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These are some of the factors that prodded doctors
at the CDC to include artificial-nail commentary in
its voluminous "Guideline for Hand Hygiene in Health-Care
Settings," released in October. One of the recommendations
was, "Do not wear artificial fingernails or extenders
when having direct contact with patients at high risk
(e.g., those in intensive-care units or operating rooms)."
Kaiser went further, applying the standards to anyone
providing hands-on care or handling instruments or equipment
that would be used directly on patients. The group's
nurse executives voluntarily removed their nails, too.
"We felt that the organisms under your nails don't
know where they are," Eck said. "They might
be in critical care or with a med/surg patient. There
was clear evidence in a high-risk environment. But germ
theory applies elsewhere, too."
NCH Healthcare System, a Florida company that consists
of two hospitals and several walk-in clinics, took a
similar approach when it banned artificial nails in
November. NCH administrators applied the prohibition
not only to direct-care health workers, but also to
cleaning staff and food servers who could conceivably
infect patients-or be infected themselves.
Part of the message has been that dumping artificial
nails protects not only patients, but also health care
workers and their families.
Another common educational element has to do with nail
care. There's no denying that nursing, with its constant
handwashing, is tough on the fingernails. Kaiser, for
its part, organized nail fairs, recommended manicurists
and distributed hand care kits.
NCH had to deal with this issue as well. "One
complaint we had was that when people took off their
artificial nails, their natural nails were deformed,
not in good repair," said Rebecca Malphus, RN,
CIC, an infection control practitioner with NCH. "That
showed us how damaging artificial nails were. In a way,
it was a blessing in disguise. Eventually, their natural
nails got healthier and grew out, and it was much better
for everyone."
According to hospital spokespeople, the education campaigns
were effective in garnering support for the policy.
"We really didn't hear too much about it,"
said Carrie Skifton, RN, NCH's vice president for nursing.
"People knew this was the right thing to do."
Eck said that only one worker, a respiratory therapist,
left Kaiser in protest. And this is a group with more
than 30,000 nurses. But that doesn't mean the prohibition
didn't ruffle a few feathers. Terri Hitt, RN, works
in labor and delivery at a hospital in Los Angeles County
and takes per-diem shifts for Kaiser. She isn't buying
Kaiser's arguments.
In Hitt's view, the no-nails policy unnecessarily impinges
upon the personal choices of its female nurses, while
offering no substantive advantages in safety. A former
manicurist, she insisted that proper hygiene is the
key to maintaining any nails, no matter the length or
material. She also wondered whether the microbial research
has any bearing on health care workers who are gloved
for patient contact. Finally, she strongly disagreed
with Eck's assessment of employee acceptance.
"They claim there was no protest from the union,
and thus there was no protest from nurses," Hitt
said. "Quite the contrary. What happened was that
many of the nurses who had objections, although they
did not leave Kaiser employment, merely transferred
to nonpatient care areas. This move decreased the number
of nurses available for patient care.
"In addition, Kaiser's policy has decreased the
number of registry nurses who will service the institution.
Kaiser's answer has been to train less-educated personnel
for roles such as scrub tech. They have no microbiology
background, and at times, their sterile technique is
questionable."
Hitt's primary employer still allows artificial nails.
As it stands, Hitt now works for Kaiser only when she
has removed her acrylics, which she changes every six
weeks. "They're getting less [of this] nurse,"
she said.
Kaiser's reaction is a polite "good riddance."
Eck remains convinced that artificial nails directly
increase the risk of nosocomial infection, and her hospital
won't hire anyone who refuses to take them off. "She
probably hasn't seen all the work done on this subject,"
Eck said of Hitt. "The evidence is simply there."
Has the policy change improved conditions? Kaiser has
conducted some observational studies of handwashing
since issuing its edict nearly a year ago. It has also
attempted to track resistant organisms across medical
centers. But it's nearly impossible to link this data
specifically to artificial nails.
"There's not much to go on, other than outbreaks,"
which Kaiser hasn't had subsequent to the policy, Eck
said. "And that's good."
Contact Phil Barber at barzell@napanet.net
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