Gloves were once a rare sight on a hospital ward.
Now gloves are constantly being donned, doffed and discarded during a nurse’s working day.
But does regularly pulling on gloves reduce the risk of infection? Do patients feel more comfortable or ‘untouchable’ if a nurse dons gloves as they approach them? And just who is protecting who when some common nursing procedures are increasingly done with a layer of latex between the nurses’ hands and the patient?
These are questions that infection control nurse specialist Dr Jennie Wilson has been researching in recent years. Wilson, now an associate professor and researcher in healthcare epidemiology at the University of West London, recently spoke to the Infection Prevention and Control Nurses College NZNO conference in Napier on her findings in a presentation called ‘To glove or not to glove?’.
Wilson, who has worked in the field of infection prevention and control for more than 30 years, says concern about the overuse of clinical gloves began to appear in the research literature about a decade ago.
It wasn’t until the HIV epidemic in the late 1980s that healthcare workers were encouraged to use disposable gloves during direct contact with patients’ blood and body fluids, because blood-borne viruses were seen to pose a risk to staff.
Wilson says this didn’t instantly trigger widespread use of gloves and in the mid-1990s there was still a concern that nurses weren’t using gloves as often as they should. But gradually the glove habit became increasingly embedded until, during the 2000s, a new concern started to surface; healthcare workers being too ready to pull on gloves and not quite so quick to pull them off or change them.
Glove cross-contamination risk
The Five Moments for Hand Hygiene guidelines were introduced by the World Health Organisation in 2009 to focus healthcare workers’ attention on good hand hygiene as a simple but effective means of infection prevention and control.
The aim is to promote the routine use of hand hygiene at each ‘moment’ to reduce the risk of cross-contamination of infection-causing bacteria or viruses from one patient (or patient environment) to another.
Wilson says if you assume cross-contamination can occur whether you touch the patient or patient environment with bare hands or gloves then not to change gloves (or use adequate hand hygiene after removing gloves) at the ‘Five moments’ would also risk cross-contamination (see box).
She was part of a research team that set out to observe when healthcare workers (HCW) at a UK hospital used gloves, why they were using them, and whether how they were using them posed a risk of cross-contamination.
They published findings in 2013 that showed nearly 40 per cent of the time that gloves were used in patient care there was a risk of cross-contamination (see box 2 for examples), including gloves used for toileting a patient not being removed before touching other surfaces or patients. The majority of the healthcare episodes using gloves involved nurses, and nurses were slightly more likely to cause cross-contamination risks than other HCW, such as doctors or healthcare assistants.
Wilson says the risk of cross-contamination from gloves had already been demonstrated by a French research team, Girou et al, recovering pathogens from 86 per cent of gloves used by HCW, even after the use of an alcohol hand rub. In 2007 another research team, led by Gonzalo Bearman, found a significant increase in healthcare-associated infections when gloves were used for all patient contact, compared with just using gloves for standard precautions (i.e. involving blood and body fluids). And a University of Otago research team reported in 2013 that it was likely poor HCW hand hygiene that led to faecal and other bacteria being found on unused gloves in glove boxes on a busy hospital ward.
Gloves not always needed
So is it a case that – rather than protecting patients from infection – wearing gloves is potentially putting patients at greater risk?
The short answer is, quite possibly. Wilson’s initial research found that not only were glove wearers failing to meet the ‘Five moments of hand hygiene’ around 40 per cent of the time, but they were also using gloves unnecessarily.
In fact, 42 per cent of the time, HCW were observed using gloves when they didn’t need to, including using gloves for low-risk procedures.
“The overall message from that was that gloves are being put on too early and taken off too late,” says Wilson. Gloves were being put on “way before” people had direct contact with the patient and then weren’t taken off immediately after doing the procedure. Or the gloves weren’t being changed, and hand hygiene used, between carrying out a ‘dirty’ and ‘clean’ procedure, for example between cleaning up a patient’s incontinence and then handling their IV device or catheter.
The research team has since extended its observations to cover two more hospitals and found exactly the same pattern repeated.
This swing in the practices of healthcare workers – who just two decades before had to be persuaded to use gloves to protect themselves but were now quick to pull on gloves even when not needed – prompted the first study to interview 25 staff at the initial hospital about what influenced their wearing of gloves.
Disgust, fear and protection
The research team found that one primary motivation for wearing gloves was an emotional response. “There was a fear and anxiety about touching things that are perceived to be unclean or dirty. And a sense of disgust – that some things were too ‘yucky’,” says Wilson.
Another major theme was that glove wearing was now part of the organisation’s culture, with gloves widely available on the ward and a perception that HCW wear gloves because it was ‘safer’.
“The overarching message that staff picked up is that they are not only protecting themselves but also protecting their patients by wearing gloves,” says Wilson. “They don’t seem to recognise that gloves don’t act as a sterile covering for the hands or that gloves aren’t immune from bacteria… gloves will pick up bacteria in exactly the same way that hands do.”
The healthcare workers interviewed were not without empathy and some expressed strong concerns that their glove-wearing might make patients feel uncomfortable or ‘dirty’. But others also had the perception that patients preferred them to wear gloves as it appeared cleaner and more clinical.
The follow-up research (yet to be published) includes interviews with patients about their views on glove use. Wilson says early indications are that the public’s perception about when gloves should be worn are quite a close match to infection control guidelines, like, for instance, expecting gloves to be worn when taking blood or clearing up after incontinence.
“You could maybe argue that the public have a clearer understanding of when gloves should be worn than perhaps the staff who are delivering the care.”
Both patients and staff talked about gloves providing a form of ‘protection’ when receiving and giving intimate cares, however. “It’s not seen to be quite as intimate if you touch somebody wearing gloves than if you touch somebody with a bare hand,” says Wilson. “When patients are having their private parts washed then perhaps they like the ‘psychological barrier’ of having a gloved rather than a bare hand.
“So there may be situations when it makes the patient feel more comfortable for staff to wear gloves but they aren’t necessarily infection control reasons.”
Wilson stresses it is really important to be clear why gloves are necessary. “Because if you are not clear when gloves are required (for infection control reasons) then you start to get into the situation that they are used as a personal preference and the reason may be obscure.”
For example, she says there is no infection control reason why nurses or other healthcare workers should wear gloves to feed a patient. “It’s quite demeaning to the patient … feeding is the kind of task that needs to be done with compassion and wearing gloves conveys the wrong message when we are helping someone with a basic human need.”
Likewise, when showering and dressing a person, unless there is incontinence, there is no reason to wear gloves, says Wilson. “It indicates some unrealistic need to protect yourself and conveys to the patient a sense that they are dirty or unclean in some way.”
Glove overuse costly and risky
But, most simply, reducing unnecessary glove use just makes good infection control sense.
Wilson reiterates that nurses and healthcare workers should think twice before using gloves as her research, and others, indicate the more often HCW wear gloves the more likely they are to risk cross-contamination. “Because they put them on too soon and take them off too late.”
The unnecessary use of gloves not only increases the risk of healthcare acquired infections, which is costly in itself to patients and hospitals, but also the risk of costly wastage of the healthcare dollar.
“We are saying that at least half the glove use, in the UK settings we observed, was unnecessary so that means half the budget we are spending on gloves in these hospitals is being wasted.” Most of those wasted gloves are also going into a clinical waste stream so there is a further cost to dispose of them.
So ‘to glove or not to glove?’ is a question that Wilson believes nurses should always ask themselves before they reach their – of course, freshly clean – hands into the closest gloves box.
Appropriate times to use non-sterile gloves are:
- direct contact with blood
- direct contact with body fluids (secretions, excretions and items visibly soiled by body fluids)
- procedures that involve a risk with direct contact with blood or body fluid
- all contact with mucous membranes or non-intact skin
- IV insertion and removal
- drawing blood
- pelvic and vaginal examinations
- contact with infectious material
Some inappropriate times to use non-sterile gloves are:
- taking blood pressure, temperature and pulse
- bathing and dressing the patient
- mobilising patient
- feeding patient
- performing SC (subcutaneous) and IM (intramuscular) injections
If gloves are worn they must be:
- changed between patients
- changed between procedures
- removed and hands must be decontaminated afterwards
High inappropriate glove use in New Zealand
Inappropriate use of non-sterile gloves continues to be a “barrier to excellent hand hygiene practice”, says the latest Hand Hygiene New Zealand report.
The national campaign regularly audits the hand hygiene practices by staff at the country’s
20 district health boards, including when gloves are put on, taken off and during patient care.
In its latest audit it found when gloves were put on that 22.6 per cent of hand hygiene opportunities were missed, compared with just under 10 per cent when gloves are taken off. It also found that once healthcare workers donned gloves they failed to complete hand hygiene at the appropriate five moments nearly 21 per cent of the time.
This is an improvement on the statistics 12 months before when hand cleaning moments were missed 33.3 per cent of the time when gloves were put on. But Hand Hygiene New Zealand remains concerned and says glove use continues to be an ongoing issue.
“A sustained focus on how to maintain good hand hygiene when using non-sterile gloves is needed to improve this aspect of patient care,” it says in its quarterly report to 30 June 2015.
The World Health Organisation’s ‘Five moments for hand hygiene’ requires hand hygiene to be performed at each required ‘moment’ irrespective of whether or not gloves are used.
A hand hygiene survey in 2014 of 344 healthcare workers from 17 DHBs showed that 93 per cent of respondents did not think that glove use was a substitute for good hand hygiene. But when asked in what instances did they need to clean their hands when wearing gloves, only 40 per cent ticked all three correct options.
Five moments for hand hygiene
- Before patient contact
- Before a procedure
- After a procedure or body fluid exposure risk
- After patient contact
- After contact with patient surroundings
Examples of glove cross-contamination
- A patient touched by a glove that had been in contact with environment outside patient’s zone
- A susceptible site, like wound or IV site, being touched by a glove that had already touched a non-sterile object or surface
- Gloves used for handling urine or assisting toileting then touching a surface or patient
- Gloves used with one patient not removed (or hand hygiene performed) before leaving the patient area for another patient.
- Failure to remove gloves and perform hand hygiene after contact with patient surroundings
*From Loveday, Lynam, Singleton & Wilson, Clinical glove use: healthcare workers’ actions and perceptions, Journal of Hospital Infection (2013)