Authors Ashley Flores, MSc, BSc, Dip Infection Control, RN, is senior nurse infection control, Mayday Healthcare NHS Trust. David J. Pevalin, PhD, is senior lecturer, Department of Health and Human Sciences, University of Essex.
Flores, A., Pevalin, D. (2007) Glove use and compliance with hand hygiene. Nursing Times; 103: 38, 46–48.
Ashley Flores and David Pevalin summarise the results of an observational study into the use and overuse of gloves and the effect on hand hygiene.
Appropriate hand hygiene is a leading measure to reduce the transmission of healthcare-associated infection. Despite evidence for the efficacy of hand hygiene, multiple studies have demonstrated low levels of compliance, with average baseline rates of 40% (Boyce and Pittet, 2002). Contributing factors include a lack of education, high workload, lack of a role model from key staff and lack of administrative leadership (Pittet and Boyce, 2001).
Published studies looking at the impact of wearing gloves on adherence to hand-hygiene policies have yielded contradictory results. One study found that healthcare workers are less likely to wash their hands after wearing gloves by as much as 25% (Whitby and McLaws, 2004). Kim et al (2003), in an observational study in ICUs in the US, found that glove use increased compliance with hand decontamination but workers did not comply with hand hygiene guidelines when attending to multiple body sites/secretions on the same patient. Therefore, the influence of glove use on hand hygiene practice is unclear.
The objectives of this research were to examine healthcare workers’ glove use by observation and to evaluate the effect that glove use has on compliance with subsequent hand hygiene.
The study took place in a large acute hospital trust serving south-west London and Surrey and used a strategy of overt, structured, non-participant observation. To assess compliance, the same observer (an infection control nurse specialist) observed all relevant staff–patient contacts. A second person (also an infection control nurse specialist) co-observed 10% of the contacts for validation purposes.
A random sample of wards was selected across the six directorates. All doctors, nurses and HCAs were observed for two 30-minute observation periods on each ward. Other staff and people who were not considered staff, such as patients and visitors, were excluded from the study.
All observations were carried out during the morning shifts, between 9am and 12pm. Wherever possible, different personnel were observed in each period.
Data collected during each observation included:
- Total number of potential glove-use opportunities;
- Actual number of glove-use episodes;
- Total number of potential hand-hygiene opportunities;
- Actual number of hand-hygiene episodes;
- Time of observation;
- Professional category of staff;
Staff were informed that they were being observed as part of a study on glove use via a poster that was displayed in their unit up to a week before the observations took place. All data collection was anonymous. A total of 12 hours’ observation was carried out – one hour per ward. One hundred and sixty-four episodes of patient care were observed, consisting of a variety of routine clinical activities such as manipulation of intravenous lines and cardiovascular observations.
Overall glove use compliance was 92.3%. The compliance to glove use for doctors was significantly lower than that of nurses and HCAs but this result must be viewed with caution as there were small numbers of doctors.
Inappropriate glove use
Gloves were overused (worn when not required) during 42% of observations. They were worn inappropriately for tasks such as collecting equipment, answering the phone, talking to patients, undertaking cardiovascular observations and writing notes.
It was also observed that gloves were worn for more than one task, for example, making a bed and manipulating an IV line. Nurses overused gloves significantly less than doctors or HCAs.
Overall hand-hygiene compliance was 64%. There was no significant difference in hand-hygiene compliance between professional groups.
Effect of glove use on hand-hygiene compliance
Hand-hygiene compliance is composed of:
1. Hand hygiene following no glove use;
2. Hand hygiene following appropriate glove use;
3. Hand hygiene following inappropriate glove use (glove overuse).
The glove-use compliance rate was significantly higher for nurses and similar to that found in other studies. Wilkinson (1992) observed glove-use compliance rates that averaged 80–94% overall, with the nurses’ glove compliance rate being 91.4% and doctors’ being 73.2%.
Although overall compliance for glove use was high, gloves were also being overused. They were worn for tasks that did not necessitate their use, and staff did not always remove them and decontaminate their hands between different patients and tasks. The proportion of glove overuse observed is consistent with the study by Girou et al (2004), who found that 20% of all patient contacts were performed with gloves that had not been removed after previous care. In their study, cross-transmission could have occurred in about one in five staff–patient contacts due to glove misuse and in 82% of high-risk care activities, such as contact with IV lines. Thompson et al (1997) found that gloves were appropriately changed in only 16% of instances.
The purpose of wearing gloves is to reduce the risks of cross-infection from staff to patients and vice versa, and to reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another (Infection Control Nurses Association, 2002). Gloves must be worn only once, for one aspect of care and one patient and, if gloves are not removed and hands decontaminated after use, the risks of cross-infection are increased (Pratt et al, 2001).
Overuse of gloves may be due to a belief that glove use obviates the need for hand hygiene (Pittet, 2001). Staff might wear gloves with the primary intention of protecting themselves and not the patient and may be unaware that contamination on gloves occurs just as on hands (Pittet et al, 1999).
The overall hand-hygiene compliance rate of 64% was higher than the average baseline rates for hand-hygiene compliance of 40%, although the methods used for defining adherence and those used for conducting observations vary considerably between studies (Boyce and Pittet, 2002).
Effect of glove use on hand-hygiene behaviour
Hand-hygiene compliance was significantly worse after inappropriate glove use. Failure to remove gloves after patient contact or between ‘dirty’ and ‘clean’ body sites on the same patient must be regarded as non-adherence to recommendations (Boyce and Pittet, 2002). Disposable gloves are single-use medical devices and are not intended to be reprocessed and used on another patient or for another procedure on the same patient (Medicines and Healthcare products Regulatory Agency, 2006).
These results show that inappropriate glove use may be a component of poor hand-hygiene compliance. Handwashing or disinfection should be strongly encouraged after glove removal.
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