The veterinary nurse's uniform's role in infection control is often considered from a parallel view point. Anecdotal evidence from colleagues and social media posts suggests that sectors of the veterinary nursing community seem to be more concerned about being mistaken for staff in a supermarket rather than questioning if they should be wearing their uniform in a non-clinical setting. With veterinary staff being highlighted as high risk groups for carrying meticillin-resistant Staphylococcus aureus (MRSA) (Feil-berg, 2015), veterinary professionals must consider their uniform's role in protecting their patients and themselves. This means reviewing how uniforms are cleaned and where they are worn.
The NHS has guidelines for staff uniform hygiene from the Royal College of Nursing (RCN) (2012). These guidelines state that nurses should:
These also include information on where staff can wear their uniform, and states they should:
These are advised as public confidence in hygiene is decreased by seeing staff in uniform outside a clinical environment. However, anecdotal evidence suggests not all guidelines are adhered to for many reasons, including a lack of awareness, training and facilities (Loveday et al, 2007; Pratt et al, 2007; Riley, 2015), and a high number of NHS staff are still seen in uniform in public.
There are no specific guidelines for veterinary nurses regarding uniform hygiene and within the verterinary community there seems to be a lack of awareness of best practice, perhaps due in part to few practices having uniform care protocols for either in-house or domestic washing and the drying and transporting of uniforms.
With matters as universal as hygiene the veterinary nursing community need not be performing at a secondary level to their NHS colleagues. With a smaller community, there is no reason why the veterinary profession should not be setting and achieving exemplary standards of infection control. The new Royal College of Veterinary Surgeons (RCVS) Practice Standards Scheme (PSS) has a specific module on infection control and this requires a named person to monitor policies and compliance (RCVS PSS 2015). There is no reason this should be limited to just PSS practices. Veterinary practices already follow hygiene and infection control protocols however, it seems the uniform's role in infection control is not always considered.
Use of personal protective equipment (PPE) and hand hygiene
While in human nursing there are guidelines on the use of PPE in the PPE Regulations 1992 (RCN, 2012) this does not cover uniforms. However it is clear that for a significant part of a shift there is no requirement to wear PPE (RCN 2012) as PPE should be used where there is a need and must be used for individual patient events as stated by the National Institute for Health and Care Excellence (NICE) (2012). This leaves uniforms as the primary layer in infection control. There are numerous areas in the hospital where transmission of bacteria or other infectious pathogens can occur (Sanon and Watkins, 2012); these include areas that may be occupied for ‘non-nursing’ roles as they do not require hands on patient care, e.g. mouse, computer keyboards and desks.
Recent research in human nurses has shown that despite wearing PPE for an entire shift there were still significant levels of bacteria on NHS nurse's uniforms at the end of a shift. These levels also increased for up to 48 hours after the end of the shift (Sanon and Watkins, 2012). Therefore, even with judicious use of PPE uniforms are still potential fomites.
It is interesting to note that in this study an erroneous finding, where one member of staff showed significantly higher bacterial readings than all other staff but with no patient contact to explain it, was attributed to potentially poor training and poor compliance with PPE usage and poor hand hygiene (Sanon and Watkins, 2012).
Current standard protocols for practice infection control in both human and veterinary nursing centre on use of PPE and hand hygiene. The study by Sanon and Watkins (2012) on human nurses indicated that infection control protocols should be reviewed, and protocols introduced for uniform hygiene. It also suggested the introduction of methods for monitoring the success of training and infection control protocols.
Washing uniforms
It is clear that uniforms play an important role in infection control in veterinary practices, therefore, it is important to consider how they should be cared for. All PPE is single use yet uniforms are worn daily for long periods. It has been a tradition to wear a clean uniform for every shift yet this is not expressly asked for by many employers. If a new uniform every day is achieved there are still many hurdles to ensuring they are as clean as possible.
Not all veterinary practices currently have the capability to wash all staff uniforms in-house. In many places inhouse laundry is reserved for the veterinary surgeon's scrub sets (personal experience). In-house uniform washing needs to ensure it achieves the standards needed for a clean uniform. Human nursing research which looked at bacterial swabs taken from scrubs and uniforms suggested that scrubs should be washed at 71°C compared with uniforms which require 60°C (Table 1) (Riley et al, 2015).
| Laundry type | Temperature (°C) | Cycle length (mins) |
|---|---|---|
| Nursing uniforms | 60 | 15 + |
| Scrubs | 71 | 15 + |
While Riley et al, 2015 have also shown that commercial machines are better able to achieve the required temperatures than domestic machines, as many as 68% of veterinary nurses launder their uniforms at home (Westgate, 2016). If nurses' (and others) uniforms are washed at home, the same standards need to be set as for in-house washing.
In-house laundry
Uniforms should be laundered at 60°C on the same day as the shift. They should also be tumble dried as this provides a second heat source to kill bacteria (Riley, 2015). Uniforms should be laundered only with other uniforms, but not scrub suits; scrubs suits should be laundered at 71°C. Riley (2015) states that standard detergents available to the public are suitable for washing uniforms if the correct amounts are used and the temperature and cycle length adhered to. The author would recommend further research in the use of veterinary detergents and virucidal agents for uniforms used in isolation facilities, as there is little current information published.
Domestic laundry
Domestic uniform washing has the added issue of a cost of time and money to the individual. With long shifts and commutes, adding the length of the average machine cycle to the working day can mean people opt for shorter or economy cycles to reduce the burden of work laundry at home; alternatively they may add their uniform to a normal household wash. If either of these options is the case then it is clear that uniforms are not being cleaned appropriately after every shift.
Research shows that uniforms need to be washed as quickly as possible once the shift is over (Loveday et al, 2007). There are also a number other factors that need to be considered, that affect how well uniforms are laundered (Loveday et al, 2007; Riley et al, 2015) (Figure 1).
Riley (2015) has found that using a standard 60°C cycle produces cleaner uniforms on post washing inspection and assessment of material's condition and bacterial load. The cycle should not be an ‘eco’ or energy saving cycle. Separating the uniform from every day clothes will reduce the contamination from bacteria in washing machine (Winter, 2015), and reduce any chances of cross contamination from household laundry to a uniform and vice versa. In a study where swabs of hands, scrubs and pets confirmed Gordonia bronchialis, subsequent surgical site infections stopped following disposal of the washing machine, confirming the possible role played by washing machines in bacterial transmission (Wright et al, 2012).
Where laundry must take place at home clothes should be washed as soon as possible and tumble dried if possible. See Box 1 for guidance (Riley, 2015; Riley et al, 2015).
Veterinary laundry is classified under the Water Regulations Advisory Board (WRAS) as Category 5 water waste. This states: ‘These require that a water fitting should not cause waste, misuse, undue consumption or contamination of the water supply and must be ‘of an appropriate quality and standard’WRAS (2009).
Regulations on disinfection of linen and uniforms by heat ask consideration of not just the time and temperature, but also the weight of the load of washing in relation to the size of the machine (Department of Health, 2016).
Where should uniforms be worn?
Where and when uniforms should be worn and how this is implemented is an important issue for the veterinary nursing industry today. It is known that uniforms carry organic material such as bacteria and viruses that can be transmitted (Green, 2014), so precautions should be taken to limit where uniforms should be worn.
Social media shows regular comments regarding veterinary nurses being mistaken for supermarket staff while shopping in their uniforms. The question is not ‘why are we mistaken’ for shop staff but ‘why are you wearing your uniform outside of the practice?’. In light of the threat of antibiotic resistance and increased understanding about the importance of infection control, consideration needs to be given to what veterinary nurses' uniforms are coming into contact with (Feilberg, 2015), and where they are subsequently worn.
Evidence in Sanon and Watkins (2012) confirms that levels of bacteria increased to provide positive swabs for MRSA after 48 hours in four out of ten uniforms. Therefore, it is not acceptable to wear uniforms for journeys either to or from work. Wearing uniforms outside the work environment increases the potential of carrying bacteria and viruses into the work place, into the home environment, or of passing on hospital-acquired bacteria and viruses to those outside the practice (RCN, 2012; Feilberg, 2015).
Although it is outside of the scope of this article, public perception of the hygiene implications of medical staff wearing uniforms outside of a clinical setting should also be considered (Department of Health, 2007). As the profession continues to push for protection of title, the title ‘veterinary nurse’ needs to be synonymous with high standards.
Transporting uniforms
Travelling in personal clothes, transporting uniforms, and changing at work is likely to be the most common option for many practices. This may be due to lack of space and time in the laundry to launder all staff uniforms in-house. Many veterinary practices are in buildings that are not purpose built and space for a fully functioning laundry can be limited by availability of power and drainage. This is especially true in practices in larger towns and cities where space is at a premium.
Clean and dirty uniforms need to be transported separately. It is recommended that the uniform is in its own bag that can easily be cleaned, as the inside of a bag can easily become a fomite. There are washable cotton laundry bags that can be bought in small sizes for a few pounds. These would provide a suitable ‘clean bag’ — a safe receptacle for laundry to be moved directly from the workplace and into the washing machine at home. The clean bag can then be washed with the uniform and is ready for the next use.
If there is no option to change at the practice, then having a ‘clean top’ to wear over the uniform is recommended in human nursing, and would also be appropriate for veterinary nurses (DoH, 2007; RCN, 2012). This provides a physical barrier for bacteria and organic matter, and disguises a medical uniform in a non-clinical setting. As this clean top could come into contact with both the end of shift unclean uniform and the next shift's clean uniform it should be laundered daily. A loose, thin jersey cotton material which washes and dries easily is best.
In the future, practices could provide branded work tops for wearing off the premises. Some practices already have these for staff comfort with cold weather clothing, and could easily incorporate infection control clean tops.
CLEAN — a new regimen
Ideally in-house laundry should be provided and staff should be able to change uniform and shoes before starting a shift. There should be adequate space for safe storage of personal clothes and items. There should also be space for spare uniforms to be stored, and for any other work clothes regularly needed such as theatre or reception wear. If this is not possible a protocol as in Figure 2 could be used.
Where there is no in-house landry available, implementing a policy where staff carry their uniform to work and change in an out of their uniform in the workplace can create more questions than it answers; there is very little evidence for nurses to make an informed decision about their uniform and its role in infection control. Consideration must be given to how the uniform is washed and also how it is transported — and these should be clearly stated in the policy. Protocols for visiting the patient in the home should also be devised. For house visits wearing the ‘clean top’ over the uniform would be advisable. This may also lead an employer to consider providing a branded clean top for staff.
Training and compliance
If in-house washing is not achievable then ensuring staff meet their obligations for uniform cleanliness is a must. Riley (2015) found a suitable scheme used in human nursing involving heat sensitive tags in uniforms that can be checked by employers. These tags are placed inside the uniform and respond to temperatures and time spent exposed to them — they can then be checked at a place of work to ensure that domestic laundry is reaching the standards required for laundry cycles. While these have a significant cost attached for daily use they could be implemented as part of your evidence for the RCVS Practice Standards Scheme Module 7 and used on a regular basis. Adequate training and support is essential to compliance.
In the NHS training and compliance is noted as a hurdle in all aspects of implementing infection control. (Loveday et al, 2007; Riley 2015, NICE 2012). The author believes that veterinary nurses' attitudes to acknowledging their uniform's role in promoting safe practice and effective infection control may not be as good as it could be. Therefore, a period of training when implementing protocols would be required. Protocols that are simplistic and able to be carried out easily will show the employer is trying to help staff comply with change (RCN, 2012).
The possible issues from poor uniform hygiene include:
A full understanding of these will encourage compliance with this aspect of a veterinary nurse's responsibility. While many people may see their current uniform hygiene as acceptable the veterinary community cannot be seen to be lax in their approach to infection control.
Conclusion
While further research is ongoing about improving uniform cleanliness, there is enough evidence to support introducing new protocols at this stage. There is no reason for the veterinary nursing community to be behind its NHS colleagues in infection control. Creating a community of infection control excellence is possible and achievable.