Introduction
Pointing the finger of professional condemnation when it comes to passing infection among people is common in a healthcare setting. I recall Archie Bunker, on the All in the Family TV show, telling the "meathead" to stay away from the hospital, because it was full of sick people. Although I laughed at the time, today I understand that hospitals can indeed be a breeding ground for germs. The simplest items, that we do not think of when trying to maintain sterile environments, can indeed be carriers of germs that can be deadly under the right circumstances.

A plethora of studies in medical literature has demonstrated that nearly everything in the healthcare setting can serve as a reservoir and a vector for opportunistic pathogenic organisms. Here, we cannot hope to cover them all, but we can take a look a few examples that will hopefully make us more aware of the role me must play in keeping medical facility environments as sterile as humanly possible.

Personal Knowledge
It is normal to see medical professionals wearing scrubs, lanyards and stethoscopes outside the hospital setting. Wearing these items has a level of status associated with it. However, they are exposing people they come into contact with to germs from the hospital, and when they return to work, they are exposing patients to germs from the outside.

In a medical facility, a great deal of attention is given to sterility. Yet, too often, what appear to be minor impediments to sterility are ignored at the peril of those whom we, as medical professionals, are supposed to serve. Effective nursing practice presupposes a variety of internal manifestations that emphasizes sterility. Yet, in practice, the simple and apparent aspects of sterility are unintentionally ignored without the medical professional being aware of this negligence (Balman, 2008. p. 12). However, there should be some credible solutions to this seemingly innocuous problem.

During one experience, I observed a Personal Service Worker who was extremely seasoned and efficient in her duties. She was meticulous, conscientious and fastidious about hygiene. However, she had a lanyard around her neck with at least a half dozen keys dangling from it. Much to my chagrin, these keys were suspended over clients as she bathed them and assessed their conditions. At one point, they were even swinging through feces filled water in the tub. Later, when working with other clients, these keys were touching various parts of the clients' bodies. Although unaware of this breech of sterility protocol, it was still an obviously significant hygienic concern that should be addressed for the welfare of the patients.

When I was a lab assistant in a British Columbia hospital, I always made sure to take off my lanyard and put it in my pocket when I left for lunch. If it was not required for re-admittance to the lab, I would have left it there. This simple act was not required, but I felt that it was imperative to avoid bringing in as many contaminants as possible. As will be discussed in the Aesthetic Knowledge section of this article, simple compassion necessitates every measure that can be conceivably carried out to avoid compromising the welfare of patients must be assiduously utilized.

Empirical Knowledge
According to an article published in Nursing Standard by J. C. Thomas (1989), almost all badges and lanyards are contaminated with pathogenic bacteria. Research indicated that doctors have four times the risk of carrying Methicillin-sensitive Staphylococcus aureus on lanyards compared to nurses (Carlisle, 1997), but there were no differences in contamination detected in identity badges. The aforementioned example experienced by me would obviously indicate that this is a concern that needs to be addressed. Even though research has been conducted periodically for a number of years, it would appear that there is relatively little being done in regards to alleviating this problem of pathogenic contamination.

In Kotsanas and Scott's (2008) research, name badges hanging from lanyards were found to be a major source of pathogenic bacteria. The researchers cultured total bacteria counts from the badges of healthcare workers from three different areas in a hospital. Bacteria counts recovered from dangling badges were 10 fold higher when compared to those attached by clips. So, it would appear that merely using a clip to adhere badges would be highly advantageous over the lanyard that has become the norm for healthcare workers. However, even the clip serves as a carrier of pathogenic bacteria, so there is apparently no way to completely eliminate this hygienic problem, unless badges are eliminated, which is highly unlikely in societies where security interests seem to trump all other concerns.

Ethical Knowledge
Although suits and ties are no longer the norm among doctors, there are still some who are more traditional in dress. Along with a dangling lanyard, the simple necktie can also be a reservoir for germs. Steven Nurkin (2004), a medical student at Rappaport University, observed that patients visiting doctors offices would often cough on the ties of physicians. He also noticed that doctors' ties would dangle about the patient while the examination was taking place. Aware that it was not ethically or morally appropriate to put your patients at risk through the unintentional negligence, he decided to conduct a study using 42 doctors who wore ties at a New York City hospital. Of the 42 physicians' neckties that were sampled, 20 contained one or more micro-organisms known to cause disease, including 12 that carried Staphylococcus aureus, five carried a gram negative bacteria, one that carried aspergillus's and two that carried multiple pathogens. Whether transferred by a lanyard or a neck tie, all of these could cause minor or major infections if transferred to susceptible patients.

Aesthetic Knowledge
Compassion is at the heart of what makes nurses valuable adjuncts to doctors and other professionals engaged in healthcare. Understanding the subjective and intuitive nature of healthcare means each practitioner must approach the client with the utmost care professionally, but must also understand that compassion must be a part of the equation. Understanding the role of peripherals in all we do as medical professionals necessitates a complete grasp of how our clothing and anything attached there to can affect the well-being of our clients. This is at the heart of our roles as compassionate, merciful individuals.

Pathogenic organisms brought in by hands, equipment, clothing or attachments can create a "perfect storm" where healthcare-acquired infections can brew, unless these workers understand and implement proper hygiene practices to help prevent the unintended transmission of bacteria and viruses (Pyrek 2002).

The majority of organisms are opportunistic pathogens in that they can only cause disease in immuno-compromised individuals or when they reach a breach in natural health defences (Kramer A. et al., 2006). The risks, however, may never be underestimated, regardless the state of clients. Simple compassion necessitates that all healthcare workers be acutely aware of their roles in assuring that sterile conditions be maintained at the highest level possible.

Conclusion
Steven Nurkin (2004), after completing his research on doctors' neckties in the U.S.A., visited Tel Aviv in 2004. In Israel, almost everyone dresses casually. He noticed that you could go days without seeing a necktie. Visiting clinics, he observed that no Israeli doctors wore neckties or lanyards. Out of curiosity, he wondered what percentage of Israeli patients acquired infections while they were in a hospital. Reviewing research by the Israeli Medical Society, he found that in Israel 2 to 5 percent of patients acquired an infection. In the USA, the figure is 5 to 10 percent, which translates into 2 million infections, 90,000 deaths and more than $4.5 billion in annual costs, according to the U.S. Centre for Disease Control (2003).

Although one cannot assume that the lower figure in Israel is completely attributable to the lack of neckties and lanyards, it is obvious that they are doing a better job than the U.S.A. in combating infections. Would some of the difference be directly related to the lack of ties and lanyards? Perhaps that is a study that needs to be undertaken.

The questions posed in this article should alert healthcare professionals to the fact that wearing lanyards and neckties is simply not in the best interests of patients. Being well dressed and having your ID displayed adds an aura of professionalism and solidifies patient confidence. However, what costs in patient well-being are being paid?

Almost every medical professional is a carrier of bacteria, from a cell phone to a stethoscope. Medical professionals could be required to be naked, but even that would carry a risk of other types of bacterial infection. There are some very simple things that can be done to alleviate many of the pathogenic organisms from being brought into the healthcare setting. Simply removing a lanyard before going out of the sterile environment, or even better, eliminating them all-together would be immensely helpful. As for neckties, its is time to eliminate them completely from the healthcare setting. As medical professionals, it is incumbent on us to do all we can to keep our patients safe from these infections, and the aforementioned steps can be a good beginning.

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