Major article
Environmental hygiene, knowledge and cleaning practice: a
phenomenological study of nurses and midwives during COVID-19
Cassie Curryer PhD a
, Philip L. Russo PhD b,c
, Martin Kiernan MPH a,d
, Karen D. Wares M.Sc. a
,
Kate Smith Grad Cert (Nurs) a
, Brett G. Mitchell PhD a,e,
*
a School of Nursing and Midwifery, University of Newcastle, Ourimbah, New South Wales, Australia
b Department of Nursing Research, Cabrini Institute, Malvern, Victoria, Australia
c Nursing and Midwifery, Monash University, Frankston, Victoria, Australia
d Richard Wells Research Centre, University of West London, Brentford, United Kingdom
e School of Nursing, Avondale College of Higher Education, Wahroonga, New South Wales, Australia
ABSTRACT
Background: Environmental cleanliness is a fundamental tenet in nursing and midwifery but often overshadowed in practice. This study explored nurses’ and midwives’ knowledge and experiences of infection
prevention and control (IPC) processes and cleaning, and perceptions about workplace risk-management
during COVID-19.
Methods: Six registered and enrolled nurses (one with dual midwife qualifications) were recruited. In-depth
telephone interviews were analyzed using Colaizzi’s phenomenological method.
Results: Four major themes were identified: Striving towards environmental cleanliness; Knowledge and
learning feeds good practice; There’s always doubt in the back of your mind; and COVID has cracked it wide
open. These articulate the nurses’ and midwives’ experiences and knowledge of IPC, particularly during
COVID-19.
Discussion: The findings emphasize the dynamic, interdependent nature of clinical (time, staff knowledge
and compliance, work processes, hospital design) and organizational contexts and environmental cleanliness, which must be constantly maintained. COVID-19 opened up critical insights regarding poor past practices and lack of IPC compliance.
Conclusions: COVID-19 has highlighted the criticality of environmental cleanliness within clinical and community settings. Evidence-based, experiential learning is important for nurses and midwives at all career
stages, but provides only one solution. Clinician-led hospital design may also reduce the spread of infection;
thus, promoting better patient care.
© 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.
Key Words:
Infection prevention and control
Compliance
Shared patient equipment
Hospital design
Evidence-based learning
Organisational contexts
Environmental cleaning is key to preventing infections in
healthcare and is cost-effective.1,2 Workplace factors such as
time pressures, staff knowledge, work processes, organizational
structures, and the everyday complexity of health care systems
can play a key role in how well environmental cleanliness is
maintained and healthcare associated infections prevented.3-6
This paper builds on previous work from the authors,7 which
explored nurses’ and midwives’ knowledge of infection prevention and control (IPC) and cleaning processes. Previous research
found that while nurses and midwives broadly understood the
importance of cleaning, not all displayed correct knowledge of
how to clean correctly nor which disinfectants to use in particular situations.7 Moreover, despite the majority indicating confidence about their cleaning ability, this confidence did not
extend to being placed in a room previously occupied by a
patient with a known infection.7 This study sought to gain
deeper insights into this critical disjuncture between infection
control knowledge and practice, particularly in light of the
* Address correspondence to: Brett G. Mitchell, PhD, School of Nursing and Midwifery, The University of Newcastle, BE Building, 10 Chittaway Rd, Ourimbah NSW,
Australia, 2258.
E-mail addresses: [email protected], [email protected].
au (B.G. Mitchell).
Funding: This study received no external funding.
https://doi.org/10.1016/j.ajic.2021.04.080
0196-6553/© 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of Infection Control 49 (2021) 1123−1128
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
COVID-19 pandemic,8 and to further identify additional barriers
to cleaning effectiveness.
METHODS
Research design
We used a qualitative approach9 and Colaizzi’s
10 method of data
analysis to explore nurses’ and midwives’ lived experiences of cleaning and infection control. Further details are provided in the supplementary material (S1).
Setting and participants
Registered and enrolled nurses and midwives who are currently
employed in clinical settings (such as hospitals or GP medical practice) in Australia.
Recruitment
Nurses and midwives were recruited through written and electronic media (emails, social media, Australian Nurses and Midwives
Association). Following the completion of an online survey (previously published),7 survey participants could opt to provide an interview. More information regarding recruitment is detailed in the
supplementary material (S1). Participants were offered a $20 gift
card as incentive and reimbursement for their time. The study
received Human Research Ethics approval.
Data collection
In-depth telephone interviews ranging between 17 minutes and
57 minutes duration were conducted between June and July 2020, at
a time in which the COVID-19 pandemic was present in Australia.
Both written and verbal consent were obtained. All interviews were
recorded with the permission of participants, transcribed and anonymized prior to analysis. Further details on data collection, including
the interview schedule questions, are provided in the supplementary
material (S1).
Ethical approval
Ethical approval for the study was provided by the Avondale University College Human Research Ethics Committee (HREC/17/QTHS/
198) and The University of Newcastle HREC (H-2020-0160).
Findings
Interviews were conducted with six participants. The participants
were all female and worked in a variety of settings (mean years
worked = 16). One nurse had dual qualifications as a midwife, but
hereafter, is referred to by her first qualification (registered nurse)
(Table 1).
Four major themes were identified (Table 2). These articulate the
nurse’s experiences and knowledge of infection control and cleaning,
particularly during the height of the COVID-19 pandemic, and their
perceptions of how well risks of COVID-19 were being managed in
the workplace.
Selected quotations are shown for illustrative purposes, with different participant’s comments represented by an alphanumeric code
(eg, P1, P2). Quotations are representative of each participant’s views
and experiences and have not been independently verified.
Many themes and subthemes were interdependent, for example,
issues such as time pressures (Chasing time), lack of training (Iceberg
tips and learning slips) and lack of supplies such as cleaning products
and personal protective equipment (PPE) (A tradesman needs their
tools and nurses do too) impacted nurses’ and midwives’ ability to
achieve a clean working environment (Striving towards environmental
cleanliness) or to keep themselves safe when caring for patients with
COVID-19 (You go home scared) (see Table 2).
Major theme 1: Striving towards environmental cleanliness
This theme aligns with the interview question: ‘why is cleaning
important?’ Cleaning was viewed as a cornerstone or inherent trait
and duty associated with being a nurse, as epitomized by Florence
Nightingale: ‘cleanliness is next to Godliness’ (P3). Cleanliness (cleaning) was also tied to patient expectations, but lacked the glamour
and excitement of ‘cutting people open and CPR and saving lives’
(P5). This perception carried through to general practice (GP) settings, hospital staff (nurses, midwives, doctors), and senior management, who failed to grasp the importance of, or time needed to
ensure environmental cleanliness (ie, cleaning is undervalued). This
theme highlights the dynamic nature of cleaning and environmental
cleanliness within clinical settings; it is not fixed, demanding constant vigilance. Therefore, cleaning and IPC measures have to be consistently, correctly applied to prevent infection. Moreover,
environmental cleanliness necessitates a concerted team effort.
Major theme 2: Knowledge and learning feeds good practice
Having staff who are knowledgeable about environmental cleanliness and who are committed towards preventing infection was critical for the optimal delivery of care, patient safety and a complicationfree patient recovery. Team effectiveness was important in terms of
mentoring, knowledge sharing and training, making sure that staff
were on the ‘same page’ (P3) and working towards similar goals (ie,
everyone’s on board), for ensuring hygiene compliance, and the
smooth flow of workplace information. The importance of correctly
applying knowledge and learning, in the context of COVID-19, was
also underscored. Auditing increased, particularly around use of PPE.
Nurses described much learning and knowledge uptake as occurring at a surface (tip of the iceberg) level only, with in some instances,
experiential learning and knowledge sharing being lost (learning
slips): ‘you’re only as good as your weakest link’ (P3). Nurses stressed
the importance of embedding cleaning knowledge and hygiene (such
as handwashing) into practice through early education, post-graduation training and mandatory accreditation. Changes in best practices
Table 1
Participant demographics
Participant Qualification Where employed State/territory Years worked (n)
P1 RN Public hospital (outpatient) Tasmania 12
P2 EN Community care NSW 4
P3 RN; RMW Public hospital (ER) NSW 36
P4 RN Public hospital (ER) ACT 24
P5 RN Private practice (GP) NSW 16
P6 RN Public hospital (mental health) NSW 4
1124 C. Curryer et al. / American Journal of Infection Control 49 (2021) 1123−1128
over time and staff tendencies towards complacency meant that
basics required annual review: ‘Just like we’ve got to do cardiopulmonary resuscitation (CPR) … we should all have to do basic hand
hygiene’ (P5). Moreover, training programs needed to be responsive
to nurses’ needs (for example, casual shift workers were not on-site
when training was conducted), individual learning styles (practical
and computer-based education, evidence-based visual learning), and
encompass cleaning staff (who when recruited received only minimal
instruction): ‘You’re not just a basic cleaner … they do other tasks
than just disinfecting the rooms.’ (P2). In this way, cleaning knowledge and hygiene practices became embedded into the organizational fabric holding everything together; there was also less chance
for slip-ups to occur.
Nurses were highly reliant on infection prevention and control
(IPC) professionals for policy updates and advice. As resourceful and
adaptive learners, and perhaps not trusting the limited information
they were receiving, three nurses (P5, P2, P4) described going online
and seeking out extra training (in addition to mandatory courses)
regarding cleaning, PPE use and COVID-19 prevention (ie, keeping
knowledge fresh). At one workplace, policy guidelines had not been
revised in over four years; consequently, much information was
redundant. Details about how to correctly maintain and sterilise
shared patient equipment such as ‘things we use to cut people open’
(P5) were also missing (not readily found). At another workplace,
policy guidelines regarding cleaning did exist, but lacked detailed
information to inform work practices. Hence, cleaning was a hit-andmiss affair; open to interpretation: ‘people aren’t aware that they’re
the person that’s supposed to be cleaning it’ (P6).
Major theme 3: There’s always doubt in the back of your mind
Workplace and operational factors (time, place, clinical setting,
organizational structures, resources and training) played a key role in
cleaning effectiveness and IPC compliance. It is notable that, prior to
COVID-19, poor cleaning and hygiene practices had been routinely
observed, however, the full implications were only now becoming
evident. Time was a key influencing factor as to whether or not cleaning was adequately performed. For one general practice (GP) nurse,
Table 2
Overview of themes
Major Theme Subtheme Quotation
Striving towards environmental cleanliness
Cleaning is a fundamental cornerstone
of nursing
‘I see it [cleaning] as a cornerstone or a huge pillar.’ (P3)
‘It is one of the first things we can do to help prevent the spread of infectious diseases
and any other kind of germs that can harm us, it’s super important.’ (P5).
There’s no excuse for dirtiness ‘There’s no excuse … It shouldn’t be up to the community nurse to be tripping over used
incontinence pads because you don’t know how to get to the garbage bin.’ (P2).
Cleaning is undervalued ‘Getting management to understand why I might need [time for cleaning] … that’s a challenge when they’re non-clinical.’ (P5)
‘[Cleaning is] highly underrated and extremely vital.’ (P3)
Environmental hygiene is important
for patient care
‘Our duty of care to our patients is to ensure that they’ve got the best environment.’ (P1)
‘It’s all about preventing, doing what you can to prevent any infection to occur to the
patient … and you don’t want to be working on dirty surfaces because that’s E. coli.’ (P2)
Knowledge and learning
feeds good practice
Everyone’s on board ‘And that’s the same for public awareness − especially with this COVID … everyone’s now
aware that handwashing is really super important’. (P5)
Embedding cleaning knowledge ‘I think it has to start from the beginning, so in the undergraduate, pre-hospital setting. It
should really be the platform from which we do any intervention.’ (P4).
Iceberg tips and learning slips ‘So we did do a couple of extra sessions … training for intubation because that’s a highly
aerosolised dangerous procedure or risky procedure, so we did do some of that, but … I
think we only touched the tip of the iceberg.’ (P3)
Keeping knowledge fresh ‘If you’re unsure and you don’t feel you’ve got enough capacity, then you go back online and
just refresh yourself on the policies and procedures of what needs to be done’. (P2)
There’s always doubt in
the back of your mind
Chasing time ‘Pre-COVID we often didn’t wipe down the monitoring equipment or the space that a
patient’s bed was allocated to … we’re pushing people through so quickly’. (P3)
Taking ownership ‘There’s this bickering between the cleaners and the nurses because they don’t think it’s
their job, and then it has to be ruled out by the nurse unit manager and the cleaners’
managers to work out who cleans what specifically’. (P6).
The outer end of horridness ‘If we swabbed all of that stuff … it would just be a petri dish of horridness’. (P3).
‘We had two or three toilets, one shower that leaked, nowhere for staff to get changed so
they had to take over a small space … from an infection control point of view − look at
the flow’. (P3).
A tradesman needs their tools and
nurses do too
‘Definitely supplies … a tradesman needs their tools, like anything in life … whether
you’re a cook, a cleaner or a nurse … you need the tools’. (P2)
COVID has cracked it
wide open
We are lucky, safe and in control ‘We have done everything that we needed to keep our patients and our staff safe’. (P1)
‘Yes, sparkling clean. Always vacuuming. I just noticed − you can smell the disinfectant,
and you can smell the bleach’. (P2)
Nurses are eating their own ‘There’s a lot of angst in the Department where people are just saying, “I don’t want to work
in it [COVID ward].” So I’ve seen poor practice, I’ve seen disharmony … breaches of confidentiality … there are very few decent nurse leaders and they’re really good at eating
their own and you just sit there going, good God, can we not work together?’ (P3)
The COVID ward is hypoxic and hell ‘Some people are happy to work in COVID areas, but it’s hot, demanding, you don’t get a
break, you can’t have a drink, and we’ve noticed all since we’ve put on the masks for
work, we’re dehydrated, we’re cramping up, we’re a little bit hypoxic.’ (P3)
‘The young nurses didn’t want to work in the COVID ward and then they came back to
people like me who were over 50 and said, “Well, you’ve got to work in the COVID ward.”
And I said, I’m not working in it.’ (P3).
Shifting sands ‘[COVID-19] is an evolving issue … one day we are being told to do one thing and then the
next day do something else’ (P4).
You go home scared ‘People forget about the impact of the disease and you go home scared … you don’t want to
bring something home.’ (P3)
C. Curryer et al. / American Journal of Infection Control 49 (2021) 1123−1128 1125
economic priorities meant that less than three minutes cleaning and
preparation time was allowed between patients: ‘they’re all timebased appointments. So it’s trying to figure out how [cleaning] can be
done and not upset the [patient] booking’ (P5). Asked if she considered three minutes to be sufficient cleaning time, the nurse replied:
A: ‘I don’t think three minutes would be enough because you have
to let some surfaces dry for up to 10 minutes, depending on what
you’ve done, to make sure that it’s germ-free, basically clean’ (P5).
Q: So when it’s only three minutes [cleaning] allocated then those
disinfectants would not have time to react?
A: No, no.
Q: And so, that surface – you couldn’t guarantee it was clean?
A: No. Well, you couldn’t because you haven’t cleaned it’ (P5).
Time constraints were also experienced in hospital settings. Two
nurses (P3, P4) spoke about working in fast-paced emergency (ED)
departments, where rapid patient turnovers and a ‘four-hour ED rule’
meant that cleaning was ‘not done, more typically than not, when it
is busy’ (P4). The interview comments suggested that ‘good’ care was
equated with speed, rather than practice: ‘when [in theatre] … It
was all about speed’ (P2). Four nurses reported that cleaning of
shared patient equipment (such as blood pressure cuffs) either did
not occur or was insufficient. One nurse (P3) suggested more staff
training was needed; however training alone cannot overcome timebased barriers. Only one nurse (P1) was confident cleaning processes
were adequate, in part because they were responsible for auditing
compliance every three to six months, and patients had their own
(rather than shared) equipment.
Other factors influencing cleaning compliance included the lack of
detailed organizational guidelines regarding recommended cleaning
methods and how often cleaning should be performed, lack of management support and role conflicts. IPC was described as a bit of a
battleground and the lack of consensus about how things should be
done made hygiene more difficult than it needed to be: ‘we just need
to have consistency and standardization as best we can with safe
practice’ (P3). Some nurses hinted at a culture of complicity around
‘bad’ cleaning practices, for example:
‘I have to say this, carefully, don’t I? … say you’ve got to do seven
beds but at the meantime you’ve got eight patients going to theatre … eight patients to do [observations] on, and you’ve got to
get these other rooms ready … it’s not [that] they [management]
don’t want to know. They do’ (P2).
Cleaning was treated as a ‘tick-box’ accreditation-focused activity;
often disengaged from the care process, ie, not considered a critical
part of patient service delivery.
Moreover, while the COVID-19 pandemic had raised awareness
about IPC, this did not necessarily guarantee that cleaning had
improved, nor to overcome an endemic, historic lack of hygiene:
‘once again, [COVID-19] has exposed an ugly crack, we don’t have
enough equipment, we never had enough’ (P3). One nurse likened this to a tradesman, such as a mechanic, being forced to
work without the necessary tools: ‘you’re begging for things that
are meant to be mandatory … it makes life incredibly hard’ (P2).
Although hospitals tend to be fairly predictable environments,
achieving high levels of cleaning and hygiene compliance is challenging. Working from an infectious disease perspective, one
nurse (P3) was highly critical about the lack of foresight used in
hospital design and planning: ‘it’s done either by an architect or
somebody who’s got the cheque book in their hand’ (P3). Design
factors in the built environment increased COVID-19 risks and
hampered IPC compliance.
Major theme 4: COVID has cracked it wide open
This theme relates to nurses’ and midwives’ experiences of working during the COVID-19 pandemic, and perceptions about how well
COVID-19 was being managed in the workplace. Positive perceptions
reflected nurses who were fairly confident about the level of overall
workplace preparedness, PPE training and information provided: ‘No
[worries], not at present. They’re very alert where I am’ (P2). They
also tended to be voiced by those not working in high volume,
COVID-19 frontline situations. For example, one nurse (P1) reported
little change in cleaning practices due to the low volume of patients
seen and already high IPC compliance. In contrast, another nurse (P3)
voiced multiple doubts regarding COVID-19 risks in the workplace.
For example, poor hygiene practices and the lack of cleaning guidelines meant that shared items and workspaces (hot desks) were
inconsistently cleaned. As ‘one of the busiest EDs in the state’ (P3),
the high-patient flow, dirty, broken equipment, and disrupted supplies due to COVID-19, meant that confidence regarding hygiene
safety was low: ‘yes, we have got increased cleaning … but the
Department was filthy before’ (P3).
Nurses and midwives working on the frontline of the COVID-19
pandemic described workplaces as toxic, creating conflict between
staff, and placing nurses under additional distress. One nurse likened
this to ‘nurses eating their own’ (P3). Finding nurses and midwives
willing and able to work in the COVID-19 ward was particularly problematic, causing long delays and tensions; and driven by nurses’ firsthand experiences of colleagues who had experienced infection or
trauma:
‘we saw how our paramedic friend got treated and we also had
[another] nurse die; attacked by a patient at our hospital … we
don’t feel valued and we don’t think that they [management] have
got our back’ (P3).
Nurses described having to quickly pivot practices in response to
emerging evidence about COVID-19, changes in recommended guidelines and working conditions, and disrupted supplies. Lacking a firm
foundation from which to practice, nurses were left negotiating shifting sands: ‘one day we are being told to do one thing and then the
next day do something else’ (P4). There was a sense of frustration
that, given the experiences of previous pandemics such as Swine Flu
and SARS, health systems were unprepared for the onslaught of
COVID-19: ‘we’re too busy putting out fires. We don’t plan, we don’t
prepare’ (P3).
As the pandemic progressed, and numbers in Australia remained
relatively small compared to overseas, the heightened awareness and
anxiety about COVID-19 seemed to dissipate. There was a perception
that Australia had been very lucky, albeit over time, hygiene complacency was on the rise: ‘we’ll just go back to the sloppiness’ (P3). The
nurses’ and midwives’ training meant that they were able to identify
when IPC was suboptimal, for example, two nurses commented
about poor cleaning practices on public transport. Nonetheless, preCOVID-19, cleaning was not prioritized. Hence, it seemed that
COVID-19 had finally ‘cracked open’, brought to light the ‘rot’ and
‘poor infection control practices [already] in existence’ (P3) within
the healthcare system: ‘You look at aged care, you look at EDs, our
patient toilets have always been dirty, our staff toilets are dirty, our
staff tea rooms are dirty. All COVID’s done is just cracked it wide
open’ (P3). However, COVID-19 had also reinvigorated nurses’ and
1126 C. Curryer et al. / American Journal of Infection Control 49 (2021) 1123−1128
midwives’ awareness of basic hygiene and cleaning; an effect which
could potentially reap positive change:
‘I think that it [cleanliness] is something we could re-focus on, and
… COVID-19 has reminded me of those basics, of what are the
basis of good healthcare. And so, we can only build from that. If
we miss this, then it doesn’t matter what else we achieve if a
patient ends up with a sepsis that we have created’ (P4).
DISCUSSION
Environmental cleanliness is a foundational concept in nursing
and midwifery,11 but one that may be undervalued or brushed aside
due to time constraints, lack of resources, and other factors.3-5,12,13 As
shown in this study, workplace factors can play a key role in shaping
compliance with IPC policies. Moreover, achieving good compliance
demands a concentrated team effort and continual, tailored learning.14 This finding concurs with Nasiri et al15 and Welsh’s
16 study,
which highlighted the need for shared responsibility and collaborative teamwork in reducing healthcare associated infections.
Constant education and reinforcement, and evidence-based practice learning is critical in overcoming active staff resistance.15,16 Likewise, in our study, evidence-based knowledge and professional
development was important for nurses and midwives, as knowledge
informed everyday working practices, such as how to prevent infection and the correct use of PPE. Hygiene and cleanliness were perceived as both shared activity and reciprocal, interdependent
relationship, existing on multiple (public, private, organizational,
clinical) levels.4,11,16,17 The findings from this study emphasize that,
while nurses and midwives broadly understood the importance of
environmental cleanliness, many workplaces failed to meet IPC
guidelines. Notably, the impact of past poor practices was becoming
evident in the context of the COVID-19 pandemic; but this does not
guarantee that cleaning will continue to improve over the long-term.
Hence, taking ownership of one’s own hygiene practices was identified as being important for reducing infections within healthcare and
community settings.
This study also emphasized how the lack of cleaning products, PPE
supplies and medical equipment, combined with outdated IPC guidelines, impacted on nurses’ and midwives’ ability to practice optimal
hygiene, comply with IPC policies, or work in COVID-19 safe
ways.4,18-20 This variation in process, supplies and equipment with
respect to cleaning, has also been identified for other occupations in
hospitals.21,22 Risk therefore became real and very personal; something few nurses had encountered. In drawing parallels between
nurses and tradesmen being forced to work without the necessary
tools, it was obvious that many nurses and midwives in this study
were not well resourced nor held in high regard. Lacking the full support of management, nurses and midwives were often left without a
solid foundation from which to provide care, and at least one nurse
was placed at high risk of COVID-19 due to overcrowded staff facilities. 19 The findings stress the importance of hospital and workplace
design in either creating or reducing infection in the healthcare
environment.3,23,24 Hospitals and healthcare facilities should factor in
sufficient space to allow for safe social distancing between staff,
patients and visitors,19,24,25 and be designed with a view to facilitating easier cleaning (for example, avoiding tight corners and rough
surfaces where debris can lodge), handwashing,26 and preventing
infection (for example, sensor-activated automatic doors and curtains, and copper-infused surfaces for frequent touch-points such as
handrails).23 Healthcare facilities should also have clear protocols for
dealing with infectious outbreaks.4,25,27,28
The findings from this study highlight that, in most cases, workplace settings were unprepared for managing the COVID-19 pandemic.8 Moreover, key lessons that might have been learnt from
previous infectious outbreaks had not been translated well into organization policy. Reflecting this deficiency, nurses and midwives in
this study called for cleaning and hygiene knowledge and evidencebased practice to be more deeply embedded into organizational cultures and accreditation.
CONCLUSION
The COVID-19 pandemic has brought home the criticality of environmental cleanliness and hygiene within clinical and community
settings. This study has highlighted the importance of evidencebased and experiential learning for nurses and midwives at all stages
of their careers, and the need for better translation of nurses’ and
midwives’ knowledge and experience gained during pandemic outbreaks. Moreover, hygiene and cleanliness should be a shared activity
and responsibility, with nurses, midwives, healthcare workers, senior
management, patients and the broader community working together
to reduce infection.
Acknowledgments
We thank the participants for supporting this research.
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be found
in the online version at https://doi.org/10.1016/j.ajic.2021.04.080.
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