Factors responsible for student nurses’ use of non-sterile gloves: An exploratory qualitative study

Abstract

Background

Disposable non-sterile gloves are part of the personal protective equipment (PPE) to be considered to protect oneself from the risk of infection. They have subsequently become the topic of concern related to increased use, inappropriate use, and potentially increasing the risk of cross-infection and environmental impact of plastic waste.

Aim/objective

This study aimed to explore the views of pre-registration student nurses about non-sterile glove use in clinical practice and to identify the factors that impact student nurses’ decision on whether to wear non- sterile gloves.

Methods

Using a social constructivist approach, the study was organised in a higher education institution. Semi-structured interviews were conducted with second year student nurses, utilising a theoretical domains framework (TDF).

Findings/Results

The key findings showed that students had limited awareness of the national infection prevention and control best practice procedures. The primary influential factors for non-sterile gloves use behaviour were personal protection, the type of care interventions required and the observations of peers and role models.

Discussion

The study found limited awareness on the importance of infection prevention and control precautions, including the correct procedure for donning, and doffing of personal protection equipment, along with a lack of confidence to challenge non-compliance.

Background

The implementation of infection prevention control (IPC) practices is fundamental in preventing the transmission of infection and providing safe and effective care (Department of Health and Social Care, 2022). Standard infection control precautions should be adopted and used consistently by everyone in all healthcare settings, regardless of a patient’s infection status to ensure harm free care (NHS, England, 2022a). Prior to undertaking any procedure, healthcare staff should assess the likelihood of exposure to blood/bodily fluids, non-intact skin, or mucous membranes, to determine the personal protective equipment (PPE) required to reduce any risks associated with the procedure. This is particularly significant as Gallagher (2022) suggests gloves use during the COVID pandemic became common practice instead of being a risk assessed practice, raising the question do healthcare professionals know when non-sterile gloves are really required, especially when the evidence base can be ambiguous. This is emphasised by Royal College of Nursing (RCN) (2017) who state that gloves should not be used as substitute for hand decontamination, nor should they be worn routinely as a ‘just in case’ measure. More importantly, Loveday et al. (2014) question whether healthcare professionals know the associated risk of transmitting infection when gloves are applied too early and removed too late, and the consequence of omitting hand decontamination following their removal. IPC is also fundamental to nursing education and clinical practice (NMC, 2018a), alongside awareness of antimicrobial stewardship (AMS) and the global threat of antimicrobial resistance. It is therefore important to ensure that student nurses obtain the knowledge and skills to promote health and prevent the spread of infection (NMC, 2018b).

Using the TDF to formulate qualitative interview questions, the aim of this study was to determine the factors that influence student nurse non-sterile glove use behaviour.

Methods

Setting

This study was conducted in a higher education institution in England in 2022 involving second year pre-registration student nurses, who had already been exposed to IPC education in the form of theory, skills, and simulation within the university and through implementation in clinical practice whilst in placement settings.

Design

A qualitative design was chosen to ascertain an expressive truth of an all-inclusive viewpoint that encourages the fundamentals of human behaviour (Greenhalgh, 2010). A case study approach was used to explore, and describe the experiences related to the factors responsible for student nurses’ use of non-sterile glove, and to summarise the behaviour that surrounds their decision-making.

Data collection

To understand student nurse behaviour, a theoretical domain framework (TDF) of behaviour change (Atkins et al., 2017) was chosen to frame the study. This integrative framework of 33 psychological theories of behaviour or behaviour change has been used as a foundation in a range of studies (Ataiyero et al., 2023; Greene and Wilson, 2022; Jones et al., 2018; Smith et al., 2019) investigating behaviour within healthcare settings and has been chosen as the most appropriate method to explore the research question, populate the interview schedule (as shown in Table 1), and identify where gaps in knowledge can be targeted to improve clinical practice.

Table 1.

Interview Schedule using the TDF Constructs.

TDF Constructs	Definitions	Guide Questions
Knowledge	An awareness of the existence of something	• Describe your understanding of the use of non-sterile gloves • Are you aware of any guidelines on the use of non-sterile gloves
Skills	An ability or proficiency acquired through practice	• Can you describe how to don (apply) non-sterile gloves? • Can you describe how to doff (remove) non-sterile gloves? • Do you change your gloves in between tasks? • Do you decontaminate hands following removal of gloves?
Social/professional role and identity	A coherent set of behaviours and personal qualities	• Do you adhere to any guidelines on the use of non-sterile gloves? • Do you think guidelines should determine the use of non-sterile gloves?
Beliefs about capabilities	Acceptance of the truth, reality or validity about an ability	• How difficult or easy do you find wearing/removing gloves? • Can you describe any previous barriers or difficulties you have encountered when donning/removing gloves? • Do you think you can improve on your use of gloves despite these barriers?
Beliefs about consequence	Acceptance of the truth, reality or validity about outcomes of behaviour	• When should you wear non-sterile gloves? • Do you wear gloves regardless of the task/intervention? • Are you aware of any associated risks with prolonged glove use? • What is the impact of inappropriate use of gloves?
Motivation and goals	Mental representations of outcomes/achievements	• Is there any need for you to improve your compliance with guidelines on appropriate glove use? • Are there any incentives for using gloves appropriately (e.g. praise/mention)? • Do the guidelines conflict with other guidelines?
Memory, attention and decision-making processes	The ability to retain information and attention to detail	• Will you remember when to don/doff gloves when wearing/removing PPE? • Do you often remember or are you likely to forget to wear/remove gloves as appropriate? • What factors influence your decision to wear gloves (e.g. time, type of care, and type of patient) • Are there clear visual aids to inform you of the appropriate use of non-sterile gloves?
Environmental context and resources	Situation or environment that discourages or encourages skills	• Are there any physical, resource and/or environmental factors that influence the use of gloves? • What type of non-sterile gloves is available to use? • What type of non-sterile glove would you wear when handling blood and bodily fluids?
Social influences	Interpersonal process that can cause change in behaviour	• Do you feel influenced by observing other practitioners' (and students') glove use? • Do you feel empowered to challenge poor use of gloves? • Can you describe how your colleagues' use of gloves influences your own glove use?
Emotion	Affect and reaction	• Do you wear gloves regardless to avoid confrontation?
Behavioural regulation	Managing or changing observed or measured action	• Do you feel non-sterile gloves are overused? • Are you aware of the environmental impact of plastic waste? • How can we improve and sustain appropriate use of non-sterile gloves?

Participants

The study was conducted using second year nursing students with an aim to have representation of students from across three disciplines (adult, child, and mental health). A purposive sampling method (Cohen et al., 2011) was chosen to obtain the data. The researcher recruited participants by asking course leads for all nursing disciplines, to share the participation information leaflet, detailing the aim and objectives of the research and their rights to participate via the specified cohort university communication platforms. The researcher received a total of five respondents who wished to participate in the research (three adult nursing and two child nursing students).

Procedure

Interviews were conducted post COVID pandemic virtually via Microsoft Teams which provided transcript and audio recordings collectively. Both written and verbal (audio recorded) consents were obtained prior to commencement of the interviews.

Ethical approval

Permissions for this study were sought from and granted by the university research ethics committee.

Analysis

Interviews were transcribed using the NVivo qualitative data analysis software (QSR International, 2020), followed by a descriptive thematic analysis using the Braun and Clarke (2006) six stage process to explore the participants responses and formulate themes and sub-themes. Coding was undertaken by reviewing the transcript of each participant to determine the relevance of their response with the definition and construct of the TDF domains. The coding revealed there were four prominent TDF domains related to the themes and subsequently noted in sub-themes (as shown in Table 2).

Table 2.

Themes Derived From the Prominent TDF Constructs.

TDF Construct	Themes	Sub-themes
Knowledge	Knowledge of guidelines to support best practice	Awareness of local and national policy
		Interpretation of national guidance
Skills	Gloving practices	Influential factors surrounding the need to wear gloves
		Order of application and removal of gloves
		Adopting behaviour of role models
Beliefs about consequence	Impact of overuse of gloves	Dermatitis and cross-infection
		Lack of risk assessment before patient contact
Environmental context and resources	Improvements and sustainability	Environmental impact
		Educational intervention

Results

Five semi-structured interviews were conducted, the coding exercise revealed four prominent TDF domains related to the themes and subsequently noted nine sub-themes. (1) Guidelines (sub-themes: awareness of local and national policy, and interpretation of national guidance), (2) Gloving practice (sub-themes: Influential Factors surrounding the need to wear gloves, order of application and removal of gloves and adopting behaviour of role models), (3) Impact of overuse of gloves (sub-themes: dermatitis, and cross-infection, and lack of risk assessment before patient contact), and (4) Improvements and sustainability (sub-theme: environmental impact and educational intervention). These are illustrated in Table 2: and discussed below. Examples of participant responses have been included in the theme discussion below and to maintain confidentiality participants have been referred to as P1, P2, P3, P4, and P5.

Theme 1: Knowledge of guidelines to support best practice

Awareness of local and national policy

Participants displayed a lack of knowledge of local and national policy, and they were unaware if there was conflict between guidelines, although they were aware that guidance was changeable through peer conversation and attendance at different trusts.

I can't say that I definitely do because I don't know what the proper guidelines are (P4).

Every trust is different, and every policy is different everywhere you go (P5).

Interpretation of national guidance

Participants were asked if guidelines should determine the use of non-sterile gloves. The responses were mixed, and reference was made to the COVID pandemic and how the guidelines seemed changeable around the use of PPE in general, although they could not recall if this was related specifically to glove use. Having autonomy in the decision-making on whether to wear non-sterile gloves was noted by P1 rather than referring to guidance they felt this should be a natural decision. This was echoed by P2 who preferred to wear gloves for specific tasks such as taking vital sign observations and administering medication.

I think it’s difficult because no set of guidelines encompasses every single situation that you're going to come across, so they will always be open for interpretation (P4).

Theme 2: Gloving practices

Influential factors surrounding the need to wear gloves

The understanding around when to wear non-sterile gloves was varied. Participants believed that the need for wearing gloves was due to the risk of infection such as when dealing with blood and bodily fluids, undertaking intimate tasks, and for any patient contact. Participants expressed that they would change their non-sterile gloves in between patients but not necessarily between tasks on the same patient, although it was noted by P3 that if a patient required the toilet, they would change their gloves before administering medication to the same patient. All participants stated that they would wear gloves regardless of the task or intervention, for self-protection, and the risk of infection. P2 added that hands are dirty and wouldn’t want anyone touching an unwell child without gloves, indicating potential lack of awareness of the effectiveness of hand decontamination between patients.

To protect yourself, cross contamination and during COVID it has become the norm (P1).

In any situation where you are potentially going to soil your hands, coming to any contact with any bodily fluids and certain cleaning products that could damage your skin (P4).

Order of application and removal of gloves

Participants were asked to describe the order of application and removal of gloves. Four out of five participants explained that they would apply their apron before donning a pair of non-sterile gloves, whereas P1 stated that they would apply their non-sterile gloves first. Most participants expressed that the order in which they would remove their PPE would be apron first, followed by non-sterile gloves. Participants expressed that they would always undertake hand decontamination following removal of non-sterile gloves, either by using liquid soap or alcohol hand gel, which seemed to depend on personal choice and the task they had just undertaken.

Take off my apron first, then I’ll take off my gloves (P1).

Adopting behaviour of role models

Participants were asked if they would challenge others about their use of non-sterile gloves, and the responses showed that four out of five participants would find it difficult to challenge others about their practices and did not feel empowered to do so. Two of the participants expressed that they would approach a fellow student if they saw inappropriate use of non-sterile gloves, by having a general conversation with them, to determine why they adopted the practices rather than using a challenging approach. Participants were probed into whether the status of the person would be a factor on their view on challenging others; however, the response remained the same. They felt that it was safer to wear non-sterile gloves and expressed that they would wear them to avoid confrontation, due to fear of ‘not fitting in’ during their placement. It was noted that as participants were unable to recall the guidance, they didn’t feel confident in what the best practice was, so found it easier to follow others and expected their supervisors to have the superior knowledge and adopt best practice and took their lead.

No, I wouldn’t be able to challenge (P1).

I would take their lead because they should be using best practice. They’ve got a student following them around. You should be able to trust that other members of staff are using best practice in these areas and setting it because I that’s what I’m there for. So, I watch what they do – monkey see monkey do (P3).

Theme 3: Impact of overuse of gloves

Dermatitis and cross-infection

Participants were asked to describe any risk factors associated with prolonged gloves use. Responses included exacerbating underlying skin conditions such as eczema, hands feeling hot and sweaty, latex allergies, and one participant mentioned dermatitis. P3 particularly mentioned that hands that are hot and sweaty would create a great environment for infection to spread due to the moisture created by the heat within the non-sterile gloves.

Contact dermatitis and latex allergies (P2).

P2 acknowledged that cross contamination could occur, and that by wearing non-sterile gloves provided a false sense of security, although they would still wear them, as hands could as easily transmit infection if not washed properly. Responses suggested that the participants showed a lack of awareness of appropriate use of non-sterile gloves, the effectiveness of hand decontamination, and lacked understanding of the potential risk of transmitting infection to patients.

No, I don’t think they’re overused (P1).

It’s one of those things that’s proven, if you don’t wear gloves, you rely on everybody washing the hands extremely well when they’ve been handling bodily fluids. You know, I don’t know. Can you trust that? I don’t know (P2).

Lack of risk assessment before patient contact

Participants were asked if they felt non-sterile gloves were overused, three out of five participants all answered yes, with the two child nursing participants expressing that they did not feel that gloves were overused and were necessary when looking after children who are already unwell, and that they wore non-sterile gloves to protect themselves from child illnesses. P2 expressed the number of cases of diarrhoea and vomiting seen amongst children is high and stated that there is a science behind wearing gloves to prevent infection, as historically people have died from infection.

Participants described the factors that influenced their decision to wear gloves before patient contact, three out of five participants explained that this would depend on the type of care being provided to the patient, and that non-sterile gloves provide a barrier between yourself and the patient.

I mean, if patients are in hospital, they're unwell acutely. The last thing they need is for you to pass something else on to them, you know, some children are vulnerable children. At the end of the day, you've got to wear them. Haven't you, to protect your patients and yourself (P2).

Theme 4: Improvements and sustainability

Environmental impact

Participants were asked about the environmental impact of plastic waste. Three out of five participants expressed that everything in healthcare is mainly disposable, and that the waste cost to the national health service must be phenomenal.

I can’t imagine the impact that it has on our environment, the amount of amount of usage that we have in PPE, and I mean that must have gone up colossally (P3).

P2 expressed they were conscious of making ethical choices at home, only buying what is needed and trying to buy organic brands, as a way of offsetting their carbon footprint, only noting the impact in their day-to-day life rather than in a healthcare setting. P4 explained that they were aware of the impact of plastic waste, however, noted they were not very good at recycling. The views voiced by P1 were limited, and they admitted they knew little about the impact of plastic waste and would like to know more about it. P5 explained that as non-sterile gloves are made from plastic, they are harming the environment.

Educational intervention

Participants were asked about how to improve and sustain the appropriate use of non-sterile gloves and provide examples of ideas. P1 and P2 were unable to provide a positive response and felt they had no idea on how this could be done. P4 and P5 expressed there is a need for education around when and why non-sterile gloves should be worn. P3, P4, and P5 suggested that visual aids be used to promote appropriate use of non-sterile gloves and recalled the hand washing technique posters that are visible in healthcare settings.

If we have more visual guidance, perhaps like the handwashing guidance then it would just come naturally to everybody (P3).

Discussion

The use of a theoretical framework explored the influential behaviours of student nurses non-sterile glove use which led to the identification of the most frequently coded constructs of the TDF.

Knowledge (Construct definition: An awareness of the existence of something)

This study confirmed that the student nurse’s knowledge and awareness of local and national guidelines was limited and open to interpretation. Studies undertaken by Mitchell et al. (2014) and Al-Rawajfah and Tubaishat (2015) identified that student nurses’ knowledge of IPC practices was inadequate, and they found that whilst students had some knowledge around IPC standard principles, they lacked insight into the transmission-based precautions (TBPs). According to the RCN (2021), gloves should be worn as part of TBPs if required determined by local policies and through risk assessment.

Skills (Construct definition: An ability or proficiency acquired through practice)

Participants’ knowledge and understanding around when to wear, change, and how to remove PPE was insufficient, increasing the risk of self-contamination of pathogens. A study undertaken by Tomas et al. (2015) identified that PPE becomes heavily contaminated during patient care activity; therefore, the way in which PPE is removed is of paramount importance to prevent self-contamination and the spread of nosocomial infections. Participants lacked insight into the correct order for removing their PPE, with the majority removing their apron first followed by their gloves. A study undertaken by Landelle et al. (2014) found that 24% of healthcare workers had Clostridium difficile spore contamination on their hands following removal of their gloves, and through simulation, they were able to provide visual feedback to participants using fluorescent lotion as a method of education and increasing awareness of the importance of removal technique. Furthermore, a study by Loveday et al. (2014) found that the inappropriate way in which gloves are used breached the principles of the ‘five moments for hand hygiene’ framework developed by WHO (2009), leading to the potential contribution of cross contamination after patient contact and after contact with blood and bodily fluids. There has been a concentrated effort over the years to promote effective hand hygiene as a measure to protect patients from infection; yet as noted by Wilson et al. (2017a), the wearing of non-sterile gloves has become embedded into everyday clinical practice, without the lack of awareness for potential cross-infection when worn and substituted for hand hygiene.

Beliefs about consequence (Construct definition: Acceptance of the truth, reality, or validity about outcomes of behaviour)

The students’ understanding of when gloves should be worn was weak. They were unaware of the consequence of not changing gloves between tasks on the same patient, as confirmed by Lee (2013) who identified obvious overuse of gloves amongst student nurses, for whom wore gloves for any procedure, despite gloves not being indicated, with little evidence to determine if risk assessment was considered. Similarly, the findings in this study verify those described by Wilson et al. (2017a) that student nurses did not utilise risk assessment to determine the use of gloves and chose to wear them routinely. More recent studies undertaken by Baloh et al. (2019) determined the over reliance of non-sterile gloves as a means of protecting oneself instead of as a way of preventing transmission of infection.

It was evident that the participants feared encountering any task they distinguished to be unclean. This emotion of fear noted by Wilson, Bak, and Loveday (2017b) stimulates the healthcare professionals to wear gloves for personal protection, with the lack of awareness of the risk of contamination to the gloves and subsequently the transmission of infection to their patients.

The interpersonal processes as to why the students wore gloves indicated that students observed differing practices and assumed the behaviour of their role models, believing they would have the greater knowledge leading to the reluctance to challenge peer practice.

Observations made by Wilson, Bak, and Loveday (2017b), suggest a strong influence of peer pressure in the use on non-sterile gloves, due to perceived cultural and social norms around personal choice, thus impacting the inability to challenge the behaviour of others.

Environmental context and resources (Construct definition: Situation or environment that discourages or encourages skills)

The mixed response provided by participants suggests limited awareness of how of non-sterile gloves behaviour can impact the environment when used inappropriately. The economic and environmental impact of non-sterile gloves has previously been noted by Wilson, Bak, and Loveday (2017b) who found that approx. 60% of non-sterile gloves are used unnecessarily, as they are worn when there is no contact with blood or bodily fluids or when there is no potential risk of infection.

When the participants were asked to about how to improve and sustain the appropriate use of non-sterile gloves, some of them expressed further education was needed, and made suggestions about having visual aids to advise of when to wear gloves, rather than the PPE posters currently displayed advising on the PPE requirements when caring for patients with potential coronavirus infection. A positive educational impact was observed in the initiative undertaken by Great Ormond Street Hospital (2019) in their ‘gloves off campaign’, which provided education and training on when gloves should be worn. They used a risk assessment matrix to determine their use when preparing intravenous medication. The campaign produced better patient outcomes by reducing skin-related problems amongst staff, reducing central venous line blood stream infections, and significantly saw the large reduction in the use of gloves throughout the hospital, saving 21 tonnes of plastic and £90,000. More recently work is underway by NHS England (2022b) they have announced targets to reach net zero CO2 emissions by 2040. Although unaware of the full impact of the NHS emissions, sustainable plans to reduce the environmental impact of PPE are proceeding.

Strengths

This study is underpinned by a TDF. It is recommended that first time users of the TDF work in collaboration with someone to discuss coding and challenges in the initial stages of the process, and that the data should be coded separately using an agreed methodical way, to increase the reliability of the coding, and to iron out any disagreements (Atkins et al., 2017). Support during this process was received by the authors’ supervisor.

Following a scoping exercise and literature review, this study is believed to be the first to solely explore non-sterile glove use behaviour amongst second year student nurses, who had already received theory and practical education of standards precautions within the university.

Limitations

The participants had previously been taught in their first year of the course by the researcher and were aware of their previous IPC specialist role and passion in the subject. Despite the researcher not providing any current teaching or academic mentoring to this cohort in the last 12 months, this raises potential social desirability bias, which can occur when using interviews to seek honest responses, to which the participants may provide a fake response to conform to socially acceptable values and avoid disapproval (Bowling and Ebrahim, 2010).

Due to the limited number of participants in this study, views from each of the three student nursing disciplines could not be obtained, therefore limiting the insight into the knowledge, understanding, and practices of the student nurse population.

Recommendations

Further research should be considered encompassing a broader representation of the student nurse population, capturing their knowledge and implementation of IPC practices. Pre-registration nursing curriculum theory needs to incorporate the standards infection control precautions, as set out in the National infection prevention, and control manual for England (NHS England, 2022a), ensuring key messages around inappropriate use of PPE, the rationale behind the risk-based approach to its use, and the correct procedure for donning and doffing to reinforce best practice.

Consideration in promoting the annual national RCN campaign ‘gloves awareness week’ in universities to increase student nurse knowledge in the efficacy of hand hygiene, highlighting the potential risk of cross-infection, occupational acquired dermatitis, and the environmental impact of their use.

Finally, provide student nurses with the skills in managing conflicting situations, empower them to be positive role models in practice, and build their resilience to challenge non-compliance.

ORCID iD

Jennifer Bate https://orcid.org/0009-0001-5854-3564