Workers in the departments of the environmental services were generally grouped into smaller units that were specialized in various tasks. Different departmental activities are designated for the units. For example, the cleaning of patient rooms, the cleaning of nursing units, the cleaning of surgical areas, the cleaning of administrative offices, the cleaning of laboratories, the cleaning of waiting areas, the cleaning of toilet facilities, the cleaning of hospital premises, and the collection and emptying of garbage from all of the above-listed sites are among the duties of the environmental service divisions of all three hospitals. 25 Hospital staff took part in this study in total. Of these, 19 were environmental service staff, and six were employees from the Infection Control and Patient Safety Departments. 20 of the study participants (i.e. 80.0 %) were female. The mean age of the participants was 38.2 with Standard deviation (SD) ± 8.2 and range 18-59.
Factors Related to Unsafe Work Behaviors
Themes and sub-themes (categories) identified
Three main themes emerged from the participants' perspectives concerning the factors associated with unsafe work behaviors- (1) Poor management and supervision of safety, (2) Unsafe workplace conditions, (3) Perceptions, skills, and training level of workers (Table 1).
Table 1 Classification of themes, categories, and codes according to the thematic analysis
Main themes
|
Subthemes (Category)
|
Sub-categories
|
Poor management
and supervision of safety
|
Ineffective safety management
|
- Lack of ready access to personal protective equipment (PPE) in the workplace.
- Poor design & quality of available PPE
- Insufficient training
- Workplace policy gaps
|
|
Poor monitoring and supervision of safety
|
- Negligent control of PPE compliance
- Haphazard safety inspections
- Haphazard inventory tracking
|
Unsafe workplace
conditions
|
Unsafe psychological environment
|
- Fatigue relating to work
- Excessive loads of work
- Delayed payments for wages and salaries that minimize security incentives
- Condescending safety supervision and maltreatment
- Stress related to work
- Separation from family
- Low organizational dedication to safety
|
|
Unsafe Physical environment
|
- Impaired concentration due to a fast-paced environment, excessive noises, and increased traffic
|
Perceptions, skills and
training level of workers
|
Workers’ perceptions
|
- Concerns of PPE interfering with work
- Hazards that are ‘normalized’ overtime
- Human factor-related phenomena such as culture, beliefs, and attitudes
|
Lacking skills to manage hazards
|
- Lack of experience and skills in dealing with hazards
|
Theme one: Poor management and supervision of safety
Ineffective safety management
Almost all of the participants described a general lack of PPE as a major barrier to safe behaviors. There was also evidence of a tendency to imply that hospital administrators have failed to understand the role that timely, adequately, and appropriately provided PPE can play in the control of hazards. As stated below, one respondent, for example, expressed frustration with the shortage of critical PPE supplies in the hospital. (P12 refers to participant 12)
P12: One barrier to safe behaviors is that the personal protective equipment if available is very worn-out and defective. I've been working here for 6 months, and so far I haven't gotten any PPE. I use the worn-out equipment that was used by those who worked here before the pandemic.
Moreover, participants indicated that a lot of personal protective equipment such as masks, gloves, and goggles were either too large or too small for them to comfortably function. So it seems the workers didn't have anything to use.
P4: Although I know we are supposed to use facemasks while cleaning, I prefer instead to cover my face with a scarf because the masks the hospital gives us do not fit properly.
Key informants considered in this study had their administrative views regarding the gaps in the supply of PPE in the departments of environmental services (K2 refers to Key-informant 2)
K2: … We [hospitals] survive with our existing old gear because the pandemic has strained all available resources. We take what we can get and use it to the best of our advantage; the government provides what it has and what it can.
The matter of training was raised by the respondents as another important reason for the failure of the staff to fully exercise safe work behavior. Participants addressed their training and shared their frustration with the training frequency (and adequacy by implication).
P16: They do train us but in my view, it's not adequate. It was only given to us once since the pandemic began … I’d have preferred it if it were at least once every few weeks. A lot of new employees have come and gone after the training. Thus, beginners are usually left to their own devices to find out why the equipment is needed and how and when it is used.
Key informants clarified that given the costs that go into scheduling a training more than once a year; priority was given to clinical workers. That is illustrated by the following extract.
K2: Training on how to protect themselves from COVID-19, as well as steps for appropriate PPE use, is given to all staff. The training was given to physicians and nurses twice this year, but it was given once to the other staff members. We must prioritize our resources, and use them more where they are most needed
The lack of best practices in safety management was also visible from the participants' testimonies. This impacted the work behavior of the staff. For instance, a worker's state of employment, i.e. whether one is a permanent or temporary employee, has a bearing on their access to the training or PPE, though both types of employees might have the same opportunity of exposure.
P13: as you know, safety goggles protect us from exposure to droplets from infected individuals, but it's hard for those of us working under temporary contracts since our bosses say it's only for permanent employees and not for others.
P8: Permanent hospital employees were given a participation fee of $7 (300 Ethiopian birr) for COVID-19 prevention training, but for workers employed under contractual terms there was no such fee. So many of our colleagues skipped the training out of anger
Poor monitoring and supervision of safety
Maintaining workplace safety and health in any workplace is as much the duty of the manager as it is the responsibility of the employees themselves. In the present study, participants discussed in detail the lack of strict supervision and scheduled inspection as one of the major barriers to safe work behavior among the cleaning staff.
P5: Supervisors came this morning but they asked us how the work was going and not about our protection. … There's no concern about what we're missing, more so when we're on the night shift.
In addition to these weak supervisions regimes, the lack of successful inventory management systems inside the hospitals was recognized as a factor that greatly impedes the pursuit of healthy work behaviors by employees.
P8: Often the hospital wards get so loaded with COVID patients that we have to work overtime and when we ask for mask or glove replacements, our superiors say okay, but once we enter the storeroom, the item is out of stock. We can't afford to lose our jobs so we work under these circumstances.
Theme two: Unsafe workplace conditions
Unsafe psychological environment
The data collected in the present study shows the prevalence of stressful workplace conditions. For example, many participants described departmental workload as stressful due to demands for productivity. They also mentioned the sacrifices that they had to make between job speed and workplace safety.
P16: We feel the pressure. We feel that any interruption in our services could cause severe problems. These patients may be individuals who we know or whom we work with. We see them fight for their lives and feel like we must make their stay here as comfortable as possible. So it’s hard when you’re feeling that, that constant urge to fix everything.
Key informants did seem to agree with some aspects of the workers’ characterization of the workplace conditions
K4: Any worker who develops or is suspected of developing symptoms gets placed in our isolation centers. So the alienation from your family and the concerns of your job security is constantly at the back of your mind ... you suffer psychologically, of course, ideally not to the point of stress-induced accidents
Others felt that they were working under extreme pressure. They stated that some mid-level staffs seem to believe, perhaps incorrectly, that exhibiting an authoritarian attitude towards workers is the way to enhance and maximize productivity and achieve objectives in the workplace.
P2: Often, because of personal or family issues, people may miss work, so our bosses come here to check who is absent and late, not to ask us if they can do something for us ... Most of the questions that are asked here are questions such as has the floor been cleaned? Have the toilets been washed? And if not; they go on a long rant but never really ask why
The apparent gap between the anticipation of the participants to benefit from reward programs and hospital administrators' inability to set up effective programs seems to affect the excitement of the employees for safe work behaviors.
P1: Here those who work hard are not valued; in other divisions, I have, many acquaintances, and for their selfless duties they get bonuses and rewards, this should be introduced here to encourage safety, to endorse hard work.
Unsafe Physical environment
Noise, increased traffic, and other changeable environmental variables impacting workplace safe behaviors were also discussed.
K6: These are unusual times, there are people in the halls, in-patient wards are packed ... people here are crying for relatives ... people there are gasping for air ... the staff is constantly interacting with each other… your voice is being muffled with masks on ... so you have to repeat things to your colleagues or you are momentarily pulling them down to be audible… COVID-19 has made hospitals congested beyond belief.
Theme three: Perceptions, skills, and training level of workers
Workers’ perceptions
Human factor-related phenomena such as culture, beliefs, and attitudes too became apparent as a major impediment to safe work behaviors. A repeated allusion from the interviewees was that some had a negative attitude towards safe work behaviors within the workforce.
P18: Several workers in our hospital believe that using personal protective equipment is a waste of time and that using masks increases the incidence of syncope because it doesn't give the brain enough oxygen, particularly the older employees. They say to us the only security I need is God.
For some, perceptions of minimal health threat from the Coronavirus dissuaded safe work behaviors.
P12: Whether or not you take precautions, we're all bound to inevitably get it ... I hear most people don't even notice when they get it ... it's like the flu at best
And yet, for a few others, age-old traditions such as herbal remedies provided them with a perceived safety net.
P6: … There is a reason why for centuries the "feto" plant (Lepidium sativum) has been celebrated as a miracle for any respiratory disease ... I know people who have recovered from the Coronavirus using just that.
Similarly, subgroup demographic characteristics (e.g., job position and experience level) also had a tremendous impact on safety perceptions. For some, the key factor in avoiding infections was to rely on experience and self-confidence while doing the work; this is reflected in their optimistic views of themselves and their conceptualizations of advantageous improvements related to age, such as the ability to execute tasks with minimal risk to oneself.
P10: the techniques of working safely and preventing any kind of danger have been perfected by seasoned staff, so I feel like I can function perfectly well if there is a pandemic or an outbreak. Guidelines add little to my know-how
Other young participants seem to have accepted that more seasoned employees are less likely than their novice peers to get a work-related illness. One worker related this to the levels of promotion that, as seen in the excerpt below, come with experience.
P6: Older and more seasoned staffs are more likely to be in team leader roles and are often active in activities that do not require them to face dangerous conditions.
Lacking skills to manage hazards
In some cases, participants were quick to point out that many of their colleagues, especially the new ones, lacked the basic skills and expertise needed for employees to properly perform their particular tasks. In their view, this led to many employees applying untested work procedures and normalizing risks in the workplace.
P14: We see inexperienced workers take greater risks when conducting routine tasks. The hospital administration frequently assigns the task of training to employees who have been on the job longer. But we don't get additional time to do that many times; we still need to finish our jobs. Therefore we leave it to the new employee to ask questions. So if you're inexperienced; cleaning hospitals in the COVID-19 era it shouldn't be your meal ticket.