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Yildirim, I., Ceyhan, M., Cengiz, A.B., Bagdat, A., Barin, C., Kutluk, T., et al. (2008). A prospective comparative study of the relationship between different types of ring and microbial hand colonization among pediatric intensive care unit nurses.

Yildirim, I., Ceyhan, M., Cengiz, A.B., Bagdat, A., Barin, C., Kutluk, T., et al. (2008). A prospective comparative study of the relationship between different types of ring and microbial hand colonization among pediatric intensive care unit nurses. International Journal of Nursing Studies, 45, 1572-1576.


Does ring wearing and ring type (plain ring and rings with stones) significantly affect microbial colonization and hand disinfection of nurses' hands in the pediatric intensive care unit?


Cohort study.


Medical and surgical pediatric intensive care units, Turkey.


Eighty-four nurses providing direct patient care, randomly but equally divided into three groups (28 wearing plain wedding rings [WR]; 28 wearing rings with stones [RWS]; 28 wearing no ring [NR]). Those nurses who (a) had scrubbed in the previous two weeks, (b) were currently receiving antibiotics, or (c) were wearing artificial nails and/or nail polish, were excluded.

Main outcome measures

Colony counts of total Gram-negative and Gram-positive bacteria.


Before the study, all nurses were educated about hand hygiene practices and were monitored two times daily throughout the study by the research assistant (RA) for compliance with infection control procedures including hand hygiene practices and study protocol. Nurses in the WR or RWS group were asked not to use any hand lotion throughout the study; they wore the ring continuously for at least 15 days before the beginning of the study; all rings were 14 or 18 karat gold. The RA obtained daily cultures (i) just after hand disinfection, and (ii) at the end of eight-hour tours of duty, using sterile gloves containing phosphate-buffered-saline solution after an alcohol-based hand disinfectant was used. Bacteria were identified with standard laboratory tests.

Main results

Total colony count of Gram-positive bacteria was 26.6 [+ or -] 14.7 cfu/ml (WR), 27.2 [+ or -] 12.0 cfu/ml (RWS), and 5.8 [+ or -] 7.1 cfu/ml (NR). Gram-positive bacteria count was significantly higher in nurses wearing any type of ring than in those wearing NR (p < 0.001); no statistical difference was detected for Gram-positive bacterial colonization between WR and RWS (p = 0.7). The most prominent Gram-positive bacteria in transient flora were S. aureus and Enterococcus. Total colony count of Gram-negative bacteria was 12.0 [+ or -] 13.1 cfu/ml (WR), 13.3 [+ or -] 14.7 cfu/ml (RWS), and 0.4 [+ or -] 0.2 cfu/ml (NR). Gram-negative bacteria count was significantly higher in nurses wearing any type of ring than in those wearing NR (p < 0.001); no statistical difference was detected for Gram-negative bacterial colonization between WR and RWS (p = 0.477). Gram-negative bacteria included Acinetobacter species, Enterobacter species, Pseudomonas species, Klebsiella species, Stenotrophomanas maltophilia, E. coli, Serratia marsencens, and Proteus mirabilis. Total counts of bacteria isolated from the hands of nurse who wore either WR (38.5 [+ or -] 17.3) or RWS (40.5 [+ or -] 20.0) were significantly higher than those with NR (6.2 [+ or -] 7.1) (p = 0.001). Total bacterial count was similar between the groups wearing WR or RWS.


Ring wearing increased the bacterial colonization of hands despite hand disinfection. Alcohol-based hand disinfection appears to be ineffective in decreasing bacterial load on the hands wearing rings. The type of ring does not appear to affect the level of hand colonization.


Hospital-acquired infection is a major cause of morbidity and mortality in critical care units throughout the world. In addition to the severe medical consequences, there are also large economical ones (Vincent, 2003). It is well known that nurses' hands serve as a major route for transmission of nosocomial infections. Even before Louise Pasteur's germ theory had been published, Florence Nightingale set forth in her Notes on Nursing (1859/1992) ways that nurses were to create and maintain a clean environment for patients, ways that included the nurses' personal cleanliness. During the same time period, Semmelweis (1861/1981) demonstrated that his hand antisepsis methods resulted in significant decreases in puerperal infection and maternal mortality, but his beliefs were largely ignored by clinicians. More than 150 years later, hand hygiene remains one of the most violated of all infection control procedures despite advances in hospital epidemiology and infection control. Less than 20 years ago, the wearing of rings while performing patient care activities was considered a breach of protocol and subject to disciplinary action, as rings were assumed to be a harbinger of bacteria and a negative influence on the efficacy of hand washing. Today, it is not unusual to see nurses wearing rings when delivering care, while the question of whether nurses and other health care providers should remove rings at work is a controversial one.

Because of this study's small sample size, it is recognized that generalizability is limited. However, Yildirim et al. (2008) have demonstrated that a well-done small study can provide good information for evidence-based decision-making at the local site level. This study adds additional support to the findings of other studies (e.g., Salisbury, Hutfiliz, Treen, Bollin, & Gautam, 1997; Trick et al., 2003). It also addresses those studies with contradictory findings (e.g., Waterman, Smeak, Kowalski, & Hade's [2006] study conducted in an operating room setting, and Jacobson, Thile, McCune, & Farrell's [1985] study conducted in a laboratory) by moving the research to a patient care setting that more accurately reflects the actual situation in most critical care settings. The report of the study design allows for easy replication and is highly encouraged, particularly if a change of policy and/or adherence to non-ring wearing is desired. Ring removal during work, along with frequent hand washing with the use of alcohol-based hand rubs, should reduce the degree of hand carriage of potential pathogens among ICU personnel.


Jacobson, G., Thile, J.E., McCune, J.H., & Farrell, L.D. (1985). Handwashing: Ringwearing and number of microorganisms. Nursing Research, 34, 186-188.

Nightingale, F. (1992). Notes on nursing. Philadelphia: Lippincott Raven. (Original work published 1859).

Salisbury, D.M., Hutfiliz, P., Treen, L.M., Bollin, G.E., & Gautam, S. (1997). The effect of rings on microbial load of healthcare workers' hands. American Journal of Infection Control, 25(1), 24-27.

Semmelweis, I. (1981). The etiology, the concept, and the prophylaxis of childbed fever (F.P. Murphy, Trans). Birmingham, AL: Classics of Medicine Library. (Original work published 1861).

Trick, W.E., Vernon, M.O., Hayes, R.A., Nathan, C., Rice, T.W., Peterson, B.J., et al. (2003). Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clinical Infectious Disease, 36, 1383-1390.

Vincent, J. (2003). Nosocomial infections in adult intensive care units. Lancet, 361, 2068-2077.

Waterman, T.R., Smeak, D.D., Kowalski, J., & Hade, E.M. (2006). Comparisons of bacterial counts in glove juice of surgeons wearing smooth band rings versus those without rings. American Journal of Infection Control, 34, 421-425.

Judy Rashotte, RN, PhD, Director, Nursing Research & Knowledge Transfer Consultant Children's Hospital of Eastern Ontario, Ottawa, Ontario
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Author:Rashotte, Judy
Article Type:Report
Geographic Code:1CANA
Date:Mar 22, 2009
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