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Sterile versus non-sterile glove use and aseptic technique

Article in Nursing standard: official newspaper of the Royal College of Nursing · October 2008
DOI: 10.7748/ns.23.6.35.s46

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Sterile versus non-sterile glove use
and aseptic technique
Flores A (2008) Sterile versus non-sterile glove use and aseptic technique. Nursing Standard. 23, 6,
35-39. Date of acceptance: April 1 2008.
Summary
There is evidence indicating that improvements in infection control
practice can reduce the incidence of healthcare-associated infection.
This article explores the evidence base for glove use and aseptic
technique. There is a lack of evidence regarding the influence of
sterile versus clean gloves in clinical care. Therefore in practice, clean
and aseptic techniques are often used interchangeably. Nurses must
learn to select clean or aseptic technique, and therefore clean or
sterile gloves, using a risk assessment protocol. Regular audits of
aseptic technique and education are needed to improve care.
Author
Ashley Flores is senior nurse, infection control, East Surrey Hospital,
Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey.
Email: ashley@flores.me.uk
Keywords
Aseptic technique; Healthcare-associated infection;
Infection prevention
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
HEALTHCARE-ASSOCIATED INFECTION
(HCAI) remains a major problem in the UK.
HCAI encompasses any infection acquired as a
consequence of health care (Department of
Health (DH) 2006). The prevention and control
of HCAIs are priorities for all parts of the NHS.
Effective prevention and control of HCAI have
to be embedded in everyday practice and applied
consistently. All staff should demonstrate good
infection control and hygiene practice, using an
evidence base to review and inform clinical
practice (DH 2006).
The DH has published various documents
relating to infection control in England and Wales:
NURSING STANDARD

The Health Act 2006: Code of Practice for the
Prevention and Control of Health Care
Infections (DH 2008).

Winning Ways: Working Together to Reduce
Healthcare Associated Infection in England
(DH 2003).

Towards Cleaner Hospitals and Lower Rates
of Infection (DH 2004).

Saving Lives: A Delivery Programme to
Reduce Healthcare Associated Infection
including MRSA (DH 2005).

Essential Steps to Safe, Clean Care: Reducing
Healthcare-associated Infections (DH 2006).
In Northern Ireland, the Department of Health,
Social Services and Public Safety (2006) has
published Changing the Culture: Infection Control
Nursing in Northern Ireland, A Way Forward,
while NHS Quality Improvement Scotland (NHS
QIS 2003) has published, among other documents,
Improving Clinical Care in Scotland: Healthcare
Associated Infection.
The most recent guidance in England and Wales
is the Code of Practice for the Prevention and
Control of Healthcare Associated Infections (DH
2008), which forms part of The Health Act 2006.
The purpose of the code is to help NHS bodies plan
and implement how they can prevent and control
HCAIs. It sets out criteria by which managers of
NHS organisations are to ensure that patients are
cared for in a clean environment, where the risk of
HCAIs is kept as low as possible. Failure to observe
the code may result in an NHS organisation either
being issued with an improvement notice by the
Healthcare Commission, or being placed on
‘special measures’ (DH 2008).
One of the duties set out in the code is the duty
to adhere to policies and protocols applicable
october 15 :: vol 23 no 6 :: 2008 35
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&
art & science infection prevention
to infection prevention, including standard
infection control precautions and aseptic
technique. For aseptic technique, the code of
practice (DH 2008) stipulates the following:

Clinical procedures should be carried out in a
manner that maintains and promotes the
principles of asepsis.

Education, training and assessment in aseptic
technique should be provided to all persons
undertaking such procedures.

The technique should be standardised across
the organisation.

Audit should be undertaken to monitor staff
compliance with aseptic technique.
The use of gloves is one of the key issues relating
to aseptic technique.
Glove use
The aim of wearing gloves is to reduce the risks
of cross-infection from staff to patients and vice
versa, to reduce transient contamination of the
hands by micro-organisms that can be
transmitted from one patient to another, and to
protect users’ hands from certain chemicals
(Infection Control Nurses Association (ICNA)
2002a). The rationale for wearing gloves will
indicate the choice of glove required.
Pratt et al (2007) carried out a systematic
review of glove use. Indications for glove use are
set out in Box 1. Gloves must be worn as
single-use items, and changed between different
patients and between different care/treatment
activities on the same patient. Gloves must be put
on immediately before an episode of care and
removed as soon as the activity is completed
(Pratt et al 2007). Although gloves offer
protection, they do not provide complete
BOX 1
Indications for glove use

Invasive procedures.

Contact with sterile sites.

Contact with non-intact skin or mucous membranes.

When handling sharp and contaminated
instruments.

All activities that carry a risk of exposure to blood,
body fluids, secretions and excretions.
(Pratt et al 2007)
36 october 15 :: vol 23 no 6 :: 2008
protection against hand contamination, therefore
hands should always be decontaminated after
glove removal (ICNA 2002b). The application of
hand disinfectants to gloved hands is not
recommended as gloves are single-use medical
devices (Medicines and Healthcare products
Regulatory Agency 2006), and alcohol products
have not been tested on latex or synthetic glove
material, only skin (Jones et al 2000).
Legislation relating to glove use is outlined
in the Control of Substances Hazardous to
Health (COSHH) Regulations 2002 (as
amended) (Health and Safety Executive (HSE)
2005a), the Health and Safety at Work etc Act
1974 and A Short Guide to the Personal
Protective Equipment at Work Regulations 1992
(HSE 2005b). Employers are required to take all
reasonable steps to ensure that personal
protective equipment (PPE) provided to
employees is used properly, and that employees
use PPE in accordance with training (HSE
2005b). Protective clothing must be worn
appropriately and correctly to manage the risk
of exposure to micro-organisms, which may be
hazardous to health.
Risk assessment
The ICNA (2002a) recommends that before use
a comprehensive risk assessment should be
undertaken to determine the most appropriate
glove type for the task to be undertaken. A risk
assessment will explore the specific nature of the
task, the type of contamination, whether the task
is sterile or non-sterile, and whether the patient
or staff member has an allergy to natural rubber
latex (ICNA 2002a).
The choice between sterile and non-sterile
gloves is based on contact with susceptible sites
or clinical devices. Sterile gloves have been
recommended to be worn in the following
circumstances (Raybould 2001):

Surgical procedures.

Procedures requiring an aseptic technique.

Sterile pharmaceutical preparations.

Invasive procedures, for example lumbar
puncture.

Surgical wound dressings.

Invasive procedures for immunocompromised
patients.

Insertion of invasive devices, for example
urinary catheters.
Aseptic versus clean technique
Aseptic technique has been defined as:
NURSING STANDARD
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‘the purposeful prevention of the transfer
of organisms from one person to another
by keeping the microbe count to an
irreducible minimum. This involves hand
decontamination, use of a sterile field, sterile
gloves and sterile equipment’ (Crow 1997).
A clean technique adopts the same aims as
aseptic technique but uses clean rather than
sterile gloves (Preston 2005). Clean technique
involves hand decontamination, maintaining
a clean environment by preparing a clean field,
using clean non-sterile gloves, sterile instruments
and prevention of direct contamination
of materials and supplies (Association for
Professionals in Infection Control and
Epidemiology (APIC) 2001).
Aseptic non-touch technique (ANTT) is a
specific method of applying aseptic technique
and was developed in the 1990s in response to
a need to standardise the practice. ANTT is a
clinical guideline for aseptic technique based
on an evidence-based framework (Rowley and
Sinclair 2004). Much of the research has focused
on intravenous (IV) therapy, but the authors
claim that the technique can also be used for
other aseptic procedures such as urinary
catheterisation or wound care. The definition
of a key part is one of the key principles of ANTT.
A key part is any part of equipment that if
touched directly or indirectly could result in
infection (Rowley and Sinclair 2004). For
example, in IV therapy key parts are parts of
equipment that come into direct contact with
the infusion fluid. Key parts should be protected
at all times using a non-touch technique (Rowley
and Sinclair 2004). Non-touch technique is a
method of manipulation of invasive devices or
wounds without directly touching the wound,
device, or any surface that might come into
contact with those sites (APIC 2001).
Insertion and care of invasive devices
Patients who develop an infection and/or
become colonised with organisms such as
meticillin-resistant Staphylococcus aureus
(MRSA) may do so because their body’s natural
defences are breached when catheters, tubes and
drains are inserted as part of the process of care
(DH 2003). In England, almost two thirds of
bacteraemia of a known source were associated
with an intravascular device or with device-related
infections, such as catheter-related urinary tract
infection or ventilator-associated respiratory
tract infection (Public Health Laboratory
Service (PHLS) 2002). Central venous catheters
(CVCs) were the most common source of
hospital-acquired bacteraemia (PHLS 2002).
For CVCs, good standards of hand hygiene
and aseptic technique can reduce the risk of
NURSING STANDARD
infection (Pratt et al 2007). Pratt et al (2007)
state that, for care of CVCs, appropriate ANTT
does not necessarily require sterile gloves, and
that a new pair of disposable non-sterile gloves
can be used in conjunction with a non-touch
technique, for example in changing catheter site
dressings. However, given the risk of
healthcare- associated bloodstream infection
linked to CVCs, trusts need to integrate the
evidence with local practice guidelines and
carefully consider whether sterile or non-sterile
gloves are required for CVC site care and for
accessing the system. In the document Winning
Ways, the DH (2003) stated that strict aseptic
technique must be carried out by trained and
competent staff for:

Urinary catheter insertion, manipulation,
washing out and urine sampling.

CVC insertion, manipulation and removal.

Insertion, manipulation and removal of
IV feeding tubes (parenteral nutrition).

Insertion of peripheral catheters.
Aseptic technique and wound care
Aseptic technique is traditionally used in wound
care, yet several authors (Briggs et al 1996,
Hollinworth and Kingston 1998) have
questioned whether this is ritualistic, based on
limited research and rationale (Gilmour 2000).
Some authors have suggested that sterile gloves
are only necessary if the practitioner’s hands
come into contact with sterile body areas such
as during surgery or urinary catheterisation.
They argue that non-sterile gloves provide
adequate infection control if linked with
effective hand decontamination (Hollinworth
and Kingston 1998).
Hartley (2005) reported that aseptic technique
is still not being carried out to a high standard
across the UK. This may be related to the
theory-practice gap and/or confusion and
complacency in professional practice (Hallett
2000). In the United States, a survey on aseptic
technique found that technique choices among
staff nurses were based on the education level of
the care giver and perception of infection risk to the
patient, and that there were no specific scientific
research studies to support the use of either ‘clean’
or ‘aseptic’ technique (Wise et al 1997).
Stotts et al (1997) examined wound healing in
a sample of 30 patients following elective
gastrointestinal surgery. Wound dressings were
changed three times per day, with aseptic
technique used for half of the patients and clean
technique for the other half. There was no
difference in wound healing after four days. This
study was limited by the small sample size and
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art & science infection prevention
the fact that patients’ wounds were assessed only
four days following surgery, before completion
of healing and with no long-term follow up.
Sage and Argall (2003) carried out a review
to establish whether the use of sterile gloves
during the treatment of simple traumatic wounds
reduced infections. Although 48 articles were
examined, the authors found no available
evidence for the use of sterile gloves in preference
to clean gloves in the treatment of simple
traumatic wounds. The authors argued that it
may be unethical to start using non-sterile gloves
and that this was an area for potential research.
St Clair and Larrabee (2002) examined the
practice of using sterile gloves for post-operative
wound dressing changes in acute care. On
reviewing the data, the authors found neither
infection rate nor wound healing was adversely
affected by using non-sterile rather than sterile
gloves. Because of the risk of increased
post-operative infection rates and delayed
wound healing, the authors found insufficient
evidence to warrant a change in practice from
the use of sterile to non-sterile gloves. The
authors concluded that multidisciplinary
studies that investigate the relative influence of
factors which influence susceptibility to wound
infection, such as surgical asepsis during the
perioperative period, and intrinsic patient
factors such as nutritional status, would be
most informative.
Where the level of risk to the patient is not
clear, erring on the side of safety must be the
only option (Heenan 1995). It is acknowledged
that in some practice environments where the
assessment of risk is low it would be acceptable
to use clean technique, for example chronic leg
ulcers when managed in the patient’s home
(Hampton and Collins 2004).
Factors to be considered when making the
choice between aseptic and clean technique for
wound care include the following (APIC 2001):

Healthcare setting, for example acute hospital
versus patient’s home.

Immune status of the patient, which is
influenced by:
– Underlying disease, for example patients with
debilitating or malignant disease.
– Age: neonates and older people are more at
risk because of their less efficient immune
system.
– Medication, for example corticosteroids and
immunosuppressive drugs.
– Patient procedures, for example surgery.
38 october 15 :: vol 23 no 6 :: 2008

Type of wound, for example acute versus
chronic.

Location and depth of wound.

Invasiveness of the procedure, for example
whether debridement or extensive packing
of the wound is to be performed.
Implications for clinical practice
Bree-Williams and Waterman (1996) found
that 33% of nurses contaminated their hands
and equipment during the aseptic technique
procedure, due to factors such as poor glove
technique and making the procedure more
complicated than necessary. Davey (1997)
found that nurses were not clear about when to
apply gloves during aseptic technique for
wound care, and that some nurses did not know
that the wound dressing could be removed with
the sterile waste bag to avoid contaminating
their hands, so reducing the need for an extra
pair of gloves or forceps.
Improving skill-based care should be a focus
for ongoing post-registration education (Preston
2004). This includes ‘skills in glove selection and
technique, maintaining a sterile field with the use
of non-touch principles and developing risk
assessment protocols’ (Preston 2005). Rowley
and Sinclair (2004) recommend implementing
ANTT in more hospitals, ensuring good practice
is created through a process of training, audit
and assessment, and continuing to evaluate it
through the audit cycle.
Wise et al (1997) found that, for wound care,
nurses seldom deviate from patterns they
learned during their basic education, so that
nursing practice patterns may be resistant to
modification by policy change alone. Regular
audits of aseptic technique, formulation of
action plans where necessary and educational
support programmes are needed to improve
standards of care (Preston 2005).
Conclusion
In practice, clean and aseptic techniques are used
interchangeably, often without risk assessment
(Gilmour 2000). Nurses must learn to select
clean or aseptic technique, and therefore clean or
sterile gloves, using a risk-assessment protocol.
Risk assessments on types of gloves, equipment
and exposure to blood and body fluids should be
completed for all aseptic procedures (Weaver
2004). This should guide nurses to adopt safer
principles when using gloves (Preston 2005).
Variability in practice occurs when nursing
practice is not guided by research (Wise et al
1997). However, it would be easy to lose track
of the principles of aseptic technique when
NURSING STANDARD
p35-39w6 10/10/08 11:13 am Page 39

questioning every action (Gilmour 1999). There
is a lack of evidence regarding the influence of
sterile versus clean gloves in clinical care, including
post-operative infection rates and delayed wound
healing rates. The risk requires further evidence
before healthcare staff change practice from sterile
gloves to clean gloves (Rosswurm and Larrabee
1999). Where the evidence base is lacking, best
practice must be guided by expert opinion and
national and international guidance, which need
to be integrated into local practice guidelines
(Pratt et al 2007).
Although ritualistic practice needs to be
questioned, with the rising incidence of
multi-resistant infections, it seems prudent
to err on the side of caution when in doubt NS

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