I SPEND A LOT OF TIME in the clinical setting, both as a visitor seeing a loved one and as a nursing instructor. I've come to realize that many of today's nurses wear their hair flowing long and unrestrained, which surprises me. Is wearing one's hair up and out of the face an outdated and meaningless historical ritual, or an evidence-based practice that contributes to infection prevention and optimal patient outcomes? Further, when nurses touch their hair, do they transfer bacteria from their hair to their hands? Can that bacteria then be transferred to a patient if they do not wash their hands after touching their hair? This article explores the evidence concerning hair restraint and infection control.
Several possible hazards come to mind regarding hair. One obvious issue is unrestrained hair falling onto the patient's bed or, even worse, into a surgical wound. Most of us dread finding a stray hair in our hotel bed or, even worse, our food. It makes sense that hair should not be introduced into patient care.
Many studies have shown that bacteria are present in hair.1-3 Recent articles concerning pathogens present in hair reference a benchmark study done by Summer and colleagues in 1965 involving 100 outpatients, 422 preoperative inpatients, and 164 nursing and medical staff.3 By pressing agar plates against the scalp, the researchers demonstrated that no hair plate was bacteria-free. After 24 hours, pathogenic bacteria were isolated from the hair of 72% of outpatients, 61% of inpatients, and 46% of medical and nursing staff. Staphylococcus aureus was the most common pathogenic bacterium found, followed by Escherichia coli and Streptococcus viridans. Several other types of pathogenic bacteria were present in smaller quantities.
This study, while valuable, is now about 54 years old. Current literature regarding testing hair for pathogens is lacking, especially regarding pathogens in the hair of nurses who provide direct patient care. However, a 2017 study conducted on 30 dental and dental hygiene students involved taking bacterial samples before and after dental clinic sessions of sterilized scrub swatches attached to a hairband and scrub pants. Microbial analysis of the swatches from the scrub pant swatch showed 250 to 60,000 colonies of bacteria per swatch and 130 to 84,800 colonies of bacteria per hair swatch after clinic sessions. Fifty-six percent of the study sample reported either washing their hair “sometimes” or not washing their hair right after the workday.1
Other research done in 2018, which studied S. aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and E. coli, focused on adherence of bacteria to hair shafts. Hair shaft samples anywhere from 3 to 9 cm from the scalp were collected from hair free of dandruff, scalp disease, and chemical treatments. The hair underwent two cycles of disinfection with 70% ethanol before being washed three times with purified water for 2 minutes in a vortex, referred to as standard washing process.
To determine if bacteria adhered to the hair shaft, hair shaft samples were tested with bacteria several times using different methods. S. aureus and S. epidermidis did not readily adhere to the hair shaft. The study demonstrated that clean hair subjected to bacteria had significant antibacterial effects against S. aureus and S. epidermidis. P. aeruginosa and E. coli both showed colonization and adherence on hair shafts. P. aeruginosa covered the hair shaft surface forming a biofilm, whereas E. coli inhabited the edges of the cuticle scales.4
A study was done in 2014 within a controlled test chamber that excluded external contamination. The researchers found S. aureus to be significant in long tied-up hair such as a ponytail as well as on the scalp.5
The American College of Surgeons guidelines for appropriate OR attire, based on available evidence during invasive procedures, state that the mouth, nose, and hair (including facial hair) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained.6
The Association of periOperative Registered Nurses guideline for surgical attire recommends a clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck. This recommendation is supported by a number of studies showing that hair can be a source of bacterial organisms and potential surgical site infection.7
Hair product hazards
The possibility of bacteria in hair products is another concern. Sampling of products such as shampoos and liquid foams show bacteria present in the products after they had been in use for 30 days.8 In one report, baby shampoo found to be contaminated with Serratia marcescens resulted in the death of a newborn and severe illness in several others in a Saudi Arabian hospital.9
Studies have also confirmed that hairspray can become contaminated with various Microbacterium species.10 Between 2009 and 2014, incidents of recall or withdrawal of hair wash products were reported to the Rapid Exchange of Information System, the European Union's rapid alert system used for consumer protection and unsafe consumer products (except for food, pharmaceutical products, and drugs). Contaminated hair dyes from five countries of origin were reported.8 Therefore, nurses may unwittingly carry bacteria to work in their hair despite meticulous personal hygiene.
Current research needed
Do nurses realize how often they touch their hair and, after touching their hair, continue to take care of a patient without performing hand hygiene? The literature review revealed no studies counting the number of times nurses with unrestrained hair touch their hair, and if they perform hand hygiene again after doing so. In addition, no studies identified hair-to-hand transfer of bacteria. The question of whether bacteria in nurses' hair can be transferred to their hands and then to the patient if they do not perform hand hygiene after touching their hair still remains. Would hair containing hair gel or hairspray allow bacteria to adhere more readily?
Other issues involve hospital policies about nurses' hair. Are nurses following hospital policies regarding how the nurse is to wear his or her hair during patient care? Does the hospital even have such a policy and, if one exists, is it enforced? Further research is needed on these issues.
Because studies have consistently shown bacteria in hair, nurses should be encouraged to examine their own practice and the practice of coworkers to see how frequently touching unrestrained hair occurs. Managers should review policies concerning hair and enforce hospital policies.
Hand sanitizer is readily available in patient rooms and throughout patient-care areas. A simple timeout procedure at the beginning of each shift can help nurses maintain accountability for proper restraint of hair and remember to perform hand hygiene after touching their hair.11 Timeout procedures during change-of-shift huddles can educate nurses about the importance of hair restraint. Adding hair touch to hand-hygiene observation checklists would benefit quality measurements of practice.
Back to the future?
One of the primary reasons female nurses once wore caps was to keep their hair in place.12 Finding new ways to ensure proper hair restraint is certainly worth thinking about. Perhaps healthcare organizations can provide a different type of cap to prevent the spread of pathogens, such as a surgical cap for nurses to keep hair up. Evidence-based research can help resolve whether restraining hair for infection prevention is a sacred cow or a legitimate concern.
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