Anyone who has visited a hospital in the past decade will be no stranger to the widespread use of clinical gloves in today’s patient care. These non-sterile gloves, made of vinyl, latex or a latex substitute called nitrile, were first introduced on a large scale in the 1990s as a means of preventing the spread of bloodborne viruses. Since then, gloves have become seemingly inseparable from the concept of hygiene during contact between medical staff and patients.

While an essential resource in preventing healthcare-associated infection (HCAI) transmission during certain procedures, recent attention has turned towards the potential for healthcare workers to misuse gloves, risking cross-contamination from patient to patient.

A recent study, published in the Journal of Hospital Infection (Loveday et al, 2013), that observed glove use in one UK hospital trust, exposed the multiple ways gloves can be misused – from wearing them in situations where they are not required to failing to observe the necessary hand-hygiene steps while wearing them.

Jennie Wilson, reader in healthcare epidemiology at the University of West London and an author on the study, explains that the investigation first seemed necessary on the basis of a clear rise in use. "We started looking at it just through observation of practice and noticing that there was a high-level of glove use. I had been working in a specialist institute for quite some time, so I hadn’t had much contact with clinical practice, then I came back into a much more clinical-facing role, and the difference in those intervening years – a decade or so – in the way that gloves were being used, just struck me."

The increased volume that Wilson observed was, in many ways, a telltale sign of the concerning trend the study was to reveal.

Cultural transmission

Carried out within six wards in one hospital over a period of 13 hours, healthcare workers were audited on the basis of ‘appropriate’ glove use – whether gloves should have been worn in the first place – and then with regard to whether correct hand-hygiene procedures were executed while wearing them. The auditors found that glove use was ‘inappropriate’ in 42% of episodes (69 out of 163) and that there was a risk of cross-contamination in 37% of episodes (60 out of 163).

Glove use was defined in the study as being ‘appropriate’ in a procedure when it contained "a risk of contact with blood and bodily fluids or mucous membranes; direct patient contact in an isolation bay or room during a defined outbreak of infection; or the use of hazardous substances, for example, disinfectants".

"Peer-observed behaviour can often become the norm, so the very clinical staff responsible for auditing hand hygiene in a department can themselves not notice discrepancies in glove use."

Risk of cross-contamination was defined as "a violation of a ‘moment of hand hygiene’", and most (48%) of the cases identified during the study were associated with failure to remove gloves or to perform correct hand-hygiene procedures after use.

These ‘moments’ are outlined in the World Health Organization’s ‘My 5 Moments for Hand Hygiene’ (M5M), which defines the key scenarios in patient care where healthcare workers need to clean their hands, such as prior to touching a patient and after risk of exposure to bodily fluids.

Significantly, however, as Wilson’s report points out, gloves are not explicitly mentioned in M5M. They are referred to in what Wilson calls "the small print" of the framework, but, she says, "it perceives that the way gloves would be used would just fit into the points of care where you would wash your hands anyway, so if you were wearing gloves you would do the same.

"But because it’s not specifically mentioned in the main framework or the diagram that everybody sees, perhaps it’s not obvious when you audit hand hygiene what you do about the use of gloves."

Another problem Wilson points out is that peer-observed behaviour can often become the norm, so the very clinical staff responsible for auditing hand hygiene in a department can themselves not notice discrepancies in glove use.

In fact, for the healthcare workers actually using the gloves, this peer-influenced behaviour forms a key part of the ‘socialisation’ theme that Wilson and her colleagues found to be a dominant motivation for misuse.

As part of the study, 25 of the observed healthcare workers were also interviewed about their attitudes towards glove use. One staff member, who self-identified as ‘still learning’, said: "I’ll watch them and think, ‘ah, they don’t wear gloves for this’ or ‘they do wear gloves for this’. So when I come to doing it, I’ll do what I think I have seen."

Inappropriate clothing

The second major theme Wilson’s team recognised was ’emotion’ – healthcare workers’ own reactions to aspects of their work that may lead to them opting for gloves; fear and disgust play a strong part. One interviewee commented: "I am more cautious about myself than what I am passing on… from one patient to the next patient, I’ll be honest."

Another said: "When I used to work in A&E, you used to get some homeless people coming in, and drunks and everything like that… I personally wouldn’t, and I don’t see any other staff member… go near them without gloves on."

Clearly, staff preference is an influential factor and an important consideration, so is there any problem with gloves being used in situations not technically considered appropriate, as long as correct hand-hygiene procedure is followed?

"There isn’t a problem per se with people wearing gloves where they may not be appropriate," Wilson explains, "although there’s clearly a cost attached to that – in many other aspects of care, we would be concerned about resources being wasted on unnecessary equipment or procedures."

However, she is also quick to emphasise: "The problem with wearing gloves when they’re not indicated is that there is a tendency not to change them. The more gloves are worn, the greater the risk that they may be worn between tasks, where really they should be changed."

Another influential factor the report uncovered was the desire to save time and resources, with one healthcare worker making the ill-judged innovation of applying alcogel over the top of gloves instead of changing them.

As Wilson explains, studies have shown that the wrinkly, uneven surface of gloved hands means that attempts to sterilise them with soapy water or alcohol tend to be unsuccessful, leaving a large number of microorganisms on the glove that will then be transferred to the patient.

"It’s important to really evaluate the extent to which the culture of an organisation has influenced the glove-use behaviour – we may find it’s very different elsewhere."

A further significant motivation, and part of the socialisation theme, was a preference perceived by staff on the part of patients; some healthcare workers felt patients would "feel more safe" if treated by gloved hands or would find procedures such as intimate hygiene less "invasive". By contrast, other interviewees said gloves made them feel "very clinical" and believed their relationship of care could be damaged by a patient’s perception that "no one wants to touch me".

The study highlighted that there is a lack of evidence concerning the views and preferences of patients towards glove care, and this is an area Wilson and her colleagues have chosen to investigate further by asking members of the public who have had recent contact with healthcare their views on glove use. The results are set to be published early next year.

Learned behaviour

While patients’ preferences are of great import in securing their comfort and peace of mind, safety with regard to cross-contamination and HCAI transmission prevention must of course be the primary concern, and so clearer, more easily digestible guidance for staff that ties proper glove use into the major hand-hygiene framework is desperately needed.

With this in mind, Wilson and her colleagues are currently repeating the original glove-use study on a larger scale, staged in two more hospitals, and are undertaking validation work to define an audit tool that goes some way towards integrating gloves into M5M.

The audit tool and accompanying research, again due to be published next year, could be used foremost by infection control practitioners as a means of identifying the systemic issues in hospitals. However, combined with training to clarify best practice, it could also potentially help nurses to audit and improve glove use on their own wards.

Repeating the interviews on a larger scale will also allow Wilson’s team to discover, with greater clarity, whether there is a widespread misunderstanding of glove hygiene across the health service, by identifying whether similar themes arise or if these are distinctive at particular sites.

"It’s important to really evaluate the extent to which a culture of an organisation has influenced the glove-use behaviour – we may find it’s very different elsewhere," she says.

What’s more, the follow-up study will help establish any variation in the behaviour of different staff groups, although it’s worth noting, Wilson points out, that of the small number of healthcare workers observed in the original study, there were no significant differences in glove use between different staff types.

"It does show that one group of staff isn’t any worse or better than the other, and I think that is really important," she explains. "I think one of the things in healthcare we’re bad at is saying, ‘ah well it’s all the doctors’ fault’ or ‘it’s all the nurses’ fault’, but actually, this is a pattern of behaviour that becomes embedded within the culture of an organisation."