Wearing scrubs in public...

[HappyNurse2005]

I was reading the paper this morning, and this topic was mentioned in teh "Ask Marilyn" column. The question and answer was this

"A question has been bothering me since I moved to a city that is home to some of the finest hospitals in the world. When I use public transportation, I see people wearing scrub suits to work. Is this acceptable? I had thought employees were supposed to change into scrubs provided at the hospital in order to leave outside germs at the door"-

and her answer

"You're right. I've noticed the same phenomenon in other cities, too. If those people are hospital employees they are endangering patients and should be reported to hospital authorities. Another growing problem is scrubs being stolen and word in other places, such as the subway, to convey an impression of respectability. Anyone seen wearing scrubs outside an appropriate environment should be regarded with caution"

What do you think?

WHen i was a student, so recently, we had to wear our scrubs into the hospital, we were told not to change at the hospital. Here I saw the OB nurses and OR nurses were the only ones who had uniforms provided to them to change into at the hospital.

[Marie_LPN, RN, LPN, RN]

Well, number one I don't think a hospital should provide scrubs for anyone outside the OR/PACU. I get real disgusted seeing people in our hospital wearing scrubs because their too darn cheap to go out and buy their own. The other problem about workers wearing scrubs outside the hospital is that you don't know if they are a nurse, MD, x-ray tech or even a housekeeper. So the general public should approach with caution because you never know if the question you want to ask could be answered by a doctor wannabe that is in reality an Engineer at the hospital. As far as nastiness on scrubs in public, I generally don't think that is the issue most of the time. Health care workers that do get body fluids on them are smart enough not to drag it through the general population and will change before heading home. Mike

Our Maternity and ER floors have hospital-provided scrubs, since they are also at risk for ruining any they would wear from home.

[Marie_LPN, RN, LPN, RN]

You know who I look at with great caution? The store employees.

I firmly believe that the grocery-store worker who doesn't wash hands properly is spreading more germs than I possibly could.

Ever been to the cash register and have a cashier with a cold handle all of your food items, then give you change?

Not to mention the half-***ed way some deli workers wear their hairnets. covering half the hair. What is the point of it if it's not covering ALL hair???

[Marie_LPN, RN, LPN, RN]

We have a sign in our hospital and ER waiting room that says if you have an upper respiratory infection, please ask for a mask. :)

steph

And i've seen people put this mask over their mouth and not their nose because "i can't wipe my nose if it's covered by a mask".

[Jamesdotter]

And i've seen people put this mask over their mouth and not their nose because "i can't wipe my nose if it's covered by a mask".

How about the ones who can't keep their hands off the mask--constantly adjusting it by handling it all over, not just by the strings.

[RainDreamer, BSN, RN]

Where I did my clinicals/preceptorship at we just wore our own scrubs, except for in the OR/PACU.

When I was doing my preceptorship in the NICU, we wore our own scrubs in. The only people required to wear the gowns were the outside visitors, we didn't have to because we had scrubs on; that's what I was told. I sometimes wore a gown anyway though, if I was holding a baby ... or sometimes it was just cold in there.

I got spit up all over my scrub top though and had to change into some scrubs that they had provided. They are such comfortable scrubs!! Way more comfy than my own scrubs. Maybe I'm the only one that thinks that the cheapy ones are more comfy, lol .... why can't they sell those kinds of scrubs in the stores?!

[fergus51]

First of all, I don't fully agree with the idea of evidence-based practice. Scandalous, you say? Perhaps. But there isn't time nor money enough in the world to test everything--throw in a bit of "who paid for that research" (think of the cigarette companies) along with Mark Twain's very valid statement that there are "lies, d*** lies, and statistics," and you have some significant ammunition with which to question scientific studies. Further, I think "positive" proof is much more reliable than "negatie proof" (we know disease is transmitted thusly vs. we know that disease is NOT transmitted this way.) Scientific method is a useful tool, but there are limitations. Oh, and then, of course, you have to have a study that is significantly seminal to make a difference; otherwise, scientific studies can get bogged down in arguments about the experiment methodology, etc.

Sometimes we have to act on the PRINCIPLES that have been proven and then make logical conclusions from those.

Let's see:

Cas we agree that, if someone is in a classroom with people who have a cold, their chances of getting a cold are greater?

Hospitals are "supermarkets" of germs; you will find worse bugs in the hospital setting than in the general environment. ISTM that I heard the reason why nurses stopped wearing caps was because they were detected as being modes of transmission of bugs; and people have eyed physicians' ties as well. In fact, hospitals can be quite dangerous places for patients just because of the types of germs that live there--they are the worst of the worst.

You've only addressed one part of the equation: bringing bugs into patients. I don't think that's the worrisome part. The worrisome part to me is spreading germs that are more endemic to the hospital environment to others, outside.

But, if we take your original scenario, that of preventing spread of disease TO patients, I do know that Kaiser in my area had any patient coming in to the clinics who had a cough to wear a mask; and that I was told by my physician to not be around patients while I had a URI.

NurseFirst

.

Yes, I do think it's a little scandalous that anyone would just dismiss scientific evidence without even examining it and instead rely on their gut. Believe it or not, there are well put together studies out there. But getting to the topic at hand.... I don't really get the point about Kaiser, but you'll notice even they didn't require you to change clothes. There's a reason for that.

First of all, if you're worried about me spreading disease to the community, the germs nurses are exposed to in a hospital are not necessarily scarier than anything outside. I work NICU. Trust me, many times what can kill my patients would not even cause the sniffles in the general public. I'm not some typhoid Mary the second I leave the unit. Patients with serious communicable diseases are assigned appropriate precautions in all units (contact precaution, isolation, etc). Those precautions are what we know are necessary to prevent the spread of disease. If you don't accept the knowledge base of infection control specialists, that's your right. I do. I accept that these people aren't lying to me when they say I probably won't get diseases by using a public bathroom and that my uniform alone isn't going to kill patients or people in the community as long as I continue to follow the practices that we already have set up. In order for my uniform to be such a dangerous thing, I would have to expose it to some microorganism (maybe I'll rub it in some disgusting wound or something, ignoring basic infection control policies), then be sure that particular microorganism can survive on my uniform (cuts the list signifigantly), then I'd have to contact strangers with my uniform ("Excuse me sir, can you rub your face against my infected-wound stained shirt for a minute?), and it would have to be able to get into the host somehow (maybe the man has a cut on him or he licks it or something) AND the host would have to be susceptible. I've yet to infect the people I've lived with with anything, even during SARS, so you'd have a hard time convincing me that my uniform is such a danger to the community. I'm open to any evidence you could show me though.

Secondly, you've again failed to adress the MANY people going in and out of the hospital every day. If the nurses' scrubs are so dangerous to public health, why on earth would we allow visitors, housekeeping, doctors, administrators, cafeteria workers, chaplains, volunteers, etc. to wear their clothes into and out of the hospital? Those people are exposed to the same germs. I worked during SARS in Toronto and they were subjected to the same InfDis requirements because they are just as exposed as the rest of us, often times more so because they don't exercise precautions well.

And finally, you haven't adressed the practicality of it. Unless I get to work, strip, wash, then put on a fresh uniform never letting the dirty clothes touch the clean area (and repeat that process to leave) I can't be completely clean. This debate reminds me so much of nurses who think that glove wearing will protect the patient. If you pick gloves up with your dirty hands, the gloves are dirty. The same thing goes with clothing. That's why most hospitals insist on infectious disease requirements that have been proven to work rather than things that just make nurses feel better. A vest you put over your scrubs is really useless unless it never comes into contact with anything from the outside. More likely nursing students put on their vest and forget about it. Then, they adjust their top, they pull their pants up and down, maybe adjust the waistband.... then touch the vest and suddenly the vest isn't any cleaner (if it ever was in the first place).

[pricklypear]

Fergus, you said it all. And you said it well.:yelclap:

[flashpoint]

I personally roll around in the patient's linen hoping to collect some good bugs after I have changed their bed...our census has been low and I am sure that my efforts are making more people sick and providing me with a good deal of job security. Someone has to do it...

I honestly don't run a bunch of errands or anything before or after work when I have my scrubs on, but if I need to stop at the grocery store or get gas in my car or something, I am going to do it. My hospital doesn't even have some place that we could change our clothes before and after our shift if we chose to...sure there are bathrooms, but I really don't want to put my clothes on the floor or on the door or anywhere in a hospital bathroom.

I am more concerned about the people who don't wash their hands or go out when they are sick or don't remember to bathe than I am about a bunch of nurses running around in scrubs.

Also...you certainly don't need to steal scrubs to get them...you can get scrubs at Wal-Mart! We have a business in town that will put the hospital logo on scrubs, lab coats, etc and they never ask for any proof that you work for the hospital before they do it!

One last thing...isn't "Ask Marilyn" supposed to be more fo rmind benders and trivia type questions? I didn't know her job was to police nurses' habits...

[nursemike, ASN, RN]

Let us not forget that germs are a.) very, very small and B.) just a theory, anyway. However, for those who are still worried, but don't have time for proper handwashing, a good alternative is clapping your hands vigorously. Many germs will be crushed by the impact, and others will fall harmlessly to the floor.

Trust me on this--I kill germs for a living.

[pricklypear]

I'm really wondering...HOW does Marylin know people steal scrubs for the purpose of conveying an aura of respectibility? Do they poll people on subways? How do these people get the scrubs from the hospital if they don't work there? Is there a black market? What is respectable about it? Is it more respectable if you have a stethoscope hanging around your neck in the subway, while you proudly wear your ill-gotten scrubs? I need to know these things.

To report people wearing scrubs on the subway to the Hospital Authorities, is it OK to approach the person wearing scrubs and ask their name, title and unit? If you don't know, how do you know WHICH Hospital Authority to report to?

[NurseFirst]

Yes, I do think it's a little scandalous that anyone would just dismiss scientific evidence without even examining it and instead rely on their gut. Believe it or not, there are well put together studies out there. But getting to the topic at hand.... I don't really get the point about Kaiser, but you'll notice even they didn't require you to change clothes. There's a reason for that.

First of all, if you're worried about me spreading disease to the community, the germs nurses are exposed to in a hospital are not necessarily scarier than anything outside. I work NICU. Trust me, many times what can kill my patients would not even cause the sniffles in the general public. I'm not some typhoid Mary the second I leave the unit. Patients with serious communicable diseases are assigned appropriate precautions in all units (contact precaution, isolation, etc). Those precautions are what we know are necessary to prevent the spread of disease. If you don't accept the knowledge base of infection control specialists, that's your right. I do. I accept that these people aren't lying to me when they say I probably won't get diseases by using a public bathroom and that my uniform alone isn't going to kill patients or people in the community as long as I continue to follow the practices that we already have set up. In order for my uniform to be such a dangerous thing, I would have to expose it to some microorganism (maybe I'll rub it in some disgusting wound or something, ignoring basic infection control policies), then be sure that particular microorganism can survive on my uniform (cuts the list signifigantly), then I'd have to contact strangers with my uniform ("Excuse me sir, can you rub your face against my infected-wound stained shirt for a minute?), and it would have to be able to get into the host somehow (maybe the man has a cut on him or he licks it or something) AND the host would have to be susceptible. I've yet to infect the people I've lived with with anything, even during SARS, so you'd have a hard time convincing me that my uniform is such a danger to the community. I'm open to any evidence you could show me though.

Secondly, you've again failed to adress the MANY people going in and out of the hospital every day. If the nurses' scrubs are so dangerous to public health, why on earth would we allow visitors, housekeeping, doctors, administrators, cafeteria workers, chaplains, volunteers, etc. to wear their clothes into and out of the hospital? Those people are exposed to the same germs. I worked during SARS in Toronto and they were subjected to the same InfDis requirements because they are just as exposed as the rest of us, often times more so because they don't exercise precautions well.

And finally, you haven't adressed the practicality of it. Unless I get to work, strip, wash, then put on a fresh uniform never letting the dirty clothes touch the clean area (and repeat that process to leave) I can't be completely clean. This debate reminds me so much of nurses who think that glove wearing will protect the patient. If you pick gloves up with your dirty hands, the gloves are dirty. The same thing goes with clothing. That's why most hospitals insist on infectious disease requirements that have been proven to work rather than things that just make nurses feel better. A vest you put over your scrubs is really useless unless it never comes into contact with anything from the outside. More likely nursing students put on their vest and forget about it. Then, they adjust their top, they pull their pants up and down, maybe adjust the waistband.... then touch the vest and suddenly the vest isn't any cleaner (if it ever was in the first place).

I'm not relying on my gut. I am relying on principles. One of those principles is that "absence of evidence is NOT evidence of absence." I think you may have missed that part of my post...I never said I relied on my gut. OTOH, that's an interesting point: I *could* surmise that you didn't read that part of my post--however, absence of evidence isn't evidence of absence (evidence of the fact the you did not read that part of my post.) I certainly think it's evidence of you jumping to conclusions about what I said, when I really never said that.

We can get into entire discussions about aerosol vs. non-aerosol, and how far a bacteria can go, or live (and who says it has to be a bacterium--how about viruses and parasites.)

Why not the rest of the hospital staff? I would say that nurses have more intimate and more prolonged contact with patients than most other hospital personnel, with, perhaps, the exception of the nurses aides. So, we have greater exposure both in terms of quantity and variety.

Perhaps, in terms of someone in NICU, you aren't exposed to bugs that are as dangerous to the general adult population--RSV comes to mind; metabolic problems like hyperbilirubinemia; congenital defects. I'm not sure that that can be said for all nurses in the hospital.

As for logistics. Hey, think outside the box! The whole issue could generally be solved not by nurses changing in and out at the hospital, but how it's addressed in multiple situations--why not wear something OVER your uniform on your way to and from the hospital...???

As for absolutes -- yep, there is no "absolute". When someone grabs "clean" gloves out of the box in the patient's room, they are still most likely cleaner than the nurse's hands, I don't care how much they've been washed. But, as far as the point you address--yep, that's right--gloves came into use because of the fear of healthcare workers getting something from the patients--no doubt about that! Nevertheless, if the ID people weren't concerned about transmission patient to patient, why wash our hands before and after each patient?

As far believing people in authority (the ID specialists), I guess I grew up with those bumper stickers that said "question authority." I also find it is a helpful attitude to have when I advocate for my patients--after all, who is at the top of medical authority chain? The physician...

Oh, and finally, about all those other people who are doing terrible things, like the butcher cutting the meat then the cheese? That is out of my domain of concern; I am entering the nursing profession, not meat-cutting or deli-work. Maybe if I were an epidemiologist...(But Robin Cook did write a pretty scary novel that involved the lack of controls over the meat industry...)

NurseFirst

[fergus51]

Nursefirst, the other hospital staff might not have as much intimate contact as nurses, but us nurses wander around the hospital. We sit in the cafeteria. We go buy stuff at the gift shop. We might even lean against the wall in the elevator. If our uniforms are so contaminated as to risk the health of the general public, surely other healthcare workers and visitors who touch all those things are just as dangerous (I won't even go into the fact that visitors often hug and kiss patients which is something I don't do;)...). Did you know that phones and door handles in hospitals are often the dirtiest things there? Those aren't only touched by nurses.

As far as our ID people... they are extremely concerned about transmission of diseases to patients. To imply otherwise isn't fair to them and if I gave you that impression, it certainly wasn't my intention. Our ID people are awesome. I don't know if you've ever done NICU nursing, but infection is one of the biggest issues we deal with and we need to be constantly vigilant about ID protocols. That said, we don't have to glove every time we touch a baby and the hospital doesn't supply us with uniforms despite your belief that it would be "cleaner". Why? Because the ID people are concerned about implementing ID principles THAT WORK. That means the protocols have to be appropriate and effective. You don't don a face shield and hair cap to put in a peripheral IV, even though it might seem cleaner because it's pointless. The research shows what works and what hasn't worked. It's not like the idea was never tried out before. Show me a unit where the infection rates increased after nurses started wearing in their own scrubs from home but all other standard ID protocols were followed and I'll jump on the bandwagon with you. I had to laugh at the absence of evidence bit... Didn't Dick Cheney say something like that a while ago:D? It's true that the absence of evidence wouldn't be particularly compelling. What is compelling to me is that hospitals tried making nurses wear hospital uniforms and changing at work, and they tried letting nurses wear their own clothes in. There wasn't a difference. That's not just "absence of evidence", that's comparative study. The basics of infection control are still the gold standard: washing your hands, obeying universal precautions, instituting other precautions based on specific diseases.