1 BACKGROUND

Although environmental services (EVS) staff work to clean hospitals, their job roles extend far beyond these chores. Studies based in the United States and Europe highlight that housekeepers alert clinical staff about patient concerns, perform clinical tasks and, most notably, provide psychosocial support to patients. As a result, many housekeepers view their work as a vocation that gives them fulfilment and meaning.1-3 One study reported that many housekeepers view themselves as healers, not just cleaners, when they assist in patient care.4 In a US hospital study, researchers noted housekeepers may spend more time with patients than other members of the hospital staff, and patients more frequently disclose their anxieties about family and illness to housekeepers than clinical hospital staff.1

Although environmental services (EVS) staff work to clean hospitals, their job roles extend far beyond these chores.

Despite serving important roles in maintaining patient safety and caring for patients, EVS workers are often overlooked by care team members. These perceptions of neglect and invisibility are expressed by hospital housekeepers in North America, Europe, Asia and Africa.5-8 Based on focus groups and structured interviews of housekeepers in a US hospital, researchers found that cleaners derive greater positive meaning from their work when they are affirmed and appreciated, but unfortunately, doctors and nurses sometimes undermine housekeepers' sense of value and well-being through an array of negative behaviours.6

Despite serving important roles in maintaining patient safety and caring for patients, EVS workers are often overlooked by care team members.

The development of our 15-min documentary film, Keepers of the House, and learning module occurred over 3 years. The film's completion and subsequent viewings for data collection took place in 201 before the onset of the COVID-19 pandemic. A link to the film itself and specific details for curriculum implementation can be found at https://sites.fhi.duke.edu/healthhumanitieslab/portfolio/keepers-of-the-house/.

The process began with our personal daily observations of housekeepers interacting with patients and their families, followed by a focus group of six hospital housekeepers. During the focus group session, housekeeper participants were asked structured questions regarding work experiences and relationships with patients, which prompted a group discussion that was later transcribed verbatim and informed a script for film interviews. Using qualitative software, Atlas ti.7 (2012), line-by-line thematic analysis identified 41 potential codes that were categorised to reveal five distinct themes.9 A peer review of the data analysis and member checking on the codes and themes were conducted.

Our videographer filmed and interviewed nine housekeepers (different from those in the focus group) and edited interview segments, along with line animation, into a 15-min documentary. The interviews with housekeepers in the documentary pointed to these important activities practiced by housekeepers: paying attention to detail, listening to patients and providing emotional support. Housekeepers also indicated the emotional impact of working with patients. In the production of this film, we chose to focus solely on the perspectives of housekeepers; therefore, patients were not interviewed.

We believe it is essential for health profession students to appreciate how hospital housekeepers influence patient care and comfort. The intent of this study was to understand how a documentary film focused on interviews with hospital housekeepers impacts healthcare educators and learners in their appreciation of the complex role of hospital housekeepers. Analysis of surveys completed by interprofessional health educators and health students after viewing the film allowed us to understand the impact of this film on viewers, and consequently shape a 60- to 90-min educational experience, cantered on the themes touched upon in Keepers of the House.

2 APPROACH

Separate audiences of interprofessional healthcare educators and healthcare learners viewed the documentary during their institution's Medical Education Day. Healthcare professions educators (physicians, nurses, nurse practitioners, occupational therapists, physical therapists, physician assistants and social workers) attended screenings followed by discussion. This same experience was repeated at a separate event for interprofessional healthcare professions students (nursing, medical, physical therapy, and physician assistant). Immediately after viewing the film, participants in each group filled out an anonymous, free-text survey intended to promote reflection on the film. Ninety-six educators and 36 students responded to the survey immediately post-screening of the documentary. The survey asked three questions: (1) What surprised you most about this film? Why? (2) What was your favourite story in the film? Why? (3) Books, films and plays have the capacity to change us. What will you take from this film to your practice in healthcare? In your life? Two researchers analysed survey data using content analysis. Motivated to capture the lived experiences of the housekeepers, we conducted another round of applied thematic analysis, with an interpretative phenomenological framework, on survey results to create a 60- to 90-min interactive curriculum. Using NVivo software and following the methods of Miles and Huberman, we captured themes that arose from the survey answers, created a codebook and used that codebook to guide our thematic analysis.10

3 EVALUATION

Table 1 highlights several impactful responses from students and educators for each question in the survey, demonstrating key messages of the film.

TABLE 1. Example quotes from students and educators for each survey question Survey question Student quote Educator quote What surprised you most about this film? Why? ‘The many, many individualized ways in which housekeepers care for patients. Beyond being kind, engaging and personable, their stories demonstrate how perceptive they are—keeping watch over patients and families (raising a bed railing, bringing food/water, advocating)’ ‘That the housekeepers discover the outcomes of patients by their empty or new room location. The lack of communication by clinical staff to these individuals’ What was your favourite story in the film? Why? ‘I loved the woman who hummed and her advice to listen. In a world where we all want to talk/be heard, it is important to take a step back and recognize the need to just listen’ ‘I loved the image of feeding the patient with “country cooking”—it seems that there was more than physical feeding happening. It felt like a way of saying “I see you”’ Books, films and plays have the capacity to change us. What will you take from this film to your practice in healthcare? In your life? ‘I will try to listen more, and to be intentional about recognizing and including respecting the contributions of housekeepers and other people who are integral to a patient's experiences but often overlooked’ ‘I want to hear more voices. And I want those voices to know that they've been heard. I'm not sure how to go about this, but I think this would bring more meaning to our daily lives’ Note: Survey responses, such as these, were used to generate the themes presented in Table 2.

Table 2 shows the outcome of the applied thematic analysis of the three survey questions, depicting the most common themes shared by respondents. Students and educators were most surprised by the depth of the housekeeper–patient interactions, the emotional impact of the job on the housekeepers, the housekeepers' roles beyond cleaning, the housekeepers' pride in their work and their candour. Notably, viewers cited many different stories as their favourite, demonstrating that viewers connected to a wide range of narratives. Finally, key takeaways from educators and students included: value housekeepers more, include housekeepers as a part of the care team, increase engagement with housekeepers, recognise that everyone has a story, build stronger connections with patients and practice active listening.

TABLE 2. Percentages of themes identified in post-screening survey via NVivo thematic analysis from health professions students (n = 36) and educators (n = 96) Student, n = 36 (%) Educator, n = 96 (%) Question 1: What surprised you most about this film? Why? Depth of housekeeper–patient interactions 39 Depth of housekeeper–patient interactions 34 Emotional impact of job on housekeeper 25 Emotional impact of job on housekeeper 19 Housekeeper role beyond cleaning 11 Housekeeper pride in work 9 Not surprised 8 Honesty and candour of housekeepers 8 Othera 21 Other 34 Question 2: What was your favourite story in the film? Why? Assisting mothers 22 Just listen 32 Prisoner 14 Plate of food 23 Collard seeds 8 Assisting mothers 14 Collecting money 8 Collard seeds 9 Just listen 8 Humming 8 Left ventricular assist device (LVAD) 8 Code Blue 8 Moving family to larger room 8 Prisoner 8 Plate of food 8 Moving family to larger room 7 Prayer cloth 8 Other 15 Other 14 — — Question 3: Books, films and plays have the capacity to change us. What will you take from this film to your practice in healthcare? In your life? Value housekeepers more 83 Value housekeepers more 57 Include housekeepers as part of the care team 44 Include housekeepers as part of the care team 31 Increase engagement with housekeepers 25 Everyone has a story 28 Build stronger connections with patients 22 Practice ‘just listen’ 15 Everyone has a story 19 Build stronger connections with patients 3 Practice ‘just listen’ 14 Increase engagement with housekeepers 3 Note: Multiple answers allowed and coded for Questions 1–3. a Responses coded as ‘other’ indicate themes that were identified by less than 6% of survey respondents.

Students and educators were most surprised by the depth of the housekeeper–patient interactions.

4 IMPLICATIONS

Film and storytelling are well-documented efficacious teaching tools in medicine. Documentary film, in particular, aims to evoke empathy and combat stereotypes.11 Our innovative educational experience hinges on this understanding by using film to highlight the narratives of hospital workers who are often undervalued and underappreciated: housekeepers.

Our innovative educational experience hinges on this understanding by using film to highlight the narratives of hospital workers who are often undervalued and underappreciated: housekeepers.

Surveys conducted after Keepers of the House screenings demonstrated a strong impact on interprofessional healthcare educators and healthcare learners. We noted that both educators and learners were surprised by similarities across all stories in the film, in particular the depth of housekeeper–patient interactions and the emotional impact of the job on housekeepers. A majority of respondents expressed intention to value housekeepers more and include them as members of the care team. Appreciating others' stories and practicing the art of listening, themes expressed in Table 2, contribute to empathetic understanding of other team members. As articulated in previous literature, increasing social valuing of hospital housekeepers not only increases their well-being but also allows the cleaners to ascribe positive meaning to their work.8, 12 Additionally, understanding the roles of other team members within the healthcare setting has been shown to foster empathy, build confidence and increase the appreciation of others roles, revealed by a UK-based study in which medical students worked as healthcare assistants.13

A majority of respondents expressed intention to value housekeepers more and include them as members of the care team.

The survey responses enabled us to identify underlying themes that resonated with the film's audiences. Based on this research, we constructed a 60- to 90-min interactive educational experience that is easily integrated into courses on professionalism, provider–patient communication and social determinants of health. This curriculum can be used with specific professional groups or interprofessional groups. The essence of the curriculum is as follows: After screening the film, individuals are given time to reflect and write on questions similar to those in our survey and are then divided into small groups to discuss one or more of the following themes: How do our actions impact housekeepers? How can we become better at noticing? How do housekeepers find meaning in their work? What can we learn from that? What can we learn from the housekeepers about working with patients?

All groups address the following question: What will you take from this film to your practice in healthcare? To your life? How might you act differently?

The film was created in the months before the COVID-19 pandemic and the recent intensification of the movement for racial justice. We believe that, in addition to the above, the film may help students develop new ways of understanding and internalizing these historic events. Students may explore the additional ways that housekeepers provide emotional support to patients during a period when visitors were not permitted in hospitals. They could also consider ways in which housekeepers and other essential workers have experienced particular forms of discrimination and hardship during the pandemic. By providing a window into the perspectives of those voices rarely heard, learners may think more holistically about their workplace and those in it.

By providing a window into the perspectives of those voices rarely heard, learners may think more holistically about their workplace and those in it.

Keepers of the House and the associated implementation curriculum serve as a bridge between underrecognised and undervalued hospital housekeepers and the rest of the hospital care teams. Survey responses demonstrated that our documentary film sparks reflection, shifts perspectives, and encourages behavior change. Furthermore, viewers expressed a new intention to value all individuals who work in their health care settings.

Survey responses demonstrated that our documentary film sparks reflection, shifts perspectives, and encourages behavior change.

ACKNOWLEDGEMENTS

Special thanks to those featured in the film: Maybelline Barahona, Lorna Fashola, Rosetta McCallum, Isaac Johnson, Barbara Myers, Eddie Oakley, Hilda Self, LaShara Springs and Maria ‘Gladys’ Velasquez. Thanks also to Louisa Joy, Thomas Johnson and Antonia Salas Munoz. This research is supported by Duke University FHI Health Humanities Lab and Duke AHEAD, Josiah Charles Trent Memorial Foundation and National Institute on Aging (Grant No. T32-AG000029-41).

CONFLICT OF INTEREST

No potential conflict of interest was reported by the author(s).

ETHICS STATEMENT

Our study was reviewed by and declared exempt from formal ethical review by the Duke Institutional Review Board (Pro000076536; 9/20/2019). Students and other participants in our survey were assured that all results would be anonymised and were informed that participation in the survey constitutes willingness to participate. All participants in the film signed a release form for dissemination outside the institution.

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