The Risk of the Rings
Study on hand contamination and ring wearing spurs debate over whether RNs should be required to take off their jewelry at work

By Donna Hemmila
April 9, 2004

When Kaiser Permanente moved to prohibit patient care employees from wearing artificial nails, the health care giant also tackled another potential source of nosocomial infection—rings.

In its nationwide hand hygiene policy, Kaiser prohibits clinicians from wearing jewelry of any kind in the OR. In other parts of the hospital, rings other than plain bands are discouraged, said Sue Barnes, RN.

Barnes, a senior consultant in patient care services in Kaiser’s Northern California region, specializes in infection control. The role of rings in potential hand contamination has received less attention and research focus than the issue of artificial nails and long natural nails.

Yet a recent study of ICU nurses that found that a strong association between hand contamination and ring wearing could draw more attention to the question of whether nurses should be asked to take off their rings at work.

“I think as we go down the road, as evidence collects that identifies this as a risk, the community will have more stringent policies,” Barnes said.

Barnes said she’s had inquiries from Kaiser physicians in response to the most recent ring-wearing study, published last year by the Infectious Diseases Society of America in its journal, Clinical Infectious Diseases.

“We’ll be discussing the issue to see if we need to adjust our policies,” Barnes said.

The study, “Impact of Ring Wearing on Hand Contamination and Comparison of Hand Hygiene Agents in a Hospital,” compared handwashing agents and looked at risk factors for hand contamination. It concluded that rings on nurses’ hands resulted in an increased presence of Staphylococcus aureus, gram-negative bacilli and Candida species. The increase was larger when more than one ring was worn.

The study focused on 66 surgical critical care unit nurses at Rush Presbyterian-St. Luke’s Medical Center in Chicago. Sampling each participant once a day, the researchers cultured 564 hands during 282 sampling episodes.

The study evaluated three handwashing agents: an alcohol-based hand rub, an antibacterial hand wipe and plain soap and water. Researchers tested one hand after a nurse’s patient care encounter and cultured the other hand after the nurse performed handwashing procedures using one of the three agents. The presence of rings, artificial nails and cuts on hands were noted.

Where’s the risk? Although the study found ring wearing increased hand contamination with potential nosocomial pathogens, its principal investigator, William Trick, MD, said the study didn’t examine the risk to patients.

“Finding contamination on a ring doesn’t mean it’s transferred to the patient,” said Trick, a staff member of the Collaborative Research Unit of John Stroger Hospital of Cook County in Chicago.

Unlike artificial nails, the wearing of rings has not been connected to any episodes of patient infection. Earlier studies that addressed ring wearing have shown that after handwashing the presence of bacteria on hands with and without rings was similar.

The CDC’s latest hand hygiene guidelines issued in October 2002 make no recommendation regarding wearing rings in a health care setting and classify the issue as “unresolved.” The CDC policy suggests—rather than recommends—removing rings, watches and bracelets before surgical scrubbing.

Before the CDC would recommend banning rings, Trick said, it would need to see documentation that contamination is transferred to patients.

“The use of rings could be a potentially contentious issue,” Trick said. “I have heard people say they are symbolic, and they don’t want to remove them.”

Trick leaves his ring at home and found that many nurses do the same. In his study, the nurses who wore rings at home but removed them before work showed no greater hand contamination than RNs who never wore rings.

The study found that the type of ring wasn’t a factor in the presence of contamination. Rings with smooth bands, set with gemstones or etched with a pattern all showed the same levels of contamination.

Whether to wear rings is a personal decision people have to make, Trick said, but he hopes hospitals will educate nursing staff and share the research data with them.

Spotty evidence. Before ring wearing becomes “the next hill to die on,” there needs to be a lot more scientific evidence to support the risk to patient safety, said Annemarie Flood, RN, a certified infection control nurse. After initial resistance, people have accepted that artificial nails shouldn’t be worn at work, she said, but that’s because nails have been associated with infection outbreaks.

Flood, who works in the epidemiology department of UCLA Medical Center, said the wearing of rings and other jewelry is not addressed in UCLA’s hand hygiene policy, but jewelry is covered in the dress code.

“You should remove your rings or at least move them when you’re scrubbing in,” she said. “Jewelry should be small and not interfere with patient care.”

Most people who scrub in remove their rings and keep them off, Flood said. She doesn’t see a need to change practices.

“I will wait for the science and wait for the studies to come out,” Flood said. “We always hope to base our practices on science.”

The CDC has no immediate plans to update its hand hygiene policy, said spokeswoman Rachael Lawton, unless enough new information became available.

“A handful of studies isn’t going to do it,” she said.

The Association of periOperative Registered Nurses recommends rings not be worn in surgical settings, and Vicki Brinsko, RN, CIC, said nurses should follow the same scrubbing guidelines when performing any invasive procedures.

“If you’re delivering day-to-day health care like taking blood pressure, I think it’s fine to leave your ring on,” she said, although she cautions against wearing large, ornate rings that could cause gloves to tear.

Brinsko teaches “Infection Control 101” at Belmont University and is the infection control coordinator at Vanderbilt University Medical Center, both of which are located in Nashville, Tenn. She also practices bedside nursing on the weekends.

She wears a wedding band and usually leaves it on while working. When she performs an invasive procedure or enters a surgical setting for observations, she removes her ring and pins it inside the pocket of her scrubs.

More data needed. Before hospitals make strong recommendations about removing rings, more data are needed, said epidemiologist John Boyce, MD, head of the Hand Hygiene Resource Center at Saint Raphael Healthcare System in New Haven, Conn. Boyce also chairs the hand hygiene task force of the Healthcare Infection Control Practices Advisory Committee. No one knows if ring wearing poses a threat to patients, he said, and there need to be more studies in that area.

“There isn’t sufficient evidence to make a strong recommendation,” Boyce said. “I wouldn’t come down on either side of the fence.”

Donald Goldmann, MD, with the department of infectious diseases at Children’s Hospital Boston, said he’d rather people didn’t wear rings at work. It’s common practice not to wear them in the OR at his hospital, but he isn’t prepared to call for a ban on ring wearing.

“On the face of it, it would be better if people didn’t wear rings,” Goldmann said. “But I don’t know what it means for someone to take off a $1,000 ring and put it in a locker while they work.”

A bigger issue, he said, is getting health care professionals to comply with established handwashing practices. CDC guidelines say the most important factor in reducing nosocomial infection is handwashing. Yet studies suggest some clinicians fail to perform this basic infection control procedure.

Handwashing shouldn’t be taken lightly, Goldmann said, and it needs to happen every time a doctor or nurse leaves a patient’s bedside.

“The time when people can say there isn’t time for hand hygiene has passed,” Goldmann explained. “This is not a trivial matter.”

Contact Donna Hemmila at dhemmila@prodigy.net.