Uniform Policy Changes:  Nurses across the country seek comfort and compliance

OR Today Magazine | Cover Story | September

While medical technology has advanced drastically in recent decades, one key element in the operating room has been virtually unchanged in more than a half-century : the medical scrub.

In 2010, the Association of periOperative Registered Nurses (AORN) announced some changes in its Recommended Practices for Surgical Attire that are affecting what OR personnel wear in the surgical environment.

These Recommended Practices have long advocated that non-scrubbed personnel wear a long-sleeved jacket that is buttoned or snapped closed during use to prevent bacterial skin shedding from bare arms, which can contaminate the sterile field. “Complete closure of the jacket avoids accidental contamination of the sterile field,” the Recommended Practice states.

To comply, some OR personnel wore their own long-sleeved shirts or fleece jackets either underneath or over their scrubs. AORN has recommended that garments be contained completely within or covered by the surgical attire, and it now recommends that OR personnel wear freshly laundered surgical attire that has been commercially (not home) laundered.

“AORN does not support the practice of home laundering of surgical attire,” says AORN’s Director of Evidence-Based Perioperative Practice Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR. “Instead, reusable surgical attire should be laundered by a designated facility-approved and monitored commercial laundry after daily use.”

Many are unaware of changes

In an informal survey conducted by OR Today, about half of the respondents (51 percent) said they were not aware of these changes to the Recommended Practices. Some respondents said that long-sleeved scrub jackets are provided to OR personnel as part of their facility’s surgical uniform policies and guidelines. However, these jackets may be uncomfortable and/or too hot, so nurses often take them off.

“The donning of warm-up jackets with long sleeves and snap closures has not been strictly enforced,” says Sharon L. Morris BSN, RN, CNOR. “However, I foresee this changing in the near future.”

About a third of respondents to the survey (37 percent) said they have found it difficult to locate long-sleeved scrubs that are comfortable and don’t have loose-fitting material that can potentially drag across the patient’s skin and contaminate the surgical site. “Our facility provides disposable warm up jackets,” said one respondent, “but they are baggy and do not fit close to the body, so they can easily drag across the patient’s skin.”

According to Spruce, most hospitals today are creating policies and following AORN’s Recommended Practices for surgical attire. “But many are having difficulties enforcing some of the recommendations due to push back from surgeons and other staff, as well as the increased cost of implementing facility scrub purchases and laundry services.” Indeed, some survey respondents cited cost as a factor in their ability to conform to the Recommended Practices.

Improving comfort and reducing contamination

One possible solution to the problems of discomfort and contamination is a recently introduced new style of scrub that features long sleeves made of a blend of polyester, nylon and spandex that are sewn directly into the scrub top: the PerforMAX power scrub from Medline. “We began asking nurses if they needed something new to help them comply with the Recommended Practices, and just about everyone said that the current scrubs uniform they were wearing did not meet their needs,” says Jennifer Walrich of Medline’s textile division, Medcrest.

Myrna Chang, DHA, RN, CNOR, the director of perioperative services and sterile processing at O’Connor Hospital in San Jose, Calif., came up with the initial design for the patent-pending PerforMAX scrub based on her own challenges in finding surgical apparel that is compliant, practical and comfortable. “For our OR circulating nurses to stay in compliance, we knew we needed to wear long-sleeved apparel,” says Dr. Chang. “But we couldn’t find a jacket where the sleeve did not touch the patient and contaminate the prepped area, and that was comfortable and looked good.”

Dr. Chang says the PerforMAX scrub’s sleeves are made of a material similar to high-performance athletic apparel, and they fit snugly around the arms to provide comfort and breathability. “Nurses in the OR have to perform for a long time during surgery, so they need material that will hold up over time and that is also comfortable.”

Footwear to help prevent STFS

Footwear is another critical component of surgical attire. The AORN Recommended Practices state that “cloth or open-toe shoes do not offer protection against spilled liquids or sharp items that may be dropped or kicked. Shoes should have closed toes and low heels to minimize the risk of injury.”

“Here at North Valley Hospital, we adhere to the current AORN recommendation of wearing clean shoes with closed toes and backs, as well as low heels and non-slip soles,” says Morris.

A report authored by the Department of Health and Human Services titled “Slip, Trip and Fall Prevention for Healthcare Workers” noted that the incidence rate of lost-workday injuries from slips, trips and falls (or STF) in hospitals was 90 percent higher than the average rate for all other private industries combined. STFs as a whole are the second most common
cause of lost-workday injuries in hospitals, the report said.

According to the report, contaminants on the floor (primarily water, grease and other fluids) are the leading cause of STF incidents in health care facilities. And one of the best ways to prevent STFs due to contaminants is to wear slip resistant shoes that are designed specifically for medical personnel.

Late last year, ICER Scrubs and Crocs joined forces to produce the Crocs Medical Apparel Line, which includes work shoes designed with the safety and comfort needs of healthcare professionals in mind. These shoes incorporate Crocs Lock technology specifically designed for slip resistance when working with slippery materials and surfaces.

“The health care industry is very specific in its requirements for the footwear that medical personnel must wear,” says Steve Wenande, senior product line manager for Crocs’ Professional Footwear Division. “Shoes must be safe, comfortable, lightweight, durable and easy to clean.”

“Preventing slips and falls and protecting feet from exposure to liquids and sharp items are important considerations in the perioperative setting,” Spruce says. “Additionally, there have been studies showing that a dedicated pair of OR shoes decreases the amount of organisms that are brought into the operative environment from the outside.”