Attitudes and beliefs, not just knowledge, influence the effectiveness of environmental cleaning by environmental service workers

Abstract

Hospital environmental service workers (ESWs) play an important role in interrupting the chain of infection because the environment is a reservoir for nosocomial pathogens. Improving ESWs' knowledge through education has been shown to improve ESW cleaning, but the behavioral determinants of their work have not been studied. Understanding and targeting ESWs' attitudes and beliefs may inform strategies to improve environmental cleaning. With the theory of planned behavior as framework, we used questionnaires and focus groups to examine intensive care unit ESWs' attitudes, beliefs [behavioral, normative, and control], and control) and intent about their job. Baseline quantitative microbial cultures of high-touch services were performed before and after cleaning. After an educational intervention addressing their attitudes, beliefs, and general infection control knowledge, attitudes, beliefs, and microbial contamination were reassessed. Beliefs were uniformly strong (4.5/5-5/5), and normative beliefs correlated best with intent to clean (R(2) = 0.3). Themes elicited from the focus groups included "me versus them," lack of appreciation, pride in work, and "if it were me." The rate of environmental contamination was significantly improved after the intervention (P = .0074 vs P = .0023, respectively); the measured relationship among attitudes, beliefs, and intent was not significantly changed. ESWs' attitudes and beliefs about their job may impact their intent to clean and in turn the effectiveness of their efforts. Understanding and addressing these attitudes and beliefs can be used to inform strategies for sustained improvement of environmental cleaning.