo working Clarity of responsibility Do what the nurses ask you to! Get other people out of trouble Teamwork Seamless support One team, not two Integrated as part of team Level playing field everyone able to participate Table 2 The description of participant s comments on the meaning of partnership working 7

8 Creating a safe environment for care What do we mean by partnership working? Nursing staff Appropriate contract negotiation (includes breakdown of tasks and responsibilities). Multidisciplinary meetings include cleaners where appropriate. Provision of good quality equipment (sign of respect). Opportunity to escalate issues or adverse reporting (use of advocate/mediator helps with language). Training and development. Incentivising/positive feedback. access/bulletins/alternative communication. Messages/posters. Involvement of estates teams. Language. Cleaning professionals Try to maintain stability of staff. Group meetings. Set and spread examples of good practice. Consider job descriptions and contracts. Training. Infection prevention and control team engagement. Director-level input. 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: reporting concerns about patient safety (recommendation 12) 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 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). 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. 8

9 Royal college of nursing Outcomes/ consequences 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. Next steps 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. 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. 9

10 Creating a safe environment for care References Calkin S, (2012) Lack of cleaning services sees nurses disinfecting beds, Nursing Times, available at: (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 Further resources Patient Led Assessment of the Care Environment (PLACE) Care Quality Commission Health Improvement Scotland - Healthcare Environment Inspectorate Health Inspectorate Wales Regulation and Quality Improvement Authority (RQIA) 10

11 The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies November 2013 RCN Online RCN Direct Published by the Royal College of Nursing 20 Cavendish Square London W1G 0RN Publication code: ISBN: