Back in nursing school, we weren’t allowed to have our fingernails visible over the pads of our fingers. Even then we already knew the potential dangers of long fingernails with our nursing and  patient care activities. The use of artificial acrylic fingernails has become more fashionable and so more nurses have begun wearing them even at work. Now that we are professionals, who’s going to discipline us about long fingernails, nail polish and artificial nails? 

In my numerous visits to several physician based infusion centers, I have seen nurses providing infusion care wearing artificial nails. One even used the tip of the nail length to thread (push) the catheter into the vein.  (“faints”) Indeed, nail care is part of personal grooming and not my concern. But when it involves poor practice and patient safety,  I make it my business.

The evidence:

• As early as 2002, the Centers for Disease Control and Prevention (CDC) published a Guideline for Hand Hygiene in Health-Care Settings, which recommended that healthcare workers “not wear artificial fingernails or extenders when having direct contact with patients at high risk” (eg, those in intensive care units, transplant units, or operating rooms). This recommendation is considered a Category IA, which is defined as “strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiological studies.” The CDC further advises nurses to check their facility’s policy regarding artificial nails, which may be stricter.

• The Joint Commission has also added these recommendations from CDC to their Infection Control standards and included the issue of artificial nails in Patient Safety Goal #7.

• Goal 7 Reduce the risk of health care-associated infection. 7A Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

• Conclusive evidence is needed whether or not artificial nails contribute to direct transmission of infections, but studies have documented healthcare personnel who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing.
• Long nails, both natural and artificial, can facilitate the colonization of bacteria on the hands by making handwashing less effective and the use of gloves less practical. The longer the nail the more likely it is that bacteria can reside under its free edge.
• A few reports have implied that nurses who wear acrylic fingernails may become colonized with Candida and, thus, become a possible risk to susceptible patients.
• Personnel wearing artificial nails have been epidemiologically implicated in several outbreaks of infection caused by gram-negative bacilli and yeast.
• In addition, acrylic nails can trap moisture and fungi that lives underneath the nail. More than 35 million people in the United States are infected with nail fungus.
• The World Health Organization (WHO) guidelines on hand hygiene state that wearing artificial acrylic nails can contribute to hands remaining contaminated with pathogens after use of soap or alcohol-based hand gels.
• Many nursing organizations such as the  Association of periOperative Registered Nurses (AORN) and the Infusion Nurses Society (INS) have strong recommendations and standards of practice on not wearing acrylic nails.
• Many hospitals and other healthcare employers have policies on the use of artificial nails.

The bottom line:

Even with standards of practice, evidence based recommendations, and the great emphasis on reducing healthcare associated infections, why do nurses still wear artificial nails?  Vanity…fashion…yes, it is a matter of personal preference and definitely,  it is a patient safety issue.

• Nurses should refrain from such a practice in the interest of preventing healthcare-associated infection. All nurses, not just those who care for perioperative patients or others at high risk for infection, should be guided by their duty to protect the patients  and the research data that suggest that artificial nails can put patients at risk.

• For any nurse performing tasks related to infusion therapy, hand hygiene (includes not wearing artificial nails) is on the top of the checklist for preventing infections.

References:

1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002.51
2. Gupta A, Della-Latta P, Todd B, et al. Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumonaie in neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol. 2004;25:210-215.
3. Joint Commission on Accreditation of Healthcare Organization. 2007 Hospital/Critical Access Hospital National Patient Safety Goals.
4. Association of periOperative Nurses. 2007 Standards, Recommended Practices & Guidelines. AORN; 2007.
5. World Health Organization. Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization: 2005.
6. Infusion Nurses Society. 2006 Infusion Nursing Standards of Practice
7. Baran R. Nail beauty therapy: an attractive enhancement or a potential hazard? Journal of Cosm Dermatol 2002;1:24-29.