Copyright EMAP Publishing 2015 This article is not for distribution

Keywords: Hand care/Hand hygiene/ Nursing Practice Neurological injury/Stroke Review ●This article has been double-blind Hand hygiene peer reviewed Although it can be difficult to maintain hand hygiene in patients with neurological injury, with the correct approaches, staff can ensure effective care is delivered Improving hand hygiene after neurological injury

In this article... 5 key Why hand hygiene is important points Hand washing Complexities of hand hygiene after acquired brain injury 1and nail care How to improve staff confidence and patient compliance are basic, but essential, tasks Spasticity after Authors Lynsay Duke is advanced Other neurological conditions can also 2 a neurological occupational therapist, Lucy Gibbison is affect the upper limbs, including spinal diagnosis can specialist clinic nurse, Victoria McMahon is cord injury and multiple sclerosis. make opening healthcare assistant; all at Walkergate Park, These figures indicate that there is a the hand difficult Centre for Neurological Rehabilitation and potentially large population in hospital Clear care Neuropsychiatry, Newcastle upon Tyne. and community settings who have upper- 3 planning and Abstract Duke L et al (2015) Improving limb and hand difficulties. They may be a consistent hand hygiene after neurological injury. unable to use their hands to wash or approach to hand Nursing Times; 111; 45, 12-15. manage the hygiene of their affected care are needed Caring for hands tightened by spasticity hands, and therefore need help in main- Care staff after stroke, brain injury or other taining hygiene. 4 may need neurological conditions can be specialist training challenging for care staff. Opening and The importance of hand hygiene to improve cleaning the hand, managing pressure Skin is our barrier to the external environ- confidence and areas, cutting nails and reducing pain ment but is vulnerable and requires skilled skill in this area becomes more complex if muscles are care. Good skin care involves four pro- Commissioned tight and short. Hand hygiene is key for cesses being carried out on a regular basis: 5care should staff but literature on patients’ hand and » Cleaning; include time for nail care is lacking, so specialist education » Hydrating; these tasks to be and care planning may be needed to help » Protecting; carried out staff ensure these activities are done well. » Replenishing (Voegeli, 2008). regularly as This article outlines the importance of Absence of any one of the processes part of holistic maintaining patients’ hand hygiene, increases the risk of skin damage. Risk is intervention explores the barriers to providing effective care and discusses how they might be overcome.

and hygiene is an important aspect of infection prevention, but can be challenging for Hpeople with neurological con- ditions that affect their upper limbs. One of the main causes of neurological condi- tions is acquired brain injury (ABI), which results in an average of 956 UK hospital admissions every day. In 2013-14 there were a total of 348,934 admissions for ABI. Of these, 445 were due to head injury and 358 to stroke – the two most common ABIs (Headway, 2015); it is predicted that 50-80% of people who have a stroke have

SPL involvement of their arms (Dobkin, 2005). Care staff must be confident in cleaning and moving hands after acquired brain injury

12 Nursing Times 04.11.15 / Vol 111 No 45 / www.nursingtimes.net Copyright EMAP Publishing 2015 This article is not for distribution

further increased by adding sustained Box 1. Case study high pressure, friction and shear, and the presence of moisture (Glasper et al, 2009). Emily Chase, aged 69, lived in a nursing hands due to the pain she experienced. Much has been written about the mainte- home and was dependent on staff for She shouted, screamed and repeatedly nance of skin care in relation to pressure all of her daily activities. She refused any attempt from staff to open ulcers and continence care focusing on experienced a subarachnoid her hand. She had been prescribed the main areas of heels and sacrum, but haemorrhage in 2001 and now had a liquid morphine for pain; the medication there is little information relating to skin left-sided hemiplegia. She was able to was being given just before lunch. care in hands with spasticity. communicate fully and had the capacity Personal hygiene and care, however, Spasticity is a symptom of upper motor to consent to treatment. usually took place at 9am. neurone damage. Muscles involuntarily Ms Chase was wheelchair dependent Staff reported they were scared tighten and, in the upper limb, a common and had a tight left hand as a result of of using scissors to cut Ms Chase’s pattern is of a flexed elbow, flexed wrist spasticity. Her fingers were fully fingernails and she indicated that she and clenched hand and fingers. clenched into the palm of her hand with knew they lacked confidence. There was If not managed correctly, the tight the joints of her fingers hyperextending no individualised care plan for her hand muscles of spasticity can cause problems, due to the pressure being exerted on and nail care, despite the difficulties such as: the palm. She was in considerable pain being experienced. » Difficulty opening the hand; as a result of the pressure and Discussions were held with staff » Clenching causing pressure areas deterioration in her skin integrity. Her and Ms Chase about the timing of her between the fingers or on the palm; nails were long, digging into her skin. analgesia. A more suitable time for hand » Changed nail growth; It was difficult to access the palm of and nail care was identified after the » Muscle shortening; Ms Chase’s hand due to the tightness of liquid morphine had been administered. » Hypersensitivity; her muscles and the orthopaedic Several practical sessions with the care » Pain. changes that had occurred as a result of staff and Ms Chase were undertaken on These problems can lead to eventual her hand being held in that position for how best to open her hand, gain access changes in the joints and tendons (Bandi several years. However, it was possible to the palm for cleaning and trimming and Ward, 2010). to make a small gap between the her nails. Consideration was also given If the hand is held tightly in a fist and is fingers and the palm. The skin of her to how Ms Chase could help care staff difficult to open, skin can break down, hand was dirty, her nails were long and with these activities. leading to an increased risk of infection. dirty, and the palmar skin was hot and A care plan was devised and used This can also lead to pain and reluctance macerated. There were large deposits of by all staff involved in Ms Chase’s to allow the hand to be handled. dried skin between her fingers and in care. This improved her confidence the palm of the hand. in the staff managing her hand and Role of care staff Ms Chase’s right hand, of which she reduced her pain; consequently, Health professionals’ hand-washing com- had full use, was also dirty and had long staff gained better access to her hand pliance is globally accepted as the most nails. Staff reported that they were and their confidence levels and skills important procedure in preventing infec- unable to help Ms Chase to wash her were enhanced. tion (National Institute for Health and Care Excellence, 2014; Dougherty and Lister, 2011) but literature about the hand al, 2008) but there are many misunder- hygiene including nail care” (Malkin and washing of patients is scant. standings surrounding the role paid staff Berridge, 2009). In addition to physical disability, neu- can play in undertaking fundamental but rological events can cause cognitive, com- undervalued interventions such as hand Factors affecting hand care munication and mental health impair- and nail care. Many agencies discourage For individuals with neurological impair- ments, which can increase dependence on staff from cutting fingernails and many ments, several factors may influence their carers (Malkin and Berridge, 2009; Sackley NHS trusts indicate that nurses should response to staff who try to open tight, et al, 2006). With impaired or limited refer patients to chiropody services (Nicol painful hands to provide care: ability to communicate their views, con- et al, 2012). However, most published lit- » Pain; sent to interventions, express discomfort erature advocating caution discusses » Anxiety; or pain, and complain about the quality of issues around toenail cutting and the risks » Limited communication and care they have received, patients become inherent with conditions such as diabetes understanding; vulnerable to harm, abuse or exploitation. and peripheral artery disease; the mainte- » Cognitive impairment; Staff who are providing hand care should nance of fingernails is not mentioned. » Lack of inhibitory control; ensure care plans identify the person’s Some authors say this causes confusion » Overstimulation; individual needs, as well as their skills about who should, and could, cut or file » Mental health issues (Bowers, 2010). and abilities. fingernails (Nicol et al, 2012; Malkin and A negative cycle of behaviour and Maintaining hand hygiene for people Berridge, 2009). Others state categorically response can quickly build up between the who cannot manage this task indepen- that routine nail care for all patients patient and the staff member providing dently will usually fall to a formal paid should be undertaken by nurses (Dough- care. If the patient displays what is carer – be that in a hospital setting, care erty and Lister, 2015) or others providing perceived as a “challenging behaviour” home or patient’s own home – or family or personal hygiene care, and that is reason- during painful or difficult tasks, these friends. Ensuring good patient hygiene is able to expect that “whoever cares for the may be less diligently provided than easier an active and important task (McGuckin et patient undertakes all aspects of personal tasks (Emerson et al, 2000).

www.nursingtimes.net / Vol 111 No 45 / Nursing Times 04.11.15 13 Copyright EMAP Publishing 2015 This article is not for distribution

Nursing Practice Review

Box 2. Basic hand care advice procurement of caring services “by the minute”. Patients notice the differences in Explain what you are about to do. Gain sides or cut them too short: leave a free the quality of care being provided during informed consent or establish that what edge between the nail and the rushed interventions by staff who may not you are doing is in the patient’s best underlying skin. Do not cut what you have been fully supported to achieve com- interests. Visually inspect the hand for cannot see. Place your finger over the petence in the tasks they are required to any skin/nail damage. nail you are cutting and use the flat edge perform, or who may not have been given ● If there are any problems, report to of the blade, not the point, to cut – this adequate time to complete them. nurse in charge/line manager/inform GP. reduces the risk of cutting the patient. Such factors are likely to negatively These may include: skin breaks, ● Dispose of, or clean, any equipment affect the confidence and work satisfac- maceration, fungal infections, ingrowing used. This should be single-patient use. tion of the staff involved in caring for peo- nails, thickened nails or exudate. Document and report what you have ple’s hands. Lack of knowledge among done and any problems that you have care staff carrying out these essential Washing hands encountered. roles may be a contributory factor to the Do not force the hand open or move the ● If the patient has a diagnosis of increasing number of patients experi- fingers quickly. Use slow, but firm, diabetes, rheumatoid arthritis, HIV, or is encing difficulty with their hands. movements. prescribed anticoagulation medication, The Care Quality Commission’s (2013) ● Immerse in a basin of warm soapy do not start nail care without discussing review of the quality of care provided to water and/or clean in the bath or shower the patient’s care plan with the nurse or older people in their own homes raised ● and/or use a hand wipe. The use of doctor in charge. concerns about: non-perfumed aqueous cream can help » Staff training needs not being identi- to lift any dried/dead skin Stretching the hand fied (and if identified, not being met); ● You may need two people if the hand ● Take your time » Lack of staff knowledge and skill; is very tight – one to hold the hand and ● Open the hand slowly » Lack of detailed care plans, including distract the patient and one to clean. ● Use techniques such as gently bending personal preferences and complex care ● Dry the hand thoroughly the wrist to gain more access to the needs. ● Apply hand cream if the patient wishes palm of the hand These concerns were confirmed by a and has no relevant allergies ● Carry out stretching/opening of the survey of the views of home-care workers ● Document and report what you have hand regularly (at least two to three conducted by the Local Government done and any problems encountered times a day) Ombudsman (2012). The survey showed ● Use hand splints/palm protectors, if that 41.1% of home-care workers had not Keep nails short provided, for the recommended wear received specialised training to help care ● Perform regular nail care schedule for people with specific needs – for ● Visually inspect the nails and ● Monitor the fit of the splint and report example, people who have had a stroke or surrounding skin, remembering to check any problems, such as pressure ulcers, have dementia. under the nail poor fit, frayed strapping or ● Clean under the nail compromised integrity of the splint Overcoming the barriers ● Whenever possible, use a single-use ● Hold the hand open with other Despite these concerns, there is little pub- nail file or disposable emery board to options, for example a roll of bandage lished evidence on how influential tar- keep the nails short; this reduces the ● Do not force the hand open or move geted educational sessions – such as how need for scissors. Shape and shorten the the fingers quickly to open and clean tight, painful hands – nail following its natural shape ● Do not allow the hand to be unopened can be for both care staff and the patients ● If using scissors, do not cut down the for a long period of time (see Box 1) receiving the care. It can be assumed that care staff would benefit from a combina- tion of: It is important to understand the con- Box 2 outlines basic hand care advice to » Increased awareness of the issues cepts of mental capacity and the patients’ which staff should adhere when con- affecting the people with whom ability to consent to hand care interven- ducting hand hygiene for patients; Table 1 they work; tions. Clarity about whether the interven- describes the routine that should be fol- » Knowledge and skills in how to manage tion – be it washing hands and cutting lowed by care givers. those issues; nails – is being done in the person’s best » Sufficient time to address the issues. interests or with their valid consent is Barriers to providing effective care Joint working between specialist ser- extremely important. Increased staff workloads and work- vices and care agencies to highlight, dis- If a patient refuses hand care, alterna- related stressors affect the approach and cuss and problem solve may allow indi- tive ways of carrying out the intervention attitude of the staff providing care and, vidualised needs to be met more or its timing should be considered in an consequently, those displaying any chal- effectively. Wade (2009) states that for attempt to reduce anxiety, help gain valid lenging behaviours and the likelihood of people with long-term conditions, collab- consent and make it a pleasant experi- their refusal to be treated (McBrien, 2010). oration between agencies is key for ence. The case study described in Box 1 In these situations, careful care planning, improving care. It could be suggested that outlines simple changes – such as provi- skill and review are essential. in this case, hand care partnerships sion of analgesia before a painful inter- Cavendish (2013) discussed the between neurological services and com- vention – that improve engagement and dichotomy between the caring role, which munity care agencies should be developed concordance. requires time, and the increasing to provide training and ongoing support.

14 Nursing Times 04.11.15 / Vol 111 No 45 / www.nursingtimes.net Copyright EMAP Publishing 2015 This article is not for distribution

The Care Act 2014 focuses on local authority assessments of care need and Table 1. Routine for managing complex hands stresses that a patient’s wellbeing, Stage Consideration including their needs in physical, psycho- logical and mental health should be sup- Assessment ● Tight muscles ported by an individualised care plan. ● Finger position This should be assessed and written by an ● Pain experienced professional and include ● Skin integrity methods to prevent, delay or reduce needs ● Cleanliness that already exist. Involving patients ● Nail length in writing their care plan, wherever ● Use/access to splinting/palm protectors possible, is essential to help raise their Care planning ● Assistance needed awareness of how they can increase their ● Analgesia self-management skills. ● Time of day best suited for the activity Having documented information ● One/two people required relating to each patient – both those who ● Issues that may affect skin healing have difficulties opening and cleaning their hands – means that regular checking Capacity assessment ● Is the patient able to give informed consent to and care of each individual’s hands should treatment or will it be carried out in their best be carried out. Having clarity about the interests? staff member’s role in cutting nails and Intervention ● Carry out intervention: washing hands, nail highlighting the issues that relate to hand cleaning, nail shortening care in care-management routines are ● Identify and treat any problems: pressure fundamental responsibilities that health ulceration, fungal nail infections, problems and social care organisations should associated with application of splints address immediately. Documentation ● Record each intervention – note achievements Conclusion and any problems Washing hands and keeping nails short Review ● Review the care plan regularly to ensure it should not be complex issues in them- continues to meet the patient’s needs selves but, if they are being neglected due to lack of staff confidence, skill or knowl- edge, or reluctance from patients due to Bowers L (2010) How expert nurses McBrien B (2010) Emergency nurses’ provision communicate with acutely psychotic patients. of spiritual care: a literature review. British anxiety, pain or, more worryingly, lack of Mental Health Practice; 13: 7, 24-26. Journal of Nursing; 19: 12, 768-773. time, then staff must return to essential Care Quality Commission (2013) Not Just a McGuckin M et al (2008) Interventional patient principles. Following routines, con- Number: Home Care Inspection Programme – hygiene model: infection control and nursing ducting regular assessment and com- National Overview. share responsibility for patient safety. Bit.ly/CQCNotJustANumber American Journal of Infection Control; pleting documentation will help care staff Cavendish C (2013) The Cavendish Review: An 36: 1, 59-62. and patients to feel confident that the Independent Review into Healthcare Assistants McNicoll A (2014) 10 ways councils are complexities of managing the patient’s and Support Workers in the NHS and Social targeting savings from adult social care in Care Settings. 2014-15. Community Care. 9 April. hands are being addressed. Bit.ly/CavendishReview National Institute for Health and Care It may be necessary to provide educa- Dobkin BH (2005) Rehabilitation after stroke. Excellence (2014) Infection Prevention and tion sessions for care staff as, although The New England Journal of Medicine; 352: Control – Quality Statement 3: Hand the tasks are not complex, the presenta- 1677-1684. Decontamination. Bit.ly/NICEQS61QS3 Dougherty L, et al (2015) The Royal Marsden Nicol M et al (2012) Chapter 10 Patient tion of the individual patients’ hands and Manual of Clinical Nursing Procedures (9th Hygiene. In: Essential Nursing Skills. 4th edn. their response to handling may be. edition) Oxford: Wiley-Blackwell. Clinical Skills for Caring. London. Mosby Training on moving and handling the Emerson E et al (2000) Treatment and Elsevier. management of challenging behaviours in Sackley C et al (2006) Cluster randomized hands and the impact of spasticity, along residential settings. Journal of Applied pilot controlled trial of an occupational therapy with highlighting approaches to care, Research in Intellectual Disabilities; 13: 4, intervention for residents with stroke in UK may result in increased skill and confi- 197-215. care homes. Stroke; 37: 9, 2336-2341. Glasper A et al (2009) Foundation Skills for Stroke Association (2012) Struggling to dence in paid care staff and measureable Caring. Using Student-Centred Learning. Recover: Life after Stroke Campaign Briefing. benefits for patients. NT London: Palgrave Macmillan. Bit.ly/StrokeRecover Headway (2015) Brain Injury Statistics. Voegeli D (2008) Care or harm: exploring References Bit.ly/BrainInjuryStats essential components in skin care regimens. Baillie L, Gallagher A (2012) Raising Kozier B et al (2008) Fundamentals of British Journal of Nursing; 17: 1, 24-30. awareness of patient dignity. Nursing Nursing: Concepts, Process and Practice. Wade DT (2009) Holistic Health Care. Standard; 27: 5, 44-49. Harlow: Pearson Education. What Is it, and how can we achieve it? Bandi S, Ward AB (2010) Spasticity. In: Stone Local Government Ombudsman (2012) Oxford: Oxford Centre for Enablement. JH, Blouin M (eds) International Encyclopedia Focus Report: Learning the Lessons from of Rehabilitation. Complaints about Adult Social Care Providers Bit.ly/RehabEncyclopedia Registered with the Care Quality Commission. For more on this topic go online... London: LGO. Bloomfield SF et al (2012) The Chain of Hand hygiene: product preference Infection Transmission in the Home and Bit.ly/LGOComplaints14 Everyday Life Settings, and the Role of Malkin B, Berridge P (2009) Guidance on and compliance Hygiene in Reducing the Risk of Infection. maintaining personal hygiene in nail care. Bit.ly/NTHHProductPref Bit.ly/IFHChainofInfection Nursing Standard; 23: 41, 35-38.

www.nursingtimes.net / Vol 111 No 45 / Nursing Times 04.11.15 15