Review of Training Requirements for Cleaning and Decontamination in the Healthcare Environment

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1 Review of Training Requirements for Cleaning and Decontamination in the Healthcare Environment April 2013 Report produced for NHS Education for Scotland and Health Facilities Scotland by

2 Contents 1. Executive Summary Introduction Training in NHSScotland Profile of domestic services staff Methodology Aim and objectives Approach Learning Mechanism Learning styles Training delivery IT/computer training Identification of training need Formal accredited training Provision for domestic assistants Provision for Supervisors and Managers Coverage of core and specialist skills Overarching Issues Working as part of a Team Career pathways progression Factors affecting the recruitment and retention of Domestic Services Staff Providing cover for staff to attend training and arranging logistics Conclusions What works well? Areas for improvement Recommendations Appendix I Core Capabilities of the Skills and Knowledge Framework Appendix 2 Bibliography Web pages Websites

3 1. Executive Summary Introduction Cleaning and decontamination of healthcare environments has a hugely important role in ensuring that the risk to patients from healthcare associated infection (HAI) is prevented. The aim of this research was to clarify and review the training programmes, education provision, policy and procedures that exist for the staff whose role it is to clean and decontaminate the NHS healthcare environment in Scotland. A further consideration of the research was to identify the key learning needs of the domestic services workforce within NHSScotland. Scope The study involved a three stage research programme in which extensive secondary research was followed-up and supplemented by contributions from key experts from organisations including NHSScotland Health Boards and NHS Special Health Boards. A total of 20 expert stakeholders took part in in-depth telephone interviews with a Pye Tait researcher. Focus groups were held in four NHSScotland Boards: Dumfries and Galloway; Ayrshire and Arran; Fife; and, Greater Glasgow and Clyde. At each location two separate focus groups were conducted for Domestic Assistants, and NHS staff from other multiple disciplines which impact upon and/or connect with the roles and responsibilities of domestic service staff and their professional training. Along with secondary data, the learning mechanisms used to deliver training programmes, education provision, and information around policy and procedures for domestic services staff were also reviewed. Gaps in provision of training and information for Domestic Assistants and Supervisors and Managers were identified as well as factors affecting the recruitment and retention of domestic services staff. Conclusions There is variation in the way that training for cleaning and decontamination is approached across NHSScotland s Health Board, in terms of delivery methods, regularity and in some cases content. The research has identified a number of practices that work well and that promote the effective prevention of HAI. The impact and importance, to HAI prevention, of a number of underpinning factors and overarching issues affecting training delivery including learning styles; delivery methods; training culture ; nature of the job roles in question and interactions between them; and availability of resources came across very strongly in the research. 3

4 Although flexibility and freedom to vary practice according to local need is a necessary requirement, this can lead to perceptions of inconsistency, as well as gaps in knowledge and competence which may impact on the prevention of HAI. The research has found a number of instances where lessons can be learned and good practices that could be emulated by different NHS Health Boards. Recommendations Education resources should be developed in HAI prevention and control that address needs and learning style of the domestic service workforce. Educational resources should, where possible, support preferred learning styles and delivery methods within the domestic services workforce. The development of educational solutions should support the buddy system ensuring buddies are confident and effective in their role and that learning opportunities are maximised. Domestic Service Managers should make greater use of the buddy system to achieve training goals and to encourage and facilitate staff progression. Experienced staff should be encouraged to put themselves forward to become buddies as a progression pathway. The buddy system should provide new employees with an informal support and social network and offer a starting point to address general queries. In turn, the system should give the buddy an opportunity to develop their skills in communication and to share the benefits of their experience. Ensure regular refresher training and guidance provision for dealing with violence and aggression as this would address the apparent ad hoc nature at present. Ensure the provision of regular refresher training on day-to-day, core technical skills that will support the reduction of HAI. Investigate further the possibility of accrediting the Workbook to introduce greater consistency and recognition of skills attainment (particularly in view of the lack of demand for other forms of accredited training). Review Supervisor training to introduce a more structured, consistent programme, or minimum requirements, covering for example: administration, staff management, and IT. Introduce basic IT training for all Domestic Assistants to widen access to other sorts of training, and to enable access to staff resources, such as intranet facilities. Ensure that induction training includes an introduction to a variety of situations and difficult circumstances, such as dealing with death and coming into contact with those who have been recently bereaved. 4

5 2. Introduction Providing a clean and safe environment for healthcare is a key priority for the NHS and is a core requirement in standards for better health. Cleaning and decontamination of healthcare environments has a hugely important role in ensuring that the risk to patients from healthcare associated infection (HAI) is prevented. Healthcare associated infections are those acquired within a healthcare environment. There are a number of factors that can increase a patient s risk of acquiring an infection, but high standards of infection control practice can minimise or even prevent the risk. The prevention of HAI is a high priority issue for NHSScotland. There are a number of actions in place to reduce HAI including processes, policies and procedures, audit and surveillance and, education and training. 1 The Healthcare Environment Inspectorate (HEI) was established in April 2009 to undertake at least one announced and one unannounced inspection to all acute hospitals across NHSScotland every 3 years. The focus of the HEI is to reduce the HAI risk to patients through a rigorous inspection framework. 2 Their aims are to: provide public assurance and protection, to restore public trust and confidence; contribute to the prevention and control of HAI; contribute to improvement in the healthcare environment including infection control, cleanliness and hygiene and the broader quality improvement agenda across NHSScotland. The HEI s function is to: give NHS Boards a proactive, assertive way to self-assess and report evidence; create a methodology for analysing NHS Board evidence that can validate, risk assess and identify targets for inspection; carry out rigorous inspections, from NHS Board level to hospital level to ward/clinical level; continuously monitor NHS Board improvement plans; make inspection findings public; 1 HAI Taskforce (2004), The Risk Management of HAI: A Proposed Methodology for NHSScotland Consultation Document 2 tions.aspx 5

6 make recommendations to Scottish Ministers. Success in reducing the risk of HAI is largely dependent on a commitment to hygiene and the prevention and control of infection by healthcare staff within the healthcare environment, as well as the public. The duties of a Domestic Assistant can help to make patients and their families feel confident that the healthcare environment is clean and safe. The fight against HAI makes it crucial that healthcare settings are as clean as possible. The knowledge and skills that Domestic Assistants have, including techniques and practices and the policies and processes underpinning them, is central to providing patients with a clean and comfortable setting and critical to preventing the spread of HAI. Through this research NHS Education for Scotland (NES) in partnership with Health Facilities Scotland (HFS) is seeking to clarify and review the training programmes, education provision, policy and procedures that exist for the staff whose role it is to clean and decontaminate the healthcare environment. Additionally, the research is tasked with identifying the key learning needs of the domestic services workforce. 2.1 Training in NHSScotland The NHS Reform (Scotland) Act 2004 enshrined in legislation a commitment to staff governance, and introduced the Staff Government Standard. Now in its fourth edition (June 2012), the Standard sets out a system of corporate accountability for the fair and effective management of all staff, and in so doing stipulates the roles and responsibilities of employers and employees in pursuit of this goal. Appropriately trained and developed staff are stipulated as a major feature of the Standard, bestowing on employers the responsibility to ensure that all staff have a: Regular, effective Personal Development Plan (PDP) and review discussion, in order to appraise past performance and identify any necessary learning and development opportunities. 3 All roles within the healthcare environment including Domestic Assistants are required to keep a PDP up to date, in collaboration with their manager through a mechanism of annual review. In support of this, the Skills and Knowledge Framework (KSF) was produced to assist staff in meeting their responsibilities to actively maintain their skills and development to ensure they are competent to perform their job safely and effectively. 3 6

7 4 Development Review Process taken from The Admin Centre Following the development of the KSF in 2004, the National Education and Training Framework for Domestic Services was devised and rolled-out across Scotland in 2007, especially for the following roles: Domestic Assistants Housekeepers Domestic Supervisors Assistant Domestic Services Manager Domestic Services Manager The Framework sets out the nationally agreed core capabilities, competences, knowledge and behaviours required of domestic services staff with the intention of introducing greater consistency and harmonisation across NHS Boards. With a particular focus on infection control specifically Standard Infection Control Precautions (SICPs) the framework describes three core and two additional capabilities expected of all domestic services staff. Whilst the purpose of the framework is to achieve consistency in practice, it is recognised that sufficient flexibility must be embedded to reflect local activity. This focus on staff development has been supported by the on-going development of a number of policies concerning infection prevention and control, such as: 4 7

8 NHSScotland Code of Practice for the Local Management of Hygiene and HAI, 2004 (currently under review); the National Specification for Cleanliness in the NHS: a framework for setting and measuring performance outcomes, April 2007; HAI mandatory Induction Training Framework which succeeded the Framework for Mandatory Induction Training in HAI for NHSScotland; National Cleaning Services Specification, April 2009; Monitoring Framework for NHSScotland National Cleaning Services Specification and Estates Monitoring Issues, January 2010; National Infection Prevention and Control Manual - Infection Prevention and Control of Healthcare-Associated Infections in Primary and Community Care, March 2012; 5 A commitment to maintaining adequate skills and knowledge is stressed through these documents by, for example, requirements for Continuing Professional Development (CPD) strategies in relation to HAI. Through the Code of Practice for the Local Management of Hygiene and HAI, an obligation is placed on healthcare workers including support staff to identify their own CPD objectives in regard to HAI, demonstrate competence in relation to prevention and control of HAI, and to set an example to others in maintaining safety in the work environment. The Healthcare Quality Strategy for Scotland published in 2010 states that...everybody delivering healthcare services in Scotland is motivated above all by the quality of service they provide in partnership with their colleagues, with patients and their families. 6 The Quality Strategy is a development of the Better Health, Better Care Action Plan (2007). The strategy builds upon improvements in tackling HAI, as well as reduction in patient waiting times and has been informed by discussions with NHSScotland Staff, independent primary care contractors as well as patients and carers. The strategy sets out a number of objectives, among them, We will work with and through people - our most valuable asset - our leaders, service users, health professionals and support staff to create and sustain a culture where quality can thrive and the contribution of every individual to quality is recognised and valued. 7 Previous research conducted in 2007, 8 and which informed the development of an education framework for administrative staff and support services, found staff had limited access to accredited learning programmes, little or no access to IT (typically used to deliver training) and that there was a lack of provision to develop trade skills. 5 This document is aimed at healthcare workers 6 The Scottish Government (2010), The Healthcare Quality Strategy for NHSScotland 7 The Scottish Government (2010), The Healthcare Quality Strategy for NHSScotland 8 Developing an Education Framework for Staff in Administrative Services and Support Services; Scoping Study and Stakeholder Consultation Report, April

9 More fundamentally, the research revealed significant challenges in regard to career progression and development and a lack of recognition concerning the contribution of such staff to the patient experience more generally Profile of domestic services staff It s not a wee woman pushing a mop; it s a profession and a very noble one Domestic Services Manager According to the most recent figures held by the Information Services Division (IDS), as of 30 th September 2010 Support Services comprised 11.8% of the NHSScotland workforce equating to approximately 19,800 individuals 10 (the total NHSScotland workforce totalled 168,051). Whilst these data provide a reliable indication of the scale of the Support Services workforce, there are no accurate figures for domestic services staff, alone. More recent projections released by the NHS National Services Scotland Information Services Division (ISD) for the financial year estimated that Support Staff would number 13,750.5 a reduction of 0.1% on the previous financial year 11. These figures are aggregated from estimates made by each of the NHS Boards: Ayrshire & Arran Borders Dumfries & Galloway Fife Forth Valley Grampian Greater Glasgow & Clyde Highland Lanarkshire Lothian Orkney Shetland Tayside Western Isles It should be noted however that the Support Staff category includes a total of 109 different job roles domestic services staff constitute only 6 of those job roles. 9 Developing an Education Framework for Staff in Administrative Services and Support Services; Scoping Study and Stakeholder Consultation Report, April It should be noted that these figures are based on whole time equivalents (WTE), rather than on headcount as the 2010 figures are. 9

10 These are: Code 78E1 78E2 78E3 78E4 78E5 78E6 Job Code Domestic Assistant Domestic Assistant higher level Domestic Supervisor Domestic Supervisor higher level Domestic Manager Domestic Manager higher level These figures should therefore be viewed as indicative only, and to provide a flavour of the potential size of the workforce. 10

11 3. Methodology 3.1 Aim and objectives The overarching aim of this piece of work was to establish the extent to which existing training programmes meet the key learning needs of NHSScotland staff that clean and decontaminate healthcare environments. The strategic aims of this project were to: provide an evidence base of available current education and training pertaining to the cleaning and decontamination of healthcare environments provided to NHSScotland staff, including scoping of all relating guidance and policy provided to staff; determine the potential impact of technological advances in the cleaning and decontamination of healthcare environments on the domestic services workforce; map the existing responsibilities of the staff who clean and decontaminate healthcare environments; establish the most effective means for the training and guidance of the healthcare domestic services workforce. The research was conducted over a 5 month period between November 2012 and March Approach A multi-faceted approach combining primary and secondary research methodologies has been undertaken spanning three, overlapping phases: Phase I: Secondary data review. Phase II: Primary research including interviews and focus groups with expert stakeholders; on-going secondary desk research. Phase III: Analysis of all data and reporting. A total of 20 expert stakeholder interviews have been carried out with individuals across Scotland from the following occupational areas: Facilities Manager Domestic Services Supervisor General Services Manager Educational Projects Infection Control Head of Safety 11

12 Manager Corporate General Manager - Facilities General Manager Facilities Hotel Services Manager Manager Nurse Adviser - HAI Support Services Manager Senior Charge Nurse Nurse Consultant HAI Public Reviewer Stakeholders interviewed were identified by NES and HFS and were drawn from across NHSScotland Healthcare Boards, NHS Special Health Boards and other sources detailed below: NHs Lanarkshire NHS Fife NHS Greater Glasgow and Clyde NHS Education for Scotland Scottish Government Health Protection Scotland Healthcare Environment Inspectorate Healthcare Improvement Scotland NHS Tayside General public hospital review volunteer NHS Dumfries and Galloway NHs Highland NHS Ayrshire and Arran Scottish Ambulance Service Focus groups were held with Domestic Assistants and separately with NHS staff from multiple disciplines which impact upon and/or connect with the roles and responsibilities of domestic service staff and their professional training. The groups took place across four NHSScotland Boards: Dumfries and Galloway Fife Ayrshire and Arran Greater Glasgow and Clyde The focus groups were organised by individuals identified and approached by NES and HFS. Nominated individuals were then responsible for organising two separate focus groups at their location, one for domestic services staff and one for staff from across multiple disciplines relating to HAI prevention. For domestic service staff separate focus groups were organised to encourage them to speak freely without the presence of their line managers and other senior staff. A wide variety of individuals with different areas of specialist expertise were invited to take part in the multidiscipline groups and although attendance, in terms of the 12

13 numbers and job roles of those who came along, varied between the four NHS Boards a broad range of job roles and responsibilities were represented. In addition to those that took part in telephone interviews, focus group attendees included: Physiotherapy Team Training Coordinator Domestic Service Lead Infection Control Doctor Catering Manager Consultant Microbiologist 13

14 4. Learning Mechanism 4.1 Learning styles Understanding learning styles is pivotal to ensuring the training that exists for the domestic service workforce is fit for purpose. There is clearly no perfect recipe either for training individuals or for encouraging further learning. Nevertheless, it stands to reason that the process of providing those responsible for the cleaning and decontamination of the healthcare environment with the necessary skills and knowledge to meet their responsibilities to the required standard begins with engagement. For the domestic workforce to have a better understanding of the subject matter they are learning, and for a more enjoyable experience to aid remembering and comprehension of training, it s important that the methods of teaching used are well suited to the types of learners within the workforce. Domestic staff are in some ways non-traditional learners in that for many it may have been a long time since they have been required to undertake any form of training. It therefore follows that confronting the constraints and barriers that exist around such issues as confidence and feeling comfortable in a training situation plays a large part in making sure that training is adequate to meet its purpose. Sometimes there are DVDs and this works quite well because it s visual and the domestics are happy to turn up and watch a DVD Telephone Interviewee Members of the domestic workforce were asked, through the focus groups, about their learning preferences. Visual and auditory, along with on-the-job learning were the most popular methods with online learning being the least favoured. Whilst online learning is becoming an increasingly common method of training delivery, feedback from both domestic services staff and NHS workers from other disciplines suggests that the effectiveness of IT as a means of training delivery for the domestic services workforce is limited by the preference of the learners. The most common form of training delivery is via a buddy system whereby new members of the domestic services team shadow and work alongside experienced staff. 14

15 seeing speaking doing Understanding listening reading Illustration of learning styles by preference of domestic services staff In developing approaches to training delivery that provide opportunities appropriate to the learner, it is necessary to assess to what extent the training resources that exist for Domestic Services staff meet their preferred learning styles. The National Cleaning Services Specification, published in 2009 states, Training programmes should be systematically applied and may well include a variety of training techniques including classroom and on the job training sessions. 12 While it is not always possible to support the learning preferences of individual workers there is clear indication from desk and primary research carried out for this study that the domestic service workforce appear to respond most positively to a blended learning approach incorporating supported classroom learning and practical demonstration. 4.2 Training delivery Induction training New recruits to the domestic services workforce undergo formal induction training with the aim of giving them a solid understanding that their role within NHSScotland is central in the fight against HAI. From Board to Board the length of induction can vary however; typically, training will cover specific aspects and discrete activities of the job and include: a breakdown of the responsibilities of the role; 12 NHSScotland (2009), National Cleaning Services Specification 15

16 an explanation of work scheduling; an explanation of Codes of Practice; explanation and/or demonstration of the correct use of equipment and materials; a breakdown of personal protective equipment used in the execution of different tasks; a tour of the healthcare site; a description of the security regulations in operation; an explanation of dealing with the Control of Substances Hazardous to Health (COSSH); an introduction to waste management rules and processes; an introduction to policies to do with linen. Within induction training there are mandatory elements. The example below is taken from one NHS Board. The requirements of mandatory training include: Moving and Handling; Fire Safety; Control of Infection; Hand Hygiene; Violence and Aggression; Elementary Food Hygiene.* * Elementary Food Hygiene is a requirement for domestic service staff whose responsibilities include the plating up and serving of food to patients. This responsibility is not widespread across NHSScotland Boards and varies from one hospital to another within individual Boards. Newly recruited NHS staff receive control of infection training as part of their induction. The Mandatory Induction training in HAI framework first introduced in 2005 has been recently revised and updated in The aims of the revised framework are stated as to: maximise the relatively limited opportunities offered during generic induction programmes to emphasise the importance of HAI and the key role individual healthcare workers can make to reducing its incidence; provide a foundation for continuing development activity designed to increase understanding. 13 Although training in the prevention of HAI is mandatory, programmes can be locally developed in line with the framework the framework provides support to 13 NHSScotland (2012), Revised Framework for Mandatory Induction Training in Healthcare Associated Infection for NHSScotland 16

17 organisations who wish to design their own HAI induction training by setting out principles underpinning the development and delivery of mandatory induction training in HAI and defining learning outcomes against which any locally developed programme should be mapped. 14 Induction training for domestic services staff, particularly at Domestic Assistant and Domestic Supervisor levels, can differ across Boards and across different healthcare settings within the same Board. In addition to mandatory elements it is common for induction training to include educating new starters in policies that are likely to include Board, divisional and specific environment policies as well as child protection regulation, domestic services standards policy and core value statement. 15 Initial training and induction involves a walk around the hospital to introduce all of the different areas, showing where the fire exits are - then it goes through the basics of cleaning, including things such as high and low dusting. I think it lasts about two days in the first week, then the same again the following week. Domestic Assistant Buddying The buddy system is intended to be one component of the overall programme of training and orientation. It provides an environment specific welcome to a new employee while enabling them to adjust to their new job and work environment and helps to promote a positive work attitude and build motivation from the outset. It is important to note however that while a buddy can provide a vital resource in promoting the prevention of HAI to a new colleague, he or she does not replace the important role the supervisor plays in orientating new people. This research revealed general support for the buddying system; however both domestic service staff and staff from other disciplines explained that they have some common concerns. For example, one attendee at a multidisciplinary focus group voiced concern that training new people may have a knock-on effect upon the productivity of the person being shadowed: Domestics end up training new people, but they have their own work to do, so there isn t enough time to train new people properly. A buddy is a knowledgeable and friendly colleague. They must have working knowledge of the healthcare environment, they should demonstrate a positive attitude, patience and strong interpersonal skills. Buddies should encourage new starters to become part of the team by reinforcing the importance of their role in preventing HAI. It is also important that someone chosen to be a buddy is able to maintain confidentiality. 14 NHSScotland (2012), Revised Framework for Mandatory Induction Training in Healthcare Associated Infection for NHSScotland 15 Information gathered from a study of job descriptions for domestic service staff 17

18 Senior domestic service staff interviewed set out the criteria they employ for choosing a buddy which involves selecting someone with the following characteristics: competence and efficiency; willingness to help others; friendliness and reliability. Evidence gathered through this research suggests that at present buddies are approached by their supervisor to take on the role. Little evidence of self-selection has come to light: a number of the Domestic Assistants who came along to our focus groups had experience of being buddies to new starters. A small number reported they were the designated buddy on their shift pattern. However, some were concerned that when they act as buddies to new staff or are responsible for working alongside staff who are not used to an area (perhaps working an overtime shift to cover absence), they may unwittingly pass on what are seen as bad habits. Bad habits where and if they exist are always unintentional, nevertheless staff reported concern that where there is a lack of refresher training, this causes anxiety that if they are not consistently adhering to the correct processes and techniques this could be passed on. there are many benefits to be gained from the proper use of a buddying system in the prevention of HAI. It can help to accelerate new employees ability to carry out their responsibilities and can assist in initial integration and orientation into environmental culture. The system can provide new starters with easy access to information and guidance in their first few shifts which in turn may have the effect of lessening any initial confusion or uncertainty often faced by new employees in any job role. Domestic Assistants who attended our focus groups explained that buddying can often be beneficial in team building, helping encourage responsibility of ownership, and encourages knowledge sharing among peers. Training is very ad hoc and is generally undertaken annually. This is usually back to basics refresher training, covering use of machinery, mops and cloths as well as the techniques we are supposed to use. Domestic Assistant On-going training Working toward the prevention of HAI, it is the responsibility of the Domestic Supervisor to monitor staff and identify any training needs. The National Cleaning Services Specification states, A record of training should be maintained and refresher training provided to all staff on a regular basis 16. The NHS Boards across Scotland differ in their approach to refresher training and in some cases there appears to be no formalised process for scheduling or carrying out training of this nature. One Domestic Manager described, 16 NHSScotland (2009), National Cleaning Services Specification 18

19 although there isn t a formal process for top up or refresher training, any needs would be picked up through monthly ward audits and inspections. Whilst our research indicates widespread disparity in the delivery of training across NHSScotland Boards there are many examples of good practice. For example, representatives of the NHS Boards we spoke to described close collaboration with Infection Control Teams (ICT) in the prevention of HAI. Research participants reported hosting and arranging training days aimed at operational services staff covering topics that include: hand hygiene and basic control of infection training along with customer care, food hygiene, and health and safety. Environmental audits were cited as an example of good practice in the prevention of HAI. These typically involve a spot check walk-around taking in multidisciplinary teams and this is supported by the National Audit Programme. 17 The Domestic Assistant and Domestic Supervisor Workbooks are key tools in the fight against HAI and appear popular with domestic and multidisciplinary staff alike. Anecdotally evidence suggests that the Domestic Assistant Workbook (known locally as the green book ) is well liked. Domestic Assistants and senior domestic staff reported that staff are willing to work through the book and, because it is presented in hard copy, they are not daunted by the task it poses. The Domestic Assistants Workbook has recently been reviewed to incorporate a healthcare support worker staff element. The workbook now takes in Healthcare Support Workers Standards which have been drawn from a separate document and includes, for example, information and questions around the Cleanliness Champions programme which is a popular tool in the prevention of HAI. Domestic Managers were involved in the review of the Domestic Assistants Workbook and on the whole feedback received through focus groups from both Domestic Assistants and senior domestic service staff was positive. It was reported that in some NHS Boards only new staff will be required to work through the reviewed workbook whereas in others we were told all staff are required to complete it as a refresher and because it s good practice 18. Domestic Supervisors responsible for overseeing the completion of the workbooks explained that they provide close support to those working through it. The current version of the Workbook was published in 2007, with a revised version planned for March Its purpose is to get supervisors supervising, not about do you know this procedure, according to one focus group attendee Training for Domestic Supervisors The training available to supervisor staff is similar to that designed for Domestic Assistants. It is common for Domestic Supervisors to be promoted from the ranks of Domestic Assistants and therefore have well developed cleaning and 17 Health Protection Scotland (2012), National Hand Hygiene NHS Campaign 18 Feedback from multidisciplinary focus group 19

20 decontamination skills, a sound knowledge of the HAI prevention requirements and understanding of the critical importance of HAI prevention. Supervisor training typically covers such aspects of the role as (but not limited to): staff training; staff delegation; promotion of HAI prevention; putting together rotas; dealing with conflict; staff monitoring and appraisal; sickness absence monitoring and carrying out the sickness absence policy; coping with grievances from staff. As with Domestic Assistant training, a buddying system is often employed. A new supervisor will shadow an existing supervisor to gain first-hand experience of the operational aspects of the role. Through focus group discussions it was put forward that reflective learning is one method valued by supervisors and their managers when training both new supervisory staff and for on-going learning. The workbook is generally felt to be a useful tool to promote HAI prevention awareness and to encourage learners to reflect on what they have learnt. Depth interview respondents also identified the following training materials: Supervisors Training Pack developed by Health Facilities Scotland (HFS); National Monitoring System Staff secondment to different NHS Boards There is a staff exchange policy in place in some, but not all, of the Boards that contributed to this research. Where this exists supervisors are seconded to other NHS Boards for varying periods of time, from just a day or two, to weeks in some instances. The purpose of this is to gain an understanding of HAI prevention methods in different settings and to spread best practice. Meetings are held with senior domestic staff from the Board to which Supervisors are seconded - usually weekly - in order to discuss what staff feel has gone well and what hasn t, as well as examples of good practice in HAI prevention or any observations of where improvements could be made. It is commonly felt by supervisors and managers who have been involved in this process that it provides a very useful means of sharing good practice between Boards, it can encourage productivity and enhance job satisfaction. 20

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