Factors associated with environmental service worker cleaning practices in health care settings: A systematic review of the literature

Published:January 08, 2021DOI:


      • Indirect contact transmission can be reduced through environmental disinfection.
      • Environmental service workers are central to effective disinfection.
      • Education combined with performance feedback essential to improved outcomes.
      • Randomized controlled trials with larger samples needed to determine effect.


      Health care-associated infections can be reduced through better environmental disinfection practices. Central to effective disinfection is the environmental service worker (ESW). The aim of this systematic literature review was to identify factors associated with the disinfection practices of ESWs in health care settings.


      A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles. Ten online databases and search engines were selected for the review of English-language studies published between 2000 and 2019.


      Thirty-one (31) eligible studies were identified. Environmental disinfection was associated with many factors (eg, knowledge, perceptions) as well as ESW exposure to education/training sessions. When education/training was combined with performance evaluation/feedback, significant improvement in ESW disinfection practices was reported.


      To sustain improvements in disinfection practices, education/training sessions need to be continuous. The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs. Future studies need to use a randomized controlled design with larger sample sizes to determine a true effect.

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        • Zimlichman E
        • Henderson D
        • Tamir O
        • et al.
        Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.
        JAMA Intern Med. 2013; 173: 2039-2046
      1. Centers for Disease Control and Prevention. Healthcare-Associated Infections (HAIs), CDC Winnable Battles Final Report, CDC. Available at: Accessed January 25, 2021.

        • The U.S. Department of Health and Human
        Overview—Health Care-Associated Infections—
        2019 (Available at:) (Accessed July 30, 2020)
      2. Siegel JD, Rhinehart E, Jackson M. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at: Accessed July 30, 2020.

        • Eckstein BC
        • Adams DA
        • Eckstein EC
        • et al.
        Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods.
        BMC Infect Dis. 2007; 7: 61
        • Loo VG
        • Poirier L
        • Miller MA
        • et al.
        A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.
        N Engl J Med. 2005; 353: 2442-2449
        • Wu HM
        • Fornek M
        • Schwab KJ
        • et al.
        A norovirus outbreak at along term-care facility: the role of environmental surface contamination.
        Water. 2005; 26: 802-810
        • Morter S
        • Bennet G
        • Fish J
        • et al.
        Norovirus in the hospital setting: virus introduction and spread within the hospital environment.
        J Hosp Infect. 2011; 77: 106-112
        • Dancer SJ.
        Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination.
        Clin Microbiol Rev. 2014; 27: 665-690
      3. Centers for Disease Control and Prevention. Environmental hygiene in healthcare | HAI | CDC. 2015. Available at: Accessed July 30, 2020.

        • Peters A
        • Otter J
        • Moldovan A
        • Parneix P
        • Voss A
        • Pittet D.
        Keeping hospitals clean and safe without breaking the bank; summary of the Healthcare Cleaning Forum 2018.
        Antimicrob Resist Infect Control. 2018; 7: 132
        • Ni K
        • Chen B
        • Jin H
        • Kong Q
        • Ni X
        • Xu H.
        Knowledge, attitudes, and practices regarding environmental cleaning among environmental service workers in Chinese hospitals.
        Am J Infect Control. 2017; 45: 1043-1045
        • Carling PC
        • Parry MM
        • Rupp ME
        • Po JL
        • Dick B
        • Von Beheren S.
        Improving cleaning of the environment surrounding patients in 36 acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: 1035-1041
        • Dumigan DG
        • Boyce JM
        • Havill NL
        • Golebiewski M
        • Balogun O
        • Rizvani R.
        Who is really caring for your environment of care? Developing standardized cleaning procedures and effective monitoring techniques.
        Am J Infect Control. 2010; 38: 387-392
        • Bernstein DA
        • Salsgiver E
        • Simon MS
        • et al.
        Understanding barriers to optimal cleaning and disinfection in hospitals: a knowledge, attitudes, and practices survey of environmental services workers.
        Infect Control Hosp Epidemiol. 2016; 37: 1492-1495
        • Dancer SJ
        • White LF
        • Lamb J
        • Kirsty KE
        • Robertson C.
        Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
        BMC Med. 2009; 7: 1-12
        • Mitchell BG
        • Hall L
        • White N
        • et al.
        An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial.
        Lancet Infect Dis. 2019; 19: 410-418
        • Ray AJ
        • Deshpande A
        • Fertelli D
        • et al.
        A multicenter randomized trial to determine the effect of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection.
        Infect Control Hosp Epidemiol. 2017; 38: 777-783
        • Jennings A
        • Sitzlar B
        • Jury L.
        A survey of environmental service workers’ knowledge and opinions regarding environmental cleaning.
        Am J Infect Control. 2013; 41: 177-179
        • Pedersen L
        • Masroor N
        • Cooper K
        • et al.
        Barriers and perceptions of environmental cleaning: an environmental services perspective.
        Am J Infect Control. 2018; 46: 1406-1407
        • Jeanes A
        • Hall TJ
        • Coen PG
        • Odunaike A
        • Hickok SS
        • Gant VA.
        Motivation and job satisfaction of cleaning staff in the NHS: a pilot study.
        J Infect Prev. 2012; 13: 55-64
        • Saeb A
        • Mody L
        • Gibson K.
        How are nursing homes cleaned? Results of a survey of 6 nursing homes in Southeast Michigan.
        Am J Infect Control. 2017; 45: e119-e122
        • Zuberi DM
        • Ptashnick MB.
        The deleterious consequences of privatization and outsourcing for hospital support work: the experiences of contracted-out hospital cleaners and dietary aids in Vancouver, Canada.
        Soc Sci Med. 2011; 72: 907-911
        • Yanke E
        • Moriarty H
        • Carayon P
        • Safdar N.
        “The invisible staff”: a qualitative analysis of environmental service workersʼ perceptions of the VA Clostridium difficile prevention bundle using a human factors engineering approach.
        J Patient Saf. 2018; 00: 1
        • Boyce JM
        • Havill NL
        • Lipka A
        • et al.
        Variations in hospital daily cleaning practices.
        Infect Control Hosp Epidemiol. 2010; 31: 99-101
        • Xie A
        • Rock C
        • Hsu Y-J
        • et al.
        Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach.
        IISE Trans Occup Ergon Hum Factors. 2018; 6: 178-191
        • Allen M
        • Hall L
        • Halton K
        • Graves N.
        Improving hospital environmental hygiene with the use of a targeted multi-modal bundle strategy.
        Infect Dis Heal. 2018; 23: 107-113
        • Matlow AG
        • Wray R
        • Richardson SE.
        Attitudes and beliefs, not just knowledge, influence the effectiveness of environmental cleaning by environmental service workers.
        Am J Infect Control. 2012; 40: 260-262
        • Mitchell BG
        • White N
        • Farrington A
        • et al.
        Changes in knowledge and attitudes of hospital environmental services staff: the Researching Effective Approaches to Cleaning in Hospitals (REACH) study.
        Am J Infect Control. 2018; 46: 980-985
        • Murphy CL
        • MacBeth DA
        • Derrington P
        • et al.
        An assessment of high touch object cleaning thoroughness using a fluorescent marker in two Australian hospitals.
        Healthc Infect. 2011; 16: 156-163
        • Ragan K
        • Khan A
        • Zeynalova N
        • McKernan P
        • Baser K
        • Muller MP.
        Use of audit and feedback with fluorescent targeting to achieve rapid improvements in room cleaning in the intensive care unit and ward settings.
        Am J Infect Control. 2012; 40: 284-286
        • Sitzlar B
        • Deshpande A
        • Fertelli D
        • Kundrapu S
        • Sethi AK
        • Donskey CJ.
        An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms.
        Infect Control Hosp Epidemiol. 2013; 34: 459-465
        • Smith A
        • Taggart LR
        • Lebovic G
        • Zeynalova N
        • Khan A
        • Muller MP.
        Clostridium difficile infection incidence: impact of audit and feedback programme to improve room cleaning.
        J Hosp Infect. 2016; 92: 161-166
        • Carling PC
        • Parry MF
        • Bruno-Murtha LA
        • Dick B.
        Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission.
        Crit Care Med. 2010; 38: 1054-1059
        • Watson PA
        • Watson LR
        • Torress-Cook A.
        Efficacy of a hospital-wide environmental cleaning protocol on hospital-acquired methicillin-resistant Staphylococcus aureus rates.
        J Infect Prev. 2016; 17: 171-176
        • Datta R
        • Platt R
        • Yokoe DS
        • Huang SS.
        Environmental cleaning intervention and risk of acquiring multidrug-resistant organisms from prior room occupants.
        Arch Intern Med. 2011; 171: 491-494
        • Goodman ER
        • Piatt R
        • Bass R
        • Onderdonk AB
        • Yokoe DS
        • Huang SS.
        Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms.
        Infect Control Hosp Epidemiol. 2008; 29: 593-599
        • Semret M
        • Dyachenko A
        • Ramman-Haddad L
        • Belzile E
        • McCusker J.
        Cleaning the grey zones of hospitals: a prospective, crossover, interventional study.
        Am J Infect Control. 2016; 44: 1582-1588
        • Boyce JM
        • Havill NL
        • Dumigan DG
        • Golebiewski M
        • Balogun O
        • Rizvani R.
        Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay.
        Infect Control Hosp Epidemiol. 2009; 30: 678-684
        • Guerrero DM
        • Carling PC
        • Jury LA
        • Ponnada S
        • Nerandzic MM
        • Donskey CJ.
        Beyond the Hawthorne effect: reduction of Clostridium difficile environmental contamination through active intervention to improve cleaning practices.
        Infect Control Hosp Epidemiol. 2013; 34: 524-526
        • Hayden MK
        • Bonten MJM
        • Blom DW
        • Lyle EA
        • van de Vijver DAMC
        • Weinstein RA.
        Reduction in acquisition of vancomycin-resistant Enterococcus after enforcement of routine environmental cleaning measures.
        Clin Infect Dis. 2006; 42: 1552-1560
        • Hota B
        • Blom DW
        • Lyle EA
        • Weinstein RA
        • Hayden MK.
        Interventional evaluation of environmental contamination by vancomycin-resistant enterococci: failure of personnel, product, or procedure?.
        J Hosp Infect. 2009; 71: 123-131
        • Harrison JK
        • Reid J
        • Quinn TJ
        • Shenkin SD.
        Using Quality Assessment Tools to Critically Appraise Ageing Research: A Guide for Clinicians. Vol. 46, Age and Ageing.
        Oxford University Press, Oxford, England2017: 359-365
        • Ma L-L
        • Wang Y-Y
        • Yang Z-H
        • Huang D
        • Weng H
        • Zeng X-T
        Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better?.
        Mil Med Res. 2020; 7: 7
        • Downs SH
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Lohr KN.
        Rating the strength of scientific evidence: relevance for quality improvement programs.
        Int J Qual Health Care. 2004; 16: 9-18
        • Müller B
        • Armstrong P
        • Lowndes R.
        Cleaning and caring: contributions in long-term residential care.
        Ageing Int. 2018; 43: 53-73
        • Dumyati G
        • Stone ND
        • Nace DA
        • Crnich CJ
        • Jump RLP.
        Challenges and strategies for prevention of multidrug-resistant organism transmission in nursing homes.
        Curr Infect Dis Rep. 2017; 19: 18
        • McMichael TM
        • Clark S
        • Pogosjans S
        • et al.
        COVID-19 in a long-term care facility—King County, Washington, February 27–March 9, 2020.
        Morbid Mortality Wkly Rep. 2020; 69: 339-342
        • Harrison EM
        • Ludden C
        • Brodrick HJ
        • et al.
        Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks.
        Genome Med. 2016; 8: 1-9
        • Morgan DL.
        Focus groups.
        Annu Rev Sociol. 1996; 22: 129-152
        • Glasow P.
        Fundamentals of Survey Research Methodology.
        2005: 1-32 (Available at:) (Accessed July 30, 2020)
        • Palesy D.
        Brief classroom training sessions for workplace readiness: are they effective?.
        Int J Train Res. 2017; 15: 119-135
        • Laker DR
        • Powell JL.
        The differences between hard and soft skills and their relative impact on training transfer.
        Hum Resour Dev Q. 2011; 22: 111-122
        • Mitchell BG
        • Wilson F
        • Dancer SJ
        • McGregor A.
        Methods to evaluate environmental cleanliness in healthcare facilities.
        Healthc Infect. 2013; 18: 23-30
        • Carling P.
        Methods for assessing the adequacy of practice and improving room disinfection.
        Am J Infect Control. 2013; 41: S20-S25
        • Bryant MR
        • Collins McLaughlin A
        • Walsh F
        The role of knowledge, control beliefs, and surface types on the risk judgments of environmental service workers.
        in: Proc 2012 Symp Hum Factors Ergon Heal Care, CA, Hum Factors Ergon Soc. 2012: 83-86 (Available at:) (Accessed July 30, 2020)
      4. Brown KG. The Cambridge Handbook of Workplace Training and Employee Development. 2017. Available at: Accessed July 30, 2020.

        • Johnson D
        • Madison S
        • Rutherford P
        • Baron EJ
        • Huang C.
        “10 tips to prevent infection”: an interactive tutorial for preventing infections.
        Am J Infect Control. 2006; 34: E53-E54
        • Sternberg RJ
        • Zhang LF.
        Perspectives on Thinking, Learning, and Cognitive Styles.
        Routledge, Abingdon, United Kingdom2014
        • Sisson GR.
        Hands-On Training : A Simple and Effective Method for on the Job Training.
        Berrett-Koehler Publishers, Oakland, CA2001
        • Bramley P.
        Evaluating Training.
        CIPD Publishing, Wimbledon, United Kingdom2003
        • Kahmann K
        • Mulder RH.
        Feedback in organizations—a review of feedback literature and a framework for future research.
        Forschungsbericht/Res Rep. 2011; (Available at:) (Accessed January 25, 2021)
        • Tyan K
        • Cohen PA.
        Investing in our first line of defense: environmental services workers.
        Ann Intern Med. 2020; 173: 306-307
        • Hauser RM
        • Warren JR.
        Center for Demography and Ecology Socioeconomic Indexes for Occupations: a review, update, and critique.
        Sociol Methodol. 1997; 27: 177-298
        • Capps R
        • Fix M
        • Passel JS
        • Ost J
        • Perez-Lopez D
        A Profile of the Low-Wage Immigrant Workforce. Immigrant Families and Workers. Facts and Perspectives Brief.
        2003 (Available at:) (Accessed July 30, 2020)
        • Mccarthy J
        • Deady R.
        Moral distress considered.
        Nurs Ethics. 2008; 15: 254-262
        • Yudhir S
        Employee's motivation: theories and perspectives.
        Asian J Multidimens Res. 2012; 1: 56-64
      5. Ramlall S. A review of employee motivation theories and their implications for employee retention within organizations. J Am Acad Bus Cambridge. 2004;14:645–650.

        • Mulvey D
        • Redding P
        • Robertson C
        • et al.
        Finding a benchmark for monitoring hospital cleanliness.
        J Hosp Infect. 2011; 77: 25-30
      6. Becker S. Sources of Demographic Data. Baltimore, MD: Johns Hopkins University, Bloomberg School of Public Health; 2008. Available at: Accessed January 25, 2021.

        • Bloom BS
        • Engelhart MD
        • Furst EJ
        • Hill WH
        • Krathwohl DR.
        The classification of educational goals.
        Taxon Educ Object. 1956; : 207
        • Krathwohl DR
        • Bloom BS
        • Masia BB.
        Taxonomy of Educational Objectives, the Classification of Educational Goals. Handbook II: Affective Domain. New York, NY: David McKay Company.
      7. K.Schmidt. The Concept of ‘Practice’: What's the Point? COOP 2014–Proceedings of the 11th International Conference on the Design of Cooperative Systems, 27-30 May 2014. Nice, France: Springer International Publishing; 2014: 427–444. Available at:‘practice’_What's_the_point. Accessed January 25, 2021.

      8. Peter GS, Richard HM, David AR. Outcome measures and case definition. Field Trials of Health Interventions. Oxford, United Kingdom: Oxford University Press; 2015:198–215. Available at: Accessed January 25, 2021.