Skin changes in geriatric nurses prior to training heralding a particular risk of hand dermatitis

ARTICLE

There are various risk occupations for irritant skin changes. Health care in general and nursing in particular is one of them [1-4]. In their population-based register study of occupational skin diseases in Northern Bavaria (BKH-N), Dickel et al. [4] observed an annual incidence rate of 4.0 cases per 10,000 health care workers for irritant contact dermatitis, compared to 3.7 cases of allergic contact dermatitis. The results of a questionnaire showed frequent skin contact with disinfectants (76%; 274 out of 360 responders) and detergents (72%; 259 out of 360 responders) at the workplace. Therefore, it seems understandable that many nurses believe that rough and scaly hands "belong to their job". A combination of frequent wet work (e.g., hand washing) with disinfections is a major cause of skin irritation in nursing [5, 6].

An aim of this prospective intervention study was to investigate the effect of frequent vocative training on the number of irritant skin changes at the end of the nurse training. At the start of the study, skin changes on the hands were evaluated. On this occasion, we noticed some differences in the age distribution, especially in participants of geriatric schools compared to other nurse schools. Skin changes seem likewise not to be the same for all nurse schools. To evaluate this in more detail, we compared demographic data and irritant skin changes of geriatric nurses with the other nurses prior to the training period.

Patients and method

Study population

In Germany, nurses are trained in specialized schools. Most of these schools are located within hospitals and are specialized in general nurses, pediatric nurses and midwifes. In contrast to these schools, geriatric nurses are trained in training centers mostly not associated with a hospital. Geriatric nurses are therefore specialized only in elderly care and are not trained for general nursing care.

Five hundred and twenty-one nurses at 14 nursing schools in Central Germany participated in this multicentre study. One hundred and forty-nine of them were geriatric nursing trainees (GNT) coming from 3 training centers, the other 372 belonged to other nursing schools like general nursing care, pediatric nurses or midwifes (other nursing trainees, ONT). All trainees of these 14 nursing schools starting in 1999 were asked to participate in this study, and only 3 refused. At most of the schools, two training courses started during 1999, one in the spring and one in the autumn. Written informed consent was obtained from all participants (or their parents when they were below 18 years of age) and the study was approved by the ethical committee of the University Hospital of Marburg.

Examination of skin changes

At the beginning of this prospective training study, some epidemiological data (like gender, age, pre-training, skin problems prior to training, retraining, reason for retraining) were obtained from all participants. Atopy score according to Diepgen et al. [7-9] was evaluated from 72% of the trainees. In addition, irritant skin changes prior to their training were recorded from all trainees, by use of the operational definitions of Uter et al. [10]. The definition of "cases" was also chosen in accordance to Uter et al. [10]. The occurrence of at least one localisation or morphology category led to the designation: irritant skin changes. The occurrence of a localization or morphology category of at least "moderate" or "severe" led to the designation: hand dermatitis.

These examinations were done during the first weeks of their training before the trainees performed practical work in their schools. Hence, the hands were not influenced by typical nursing work. Examinations were performed in April/May and September/October 1999. The ratio geriatric nurses/other nurses was the same in spring and autumn (approx. 1:2.5).

Statistical methods

Data entry was done by means of SPSS 10.1. The statistical analysis was done with SAS^TM. Categorical data were described in the form of absolute and relative frequency. Continous data or scores were described by mean, standard deviation median and 1st and 3rd quartiles (Q1 and Q3). Possible differences between the groups were tested with Fisher's exact test in case of caterogical data and Wilcoxon-Mann-Whitney U-Test in case of continuous data. The level of significance alpha was set at 5%.

Results

The results are listed in detail in Table I.

The mean age of all participants was 22.3 years (standard deviation (SD) 6.6; median (M) 20). The mean age of the GNT was 26.3 (SD 9.5; M 22) while that of the ONT was 20.7 (SD 4.1; M 20). This difference between GNT and ONT was significant (p < 0.001). 15% of all participants were male (12% of the GNT and 16.1% of the ONT).

Some trainees were in the process of retraining, the percentage was 38.3% in GNT and 24.2% in ONT (p < 0.001). Some of these individuals stated that they wanted to be re-trained because they had developed hand dermatitis in their previous job. In the GNT there were 4 individuals, and in the ONT 1 individual, with a second training because of hand dermatitis. The previous job was dental assistant, hair dresser, nurse assistant and domestic science in the GNT group and car mechanic in the ONT group. The retraining was initiated by the trainee himself in three cases and by the employment office in two cases. All of these individuals had performed allergic patch tests before changing their jobs, but none of them had had a relevant sensitization to an occupation related allergen (like acrylate in dental personnel). Only one of the five before mentioned trainees had an atopic history (atopy score of > 10).

At the beginning of the training period 30.3% trainees showed irritant skin changes (mostly of minor degree) on their hands, 25.8% of the ONT and 41.6% of the GNT (p < 0.001). Similarly, the number of trainees with hand dermatitis tended to be higher at the GNT (18.1%) than at the ONT (14.0%), but this finding was statistically not significant.

The differences in atopy score between GNT (5.9; SD 2.2; M 5) and ONT (6.3; SD 2.6; M 6) was not statistically significant. In both groups, a similar portion of individuals had an atopy score of > 10.

Discussion

When the prospective interventional study "prevention of irritant contact dermatitis in nurse trainees" was started, distinct differences in the composition in geriatric nurse schools compared to all other nurse schools were obtained. The geriatric trainees were older. Far more individuals were seen with an age of > 30, resulting in a higher median age. This significant difference may be due to the fact that geriatric nursing is not a popular job. Comprehensive care of elderly people is often associated with wet work, incontinent people, senile dementia and a mixture between aggressive behavior disorder and bedridden destiny. Hence, not many adolescents choose geriatric nursing as their favorite job. However, the number of old people in need of care is rising and will continue to rise with increasing life expectancy. As a consequence, the geriatric nurse is becoming more and more a job with a guarantee of employment. Individuals with a lower expected chance on the general job market may be more likely to choose the training as a geriatric nurse, e.g., older individuals with a second training (no matter why they do not work in their first trained job) or home makers (after the children have left their home), etc. A higher number of retrained individuals was therefore observed in our study.

A dermatological problem arises because older trainees, who have had worked in risk occupations for irritant skin changes, may probably have a higher risk for developing irritant hand dermatitis in a high risk occupation like geriatric nursing. Indeed, we found significantly more and stronger irritant skin changes at GNT at the beginning of the training. 41.6% of all GNT had irritant skin changes and 18.1% can even be classified as individuals with hand dermatitis. This point prevalence of hand dermatitis is much higher than documented in other epidemiological studies (5.4%) [11]. However, the criteria of classification are hardly comparable, because the definition of hand dermatitis used in this study (in accordance to Uter et al. [10]) is a distinct one, because we wanted to record all minor clinical changes which are possible precursors of relevant hand dermatitis [12, 13].

The group of the ONT consists in the majority of individuals who have finished school just before starting the training. Taking this group as a standard, the GNT showed 15% more irritant skin changes. It is obvious that the GNT have even at the start of the training a much worse skin condition, however, the number of people with an atopic disposition (atopy score > 10 according to Diepgen et al. [7-9]) was approx. the same in GNT and OTN. It is known from earlier studies that irritant skin changes (prior to training) are associated with a high risk of developing further irritations and also with a higher risk of manifest irritant hand dermatitis [14]. Hence, many GNT may have, even prior to their training, a higher risk to develop irritant dermatitis.

Surprisingly, some geriatric nurses have chosen this retraining because they had developed irritant hand dermatitis in their previous job (dental assistant, hair dresser, nurse assistant, domestic science and car mechanic). It makes no sense to perform such retraining in a classical high risk occupation for irritant hand dermatitis [15]. However, four GNT and one ONT have done so. The higher number of GNT performing this retraining is most likely due to the reasons of older trainees discussed above: higher chances of an employment for subjects with lower chances on the general job market. This problem is made even more critical by the fact that in only three cases has the trainee initiated this retraining, without professional consultation concerning the career planning. In two cases the official job office gave the recommendation to perform this retraining, knowing the problems with irritant skin changes in the previous job. On the other hand, no individual performed a retraining initiated by a workers' compensation board (Berufsgenossenschaft).

Our results are alarming because they show that many individuals with a higher risk of irritant skin changes become trainees for elderly care. Comprehensive information about the risk of hand dermatitis is needed to avoid high risk individuals becoming such trainees [16-19]. Furthermore, primary prevention even in training periods is a very effective tool for reducing irritant skin changes [19, 20]. However, as long as the job situation in elderly care is not changed, this profession will most likely still serve as a sheet anchor for individuals with lower chances on the general job market regardless of the skin conditions of their hands.

Article accepted on 22/7/02

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