INFECTION CONTROL “The majority were either trained by a


colleague or it was in their basic training some years ago, but very few had formal training from their employer,” said Martin Kiernan. “One in three had received no cleaning training at all; some 20% had received no formal training in cleaning mattresses, yet all the mattresses were cleaned by nurses; while 30% had received no training in cleaning of clinical equipment. Most people had no training at all on cleaning of human waste disposal products, such as bed pans. This is despite the fact that these are a major source of pathogens,” he added. The survey also asked about nurses’


confidence in their cleaning abilities – 80% said they could clean, yet 60% said that their ability to clean had not been assessed. How did they know if they were cleaning effectively, therefore? A further study, by Anderson et al, also


involved an audit of cleaning effectiveness of clinical surfaces and equipment using an ATP assay.4


The audit found that


professional cleaning staff were much better at cleaning than nurses. “This should come as no surprise –


they are trained, receive education and updates on cleaning technologies, and how to use the equipment they use. When nurses clean they may raid the domestic’s cupboard and see what is available and have a go, or use wipes. Are they using the proper equipment? Hotel services may be using microfibre, everyone else is using something else. Where is the consistency?” said Martin Kiernan. In fact, the study looked at 27 items


cleaned by clinical staff – 89% failed the benchmark for cleaning. The authors concluded that nursing staff should receive ‘relevant and regular training’. “So how are we going to teach nurses


how to clean effectively?” asked Martin Kiernan. “If you simply tell people how to clean, they will forget it. If you show them, they may remember it. But it is better to involve them, so they understand.” He suggested that the use of UV


markers is one approach that may help in training. UV markers are used to test whether items thought to be high-touch are properly cleaned. Using this approach, a study by Carling et al showed significant failures in terminal cleaning of isolation rooms – UV markers indicated that 49%


‘There are still some directors of nursing that are resistant to training nurses to clean, as they feel it is not a nurse’s job. However, given the increasing pressures being faced by the health service, the situation is only going to get worse.’


of services were not clean.5 The authors


also found wide variation in cleaning performance – in some instances, 81% of high touch areas were not cleaned. In a study by Alfa and Dueck et al,a


UV-visible marker further confirmed that environmental persistence of Clostridium difficile spores in toilets of patients with C. difficile-associated diarrhoea is associated with lack of compliance with cleaning protocols.6 “The UV marker was found on half of


the toilet samples and 75% of the commode samples. In fact on 72% of all days sampled, commodes were not cleaned at all. Hopefully, this would not happen today. In my organisation, we randomly test commodes once a week and this has resulted in an improvement in cleaning,” said Martin Kiernan. One approach that could help improve


nurses’ understanding of cleaning is the use of a ‘pictorial’ manual, Martin Kiernan suggested. The concept, developed by Judy Ptak et al,7


is to


provide a visual tool to identify which items should be cleaned by the nursing staff and how cleaning should be performed. A key aim of this approach is to prevent misunderstandings over division of cleaning tasks and to ensure key areas are not missed as a result. The approach is simple and practical, but an important aspect of this work is also the fact that staff are involved in deciding who will be responsible for cleaning specific items. Drawing his presentation to a close,


Martin Kiernan went on to suggest some further research opportunities in the area of nurse cleaning – including qualitative research of nurses’ knowledge and attitudes to cleaning, and the impact of training and education on nurses’ ability to clean. In conclusion, he commented: “There


are still some directors of nursing that are resistant to training nurses to clean, as


‘A survey of over 1,000 nurses and healthcare assistants found that over half believed that cleaning services were inadequate and a fifth said hospital managers had cut back on cleaning.’


44 THE CLINICAL SERVICES JOURNAL


they feel it is not a nurse’s job. They do not accept that this is a regular occurrence. However, given the increasing pressures being faced by the health service, the situation is only going to get worse. It is time to ‘get real’ and accept the obvious – nurses do clean, and need to, but they do not do it well. Therefore, someone needs to train them to do it and convince them of its importance.”





* Prof. Tanner was announced as the winner of the IPS Research Award for her work on highlighting patients’ experiences of SSIs.


References 1 Nseir S, Blazejewski C, Lubret R,Wallet F, Courcol R, Durocher A, Intensive Care Unit, Calmette Hospital, University Hospital of Lille, Lille, France. Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit. Clin Microbiol Infect. 2011 Aug;17(8):1201-8. doi: 10.1111/j.1469- 0691.2010.03420.x. Epub 2010 Dec 13.


2 Dumigan D, Boyce J, Havill N, Golebiewski M, Balogun O, Rizvani R. Who is really caring for your environment of care? Developing standardised cleaning procedures and effective monitoring techniques. Am J Infect Control. 2010 Jun; 38(5): 387-92.


3 Havill, N; Havill H, Mangione E; Dumigan D; Boyce J. Cleanliness of portable medical equipment disinfected by nursing staff. Am J Infect Control. 2011 Sep; 39(7): 602-4. Epub 2011 Apr 15. PubMed PMID: 21496956.


4 Anderson RE, Young V, Stewart M, Robertson C, Dancer SJ. Cleanliness audit of clinical surfaces and equipment: who cleans what? Journal of Hospital Infection 78 (2011) 178e181.


5 Carling et al. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals, ICHE 2008:29:1-7.


6 Alfa M, Dueck, Olson N, DeGagne P, Papetti S,Wald A, Lo E, Harding G. UV-visible marker confirms that environmental persistence of Clostridium difficile spores in toilets of patients with C. difficile-associated diarrhea is associated with lack of compliance with cleaning protocol. BMC Infectious Diseases 2008, 8:64 doi:10.1186/ 1471-2334-8-64.


7 Judy Ptak et al. Who’s Responsible for Cleaning That? Outpatient Surgery September 2009.


NOVEMBER 2012


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