are "fake nails" okay for nurses?

Hellllllo Nurse, BSN, RN · Dec 10, 2004

Beautiful Hands or Bacterial Bouquet?

Willa M. Doswell, RN, PhD, FAAN

Nettie Birnbach, RN, EdD, FAAN

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Long, sleek, richly colored nails crowning fingers adorned with intricately designed rings are a fashion statement-and, unfortunately, a bacterial bonanza. Why? Because long fingernails, rings, and all sorts of nail treatments are known to harbor bacteria, such as Pseudomonas aeruginosa and Klebsiella, as well as the yeast Candida parapsilosis, which can wreak havoc on patients' health.1,2

In 1997-1998, 16 babies died in the neonatal ICU at Children's Hospital of Oklahoma, Oklahoma City. The deaths were linked to the babies' exposure to two nurses harboring P. aeruginosa under long or artificial fingernails. After investigating, the US Centers for Disease Control and Prevention (CDC) recommended improved handwashing and short, natural fingernails for nurses. As a result, all nurses at Children's Hospital now have piano-playing-length nails.3

A study conducted at the University of Michigan and Dalhousie University found that of seven healthcare workers with longer nails, all seven harbored harmful germs compared with two of 11 healthcare workers with shorter nails, suggesting long nails are a health hazard.4

The unfortunate reality today is that about one in 10 patients acquires an infection as a direct result of being hospitalized.5 Fearful of acquiring infections, patients may opt to postpone or avoid medical procedures instead of seeking timely treatment in hospitals. Modern hospitals contain an amazing array of computerized instrumentation designed to enhance patient care. Ironically, in spite of these high-tech amenities, invisible armies of the oldest forms of life on earth jeopardize the safety of patients and healthcare workers.

An awareness of the presence of germs in healthcare settings is critical to establishing a truly healing environment. Infection control programs, when properly carried out, make use of Environmental Protection Agency-registered disinfectants, such as chlorine bleach, to kill germs that live on hospital surfaces, needles, syringes, and numerous other bacterial bastions. But since hands are the primary instrument of nursing care and potential conduits of disease, hand hygiene is the subject of enormous concern. About a third of all hospital infections can be prevented by handwashing, identifying patients at risk, and attending to sterilization and disinfection procedures.5 According to the CDC, handwashing is the single most important tool available to prevent the spread of infections.6

In addition to thorough washing with soap and water, proper hand hygiene includes attention to fingernails and jewelry. The longer the fingernails and more intricate the jewelry, the greater the available surface area to which germs may attach. Grooves, scratches, or chips in nails or nail polish and intricate jewelry surfaces provide a multitude of safe environments for microbes. Artificial nail applications, with their dark, moist areas, are particularly inviting to microbes.7 Rings, especially those parts in contact with skin, also act as moisture traps, providing another haven for microscopic life. Additionally, sharp edges of jewelry or ragged fingernails have the potential to tear examination gloves, breaking this protective barrier. It makes sense for nurses to trim fingernails to the tips of fingers (no longer than about 3 mm),1 file them and relegate all but the simplest adornments to the jewelry box before reporting for duty.

Do nurses know how patients feel about the choice of fashionable versus hygienic nails? We can offer one account. Recently, our colleague Mary related something that happened during her annual physical exam. Mary's doctor suggested his nurse remove an ear wax build-up in Mary's ear using warm water irrigation. After consenting to the treatment, Mary watched, appalled, while the nurse assigned to the task submerged her entire hand into the basin of irrigation water to sense its temperature. The fingers of the nurse were topped with half-inch-long, silver-painted nails. Mary was struck with the thought that whatever germs were harbored under those pretty nails would soon be injected into her ear canals! She quickly declined treatment.

As caregivers, nurses can instill confidence in patients by demonstrating good hand hygiene that includes not only frequent handwashing, but also forgoing fashion for cleanliness. Nurses' hands are simply too important to become vehicles of germ transmission.

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The authors are members of the Nurses Leadership Council, an independent body of nurse scholars who serve as advisers to the Chlorine Chemistry Council®.

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References

1. Long Fingernails on Health Care Workers Potential Risk to Patients. Infectious Disease Society of America website. Available at: http://www.idsociety.org/Template.cfm?Section= News_Releases1&CONTENTID=5296&TEMPLATE=/ ContentManagement/ContentDisplay.cfm. Accessed April 1, 2004.

2. Potentially fatal germs under fingernails of hospital personnel should be "eradicated," study says. CNN website. Available at: http://www.cnn.com/2000/HEALTH/09/07/ hospital.bacteria. Accessed April 1, 2004.

3. Cole C. Nail bacteria linked to baby deaths. Available at: http://www.earthchangestv.com/biology/0324nailbacteria.htm. Accessed April 1, 2004.

4. McNeil SA, Phelps A, Barnes AL, Kauffman CA. The effect of fingernail length on microbial colonization of the hands of health care workers. Presented at: Infectious Disease Society of America 39th Annual Meeting, 2001, San Francisco, CA.

5. Tilton D. Nosocomial infections: diseases from within our doors. Available at: http://www.nursingceu.com/NCEU/courses/ nosocomial. Accessed April 1, 2004.

6. O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: The theory of planned behavior. Am J Infect Control. 2001 Dec;29(6):352-360.

7. Bjerke NB. Disinfecting those digits is critical to good handwashing. Infection Control Today website. Available at: http://www.infectioncontroltoday.com/articles/271bpract.html. Accessed April 1, 2004.

HAngel · Dec 10, 2004

I started a thread on this subject a few weeks ago ... I've had acrylics (kept short, pink & whites only, clear nail polish, done in an upscale salon) for 16 years. I'm so vain that taking them off seemed like death to me.
But guess what? I read all of the responses here and realized that my vanity was not worth the risks. So I had them taken off two weeks ago. As I type this, my nails are weak (just put another coat of stregthener on) and I hate how they look and how they feel (especially when making beds! ugh!). But I made the best decision and they will get better soon ....
I hope you'll come to a similar realization ... if you knew me, you'd know how hard this was for me, I still have friends who pick up my hands each time they see me and say they wouldn't have believed it without seeing it! Me without nails! It's worth it though. Absolutely.

Everyone I guess has to decide for themselves, but the evidence is pretty convincing... Good for you for sacrificing something that was a part of you and important to you for you and your patients' sake... says a lot of you and your character :)

Hangel

Marie_LPN, RN, LPN, RN · Dec 10, 2004

Beautiful Hands or Bacterial Bouquet?

Sums it up for me.

Any nurse doing hands-on pt. care should know better than to have those things on. It really burns me up to see nursing students with fake nails, because they're providing hands on care as well.

jaimealmostRN · Dec 10, 2004

Thumbs Down on Fake Nails

Kim Gennaro, RN IV, MSN, CCRN, ARNP

Masthead Date March 25, 2002

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Certain Gram-negative pathogens, such as Pseudomonas aeruginosa and Candida albicans, can flourish under fingernails' subungual area, making effective handwashing much more difficult. Not surprisingly, research1-4 shows a direct correlation between long or artificial nails and increased incidence of nosocomial infection in hospitals.

That risk is what brought about a new dress code at Memorial Hospital West. Patient-focused care has always been the emphasis since the Pembroke Pines hospital opened its door in May 1992, so in summer 2000, when three infections turned up at the hospital's Family Birthplace, the nursing staff, led by Mary Roberts, RNC, MSN, director of nursing for maternal services, immediately embarked on a tougher handwashing and hygiene policy.

They're mighty pretty, but they're still a no-no, say many researchers. That's why Memorial Healthcare System's three hospitals are banning artificial nails.

Policy Catches On

With the research evidence in hand and a strong recommendation from the Association for Professionals in Infection Control, the Centers for Disease Control and Prevention, and the Hospital Infection Control Practices Advisory Committee, the maternal services dress code was revised to ban artificial nails at the Family Birthplace. The policy was implemented in September 2000.

News of the revision was a topic at the following Practice Care Council meeting, and some members volunteered to form a task force to review the likely impact of such a policy for different clinical areas like the OR, ED, and ICU.

The task force's activities began in March 2001 with a brainstorming session, which involved 11 nurses who reviewed research articles provided by Kim Mahon, BHSA, CIC, manager of infection control, and Sue Bradford, RN, the hospital's chief operating officer. Dietitian Melissa Santoro, RD, advised the group that the dress code for food and nutrition services employees had excluded long or artificial nails since spring 1999.

Next came the deliberation phase, during which task force members disseminated the information to their clinical areas. Research articles were posted in the nurses' lounge, and the issue was discussed at staff meetings. Most nurses voiced their clear support while underscoring the importance of basic handwashing technique and the essentials of short, clean nails in preventing the spread of infection. Even before a more global policy could be instituted, nurses began taking action-

ICU Clinical Manager Robin Larghi, RN, CCRN, for example, removed her artificial nails as soon as she read the research posted in her unit.

Directive Wins, Hands Down

It was relatively easy to finalize a draft on the new dress code since the nursing staff had basically approved the change after reading and analyzing the task force's research data. It was generally regarded as a great opportunity for the nursing staff to take a stand on something that could affect both their personal and professional lives.

In July 2001, the Quality Improvement and Research Council sponsored a grand rounds presentation on artificial nails in the workplace. The one-hour panel discussion format helped elaborate needed research-based changes in clinical practice. Members of the panel included nurses from the Family Birthplace, infection control, surgical services, and intensive care/cardiac care, as well as the directors of licensure/credentialing and human resources.

The presentation reinforced the new dress code, which in finalized form required that effective August 2001, direct care providers must stop wearing long or artificial nails (Occupational Safety and Health Administration guidelines on Category I and II exposure to blood-borne pathogens formed the basis for classifying direct care providers). The revised policy ultimately would be addressed in orientating new employees and during annual reviews.

But the good news doesn't stop there: Memorial Hospital West's innovation is the impetus behind practice changes affecting direct care providers at Memorial Hospital Pembroke, Pembroke Pines, where a new artificial nails policy took effect in January 2002. This April, the same requirement goes into force at the third acute care facility in the Memorial Healthcare System, Hollywood-based Memorial Regional Hospital.

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Kim Gennaro, RN IV, MSN, CCRN, ARNP, is a critical care nurse at Memorial Hospital West, Pembroke Pines.

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References

1. Moolenaar RL,Crutches JM, San Joaquin VH, et al. (2000). A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission. Infect Control Hosp Epidemiol. 21(2):8085.

2. Foca J. Jacob K, Whittier S, et al. Endemic Pseudomonas aeruginosa infections in the neonatal intensive care unit. New Engl J Med. 2000;343(10):695-700.

3. McNeil SA, Foster CL, Hedderwick SA, Kaufman CA. Effect of handcleansing with antimicrobial soap and alcohol-based gel on microbial colonization of artificial nails worn by health care worker. Clin Infect Dis. 2001;32(3):367-372.

4. Parry MF, Grant B, Yukna M, et al. Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis. 2001;32(30):352-357.

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jaimealmostRN · Dec 10, 2004

IMO, after blow-drying my hair, shaving legs, applying make up, ironing my scrubs/choosing an outfit when not in school, its nice to have an excuse NOT to do one more thing (nails)! But honestly I think it's kinda a nursing/medical faux pas...everyone knows its bad, but if you do it anyway it seems to send that message that you don't care. JMO though, so no one get mad :)

Jo Dirt · Dec 10, 2004

I don't think fake nails are good for anyone to wear. What is wrong with natural short clean healthy nails?

Marie_LPN, RN, LPN, RN · Dec 10, 2004

Fake OR overlay is a breeding ground for bacteria.

Long Term Care Columnist / Guide · Dec 11, 2004

Not only are artificial nails a literal breeding ground for all kinds of nasties, they do bad things to the nails God gave you.......they don't allow your natural nails to 'breathe', making them porous, thin, and brittle. Which puts YOU at risk for an infection, as well as your patients.

Trust me, fake nails aren't worth it. :stone

Euskadi1946 · Dec 12, 2004

I've worn acrylic nails for many years both in and out of the clinical setting. The secret to keeping the fungus at bay is to have an excellent nail tech who keeps her station scrupulously clean, keeps her nail equipment sterile. When there is a crack you need to repair it immediately and get a fill every 2 to 3 weeks. When I did bedside care, my acrylic nails were short and scrupulously clean. The last hospital I worked passed a policy banning acrylic nails and in order to keep my job I got rid of mine. Now I'm in a different part of nursing and have started to wear my acrylic nails again.

RoxyBen · Dec 12, 2004

I am a nursing student graduating next month. I wore "fake nails" before nursing school, but my program did not allow them during school. I am considering getting them again after graduation. What is your opinion and the policies at the facilities where you work? Are they a health hazaard to patients if proper handwashing precautions are used? Have you read any studies on the "fake nail" issue?

OSHA says NO to fake nails for nurses. Nuff said.

SmilingBluEyes · Dec 12, 2004

I happen to think they are better and healthier than natural nails. Natural nails are porous and can harbor loads of bacteria. Gels are impermeable. Plus, acrylics do not just 'fall off'... they're tough and strong... I wouldn't do without them! My hands are CLEAN, and well kept... if anything, my nails being well manicured show that I care about personal hygiene. Not to mention, I happen to wear gloves every time I perform patient care, so what is the problem?? It always makes me laugh when I hear this arguement. I'll wear them always.

Even though study after study bears you out wrong? What a shame. I am not saying you are stupid, but you are acting in ignorance. And NO gel is "impermeable"; that is a myth. Ok well, laugh all you want. I don't think it's very funny, myself. Acrylics do not belong in patient care areas, period.

dolphinlpn · Dec 12, 2004

Hi everyone,

I have a story and unfornatuley it is true. I work in LTC, and a resident had a PT/INR of 83 and inr was 10.3 I couldn't believe those numbers when I first seen them , but anyway a CNA had long nail, not fake and she gave the resident a skin tear by accident and we had a hard time getting it under control. Needless to say after that the cna doesn't have long nails anymore. I love long nails too, but they don't belong in the medical profession.