Healthcare Staff Well-being strategy 3

How to improve healthcare staff's well-being - strategy no.3

In our 2 previous articles (see links below), we have identified a few causes of stress among healthcare facilities' staff. We have enumerated a few strategies which are intended to reduce or entirely remove the presence of stressors from the physical working environment in order to alleviate emotional tensions. Among these, are:

Reconnecting with nature (link to 1st strategy article)
Team building and places of respite (link to 2nd strategy article)

And now we find ourselves in the middle of a pandemic which puts anyone of us who follows the latest news feeds face to face with what stress can mean for healthcare workers. We have read numerous posts from hospital staff (both front-line healthcare workers as logistic and administrative staff) crying out for help. Sources of distress are numerous, such as incapacity to treat patients due to lack of equipment, being faced to death for doctors whose specialties never trained them for this and isolation from caring family members. But the fear of contamination is probably the most generally unnerving.

A striking raise of depression rates, anxiety and insomnia among caregivers seems inevitable after Covid-19 epidemic.

Indeed, in China, where the epidemic started, investigators, led by Jianbo Lai, MSc, from Zhejiang University School of Medicine, Hangzhou, China, have published the results of a survey of more than 1200 healthcare workers in this country. The survey was conducted over a period of a week only and did not take into account the previous psychological conditions of the surveyed, but still the findings are striking: about 50% reported at least mild depression; 14% of physicians and nearly 16% of nurses reported moderate or severe depressive symptoms and about 34% reported insomnia (read the full report on Jama Network Open). As expressed in their conclusion: "The psychological response of health care workers to an epidemic of infectious diseases is complicated.

Sources of distress may include feelings of vulnerability or loss of control and concerns about health of self, spread of virus, health of family and others, changes in work, and being isolated."

This brings us to the need of yet another "passive" strategy to help healthcare personnel's well-being: providing a safe environment.

Yes, we are facing exceptional times, and this article is not meant to address pandemic crisis only, because, truly, healthcare facilities need to be ready to front all types of sanitary situations.

Under all circumstances, it is crucial to continuously comfort healthcare staff by creating environments that fulfill their need for safety.

Security encompasses many aspects, such as protection against aggressive acts (usually from patients) or reduction of risk for falls or injuries. In this article we will however focus on one of the primary causes of anxiety for healthcare staff: infection control and prevention and the psychological effects of the measures taken. Staff's perception of cleanliness is indeed not to be underestimated if we want to address their psychological well-being.

1. Infection Prevention and Control

As we saw above, one of the primary risks any healthcare worker takes when working in hospitals or clinics is that of contracting contagious illnesses him- or herself. Hospitals are well aware of this complex subject which is the continuous source of many studies. This is why infection prevention officers are now commonly part of their staff.

Infection prevention can only be done if the environments can be kept clean easily, efficiently and durably.

Pathogens can be borne through different media. Some are airborne, some waterborne and lots land on surfaces frequently being touched. Hand washing and cleaning of surfaces is thus key to avoiding transmission. So is keeping surfaces dry as well, because microbes die off as the surface dries.

In order to achieve these goals, it is crucial that, from the inception of the design process of a healthcare building (either new construction or renovation), the architects, designers and MEP (mechanical, electrical and plumbing) engineers, work in an integrated fashion with the infection prevention team and technical managers of those facilities. Working with knowledgeable experts is the best way to achieve environments that facilitate IPC (infection prevention and control). At a minimum, this integrated design team needs to consider the below strategies.

a. Hand Sanitation

Installing a wash basin at the entrance of each patient room is a practical way to promote handwashing before and after seeing the patient.

b. Materials' Selection & Application

To ease the removal of pathogens from surfaces when cleaning, care needs to be given to the choice of the finishes and to the way they are applied or joined. When selecting the materials, we must first understand to which category the room belongs (ranging from the most critical to the least critical areas) and then understand how the applicable surface can or will be cleaned (manually or mechanically and with which type of disinfectant). Clearly the surface needs to ease the cleaning process and at the same time be able to retain all of its properties. Some studies have shed light on commonly used materials and what types of pathogens will adhere to them. Although many studies are still inconclusive, especially for soft finishes on which they are trickier to measure, we can still draw a few conclusions.

First of all microorganisms tend to nestle in micro-topographies of the material's surface where they are difficult to remove. The more critical a room is, the more it is essential to avoid porous or rough materials. Not only will microbes get trapped in them but so will water used for cleaning, making these porosities ideal nests for pathogens to grow. Joints and seams between elements need to be minimized or sealed properly for the same reasons. Finally, sharp or right angles at junctions between different elements need to be avoided as well.

Coved skirtings are for instance a widely used solution to avoid the accumulation of dirt and microorganisms between walls and flooring.

Consider using self-cleaning materials.

Certain materials have self-cleaning properties. It's the case of those containing silver or copper (eg. metal alloys, copper beds or fabrics with copper wires) which are naturally resistant to microbes. Researchers are biomimicking the roughened surfaces of the lotus leaf to create finishes with miniature air pockets that minimize the contact area between the surface and a liquid. Other materials however have been treated with antimicrobial chemicals and should therefor be evaluated carefully as they may be toxic or could contribute to the resistance of certain bacteria.

c. Fixtures and Furniture Selection

The same principles should be applied when selecting furniture. Bacteria will equally get trapped in micro-cavities, eg. seams of fabric on upholstered chairs, spaces between cushions of sofas,... It is thus essential to choose furniture that contains minimum pockets for dirt and that can easily be cleaned, such as removable cushions on sofas, crypton® backing on fabrics, washable privacy curtains, vinyl finishes,... .

Furniture on wheels, recessed equipment, full-height cabinets and sloped surfaces for a hassle-free cleaning.

Furthermore, furniture and fixtures should not be an obstacle for the sanitation process. They should thus be easily movable or have sufficient clear space around and underneath them to ease the cleaning of the room. Horizontal surfaces out of hand's reach should be avoided as they quickly collect dust and germs. Instead, opt for sloped surfaces, full-height or recessed elements.

In wet rooms potential sources of contamination through waterborne microbes should be minimized. Leakage from sinks or wash basins is for instance a quite common problem. Therefore avoiding the placement of enclosed cabinets below these are a good solution to first of all, identify the leakage problem quickly as it will spill on the floor, and secondly prevent accumulation of moist on a rarely cleaned horizontal surface.

It was also demonstrated that faucets with aerators, designed to reduce water consumption, show significantly higher levels of infectious pathogens in the water (Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America, Feb. 2014). Laminar flow faucets on the other hand keep water from mixing with germ-filled air but still reduce water flow and consumption.

Finally contact-less fixtures and equipment should be promoted where possible. Think of motion sensors automation or commonly used elbow faucets at scrub sinks for instance.

d. Air Quality

We have all learned the lesson from the plague epidemic, or Black Death, in the 14th century, where it was believed that diseased needed to be locked up in the dark:

Properly ventilating a room is crucial to prevent the accumulation of airborne germs.

What does properly ventilating mean? The aim is to maintain comfortable levels of temperature and humidity, control odors, remove contaminated air and circulate the air within the building such as to minimize risks for transmission of infectious airborne pathogens.

The temperature in healthcare facilities should be such as to ensure good comfort levels for patients and staff alike. This can either be achieved by equipping those with individual thermostats or by setting the temperature to a range of 21 - 24°C (depending on the section distributed by the HVAC system). Critical rooms such as operating theaters, endoscopy suites and cleanrooms need to be slightly cooler. Temperatures here are set between 20-23°C so as to ensure physically active staff to feel comfortable. At this range the body temperature of the patient is most likely not to drop too much as this would put her or him at a higher risk of infection.

High levels of relative humidity (above 60%) in the air can promote fungal growth and should thus be avoided. They are furthermore perceived as uncomfortable. The most comfortable range lies between 30 and 60% of relative humidity at the above room temperatures.

Additionally, the air needs to be carefully circulated to avoid transmission of airborne diseases. Air intakes need to be located at sufficient distance from potential sources of contamination. It is recommended to keep a minimum distance (approx. 7,5m) between air intakes and exhausts to prevent sucking contaminated exhausted air back into the system. They should also be placed high enough above the ground floor and the roof level.

For the same reason, some rooms in hospitals are pressurized to isolate highly infectious or high-risk immunocompromised patients. In other words, the difference in pressure will move air from positive to negative pressure air zones. Negative pressure rooms are designed to hold infectious patients so as to prevent airborne microorganisms in the room from entering adjacent public spaces. Some of these rooms are isolated with an ante-room and are intended for highly infectious patients. PE (Protective Environment) rooms on the contrary work with positive rooms so as to keep high-risk immunocompromised patients safe during recovery.

Finally, cleaning of the air through appropriate filters needs to happen at different points of the ventilation system. A minimum of 2 sets of filters is to be applied when part of the indoor air is recirculated into the building. First set is to be installed at the outdoor air intake to remove pollutant particles from the air. The second set should be placed where new air has been mixed and reconditioned with recycled air to prevent recirculation of unwanted particles. HEPA filters (costly, but highly effective filters) are to be installed in special-care areas for extra precautions. Think of critical operating theaters or the above mentioned PE rooms.

e. Conclusion and Resources

We have addressed different aspects of IPC pertaining to the physical environment of a clinic or hospital, such as access to hand sanitizer and wash basins, finishes, furniture, fixtures and air quality. These are just a few strategies that need to be taken into consideration by the integrated design teams, but there are many more: water quality, circulation flows, proper design of central sterile services department, clear marking of sterile areas, waste management,... . If you would like to read more on this topic, I encourage you to read the following resources:

On the design of healthcare environments:

The Center for Health Design, Infection Control,(https://www.healthdesign.org/topics/infection-control)
Centers for Disease Control and Prevention, https://www.cdc.gov/
Health Facility Guidelines, Infection Control, http://healthfacilityguidelines.com/GuidelineIndex/Index/Infection-Control

On infection control and prevention research and guidance:

WHO's infection prevention and control section, https://www.who.int/infection-prevention/about/en/
European Center for Disease Prevention and Control, https://www.ecdc.europa.eu/
Healthcare Without Harm, green cleaning guidance, https://noharm-europe.org/sites/default/files/documents-files/5717/finalhhgreencleaningguidance-version2.0december2016.pdf
Facility Guidelines Institute, https://fgiguidelines.org/

Additionally hospital accreditations, such as Joint Commission International and Accreditation Canada also prescribe uses of different guidelines for a better IPC.

2. Perception of cleanliness

If the physical environment has been designed to help IPC, results will be recognized and healthcare staff will soon be aware and comforted by the positive outcomes of the measures taken. The WHO has estimated that "effective infection prevention and control reduces health care-associated infections by at least 30%".

However, the perception of cleanliness is not always in line with the actual physical cleanliness of a facility.

In their study An exploratory study into the factors that influence patients' perceptions of cleanliness in an acute NHS trust hospital, 2007, Whitehead, H., May, D., and Agahi, H. have questioned different members of in-patient hospitals' personnel as well as in-patients themselves in order to identify how patients perceive the cleanliness of a facility in the UK.

The main themes of influence were found to be the appearance of the environment, staff behavior and the actual physical cleanliness. As the appearance of the environment was concluded to be the primary influencer, patient and staff alike suggested that a well maintained and presented building lead the patients to believe it was actually clean. Positive aspects of the environment, were often cited using the words "uncluttered", "tidy" and "well kept". "Bright and airy spaces" also had a positive impact, and staff found that patient would also be influenced by the refurbished areas with pale woodwork and modern colors, likely because these reflected the latest trends in the residential sector. Older non-refurbished areas carried an image of dirtiness with them despite their real hygiene level.

Even if only the perception of patients was surveyed in this study, it is not unreasonable to think that the staff, as human beings, would be influenced by similar factors. There is a complex set of perceptions at play, between what people consider to be important, what they observe and what they expect as well as their educational background (knowledge of IPC as an example). But keeping these findings in mind when (re)designing healthcare facilities should not only

help patient satisfaction but also staff well-being by creating those perceivably clean environments that respond to our need for safety.

by Sylvie Meunier

April 16, 2020

link to 1st strategy article - reconnecting with nature
link to 2nd strategy article - team building and places of respite