Opinion and practice of gloving among nurses in a University Teaching Hospital

Prof. Manda Venkatramana MS, FRCS Dean, Gulf Medical College Professor of Surgery, Gulf Medical University Ajman, UAE, P O Box- 4184 manda_venkat@hotmail.com Dr. Sreedharan Jayadevan Ph.D Assistant Director, Research Division Gulf Medical University, Ajman-UAE drjayadevans@gmail.com Dr. Muttapppallymyalil Jayakumary MD Research Associate, Research Division Gulf Medical University, Ajman-UAE drjayakumary@gmail.com Correspondence: Dr. Jayadevan Sreedharan Ph.D Assistant Director, Research Division Gulf Medical University Ajman, UAE, P O Box- 4184 Email- drjayadevans@gmail.com Phone No : +9716-7431333, Fax: +9716-7480779

ABSTRACT Background: Proper gloving handling can decrease infections in hospital settings. Lack of knowledge amongst healthcare providers can transmit micro-organisms that are responsible for hospital acquired infections. Aims: Assess opinion about glove handling and practice in routine patient care. Materials and Methods: Nurses working in Gulf Medical College Hospital and Research Centre, Ajman, United Arab Emirates participated in this cross sectional study. Structured, open-ended, self administered, piloted questionnaire was used. Chi-square test was used to find the association. Results: Nurses' ages ranged from 19 to 48 years. Mean (SD) duration of clinical experience was 6.61 (4.19) years. 70 (70.7%) would use gloves only on contact with blood and body fluids; 16 (16.2%) said they would use it only on contact with patient skin and only one nurse (1%) mentioned using gloves only while handling sharps. Conclusion: There is need to motivate nurses to adhere to gloving practices by providing in-service training programs. Key words: Nurses, Gloving, Opinion, Practice

INTRODUCTION

Gloving is one of the most important factors in preventing the spread of infection and development of antibiotic resistance in healthcare settings [1]. Proper glove handling decreases the occurrence of infections in hospital settings and lack of knowledge amongst healthcare providers can transmit micro-organisms that are responsible for hospital acquired infections. The standard precautions should be followed for each patient care in order to protect health care providers and patients from risks associated with contact with blood and other biological liquids. As delivery of medical care moves increasingly to an outpatient setting, patients who require hospitalization have more acute illnesses and heightened susceptibility to nosocomial infections. These infections form a major challenge in the medical field. On an average nosocomial infection complicates 7% to 10% of hospital admissions [2]. Universal precautions involving the use of gloves, can reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infective materials, hence effective glove handling is one of the most important measures for preventing and controlling such infections [3]. Proper gloving of hands is an effective prophylactic disinfection that can prevent nosocomial infections, particularly in high risk areas of the hospital like the intensive care units. Despite this, compliance with glove handling amongst health care workers, including physicians and nurses, remains under 50%, which is unacceptably low. [4-6]. Educational programs to improve hand washing by health care providers by increasing their awareness about nosocomial infection have had limited success [1]. The present study was conducted to assess the opinion of gloving of hands during routine patient care and to determine the situation of nurses' hand gloving practice.

METHODS

This cross sectional study was conducted among the nurses involved in virtually every aspect of nursing duties in Gulf Medical College Hospital and Research Centre, Ajman, United Arab Emirates (UAE) from February to May 2009. A structured, open-ended, self administered, pilot tested questionnaire was used to assess the opinion of nurses on glove wearing/handling and determine the practice among nurses. Informed consent was obtained from the participants before administering the questionnaire. Anonymity was maintained, a structured open-ended questionnaire on which the nurses were asked not to enter their names or any other information that could reveal their identity. The questionnaire contained questions on their opinion and factors related to glove wearing in addition to socio-demographic information. The data from the questionnaire were coded and entered into an Excel spreadsheet and analysis done using PASW 17. Chi-square test was used to compare parametric variables and mean (sd) to get the average for the same. p value of < 0.05 was considered statistically significant.

RESULTS

A total of 101 nurses at the Gulf Medical College Hospital and Research Centre, Ajman, UAE were surveyed with a response rate of 99%. All nurses participated in this study, which included 11 males and 90 females. The nurses' ages ranged from 19 to 48 years. The mean (sd) age of the respondent was 29.59 (5.96) years. Work experience of the nurses varied between 10 months and 22 years. Mean (sd) duration of clinical experience was 6.61 (4.19) years. 51.5% had less than 5 years of clinical work experience, 32.7% had 5 to 10 years experiences and only 15.8% had more than 10 years of clinical work experience. Details are in Table 1.

In the present study, when nurses were asked if they think that it is important to wear gloves, 100 out of 101 (99%) nurses responded, and of the 100, all (100%) responded in the affirmative.

Table 2: Distribution of participants according to duration of work experience and opinion on gloving

Of the nurses who did not respond to this knowledge-based question, on analysis it was found that one used to wear gloves in all three situations in actual practice and the other nurse used to wear gloves occasionally in contact with patient skin but always in contact with blood and body fluids and sharps (syringes).

On further analysis of the responses of 6 nurses who thought of using gloves in all three situations, whether they practiced what they knew, it was found that 4 did practice using gloves in all three situations; one nurse used gloves always when in contact with blood and body fluids but occasionally in the other two situations and one always used gloves during contact with sharps and blood and body fluids but only occasionally used when in contact with patients' skin. These 6 nurses were also found to change gloves, one for each patient.

With regard to the question about how often they used gloves in the three situations mentioned above, reflecting their actual day to day practice, we got a response rate of 87%. 13 did not respond to this question. We found that of the 88 nurses who did respond, 29 nurses (33%) said that they always used gloves and 59 nurses (67%) said they used gloves only occasionally in all three situations.

Of the 29 nurses who always used gloves in all three situations, 28 nurses (96.6%) changed gloves one for each patient and one nurse did not respond to a question on frequency of changing gloves.

94 out of the total 101 nurses responded for the practice of use of gloves when in contact with patients' skin. 38.3% wore them always during contact with patient's skin and 58 (61.7%) used them only occasionally. The response rate for the question reflecting practice of use of gloves during contact with blood and body fluids was 97%; 3 did not respond to this question. 93 out of the remaining 98 or 94.9% of nurses always used gloves when in contact with blood and body fluids and only 4 nurses (4.1%) used gloves occasionally and one nurse said she never used gloves in this situation. Regarding practice of wearing gloves when sharps (syringes) are used, 90 nurses responded out of 101, making the response rate 89.1%. Out of the 90 who did respond, 62 nurses (68.9 %) practiced wearing gloves always when they came in contact with sharps (syringes) and 27 nurses (30%) occasionally wore gloves in this situation. One nurse (1.1%) never wore gloves when sharps are used though no reason for the same was mentioned. Details are given in Table 3.

Table 3: Distribution of participants glove use according to situation

When asked about the frequency of changing gloves, 98 out of 101 nurses responded. Out of the 98 nurses who did respond, 96 nurses (98 %) said they changed gloves one for each patient and only 2 nurses (2%) said they occasionally changed gloves.

To know whether years of work experience did have an influence on the frequency of changing gloves by practicing nurses, we found that 96% of nurses with less than 5 years experience changed gloves one for each patient and those with 5 to10 years and more than 10 years work experience, did change gloves one for each patient.

For a question on the necessity to wash hands after removal of gloves, 99 nurses responded out of the 101, and all (100%) felt that it was indeed necessary to wash hands after removing gloves.

But in practice, we asked whether they do wash hands after removal of gloves, 97 nurses (96%) said they always washed hands after removal of gloves and only 4 nurses (4%) said they only occasionally washed hands after gloves removal.

Irrespective of their years of work experience, all participants felt that they should wash hands after removal of gloves.

In our study, 94.2% nurses with work experience less than 5 years always washed hands after glove removal in actual practice, 97% of nurses did the same with work experience 5 to 10 years and 100% of nurses with work experience more than 10 years, thus highlighting the fact that with work experience the habit of washing hands after removal of gloves also improved.

DISCUSSION

The opinion regarding use of gloves always in all the three situations asked in the questionnaire, were, when in contact with patients' skin, blood and body fluids and when using sharps (syringes) was influenced by years of work experience.

In a study carried out in Jordan conducted among dental nurses working in commercial laboratories, only 16 percent of them wore gloves with a compliance rate of only 2.5% [7] showing a clear lack of compliance with infection control procedures. When nurses were educated, the compliance rate rose from 70% to 93% for nurses with less than 3 years of experience [8]. For the more experienced (more than 4 years) registered nurses, the compliance rate before the program was only 15% and after educating them it rose to 93%, but declined to only 50% by the fifth month [8].

In our study, among nurses with less than 5 years experience, 31.1 % used gloves always in all 3 situations, with a 5 to 10 years experience, 37 % used gloves in all three situations and with an experience of more than 10 years, 31.3 % wore them in all three situations. This fact emphasizes the need for frequent reinforcement to avoid complacency to set in.
The CDC guidelines recommends the use of gloves in all three situations asked in the questionnaire, namely when coming in contact with patient skin, blood and body fluids or while handling sharps.

When asked about how often they used gloves in the three situations mentioned above, reflecting their actual day to day practice, in our study we found that 33% would always wear gloves in all three situations. 38.3% wore it always during contact with patient's skin. 94.9% wore it always when in contact with blood and body fluids. 68.9 % of nurses wore gloves when they came into contact with sharps (syringes).

In one study it was reported that gloves are not always worn during contact with patients' secretions and sharp instruments and hands were decontaminated in 28.9% with patient contacts [9]. It was suggested in another study that by using gloves 95% of contacts to body fluid would be prevented [10]. In our study, among the 99 nurses, 70 would use gloves only on contact with blood and blood fluids, 16 would use them with contact with patient skin and only one nurse would practice wearing gloves during usage of sharps. Only six nurses thought of wearing gloves in all three situations.

Changing of gloves is an important factor in hand hygiene; it was found in a study carried out in England that only one fifth of respondents were found to change gloves between patients. Of those participants who did not change gloves between patients, half considered that blood contact was not a reason for changing gloves [11]. About 98% reported changing gloves after contact with each patient [11]. In support of glove changing it was confirmed that obstetric nurses may decrease the number of post-cesarean wound infections by having the entire team change surgical gloves after delivery of the placenta [12]. Whereas this was opposed by another study where there were no statistically significant differences in measures of post cesarean febrile morbidity based on intra-operative glove change [13]. However, in a study changing gloves did seem to reduce the number of bacterial species [14-15].

Hand washing is strongly encouraged after removal of gloves [1]. In the present study, it was encouraging to find 100 % of the respondents answering in the affirmative about the necessity to wash hands after removing gloves. On questioning about application of the same in their day to day practice we found that 96 % actually practiced it. When we compared the data with their practice towards hand washing after the use of gloves we found that nurses compliance with hand-washing increases with increased work experience.

Reducing health care-associated infections requires that health care workers take responsibility for ensuring that hand hygiene becomes an everyday part of patient care [16]. Improving hand hygiene compliance will require changing healthcare workers behavior towards glove use [15]. It was shown that the majority of the literature indicates an incomplete knowledge among trained nurses of the principles and application of universal precautions and also the questionable ability of the trained nurse to fulfill his/her role as health educator, teacher and therefore effective infection control practitioner. This underscores the role of education in improving the knowledge of trained nurses and recommends implementation of in-service training and pre-registration education [17].

CONCLUSION
In conclusion, it has been observed that there is a dichotomy between opinion and practice of gloving among nurses which can effectively be bridged by in-service training and education. Education to improve adherence to infection control precautions is the primary intervention that has been studied.

REFERENCES

1. Doebbeling BN, Pfaller MA, Houston AK, Wenzel RP. Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med 1988; 109(5):394-398.
2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121(2):182-205.
3. Centres for disease control and prevention 1996. Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections.
4. Thompson BL, Dwyer DM, Ussery XT et al. Hand washing and glove use in a long term - care facility. Infection Control Hosp Epidemiol 1997; 18:97-103.
5. Rotter ML. Hand washing and hand disinfection. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control.Baltimore: Williams and Wilkins. 1996 1052-1068.
6. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42(1):121-130.
7. Al-Dwairi ZN. Infection control procedures in commercial dental laboratories in Jordan. J Dent Educ 2007; 71(9):1223-1227.
8. Friedland LR, Joffe M, Wiley JF, et al. Effect of educational program on compliance with glove use in a pediatric emergency department. Am J Dis Child 1992; 146(11):1355-1358.
9. Gould D, Wilson-Barnett J, Ream E. Nurses' infection-control practice: hand decontamination, the use of gloves and sharp instruments. Int J Nurs Stud 1996; 33(2):143-160.
10. Kristensen MS, Sloth E, Jensen TK. Procedure-related rate of contact of intensive care unit personnel with patient body fluids. Intensive Care Med 1991; 17(5):276-280
11. Burke FJ, Wilson NH, Cheung SW. Trends in glove use by dentists in England and Wales: 1989-1992. Int Dent J 1994; 44(3):195-201.
12. Ventolini G, Neiger R, McKenna D. Decreasing infectious morbidity in cesarean delivery by changing gloves. J Reprod Med 2004; 49(1):13-16.
13. Cernadas M, Smulian JC, Giannina G, Ananth CV. Effects of placental delivery method and intraoperative glove changing on postcesarean febrile morbidity. J Matern Fetal Med 1998; 7(2):100-104.
14. Zdanowski Z, Danielsson G, Jonung T, et al. Intraoperative contamination of synthetic vascular grafts. Effect of glove change before graft implantation. A prospective randomised study. Eur J Vasc Endovasc Surg 2000; 19(3):283-287.
15. Girou E, Chai SH, Oppein F, et al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect 2004; 57(2):162-169.
16. Trampuz A, Widmer AF. Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004; 79(1):109-116.
17. Roberts C. Universal precautions: improving the knowledge of trained nurses. Br J Nurs 2000; 9(1):43-47.