Healthcare workers’ compliance with
glove use and the effect of glove use
on hand hygiene compliance
Flores A1, Pevalin DJ2
1. Senior Nurse Infection Control, Infection Control Department, Mayday Healthcare NHS Trust, Mayday University
Hospital, 530 London Road, Croydon CR7 7YE
2.
Double-blind peer reviewed paper
Lecturer, Department of Health and Human Sciences, University of Essex, Wivenhoe Park, Colchester CO4 3SQ
Accepted for publication: 23 October 2006
Key words: Glove use, compliance, hand hygiene, observation
Abstract
espite considerable evidence that appropriate
D hand hygiene is the leading measure to prevent
healthcare-associated infection, compliance with
infection control recommendations remains low among
healthcare workers. Literature regarding the role that
concomitant glove use has on compliance with hand
hygiene is limited and conflicting. The aims of this study
were to examine healthcare workers’ glove use by obser-
vation and to evaluate the effect that glove use has on
compliance with hand hygiene. Non-participant observa-
tion was carried out on 12 randomly-selected wards in
two district general hospitals. Although the overall com-
pliance rate for glove use was high at 92%, gloves were
also overused. The proportion of glove overuse was 42%.
Overall hand hygiene compliance was 64%. However,
hand hygiene compliance was significantly worse follow-
ing glove overuse, demonstrating that inappropriate
glove use may be a component of poor hand hygiene
compliance. Recommendations arising from these
results are that, in order to improve adherence to hand
hygiene recommendations, multi-faceted interventions
should be aimed at changing healthcare workers’ glove
use behaviour.
Introduction
Several studies have provided evidence that wearing gloves can
help reduce transmission of pathogens in healthcare settings (Boyce
and Pittet, 2002).
Although gloves offer protection, they do not provide complete
protection against hand contamination, therefore hands must be
decontaminated after gloves have been removed (ICNA, 2002a).
The overall trend is that compliance with infection control precau-
tions such as glove use and hand hygiene among healthcare
workers is poor (Pittet and Boyce, 2001; Kim et al, 2003).
The effect of glove use on hand hygiene behaviour
Appropriate hand hygiene is considered to be the leading measure
to reduce the transmission of healthcare-associated infection (Pittet
and Boyce, 2001).
Despite evidence for the efficacy of hand hygiene being available
since the findings of Semmelweis (1941) in 1861, multiple studies
have demonstrated a low compliance of healthcare workers with
hand hygiene with average baseline rates of 40%.
The methods used for defining adherence and those used for con-
ducting observations vary considerably among studies, and reports
do not provide detailed information concerning the methods and
criteria used (Pittet and Boyce, 2001).
Nevertheless, a number of factors have been identified as con-
tributing to the poor level of compliance, including lack of
education, high workload, lack of a role model from key staff and
lack of administrative leadership (Pittet and Boyce, 2001).
Despite hand hygiene compliance being extensively studied, the
impact of wearing gloves on adherence to hand hygiene policies
has not been definitely established, because published studies have
yielded contradictory results (Boyce and Pittet, 2002). A few stud-
ies have found that healthcare workers are less likely to wash their
 hands after wearing gloves (Pittet et al, 2000a).
For example, in their observational study of hand hygiene com-
pliance, glove use was shown to diminish compliance with
handwashing protocols by as much as 25% (Whitby and McLaws,
2004).
Wearing of gloves might represent a barrier for compliance with
hand hygiene; indeed, healthcare workers might wear gloves with
the primary intention to protect themselves and not the patient,
and may be unaware that contamination on gloves occurs just as
on hands (Pittet et al, 2000a).
Other studies have found that personnel who wore gloves are
more likely to wash their hands after patient care. For example, Kim
et al (2003) carried out an observational study in intensive care
units in the US. They found that glove use increased compliance
with hand decontamination, but that workers did not appropriate-
ly 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
still unclear. Previous research has been conflicting, and prior stud-
ies have addressed this issue within individual specialities.
Therefore, it is necessary to examine this issue further, in order to
establish whether frequent glove use should be encouraged or dis-
couraged. 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 hand hygiene.
This information can potentially be used to inform interventions
to improve compliance with glove use and hand hygiene.
Methods
This study took place in a large acute hospital trust serving south-
west London and Surrey. the trust consists of two district general
hospitals, both offering an extensive range of acute services. Every
bay (four to six beds) and single room has a sink with liquid soap
and paper towels.
At the time of the study, alcohol gel/rub was available outside
every single room and in every bay. The data collection took place
throughout February to April 2005.
The strategy of overt, structured, non-participant observation was
selected. The observation methodology was adapted from existing
methods (Kim et al, 2003; Pittet et al, 2000a; Girou et al, 2004).
Data collected during each observation period included:

Total number of potential glove use opportunities

Actual number of glove use episodes

Total number of potential hand hygiene opportunities

The actual number of hand hygiene episodes

Time of observation

Task/activity

Professional category of staff

Ward/directorate.
To assess compliance, the same observer (an infection control
nurse specialist) observed all relevant staff-patient contacts. A sec-
ond observer (also an infection control nurse) co-observed 10% of
the contacts for validation purposes.
Inter-observer testing took place during the observations on the
maternity wards. The Cohen’s kappa coefficients for the observa-
Double-blind peer reviewed paper
tions ranged between 0.81 and 1.0. Landis and Koch (1977)
suggest that kappa over 0.8 is almost perfect agreement.
Sampling
Clinical care is managed by six different directorates in the trust –
critical care, emergency and medical services, surgical services, chil-
dren’s services, renal and women’s health. In order to obtain a
balanced distribution throughout the directorates, a random sample
of wards, stratified by directorate, was chosen using a random
number table.
Only wards in which activity could be unobtrusively viewed were
included in the sample, for example, ‘nightingale’ wards or wards
with four- to six-bedded bays.
16 British Journal of Infection Control DECEMBER 2006 VOL. 7 NO. 6
Wards were included in the study only after verbal consent from
the nurse managers and/or modern matrons and ward managers for
all selected wards. None of the wards refused participation.
Definitions
Terms relevant to hand hygiene are defined below, as described in
the literature (Pittet and Boyce, 2001; Kim et al, 2003; Larson,
1995):

‘Handwashing’ (not including surgical hand scrub) refers to
the action of washing hands with an unmedicated detergent
and water to remove dirt and transient flora, in order to prevent
cross-transmission

‘Hand disinfection’ refers to any action in which an antiseptic
solution is used to clean hands, either medicated soap or alco-
hol gel/rub

‘Hand hygiene’ refers to decontamination of hands, either
washing or disinfection

‘Hand hygiene opportunities’ are defined as all situations in
which hand hygiene is indicated, according to published guide-
lines (ICNA, 2002a; Pratt et al, 2001). These include before
and after significant physical contact with a patient, and after
removal of gloves

‘Glove use opportunities’ are defined as all situations in which
glove use is indicated, according to published guidelines (Pratt
et al, 2001; ICNA, 2002b). This includes contact with body
fluids, mucous membranes and non-intact skin

‘Hand hygiene compliance’ is measured as the number of times
hand hygiene occurs divided by the total number of hand
hygiene opportunities. This includes hand hygiene following
glove non-use, appropriate glove use, and inappropriate glove
use

‘Glove use compliance’ is measured as the number of
times glove use occurs divided by the total number of glove
use opportunities

‘Glove overuse’ is defined as the use of gloves when
not required.
Observation
All doctors, nurses and healthcare assistants were observed for two
30-minute observation periods on each selected ward. Other
groups of staff and people in the ward who were not considered
staff, such as the patients and visitors, were excluded from the
study.
Time sampling is often necessary to ensure that if certain indi-
viduals are observed on more than one occasion, they are not
always observed at the same time of day (Bryman, 2004).
However, during pilot work, it was found that most ward activity
took place during the early shifts.
Therefore, in order to ensure glove use behaviour was observed,
all the observations were carried during the morning shifts,
between 9am to 12pm. Wherever possible, different personnel
were observed in each period.
Ethical issues
Staff members were informed that they were being observed as part
of a study on glove use via a poster that was displayed in the unit
up to a week before the observations took place. Data collection
was anonymous. Permission to carry out the study was sought
from relevant managers. Direct patient care was not observed when
staff used curtains to maintain patient privacy and dignity. A
patient information sheet was given to all patients in the observa-
tion area. Approval for this study was obtained from both the trust
and local research ethics committee.
Results
Some 12 hours of observation were carried out – one hour per
ward. A total of 164 episodes of patient care were observed, con-
sisting of a variety of routine clinical activities such as manipulation
 Table 1. Glove use compliance, glove overuse and hand hygiene compliance by directorate

Glove use compliance Glove overuse Hand hygiene compliance

Directorate Na % Nb % Nc %

Surgical 8/10 80 7/15 47 13/25 52

Children’s 9/11 81 6/17 36 17/24 71

Renal 31/31 100 3/6 50 22/35 63

Critical care 11/13 84 7/16 43 18/27 67

Medical 9/9 100 8/16 50 10/14 71

Women’s health 4/4 100 1/6 16 9/13 69

x2 (df) 8.6(5) p=0.127 2.6(5) p=0.758 3.6(5) p=0.608

Overall 72/78 92 32/76 42 89/138 64

a
Notes: – Number of glove use occasions/Number of glove use opportunities
b
– Number of glove overuse occasions/Number of non-glove use opportunities
c
– Number of hand hygiene occasions/Number of hand hygiene opportunities

Table 2. Glove use compliance, glove overuse and hand hygiene compliance by profession

Glove use compliance Glove overuse Hand hygiene compliance

Profession Na % Nb % Nc %

Doctors 5/7 71 6/11 55 7/14 50

Double-blind peer reviewed paper

Nurses 46/50 92 13/46 29 61/88 69

Healthcare 21/21 100 13/19 69 21/36 58

assistants

x2 (df) 6.1(2) p=0.048 9.7(2) p=0.008 3.1(2) p=0.214

Overall 72/78 92 32/76 42 89/138 64

a
Notes: – Number of glove use occasions/Number of glove use opportunities
b
– Number of glove overuse occasions/Number of non-glove use opportunities
c
– Number of hand hygiene occasions/Number of hand hygiene opportunities

Table 3. Hand hygiene compliance following glove
non-use, use or overuse
Na %
No glove use 40/55 73
Glove use 43/65 66
Glove overuse 6/18 33
x2 (df) 9.3(2) p=0.009
Overall 89/138 64
a The proportion of glove overuse observed is consistent with the
Notes: – Number of hand hygiene occasions/Number of types of
glove use/non-use occasions
of intravenous lines and cardiovascular observations.
Glove use compliance, glove overuse and hand hygiene compli-
ance by directorate is shown in Table I, and by profession in Table
2. These two tables combine three cross-tabulations each with the
X2 and p-value reported for each cross-tabulation.
Glove use
Overall glove use compliance was 92%. There was no difference
in glove use compliance by directorate. The compliance to glove
use for doctors was found to be significantly lower than that of
nurses and healthcare assistants.
However, it is worth pointing out that these results must be
viewed with some caution because of the small numbers involved
(Hinton et al, 2004).
Inappropriate glove use
During the observation period, gloves should have been worn for
48% of the patient contacts, e.g. contact with body fluids, non-
intact skin and mucous membranes. However, gloves were actually
worn during 64% of patient contacts. The proportion of glove
overuse was 42%, defined as those who wore gloves when not
required but not including those in the sample who wore gloves
appropriately.
Gloves were worn inappropriately for tasks such as collecting
equipment, answering the phone, talking to patients, cardiovascu-
lar observations and writing notes.
It was also observed that gloves were worn for more than one
task, for example, wearing the same pair of gloves for making a bed
and manipulation of an intravenous line.
Microbial transmission could have occurred in all patient con-
tacts following the continued use of gloves without removal.
There was no difference in glove overuse by directorate but by pro-
fession, nurses overused gloves significantly less than doctors or
healthcare assistants.
Double-blind peer reviewed paper
Hand hygiene compliance
Overall hand hygiene compliance was 64%. There was no signifi-
cant difference in hand hygiene compliance by directorate or
profession.
Effect of glove use on hand hygiene compliance
Hand hygiene compliance is composed of three elements: hand
hygiene following glove non-use; hand hygiene following appro-
priate glove use; and hand hygiene following inappropriate glove
use (glove overuse).
The hand hygiene compliance rates by these three elements are
presented in Table 3. Hand hygiene compliance is significantly
worse following inappropriate glove use.
18 British Journal of Infection Control DECEMBER 2006 VOL. 7 NO. 6
Discussion
Glove use compliance
The overall glove use compliance rate (92%), and the fact that the
compliance rate for glove use was significantly higher for nurses is
similar to that found in other studies. For example, Wilkinson
observed glove use compliance rates, which averaged 80% to 94%
overall, with the nurses glove compliance rate (91.4%) being high-
er than the doctors rate (73.2%), a finding that is consistent with
the present study (Wilkinson, 1992).
The findings of this study indicate that although the overall com-
pliance rate for glove use was high at 92%, gloves were also
overused. Gloves were worn inappropriately for tasks that did not
necessitate the use of gloves, and healthcare workers do not always
remove gloves and decontaminate hands between different patients
and tasks.
studies by Girou et al (2004) and Thompson et al (1997) who
found that 20% of all patient contacts were performed with gloves
that had not been removed after previous care and that gloves were
appropriately changed in only 16% of instances.
The aim of wearing gloves is to reduce the risks of cross-infection
from staff to patients and vice versa, and to reduce transient cont-
amination of the hands of personnel by flora that can be
transmitted from one patient to another (ICNA, 2002b).
A key recommendation is that gloves must be worn only once,
for one aspect of care and one patient (Pratt et al, 2001). Thus, if
gloves are not removed and hands decontaminated after use, then
the risks of cross-infection are increased.
Overuse of gloves may be due to a belief that glove use obviates
the need for hand hygiene (Pittet, 2001). Healthcare workers might
wear gloves with the primary intention to protect themselves and
not the patient, and may be unaware that contamination on gloves
occurs just as on hands (Pittet et al, 2000b).
Hand hygiene compliance
The overall hand hygiene compliance rate was 64%. There was no
significant difference in hand hygiene compliance by directorate or
profession.
This rate is higher than the average baseline rates for hand
hygiene compliance of 40%, although the methods used for defin-
ing adherence and those used for conducting observations vary
considerably among studies (Pittet and Boyce, 2001).
Effect of glove use on hand hygiene behaviour
Hand hygiene compliance was significantly worse following inap-
propriate glove use. Failure to remove gloves after patient contact
or between ‘dirty’ and ‘clean’ body-site care on the same patient
must be regarded as non-adherence to hand hygiene recommenda-
tions (Pittet and Boyce, 2001).
Disposable gloves are designated as single-use medical devices,
and are not intended to be reprocessed and used on another patient
or for another procedure on the same patient (Medical Devices
Agency, 2000).
These results are important because they demonstrate that inap-
propriate glove use may be a component of poor hand hygiene
compliance.
This finding supports the results of other studies. For example,
Girou et al (2004) found that hand hygiene was not undertaken
due to improper gloving in 64.4% of instances. Failure to remove
contaminated gloves was a major component in the poor compli-
ance with hand hygiene and carried a high risk of microbial
transmission.
In their observational study of hand hygiene compliance, Whitby
and McLaws (2004) found that glove use diminished compliance
with handwashing protocols by as much as 25%.
In the US the use of gloves has been encouraged as a means of
preventing cross-infection, especially for preventing the spread of
multi-resistant bacteria (Garner, 1996).
 There is some evidence that universal gloving (i.e. wearing
gloves to care for all patients) has helped control outbreaks of van-
comycin-resistant enterococcus (VRE) and meticillin-resistant
Staphylococcus aureus (MRSA) (Hartstein et al, 1995).
However, given that inappropriate glove use may affect hand
hygiene compliance, the results of this study do not support the
routine encouragement of universal gloving. The practice of rou-
tinely wearing gloves for all care of patients positive for a
multi-resistant organism can be questioned. Rather, the use of
gloves should be based on a risk assessment of the level of antici-
pated contact with the patient and their environment.
Thus, the recommendations arising from this study are that
healthcare worker glove use behaviour must be improved. This, in
turn, could help improve adherence to hand hygiene recommen-
dations.
The results of this study do not support the view that if health-
care workers are concerned about the personal risk from
transmission of pathogens, they are more likely to wear gloves and
wash their hands afterwards (Lankford et al, 2003). They may
assume (incorrectly) that the use of gloves obviates the need for
hand hygiene (Farr, 2000).
There are some limitations to this study that need to be borne in
mind. The small sample sizes may have resulted in the study lack-
ing power to detect significant differences between groups (Hinton
et al, 2004).
Also, the presence of an observer may have affected the behav-
iour of staff – the ‘reactive effect’ (Bryman, 2004). This may have
resulted in an underestimation of inappropriate practices and hand
hygiene may have occurred more frequently because participants
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British Journal of Infection Control 19