Hand hygiene needn’t mean sore skin

For many nurses the price of good hand hygiene is sore, broken skin. New guidance from the RCN shows how to combine best practice with skin care

For many nurses the price of good hand hygiene is sore, broken skin. New guidance from the RCN shows how to combine best practice with skin care

Picture: iStock

Hand hygiene requirements can put nurses in a constant cycle of hand washing, rubbing alcohol hand sanitiser into their skin and wearing gloves. While this regimen is a vital part of protecting the health of patients and staff, it can lead to sore, dry and cracked skin.

The difficulties caused can go beyond the discomfort and pain of dermatitis, and it can ultimately prevent a nurse from doing their job.

Helen O’Boyle, an intensive care nurse at a London trust, was left with red, split and bleeding hands after her skin became damaged by constant hand washing and glove use early this year. She was almost in tears from the pain, and was wearing gloves more to protect her broken skin.

‘My hands are the tools of my trade and how I deliver care,’ she says. ‘If there is a problem with them I am in real difficulty. My hands got so sore and itchy. They were bleeding and it got to the point where I thought I can’t do this any more. It was dreadful.’

‘Staff often miss the early signs of dermatitis. They think it’s just sore skin’

Rose Gallagher, RCN professional lead for infection prevention and control

She went to see the occupational health team and was distressed to be told she might have to move to a different department with less intensive hand hygiene demands. This prompted her to see her GP, who gave her steroid cream and a gentle soap substitute. She also found a good hand cream, designed for nurses and people who wash their hands a lot, and reduced her reliance on gloves.

Ms O’Boyle says: ‘I am a lot more aware of moisturising my hands before, during and after work and only wearing gloves when I need to. I make sure I am keeping on top of it and they are much better now, just a bit dry.’

Work-related dermatitis

Damaged, broken skin can prevent effective hand hygiene and leaves a nurse more likely to pick up skin infections. For some nurses this can mean having to move away from roles that demand intense hand hygiene, such as theatre or intensive care nursing, or have breaks from clinical work while their hands heal. This can limit career choices and put more pressure on depleted teams.

Accurate figures on the number of nurses affected by dermatitis on their hands are difficult to find. The Health and Safety Executive estimates that each year in the UK 1,000 healthcare workers develop work-related contact dermatitis, nearly seven times higher than the average for all professions. But the RCN says this statistic is the ‘tip of the iceberg’, with many more likely to be suffering.

Hand wash or hand rub?

  • Wash hands with soap and water when visibly dirty or obviously soiled with blood or other body fluids and after using the toilet
  • Wash hands with soap and water where alcohol hand rubs are known to be less effective, such as when caring for patients with known or suspected Clostridium difficile or norovirus infections
  • Wash hands with soap and water if an alcohol-based hand rub is not available
  • Use an alcohol-based hand rub as the preferred means of routine hand hygiene in all other clinical situations

Source: RCN’s Tools of the Trade

While there has been a lot of work to improve the tolerability of products such as alcohol rubs, it appears that skin problems are increasing. The University of Manchester found that healthcare workers were 4.5 times more likely to suffer from irritant contact dermatitis in 2012 than in 1996. The researchers attributed this to the drive to improve hygiene.

In a study involving more than 9,000 healthcare staff in Sweden, 21% reported hand eczema. In their daily work, 30% reported hand washing with soap more than 20 times, 45% used hand disinfectants more than 50 times and 54% wore gloves for more than two hours.

The more people washed their hands with soap and the longer they wore gloves, the more likely they were to report eczema, according to the study published in the British Journal of Dermatology.

Confusion among staff

Tools of the Trade, a new publication from the RCN, emphasises the importance of correct glove use and hand hygiene, both for patient and healthcare staff safety and to protect nurses’ skin. Currently there is confusion among some staff about when gloves should be worn, leading to them being worn more than necessary.

RCN professional lead for infection prevention and control Rose Gallagher says: ‘We know dermatitis is a problem and we also know it is underreported. One of the big problems is awareness.

Nurse Helen O’Boyle had red, split and bleeding hands after her skin became damaged
by constant hand washing and glove use.

‘Staff often miss the early signs – they think it’s just sore skin. Including it in our guidance is one of the first steps for people to think if they do get sore hands, what can they do about it, and how bad is it.’

The college has published photographs of hands affected by dermatitis that can be put up in healthcare settings to help nurses assess whether they are affected, and how severely.

The nature of nurses’ work means regular contact with potentially irritating chemicals, water and other products. Contact dermatitis is caused by an irritant or allergen, which can include chemicals found in soap, gloves, wipes, some detergents and drugs including steroids and antibiotic solutions.

‘Our hands are our tools, and we cannot work if our hands cannot function’

Rose Gallagher

Rubbing the hand against the allergen or irritant can make the condition worse, while repeated contact with water can damage the skin. Prolonged use of water and extended periods of glove use prevents sweat evaporation, making the skin soggy and disrupting its barrier function.

Cold weather and low humidity can also have a drying effect on the skin, leading to an increased risk of skin problems.

All of these factors can lead to signs of dermatitis, including redness, warmth, small blisters, swelling, cracked or weeping skin, itching and skin infection.

Only use gloves when necessary

Looking after the skin while sticking to hand hygiene protocol is essential, according to the RCN. It has launched posters to encourage nurses to use gloves only when necessary, as they are not a substitute for hand hygiene.

Handwashing dos and don’ts

  • Wet your hands before applying soap, and rinse them in water that is neither too hot nor too cold
  • The optimum temperature for rinsing is 32C
  • Temperatures over 40C may be too hot for some people and could exacerbate skin problems
  • Using mixer taps, so that the temperature of water can be controlled, is an important aspect of protecting the skin
  • Hands need to be dried properly, and the most effective way is to use soft and absorbent paper towels
  • Skin should be patted dry, paying attention to each finger and the skin between the fingers
  • Hot air dryers should not be used due to the risk of re-circulating microorganisms in air currents

Regular use of hand creams or conditioning creams after hand washing and at the end of each work period should be encouraged.

When there is a problem, nurses are urged to take action as soon as they spot symptoms, rather than waiting for the condition to become entrenched.

For those working at larger organisations, the occupational health department should be able to provide help, says Ms Gallagher. For others, a GP or practice nurse should be the first point of contact. ‘We encourage nurses to go and see their GP and get referred appropriately. The most important thing is to go and see someone about it and get something done.’

Regular skin surveillance

Under health and safety regulations, employers should put in place procedures to check the skin of workers exposed to the risk of occupational contact dermatitis. Known as health surveillance, skin checks are used to identify cases of occupational contact dermatitis at an early stage while it is still reversible.

Some organisations carry out skin surveillance at regular intervals, such as monthly or yearly, as well as six weeks after a staff member starts in a role where there is exposure to known irritants or allergens. Staff can then be referred to occupational health teams promptly.

Ms Gallagher urges nurses not to neglect their hands in the daily rush to help patients. ‘Our hands are our tools, and we cannot work if our hands cannot function.’

How to prevent and manage dermatitis

  • Always follow good hand hygiene techniques
  • Remember that wearing gloves is not an alternative to hand hygiene
  • Avoid direct contact between unprotected hands and hazardous substances and/or wet work (defined as 20 or more hand washes a day), where this is sensible and practical
  • If you cannot avoid contact, protect the skin and regularly apply hand moisturisers
  • Check skin regularly for the first signs of itchy, dry or red skin and use hand moisturisers

Source: RCN leaflet Are you glove aware?

Erin Dean is a freelance health journalist


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