We’ ll be sitting around in our infection prevention group talking about fingernails and policy for an hour and in the end, I’ m like, well, how are we going to enforce this? How are we going to figure out who’ s doing what? And then what are we going do about it? I think those are some of the biggest challenges with fingernail stuff. I personally am not big on doing anything special with my nails, but I know that for many of our staff, it is a hill that they are willing to die on.” mis-opportunity, I think that they don’ t have dedicated time to do these, as they’ re doing them as they’ re doing their normal work, so I feel like probably when they see someone wash their hands, they mark it down to get their number and they’ re not systematically looking for in and out of the same room. So, that’ s an issue. We’ ve used volunteers at different times, but sometimes we have them, sometimes we don’ t. We’ ve explored electronic hand hygiene monitoring systems but decided they weren’ t scalable. But using our methods, last month we had 15,000 observations across three hospitals.”
Sickbert-Bennett reported that her facility“ simplified our moments to just be clean and clean out, and we have an electronic app that’ s available to everyone, so no training required to submit observations. It’ s very much like a crowd-sourcing type app with the idea that the more important metrics to us, which we track alongside with number of observations and of course percent compliance, which we know is highest for the reasons others have already shared; we also track the number of unique observers and the percentage of feedback given. We also do independent infection prevention rounds to get another angle of hand hygiene compliance, but our thought process is that it’ s more important to get more staff involved in watching each other and providing direct feedback as the intervention, so it’ s kind of a monitoring and intervention program rolled in one that doesn’ t as much require digesting the data, preparing the reports, presenting it to people, getting them excited about changing, etc. In just looking at our July data across our UNC health system, we had almost 60,000 observations put in and almost 60 percent of them had feedback associated with them. We have used that as a practice for having patient safety-related conversations, even if it’ s thanking somebody for washing their hands, trying to empower everyone to be a part of the program and speak up when they see a moment that was almost missed or actually missed.”
Trish Perl, MD, MSc, a professor in the Department of Internal Medicine at UT Southwestern Medical Center, noted,“ We have done a little of what everyone has described and focused not only on using volunteers but also worked with occupational health and identified individuals who’ ve been put off work for certain reasons and repurposing them. What I would say about that is it has been eye-opening for those individuals and they’ ve become our secret ambassadors in a way. So, it is a strategy that I think has some utility. Aside from that we have done in-and-out as well as the Five Moments of Hand Hygiene, and the argument for doing the Five Moments is that it’ s teachable and you if you intervene, you can comment on what was the behavior that was missed or what was the issue that was missed? And I can’ t say that I have a preference. I can see that both are very useful and you just have to use what’ s effective in that particular setting.”
The panelists then turned to questions from town hall attendees.
One of the most popular topics for questions was fingernails; an attendee inquired if there has there been any research on facilities not enforcing or abandoning fingernail policies, noting that oftentimes there is noncompliance with no oversight and no enforcement due to staffing issues.
“ That’ s one of the biggest challenges I’ ve seen,” Linam acknowledged.“ We’ ll be sitting around in our infection prevention group talking about fingernails and policy for an hour and in the end, I’ m like, well, how are we going to enforce this? How are we going to figure out who’ s doing what? And then what are we going do about it? I think those are some of the biggest challenges with fingernail stuff. I personally am not big on doing anything special with my nails, but I know that for many of our staff, it is a hill that they are willing to die on. If you’ re going to make some big changes to what you’ re asking people to do, you will need to have a good reason, and you must be able to enforce it, because all it takes if you write up one person for having the wrong kind of nails, and if you aren’ t consistent, it all goes sideways.”
Sickbert-Bennett noted,“ I think it would be very difficult not to have a fingernail policy at all, and I think you would be cited if you didn’ t, but I agree that it’ s almost impossible to enforce. It has to be at the management level, but what we often see are the managers and other leaders are the ones who have the really nice nails, and they may or may not have direct patient-care responsibilities; often they do, but even if they don’ t, they’ re not really leading by example, right?”
She continued,“ Our fingernail policy as written currently is very vague, but we do say no gel, no dip, or whatever it is, but that’ s even more difficult to enforce.
We have done a little of what everyone has described and focused not only on using volunteers but also worked with occupational health and identified individuals who’ ve been put off work for certain reasons and repurposing them. What I would say about that is it has been eyeopening for those individuals and they’ ve become our secret ambassadors in a way.”— Trish Perl, MD, MSc
I think we’ re going to focus more toward focusing on who is the population who really needs to have this policy, such as personnel in the OR, in sterile places versus other patient-care activities versus completely administrative. And then focusing on length and truly artificial nails, not worrying about what type of polish it is, because again, I don’ t know that by looking at someone’ s nails. So, how would you expect anyone to enforce that? I don’ t have a good answer about the enforcement, as I agree that it is tricky.”
Perl agreed about the difficulty of enforcing a fingernail policy.“ The one place that I’ m more cautious as in neonatal intensive care units, as there is anecdotal evidence about outbreaks, that gives me pause.”
Linam replied,“ In the last year or so, we, as a hospital, have worked to try to up our game on fingernail
16 • www. healthcarehygienemagazine. com • sept-oct 2025