A new document from the Royal College of Nursing details the importance of wearing gloves in a healthcare environment. Diane Romano-Woodward examines what the guidance covers.
"My trust's policy says I have to wear gloves when taking blood pressure. Is this right?" This question was asked by one of the audience members at the launch of Tools of the trade, the Royal College of Nursing's (RCN) new guidance on glove use and the prevention of contact dermatitis. The guidance is aimed at all healthcare workers and safety representatives working in the field of healthcare. It is a bold attempt by the RCN to integrate advice on the prevention of dermatitis, including information on hand hygiene, glove choice as personal protective equipment and as an infection control measure, and the dangers of overuse. It was designed to be easily understood and practical for members who are experiencing problems with glove usage, or with dermatitis. It will also be useful for policymakers in any type of work where examination gloves are used.
The contributors included specialist nurse practitioners in the fields of infection control and occupational health. There was input from the Health and Safety Executive (HSE) and the RCN's employee relations team, as well as the RCN Safety Representative's network, the RCN Infection Prevention and Control network and the NHS supply chain. To produce a consensus document that all interested parties could agree to would have been no mean feat.
There are two formats to the guidance: a comprehensive document of approximately 40 pages and a short guide of eight pages. These are available as hard copies and as downloads from the RCN website.
Contact dermatitis is the main work-related skin condition affecting the hands of healthcare workers, and the guidance covers glove use, infection prevention and control practice, and the importance of considering glove use from a holistic perspective. The RCN places importance on prevention because of the realisation that dermatitis affects not only the individual with the condition, but also patient care, with the risk of transmission of infections and reduced staff numbers if individuals are required to remove themselves from the workplace to allow healing to take place.
The guidance document begins with a glossary of terminology. Medical gloves are defined as single-use items for medical or nursing procedures, and include surgical and examination gloves. Surgical gloves are sterile and designed to meet the requirements of users under surgical conditions, whereas examination gloves can be sterile or non-sterile to protect the patient and/or healthcare workers from microbial contamination. The guidance also refers to protective gloves that are used to protect the healthcare worker from chemicals such as disinfectants and cytotoxic drugs.
The guidance focuses on the use of examination gloves and protective gloves for patient care, rather than surgical gloves or those used for general cleaning, food handling or sharps-injury prevention.
The guidance was designed to be easily understood and practical for members who are experiencing problems with glove usage, or with dermatitis."
This is an important distinction, as OH advice derived from evidence-based guidance from the British Occupational Health Research Foundation (BOHRF) on the use of cotton liners is not included. This may be because it was perceived as not practicable in the circumstances of frequent glove changes when dealing with different patients. The use of liners would certainly be more relevant if gloves were being used for longer periods.
Section one of the guidance includes an introduction and the recommendations that "identify current gaps in knowledge and support improved use of gloves in clinical practice".
Estimates of work-related dermatitis in healthcare workers may not be truly representative. Many continue to work with dermatitis and may not seek advice from their GP or OH department. Internationally, the incidence rates for dermatitis in healthcare workers are high, with those in Australia, the US and Japan reporting prevalence of levels between 43% and 59%.
The impact of the condition on the individual can be significant; the skin may be cracked and bleeding, with the risk of picking up infections. There may be psychological effects associated with pain and disfigurement, as well as social withdrawal. Although in the main amenable to treatment and work modifications such as avoidance of further exposure, for some the dermatitis may become chronic so that it does not resolve even if exposure ceases.
Section two of the guidance contains an introduction to the functions of the skin, including sensation, regulation of temperature, and vitamin D production and the importance of it as a barrier. The skin's structure is discussed, along with a table outlining signs and symptoms of dermatitis and its associated impact on functioning. There is mention of atopy as an inherited tendency allergy and that working as a healthcare worker may cause aggravation by exposure to working conditions, such as frequent hand washing and chemicals. There is also a useful definition of the difference between irritant and allergic contact dermatitis, and a box containing a description of the difference between urticaria, a type one immediate hypersensitivity response, and type four delayed sensitivity.
Section two contains photographs of affected skin, which may be useful to educate workers about the effect of the hazards.
A table of commonly encountered allergens and irritants that cause dermatitis is followed by a discussion of the effect of water on this skin.
Section three deals with the use of gloves in a healthcare setting. There is a general introduction to the Control of Substances Hazardous to Health Regulations 2002 and a definition of personal protective equipment. The importance of risk assessment in the choice of gloves is stressed, and there is mention of the HSE's guidance to minimise the risk of latex allergy. Key issues in the assessment include:
- task to be performed;
- anticipated contact and compatibility with chemicals and chemotherapeutic agents;
- latex or other sensitivity;
- glove size required; and
- the organisation's policy for creating a latex-free environment.
The relevant European standards are also discussed in section three, including:
- EU standard EN455 - this standard covers single-use examination gloves that come under the Medical Device Directive and is concerned with protecting the patient. Gloves should be suitable for protection against liquid penetration and micro-organisms but are not tested for chemical permeation; and
- EU standard EN420 - this standard is concerned with protecting the wearer from chemical permeation.
The guidance points out that not all gloves meet both standards and, in particular, staff need to ensure that the gloves used for disinfection of the workplace or patients' equipment are able to protect appropriately against chemical exposure.
There is a link in Appendix 3 to the World Health Organisation's (WHO) "glove pyramid", which guides the wearer through the indications for sterile gloves, examination gloves or no gloves. It is here that the answer to the question posed at the start of this article can be found. Gloves are not indicated if there is no potential for exposure to blood or bodily fluids, even for direct patient exposures such as taking blood pressure or performing subcutaneous or intramuscular injections.
Internationally, the incidence rates for dermatitis in healthcare workers are high, with those in Australia, the US and Japan reporting prevalence of levels between 43% and 59%."
Section five starts by defining standard precautions and contact precautions, which is good revision for those who have been away from frontline nursing for some time. The requirements for hand hygiene are expanded, including changing gloves while attending to a patient if a different task is to be undertaken. The WHO's "Five moments for hand hygiene" is introduced and published as Appendix 5, and there is a list of good-practice points for glove use.
Table five in the RCN guidance outlines the roles and responsibilities for glove use by category, including all staff providing direct care, managers, infections prevention and control staff, health and safety staff/representatives and procurement staff. The role of OH staff is outlined as:
- provide advice on safe glove selection and risk assessment on latex glove use;
- introduce and facilitate health surveillance programmes;
- provide guidance on hand care; and
- work collaboratively with infection and prevention control, management, and procurement staff.
This section rounds off with advice on latex sensitivity and disposal of gloves, with a highlighted sub-section on glove use and venepuncture. As venepuncture is within the role of many OH practitioners, it may be useful in the formulation of local policies.
Avoid, protect, check
From an OH perspective, the last section on the prevention and management of occupational dermatitis is likely to be of greatest interest. It is structured using the HSE's APC (avoid, protect, check) approach:
- Avoid direct contact between unprotected hands and hazardous substances and/or wet work where sensible and practicable.
- Protect skin if you cannot avoid contact.
- Check hands regularly from the first signs of itchy, dry or red skin.
The fundamentals of hand washing are also covered in the final section, with the advice to wet hands before applying soap, and to rinse well in water at an optimum temperature of 32˚C. Hand dryers are not to be used in clinical settings because of the risk of recirculating micro-organisms via air currents, and skin should be patted dry, paying attention to each finger and the skin between the fingers.
Secondary prevention by detecting disease at an early stage is promoted for all as a visual check on a monthly basis.
This issue was discussed in depth during the formulation of the guidance and it was felt that nurses and healthcare assistants involved in direct patient care were exposed to multiple hazards associated with gloves, wet work, detergents and other substances.
HSE guidance note MS 24 Medical aspects of occupational skin disease states: "The frequency of inspection or examination will depend on the nature of the risk, but a brief weekly or monthly routine is often appropriate."
There were concerns highlighted in the HSE inspectors' report and anecdotal reports that, in some trusts, skin surveillance for dermatitis was an "annual check" by OH. Therefore, the guidance advises undertaking monthly visual skin checks, with annual questionnaires to support skin-surveillance programmes, but not as a substitute for regular visual checks.
The guidance provides a good opportunity to review policy and practice with regards to glove use and dermatitis."
The implications for OH providers who have healthcare clients may be an increased need to train local laypersons to inspect skin and to refer for advice. This will increase the number of referrals received for skin problems, whether they are found to be occupational or not. This will be beneficial in the early identification of dermatitis, and problems that are caused or exacerbated by work can be dealt with at an early stage and risks reduced by improving control measures. It is hoped that this will prevent conditions from ending careers and also reduce the infection risks to patients.
Policy review and practice
Whether the employer you are providing a service for employs healthcare workers or not, this guidance provides a good opportunity to review policy and practice with regards to glove use and dermatitis. As a minimum, OH practitioners undertake procedures where gloves are used and may need formalisation of informal policy and practice. This may include documenting the condition of skin on a monthly basis.
If gloves are used for any activity, for example catering, or employees are potentially exposed to skin irritants or sensitisers, take the time to review the other guidance from the Royal College of Physicians (on latex) and BOHRF.
Check that your pre-placement questionnaires ask appropriate questions for the exposures that are likely to be encountered. Ensure that individuals who have been offered a job that will expose them to causes of occupational contact dermatitis are asked if they have a personal history of dermatitis, particularly in adulthood. Advise them of their increased risk and to care for and protect their skin, and document this advice carefully in the occupational health record. Similarly, if the individual has a personal history of atopy and the work will expose them to the causes of occupational contact urticaria, they should be advised of their increase risk and to care for and protect their skin.
For those providing a service for healthcare workers, it may be appropriate to take the following actions:
- discuss the RCN guidance with all interested parties, including safety representatives, possibly through the company's safety committee;
- anticipate an increase interest in the subject and also an increased demand for anonymous collective data on incidence of dermatitis or skin problem referrals to occupational health teams;
- ensure consistency of advice and actions throughout the occupational health team by discussing and agreeing the approach;
- if not already in place, prepare procedures for onward referral to an appropriately qualified and experienced physician;
- prepare advice paperwork for those who are referred to OH. A list of relevant information that may be required (eg lists of substances handled, type of gloves used, improvement away from work, etc) can be found in section six of the guidance;
- ensure that there is an understanding of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, and that the requirement for reporting does not override medical confidentiality; and
- be able to advise on how to apply for industrial injuries disablement benefits.
Diane Romano-Woodward is an occupational health adviser and director of Sunny Blue Sky Ltd. She was a contributor to the RCN guidance.
Recommendations from the Royal College of Nursing
1. Hand-hygiene education should include information to support staff so that they can maintain the integrity of skin as a result of work-based activities. This should include the importance of skin care and skin surveillance, the importance of good hand-washing techniques and the use of hand moisturisers.
2. Gloves should never be used as an alternative to hand hygiene and organisations must make clear their expectations regarding glove use and misuse through local policies and procedures, education and audit.
3. Skin surveillance should be undertaken monthly, using visual checks to determine if signs of dermatitis are present among staff. Annual questionnaires may be suitable to support skin-surveillance programmes, but should not be considered a substitute for regular visual checks.
4. Glove-use policies within organisations should include information on the purpose of skin-surveillance programmes, as well as the requirements of the scheme and the results from the report.
5. Cases of occupationally acquired dermatitis and trends in skin-surveillance results should be reported and discussed, and concerns should be escalated through local governance systems.
6. A national validated glove-use audit tool is required to support the auditing of glove use to complement evaluation of hand-hygiene practice in healthcare.
7. Further work is required to understand the behavioural aspects of glove compliance.
8. Research is required on the best methods to deliver education and assure compliance with glove use by clinical staff.
9. The importance of local partnership working in relation to the supply and use of gloves in practice should be emphasised between procurement, infection control, occupational health and health and safety.
10. Further work is required to address glove use by non-clinical staff in relation to risks in healthcare.
"How do I prevent skin problems in my business?" HSE.
HSE guidance note MS 24: "Medical aspects of occupational skin disease".
NHS Plus, Royal College of Physicians, Faculty of Occupational Medicine (2008). "Latex allergy: occupational aspects of management. A national guideline". London: RCP.
Nicholson PJ, Llewellyn D (eds). "Occupational contact dermatitis and urticaria". British Occupational Health Research Foundation. London. 2010. p.6.