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Nursing wound care survey: Sterile and nonsterile glove choice
Nursing Wound Care Survey Steri e ond Nonsterile G ave Choice Lowell C; Wise, RN, DNSc, Jane Hoffman, RN, MS, Lynne Grant, RN, MSN, CETN, CNS, and Janet Bostrom, RN, PhD
Purpose: The application of sterile and clean procedure to the practice of wound care nursing was examined. Design: This prospective, descriptive study surveyed staff nurses regarding glove use. Subjects and Setting: Seven hundred forty-three staff nurses from five health care agencies in the San Francisco Bay Area responded to the survey. Instruments: A self-report wound care survey instrument was d e v e l o p e d by Nursing Consortium for Research and Practice members from information a d a p t e d from the wound care literature. The questionnaire comprised 31 questions and required approximately 10 minutes to complete. Methods: Nursing Consortium for Research and Practice members obtained approval from their respective institutional human subjects committees and distributed questionnaires among all nurses e n g a g e d in direct care. Some a g e n c y representatives personally handed the survey instruments to subjects, but most distributed them through their agencies' personnel mailing systems. Results: Seven hundred twenty-three (38%) of 1900 questionnaires were completed and returned to the five site coordinators. Differences were found between acute care and home health nurses. Acute care nurses were more likely than home care nurses to use sterile gloves in all wound care situations. Conclusion: Greater variation was found with regard to sterile technique in wound care practice than in previously reported studies. Although patient risk factors and wound type significantly influenced the choice of sterile or clean gloves, additional environmental and personal factors exerted considerable influence. These included health care setting, degree of professional education, and nurses' experiential background. Attempts to modify practice through policy change alone may not be sufficient to overcome resistance to change, instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can a d a p t to new practices and clinical policies. (J WOCN 1997;24:144-50)
Dr. Wise is Director of Research for Patient Care Services, Stanford Health Services, Stanford, California. Ms. Hoffman is Staff Development Coordinator, Colombian Good Samaritan Health System Home Care and Hospice, San Jose, California, Ms. Grant is Clinical Nurse Specialist, Sequoia Hospital, Redwood City, California. Dr. Bostrom is Director of the Office of Outcomes Measurement, Stanford Health Services, Stanford, California.
Thisstudy was funded by the Nursing Consortium for Research in Practice. Reprint requests: Lowell C Wise, RN, DNSc, Director of Research for Patient Care Services, Stanford Health Services, 300 Pasteur Dr., Room HO105, Stanford, CA 94305.
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care delivery in America is H ealth changing at an unprecedented rate. Part of the change is caused by improvements in the machinery that drives technologic innovation. Much of the change is related to changes in the economic environment within which health care providers must function. During the 1980s-for the first time in American h i s t o r y - society's ability to provide quality health care exceeded the ability to p a y for it. In an effort to develop less costly methods for delivering care, hospitals shifted their focus from inpatient care toward outpatient and ambulatory care. Hospital stays were shortened, and m a n y medical and surgical procedures were m o v e d from the inpatient to outpatient setting. Within this climate of rapid change and adjustment, health care providers must determine which traditional practices are effective in terms of both cost and quality, and virtually every traditional health
care service must be scrutinized to increase efficiency and contain costs. One tradition worthy of scrutiny is the indiscriminate application of sterile procedure to the entire spectrum of w o u n d care. Surgically aseptic (sterile) supplies are more costly than medically aseptic (clean) supplies. One San Francisco Bay Area hospital reported the cost of sterile, prepackaged latex gloves as $0.28 a pair; in contrast, clean gloves cost only $0.04. That hospital's annual expenditures for all latex gloves exceed $600,000.00, so the economic impact of glove choice alone could be substantial. In 1994, a multihospital research consortium agreed to explore the issue of glove choice among nurses in acute and home care settings. The Nursing Consortium for Research in Practice (NCRP) is jointly funded through membership by seven San Francisco Bay Area health care agencies. Its m e m b e r s jointly conduct research surrounding clinical issues of c o m m o n interest within their clinical settings. With respect to the issue of glove choice, consortium members surveyed nurses to discover how nurses choose between sterile and clean procedure in specified wound care situations. Because glove choice often indicates the degree of asepsis practiced within w o u n d care, the survey focused solely on nurses' glove choices.
BACKGROUND Although the efficacy of sterile gloves and sterile technique in minimizing wound infection is well established for surgical procedures, 1their use after the operation is less understood. Relatively few investigators have explored the efficacy of sterile procedure within "clean" or nonsterile environments. Those who have indicate that the substitution of nonsterile for sterile gloves m a y be benign. For instance, Sadowski and coauthors 2 studied sterile versus nonsterile glove use in a burn unit. All of the study patients underwent dressing
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changes with nonsterile gloves obtained from boxes left in patients' rooms. Wounds and unused gloves within rooms were cultured, and the results were compared. The predominant bacterial contaminant was Staphylococcus aureus, but there was no evidence that gloves were the source of this contamination. In fact, they found the patient to be the exclusive source of contamination and concluded that use of nonsterile gloves provided a cost advantage w i t h o u t any increase in patient morbidity. The presence of bacterial contamination in wounds does not necessarily lead to infection or impaired healing. Some researchers have produced evidence that under certain circumstances the presence of n o m i n a l quantities of bacteria in wounds actually speeds healing. 36 Stotts has reported preliminary results of an ongoing study evaluating sterile versus nonsterile w o u n d care a m o n g patients with a variety of wound categories (Stotts N, personal communication, June 14, 1993). The study sample consisted of more than 200 inpatient and outpatient subjects requiring w o u n d care. Rather than focusing specifically on glove use, the study compared w o u n d treatment, in which all equipment involved in dressing management is either sterile or nonsterile. Although results were preliminary, Stotts noted no a p p a r e n t trend toward difference in infection frequency between the two treatments. National policy-making bodies have not yet offered guidance for glove selection, except in the case of pressure ulcers. The Agency for Health Care Policy and Research (AHCPR) 7 recommends clean or nonsterile procedure in the treatment of pressure ulcers. The Centers for Disease Control and Prevention's "Guideline for Prevention of Surgical Wound Infections "8 recommends sterile glove use for postoperative incision care for the first 24 hours. Beyond these, however, neither the Center for Disease Control and Prevention nor the AHCPR offers recommendations for sterile and clean glove choice for other w o u n d categories. There is almost no research evidence to provide guidance for glove choice in general w o u n d care, but one can at least explore the range of current practice. Stotts and coworkers 9surveyed the wound care practices of a national sample of ET nurses. Several questions in the survey related to nurses' choice of sterile and nonsterile
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technique in w o u n d care. Although this sample reported choosing nonsterile technique half (52%) of the time, conditions influencing choice depended largely on w o u n d type and practice setting. For example, ET nurses chose sterile technique approximately 80% of the time for immunosuppressed patients, open surgical wounds, or patients whose wounds exposed viable bone, tendon, or ligament. Respondents chose nonsterile technique abou t 80% of the time for stasis and pressure ulcers, fistulas, malnourished patients, and geriatric patients. Nurses disclosed a tendency to use sterile technique more often in acute care (55%) than in ambulatory settings (43%). The findings from these studies raise questions concerning individual nurses' decision-making processes when selecting sterile or nonsterile gloves for dressing changes. For instance, which gloves do nurses automatically choose when not specifically directed by a physician? What conditions dictate glove choice? Are nurses guided more by written policies or by personal or professional values? If they are guided more by personal or professional values, then what are these values? The purpose of this study was to extend the work of Stotts and coworkers 9 by surveying nurses other than ET nurses, and to identify the factors that determine nurses' glove choices in wound care.
METHODS
Design This prospective, descriptive s t u d y surveyed staff nurses at five Bay Area health care agencies regarding glove use. The sites consisted of one Veterans Affairs Medical Center, one county Visiting Nurses Association (VNA), two community general hospitals, and one university hospital. All sites were members of the NCRP. A self-report w o u n d care survey instrument was developed by NCRP members from information adapted from the
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wound care literature. The questionnaire consisted of 31 questions and took approximately 10 minutes to complete. The first eight questions asked for professional b a c k g r o u n d information. Seven questions asked nurses to indicate their glove choices for specific w o u n d care situations. They were given four choices for each wound situation (no gloves, sterile, clean, or "variable") Fifteen items listed potential forces that might motivate a nurse to choose a particular t y p e of glove. Each potentially influential factor could be ranked on a 6-point scale from "little to no influence" to "moderate to very [influential]." Nurses were asked to rate the degree of influence for each of the items. These ratings were then rank ordered a m o n g all respondents. One final question asked nurses to identify their own a g e n c y ' s glove policy for packing a w o u n d from a list of choices.
Procedure The survey instrument was field tested with managers, clinical nurse specialists, and nurse educators from each of the study agencies. Nurses chosen for the field test possessed expert knowledge regarding w o u n d care and were excluded from the test sample. Respondents were asked to critique wording for clarity and readability and content for its representation of the most commonly encountered wound care situations. Field-test subjects identified relatively few cases of ambiguous or unclear word choices. No additional wound care situations were suggested by subjects. Finally, the questionnaire was subjected to evaluation for face validity by a panel of nurse wound care experts. They found that the final version of the survey instrument adequately addressed both the range and clarity of both content and choices offered to potential subjects. Members of the NCRP acted as site coordinators within their own institutions. After obtaining approval from their respective institutional human subjects committees, each distributed questionnaires among all nurses engaged in direct care. Some agency representatives personally handed the surveys to subjects, but most distributed them through their agencies' personnel mailing systems. Nurses indicated their willingness to participate by returning unsigned, completed questionnaires by institutional mailing systems.
RESULTS Seven hundred twenty-three of 1900 questionnaires (38%) were completed and returned to the five site coordinators. Return rates varied from 23% at one community hospital to 60% at the VNA. R e s p o n d e n t s ' ages were r e p o r t e d by decade categories. The median age range for this sample was 40 to 49 years. The average time since graduation from basic nursing training was 15.4 years. The average length of nursing practice was 14.8 years. This small difference between years since graduation and years of total practice suggests that most of the responding nurses had practiced continuously since graduation. The countries within which nurses received their basic nursing program were United States (n = 568, 79%), Philippines (n = 71, 9.8%), United Kingdom (n = 27, 3.9%), Canada (n = 16, 2.2%), and other (n = 41, 5.1%). Nurses reported their basic educational preparation as licensed vocational nursing (n = 52), associate degree (n = 158), diploma (n -- 167), and baccalaureate (n = 331). The largest specialty represented was critical care (n = 196), followed by medical-surgical nursing (n = 140).
Glove Choice in Wound Care Situations Sixty-one percent of respondents (n = 427) indicated that their choice of sterile or nonsterile gloves varied in the general care of w o u n d s and w o u n d dressings (Table 1). Sterile gloves were chosen more often than nonsterile gloves for packing wounds, for dressing purulent wounds, when w o u n d s had tunneling, and for exposed orthopedic wounds. Clean gloves were generally preferred for dressing changes over intact surgical wounds and pressure ulcers. This pattern of glove choice remained consistent among the four acute care hospitals. Home care nurses, in contrast, preferred nonsterile gloves for all situations except exposed orthopedic wounds. The differences between acute care and home care practices canbe seen more clearly when agency types are compared (Table 2). Acute care nurses indicated they were likely to use nonsterile gloves less than one third as often (20% of the time) as did home care nurses (67% of the time) for all kinds of wound care situations. Differences were greater with respect to wounds requiring
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Table 1. G l o v e c h o i c e in s e v e n w o u n d c a r e situations. Wound core situation When performing wound care, I use.., To pack a wound, I use.,. To dress a purulent wound, I use... To change a dressing on an intact incision, I use... To change a dressing on a pressure ulcer, I use.,. If a wound has tunneling, I use... For exposed orthopedic wounds, I use...
packing (8% vs 57%) and tunneling wounds (11% vs 70%). The two groups of nurses made similar choices only with respect to exposed orthopedic w o u n d s (13% vs 24%). In all seven of the w o u n d care situations, licensed vocational nurses were more likely to use sterile rather than clean gloves. This difference was statistically significant in only two cases, when changing dressings on an intact surgical dressing (H2 = 24.04,df= 12,p = 0.02) and for general w o u n d care (Xa = 17.63, dr= 9, p = 0.039).
Factors Influencing Glove Choice Tables 3 and 4 list the frequencies and rankings for responses to the question, " H o w influential are the following factors g o v e r n i n g y o u r choice of glove type to use in w o u n d care?" A m o n g all nurses, type of w o u n d , exposed bone, and imm u n o s u p p r e s s i o n were the three m o s t influential factors in glove choice. Nurses' responses were rank ordered b y institution and the profiles were compared. The resulting profiles were similar a m o n g the four hospitals but differed from the V N A sample (Table 4). Visiting nurses ranked the availability of gloves as more influential than did hospital nurses. Physician preference, w h i c h was a m o n g the least influential factors for hospital nurses, was a m o n g the m o s t i n f l u e n t i a l for V N A nurses. Profiles of influence also differed between registered nurses and licensed vocational nurses. Licensed vocational nurses ranked the following factors as significantly more influential than did registered nurses: agency policy (Ha = 29.31,df= 15,p = 0.015), glove availability (X2 = 37.13, df = 15, p = 0.001), and "the w a y I was taught in school" (X2 = 38.87, df = 15, p = 0.0007).
Organizational Policy The final question in the survey tested nurses' knowledge regarding the nature
No gloves (%) 0.1
4 0,6
Clean gloves (%) 22 10 34 66 57 13 14
Sterile gloves (%) 17 76 41 18 23 73 75
Variable (%) 61 14 25 12 19 14 12
Table 2. P e r c e n t a g e of t h e t i m e nonsterile ( c l e a n ) g l o v e s a r e used to c h a n g e dressings b y a g e n c y t y p e a n d t y p e of w o u n d Type of wound Wound care in genera/ Acute wounds Wounds requiring packing Intact incision (surgical)
Exposed orthopedic wounds Chronic wounds Tunneling wounds Purulent wounds Pressure ulcers
Acute care patients (%, n = 693) 20%
Home care patients (%, n = 30) 67%
8% 69% 13%
57% 90% 24%
11% 32% 56%
70% 80% 100%
of their own institutional w o u n d care policy for packing w o u n d s (Table 5). The five agencies' policies are identified in the table by the asterisks. Only three of the five agencies had written policies governing glove choice, and all specified sterile gloves. Only 297 of 723 nurses (41%) correctly guessed their respective agencies' policies. More than 20% admitted that they were u n a w a r e of their a g e n c y ' s w o u n d care policy regarding sterile glove use. \
DISCUSSION This survey extends the w o r k of Stotts and colleagues, 9w h o reported on American nurses' w o u n d care practices. Their sample comprised members of the WOCN, and our sample comprised staff nurses. As in the research reported b y Stotts and associates, 9nearly half of our study sample were baccalaureate prepared. The average length of experience was also similar (14.8 years vs 19.4 years). Participants in our investigation were neither advanced practice nurses nor w o u n d care specialists (e.g., certified w o u n d care nurses or ET nurses), and 6% of the current participants were licensed vocational nurses. Our study population was therefore likely
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Table 3. Frequencies for responses to the question, " H o w influential are the following factors in g o v e r n i n g your c h o i c e of sterile or nonsterile gloves?"
Response frequencies (%) Motivating influences Length of time since surgery Size of wound Amount of drainage Type of drainage Type of dressing Type of wound Exposed bone, tendon, etc. Immunosuppression of patient Cleanliness of surroundings Availability of gloves Agency policy Physician preference Research findings Way I was taught in school
Little or none 33.80 39.80 32.60 26.70 13.20 6.30 4.00 4,10 27.70 55.10 16.10 23.10 14.00 16.70
Some to average 21.60 23,40 21.50 18.60 12.40 ' 6.40 1.70 3.80 24.20 18.70 22.90 21.10 28.80 28.00
Moderate to very 53.60 40.80 48.40 54.70 74.40 87.00 94.30 92.20 48.20 26.20 61.00 55.80 57.20 55.30
Table 4. Rankings for responses to the question, " H o w influential are the following factors in g o v e r n i n g your c h o i c e of sterile or nonsterile gloves?"
Response rankings grouped by agency
Exposed bone Immunosuppression Type of wound Type of dressing Agency policy Research finding Way I was taught Physician preference Type of drainage Cleanliness of surroundings Amount of drainage Time since surgery Wound size Availability of gloves
Total (n = 723) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Community hospital I (n= 133) 1 2 3 4 7 9 6 10 5 8 11 12 13 14
Community hospital 2 (n= 91) 1 2 3 4 6 5 9 7 8 10 11 12 13 14
to share some b u t n o t all of the practice p a t t e r n s r e p o r t e d b y Stotts a n d associates. 9 For example, differences b e t w e e n acute a n d h o m e care n u r s e s were m u c h greater in our i n v e s t i g a t i o n t h a n in that of Stotts a n d associates2 In addition, acute care n u r s e s in our s a m p l e were b e t w e e n two a n d seven times more likely to choose sterile gloves in the care of chronic w o u n d s than were home care nurses from our study p o p u l a t i o n or n u r s e s i n the overall s t u d y p o p u l a t i o n of Stotts a n d colleagues. 9 R e s p o n s e s from the staff n u r s e s par-
University hospital 3 (n = 342) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
VNA (home care; n=30) 1 3 5 6 4 8 11 2 12 7 14 9 13 10
Veterans hospital 4 (n= 127) 1 2 3 4 6 7 5 11 9 8 12 10 13 14
ticipants in our s t u d y closely r e s e m b l e d Stotts a n d c o l l e a g u e s ' s a m p l e of W O C N m e m b e r s 9 w i t h r e s p e c t to the u s e of n o n s t e r i l e t e c h n i q u e for e x p o s e d orthopedic w o u n d s and among i m m u n o s u p p r e s s e d p a t i e n t s . A c u t e care a n d h o m e care n u r s e s i n this s t u d y u s e d n o n s t e r i l e gloves 13% a n d 24% of the time, comp a r e d w i t h W O C N m e m b e r rates of 14% a n d 33%. W O C N m e m b e r s indicated that i m m u n o s u p p r e s s i o n caused them to limit n o n s t e r i l e t e c h n i q u e from 16% to 29% of the time, w h e r e a s the n u r s e s i n our
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Table 5. Response t a b l e for the question, "Our a g e n c y policy for p a c k i n g w o u n d s requires,,." Response categories
Sterile Either--nurse choice No policy Clean I do not know
1 2 3 4 5
Community hospital I (%,n= 133)
Community hospital 2 (%,n=91)
University hospital3 (%,n= 342)
VNA (home care; %, n=30)
Veterans hospital 4 (%,n= 127)
67 6 3* 5 19
50 9 2* 16 22
61" 4 2 0 24
7" 3 0 72 17
63" 5 0 4 27
*Actual agency policy,
sample identified immunosuppression as second in i m p o r t a n c e to e x p o s e d orthopedic wounds as a motivating factor in the selection of gloves. In both studies, acute care nurses were more likely to choose sterile rather than nonsterile t e c h n i q u e than were nurses in outpatient settings. Only one of the seven wound care situations listed in our survey d e m a n d e d sterile procedure (exposed orthopedic wounds), however, so it is likely that u n n e c e s s a r y use of more expensive sterile supplies often occurs. This conclusion is even more compelling because 41% of our respondents (n = 296) indicated a preference for using sterile gloves when dressing a purulent w o u n d (Table 1).
Clinical Implications If practice were guided by research, we would have expected to find more than 57% of this sample reporting the use of clean procedure for dressing pressure ulcers. Our findings show that some agencies have done a better job than others in educating nurses with regard to the AHCPR guidelines. The message has not yet reached practicing nurses. In addition, if practice were guided by research, we would have expected to find a high number of nurses using clean gloves in the care of pressure ulcers. In contrast to this expectation, 43% of the sample chose something other than clean gloves for pressure ulcers, despite scientific evidence and AHCPR guidelines ~ (Table 1). The results of this survey illustrate the variability in practice that occurs when nursing practice is not guided by research. When science fails to provide guidance for w o u n d care practice, nurses must choose their practice standards from a range of authorities. Within this sample, the authorities most often identified were past practice and the educational expe-
rience. Agency policy proved to be among the weakest influences on practice. One puzzling finding was that home health care nurses rated "physician preference" as the second strongest determinant of glove choice, particularly because home care nurses are customarily regarded as more independent in their nursing practice. It is possible that the perception of independence only reflects independence from agency control, not from the physician. The inaccuracy with which nurses in all five agency settings perceived their agency's wound care policies is remarkable. Nurses from only two hospitals (University and Veterans Affairs) were able to correctly state their agency's glove policy correctly more than half the time (61% and 63%, respectively). In the remaining three agencies, more than 90% of respondents gave incorrect answers. In all five agencies, there was a high degree of concordance between actual practice and nurses' assumption of wound care policy. It is possible that with regard to some nursing activities, such as w o u n d care, nurses seldom deviate from patterns they learned during their basic education. A majority of nurses (385) indicated that "the way I was taught in school" influenced them "moderately" or "very much." If lessons learned in basic nursing programs become persistent templates for future behavior, then the importance of teaching w o u n d care methods that reflect the current state of the science is a p p a r e n t . In our i n v e s t i g a t i o n , an inverse relationship between the influence of basic education and the amount of professional education was observed. Nurses p r e p a r e d at baccalaureate or higher level tended to rate this influence lower than did licensed vocational nurses and associate degree nurses. These findings suggest that nursing practice patterns may be resistant to modi-
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ficationby policy change. Merely publishing changes within a policy may not be sufficient to effect a corresponding change in nursing practice. Health care agencies need to review more than the soundness of their clinical policies. They also need to compare the compatibility of these policies with nurses' practice patterns and their philosophic or theoretic orientations. For example, if an agency wished to change wound care policy so that nonsterile technique would be substituted for sterile in certain wound care procedures, it is entirely likely that the agency would see no reduction in sterile supply use. There would be no reduction unless a substantial attempt toward reeducating the staff and subsequently monitoring clinical practice were made.
Economic Implications Most nurses chose sterile procedure, the safest and most conservative approach. Although sterile practice is considered the safest practice in w o u n d care, it also remains the most expensive.
dence suggesting that additional environmental and personal factors exert considerable influence. Variables that affect practice patterns include health care setting, degree of professional education, type of w o u n d care under consideration, and n u r s e s ' experiential background. Some evidence suggests that methods learned during initial education may limit nurses' ability to modify their practice later in their careers. If this is true, then attempts to modify practice through policy change alone may not be sufficient to overcome resistance to change. Instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can adapt to new practices and clinical policies. More research is needed to examine these factors and their influence on the clinical change process. Cost-effectiveness and soundness of practice pattern are extremely i m p o r t a n t in establishing sound clinical policy. Without consequent behavioral change, however, the potential benefits of these practice changes may never occur.
Limitations This exploratory survey of wound care practice among staff nurses was limited to five health care agencies. A larger, more geographically diverse sample might show more or less variation among agencies and settings. The use of five health care facilities in one metropolitan area of the country represents a limitation of our investigation. Another limitation of our study lies in the content and form of selfreport measures. Because there were no existing survey forms capable of capturing the themes we wished to explore, we relied on an untested survey instrument designed for this study. In an effort to limit the length of the questionnaire and keep the study's focus relatively broad, we necessarily left out a level of detail that u n d o u b t e d l y would have expanded knowledge about w o u n d care in certain areas.
SUMMARY We found greater variation in w o u n d care practice with respect to sterile technique than has been previously reported. As reported in earlier studies, issues such as patient risk factors and w o u n d type weigh heavily in the choice of sterile or clean gloves. Our study also found evi-
REFERENCES 1. Ehrenkranz NJ, Meakins JL. Surgical infections. New York: Liffle, Brown; 1992. 2. Sadowski DA, Pohlman S, Maley MP, Warden GD. Use of nonsferile gloves for routine noninvasive procedures in thermally injured patients. J Burn Care Rehabi11988;9:613-5. 3. Carrel A. Cicatrization of wounds. XlI: factors initiating regeneration. J Exp Meal 1921;34:425-34. 4. Laato M, Niinikoski J, Lundberg C, Gerdin B. Inflammatory reaction and blood flow in experimental wounds inoculated withStaphylococcus a u r e u s . Eur Surg Res 1988;20:33-8. 5. Levinson SM, Kan-Gruber D, Gruber C, Molnar J, Seifter E. Wound healing accelerated by Staphylococcus aureus. Arch Surg 1983;118: 310-20. 6. Tenorio A, Jindrak K, Weiner M, Bella E, Enquist IF.Accelerated healing in infected wounds. Surg Gynecol Obstet 1976; 142'.537-43. 7. Bergstrom N, Benneff MA, Carlson CD, et al. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. Rockville, MD; U.S. Department of Health a n d H u m a n Services, A g e n c y for Health Care Policy a n d Research. A H C P R Publication No. 95-0652. D e c e m b e r ]994. 8. Centers for Disease Control. Guidelines for prevention of surgical wound infection, 1985. Springfield, Virginia: CDC, 1985. 9. Stotts NA, Barbour S, Slaughter R, Wipke-Tevis D. Wound care practices in the United States. Ostomy Wound Manage 1993;39:53-9.
Purpose: The application of sterile and clean procedure to the practice of wound care nursing was examined. Design: This prospective, descriptive study surveyed staff nurses regarding glove use. Subjects and Setting: Seven hundred forty-three staff nurses from five health care agencies in the San Francisco Bay Area responded to the survey. Instruments: A self-report wound care survey instrument was d e v e l o p e d by Nursing Consortium for Research and Practice members from information a d a p t e d from the wound care literature. The questionnaire comprised 31 questions and required approximately 10 minutes to complete. Methods: Nursing Consortium for Research and Practice members obtained approval from their respective institutional human subjects committees and distributed questionnaires among all nurses e n g a g e d in direct care. Some a g e n c y representatives personally handed the survey instruments to subjects, but most distributed them through their agencies' personnel mailing systems. Results: Seven hundred twenty-three (38%) of 1900 questionnaires were completed and returned to the five site coordinators. Differences were found between acute care and home health nurses. Acute care nurses were more likely than home care nurses to use sterile gloves in all wound care situations. Conclusion: Greater variation was found with regard to sterile technique in wound care practice than in previously reported studies. Although patient risk factors and wound type significantly influenced the choice of sterile or clean gloves, additional environmental and personal factors exerted considerable influence. These included health care setting, degree of professional education, and nurses' experiential background. Attempts to modify practice through policy change alone may not be sufficient to overcome resistance to change, instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can a d a p t to new practices and clinical policies. (J WOCN 1997;24:144-50)
Dr. Wise is Director of Research for Patient Care Services, Stanford Health Services, Stanford, California. Ms. Hoffman is Staff Development Coordinator, Colombian Good Samaritan Health System Home Care and Hospice, San Jose, California, Ms. Grant is Clinical Nurse Specialist, Sequoia Hospital, Redwood City, California. Dr. Bostrom is Director of the Office of Outcomes Measurement, Stanford Health Services, Stanford, California.
Thisstudy was funded by the Nursing Consortium for Research in Practice. Reprint requests: Lowell C Wise, RN, DNSc, Director of Research for Patient Care Services, Stanford Health Services, 300 Pasteur Dr., Room HO105, Stanford, CA 94305.
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care delivery in America is H ealth changing at an unprecedented rate. Part of the change is caused by improvements in the machinery that drives technologic innovation. Much of the change is related to changes in the economic environment within which health care providers must function. During the 1980s-for the first time in American h i s t o r y - society's ability to provide quality health care exceeded the ability to p a y for it. In an effort to develop less costly methods for delivering care, hospitals shifted their focus from inpatient care toward outpatient and ambulatory care. Hospital stays were shortened, and m a n y medical and surgical procedures were m o v e d from the inpatient to outpatient setting. Within this climate of rapid change and adjustment, health care providers must determine which traditional practices are effective in terms of both cost and quality, and virtually every traditional health
care service must be scrutinized to increase efficiency and contain costs. One tradition worthy of scrutiny is the indiscriminate application of sterile procedure to the entire spectrum of w o u n d care. Surgically aseptic (sterile) supplies are more costly than medically aseptic (clean) supplies. One San Francisco Bay Area hospital reported the cost of sterile, prepackaged latex gloves as $0.28 a pair; in contrast, clean gloves cost only $0.04. That hospital's annual expenditures for all latex gloves exceed $600,000.00, so the economic impact of glove choice alone could be substantial. In 1994, a multihospital research consortium agreed to explore the issue of glove choice among nurses in acute and home care settings. The Nursing Consortium for Research in Practice (NCRP) is jointly funded through membership by seven San Francisco Bay Area health care agencies. Its m e m b e r s jointly conduct research surrounding clinical issues of c o m m o n interest within their clinical settings. With respect to the issue of glove choice, consortium members surveyed nurses to discover how nurses choose between sterile and clean procedure in specified wound care situations. Because glove choice often indicates the degree of asepsis practiced within w o u n d care, the survey focused solely on nurses' glove choices.
BACKGROUND Although the efficacy of sterile gloves and sterile technique in minimizing wound infection is well established for surgical procedures, 1their use after the operation is less understood. Relatively few investigators have explored the efficacy of sterile procedure within "clean" or nonsterile environments. Those who have indicate that the substitution of nonsterile for sterile gloves m a y be benign. For instance, Sadowski and coauthors 2 studied sterile versus nonsterile glove use in a burn unit. All of the study patients underwent dressing
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changes with nonsterile gloves obtained from boxes left in patients' rooms. Wounds and unused gloves within rooms were cultured, and the results were compared. The predominant bacterial contaminant was Staphylococcus aureus, but there was no evidence that gloves were the source of this contamination. In fact, they found the patient to be the exclusive source of contamination and concluded that use of nonsterile gloves provided a cost advantage w i t h o u t any increase in patient morbidity. The presence of bacterial contamination in wounds does not necessarily lead to infection or impaired healing. Some researchers have produced evidence that under certain circumstances the presence of n o m i n a l quantities of bacteria in wounds actually speeds healing. 36 Stotts has reported preliminary results of an ongoing study evaluating sterile versus nonsterile w o u n d care a m o n g patients with a variety of wound categories (Stotts N, personal communication, June 14, 1993). The study sample consisted of more than 200 inpatient and outpatient subjects requiring w o u n d care. Rather than focusing specifically on glove use, the study compared w o u n d treatment, in which all equipment involved in dressing management is either sterile or nonsterile. Although results were preliminary, Stotts noted no a p p a r e n t trend toward difference in infection frequency between the two treatments. National policy-making bodies have not yet offered guidance for glove selection, except in the case of pressure ulcers. The Agency for Health Care Policy and Research (AHCPR) 7 recommends clean or nonsterile procedure in the treatment of pressure ulcers. The Centers for Disease Control and Prevention's "Guideline for Prevention of Surgical Wound Infections "8 recommends sterile glove use for postoperative incision care for the first 24 hours. Beyond these, however, neither the Center for Disease Control and Prevention nor the AHCPR offers recommendations for sterile and clean glove choice for other w o u n d categories. There is almost no research evidence to provide guidance for glove choice in general w o u n d care, but one can at least explore the range of current practice. Stotts and coworkers 9surveyed the wound care practices of a national sample of ET nurses. Several questions in the survey related to nurses' choice of sterile and nonsterile
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technique in w o u n d care. Although this sample reported choosing nonsterile technique half (52%) of the time, conditions influencing choice depended largely on w o u n d type and practice setting. For example, ET nurses chose sterile technique approximately 80% of the time for immunosuppressed patients, open surgical wounds, or patients whose wounds exposed viable bone, tendon, or ligament. Respondents chose nonsterile technique abou t 80% of the time for stasis and pressure ulcers, fistulas, malnourished patients, and geriatric patients. Nurses disclosed a tendency to use sterile technique more often in acute care (55%) than in ambulatory settings (43%). The findings from these studies raise questions concerning individual nurses' decision-making processes when selecting sterile or nonsterile gloves for dressing changes. For instance, which gloves do nurses automatically choose when not specifically directed by a physician? What conditions dictate glove choice? Are nurses guided more by written policies or by personal or professional values? If they are guided more by personal or professional values, then what are these values? The purpose of this study was to extend the work of Stotts and coworkers 9 by surveying nurses other than ET nurses, and to identify the factors that determine nurses' glove choices in wound care.
METHODS
Design This prospective, descriptive s t u d y surveyed staff nurses at five Bay Area health care agencies regarding glove use. The sites consisted of one Veterans Affairs Medical Center, one county Visiting Nurses Association (VNA), two community general hospitals, and one university hospital. All sites were members of the NCRP. A self-report w o u n d care survey instrument was developed by NCRP members from information adapted from the
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wound care literature. The questionnaire consisted of 31 questions and took approximately 10 minutes to complete. The first eight questions asked for professional b a c k g r o u n d information. Seven questions asked nurses to indicate their glove choices for specific w o u n d care situations. They were given four choices for each wound situation (no gloves, sterile, clean, or "variable") Fifteen items listed potential forces that might motivate a nurse to choose a particular t y p e of glove. Each potentially influential factor could be ranked on a 6-point scale from "little to no influence" to "moderate to very [influential]." Nurses were asked to rate the degree of influence for each of the items. These ratings were then rank ordered a m o n g all respondents. One final question asked nurses to identify their own a g e n c y ' s glove policy for packing a w o u n d from a list of choices.
Procedure The survey instrument was field tested with managers, clinical nurse specialists, and nurse educators from each of the study agencies. Nurses chosen for the field test possessed expert knowledge regarding w o u n d care and were excluded from the test sample. Respondents were asked to critique wording for clarity and readability and content for its representation of the most commonly encountered wound care situations. Field-test subjects identified relatively few cases of ambiguous or unclear word choices. No additional wound care situations were suggested by subjects. Finally, the questionnaire was subjected to evaluation for face validity by a panel of nurse wound care experts. They found that the final version of the survey instrument adequately addressed both the range and clarity of both content and choices offered to potential subjects. Members of the NCRP acted as site coordinators within their own institutions. After obtaining approval from their respective institutional human subjects committees, each distributed questionnaires among all nurses engaged in direct care. Some agency representatives personally handed the surveys to subjects, but most distributed them through their agencies' personnel mailing systems. Nurses indicated their willingness to participate by returning unsigned, completed questionnaires by institutional mailing systems.
RESULTS Seven hundred twenty-three of 1900 questionnaires (38%) were completed and returned to the five site coordinators. Return rates varied from 23% at one community hospital to 60% at the VNA. R e s p o n d e n t s ' ages were r e p o r t e d by decade categories. The median age range for this sample was 40 to 49 years. The average time since graduation from basic nursing training was 15.4 years. The average length of nursing practice was 14.8 years. This small difference between years since graduation and years of total practice suggests that most of the responding nurses had practiced continuously since graduation. The countries within which nurses received their basic nursing program were United States (n = 568, 79%), Philippines (n = 71, 9.8%), United Kingdom (n = 27, 3.9%), Canada (n = 16, 2.2%), and other (n = 41, 5.1%). Nurses reported their basic educational preparation as licensed vocational nursing (n = 52), associate degree (n = 158), diploma (n -- 167), and baccalaureate (n = 331). The largest specialty represented was critical care (n = 196), followed by medical-surgical nursing (n = 140).
Glove Choice in Wound Care Situations Sixty-one percent of respondents (n = 427) indicated that their choice of sterile or nonsterile gloves varied in the general care of w o u n d s and w o u n d dressings (Table 1). Sterile gloves were chosen more often than nonsterile gloves for packing wounds, for dressing purulent wounds, when w o u n d s had tunneling, and for exposed orthopedic wounds. Clean gloves were generally preferred for dressing changes over intact surgical wounds and pressure ulcers. This pattern of glove choice remained consistent among the four acute care hospitals. Home care nurses, in contrast, preferred nonsterile gloves for all situations except exposed orthopedic wounds. The differences between acute care and home care practices canbe seen more clearly when agency types are compared (Table 2). Acute care nurses indicated they were likely to use nonsterile gloves less than one third as often (20% of the time) as did home care nurses (67% of the time) for all kinds of wound care situations. Differences were greater with respect to wounds requiring
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Table 1. G l o v e c h o i c e in s e v e n w o u n d c a r e situations. Wound core situation When performing wound care, I use.., To pack a wound, I use.,. To dress a purulent wound, I use... To change a dressing on an intact incision, I use... To change a dressing on a pressure ulcer, I use.,. If a wound has tunneling, I use... For exposed orthopedic wounds, I use...
packing (8% vs 57%) and tunneling wounds (11% vs 70%). The two groups of nurses made similar choices only with respect to exposed orthopedic w o u n d s (13% vs 24%). In all seven of the w o u n d care situations, licensed vocational nurses were more likely to use sterile rather than clean gloves. This difference was statistically significant in only two cases, when changing dressings on an intact surgical dressing (H2 = 24.04,df= 12,p = 0.02) and for general w o u n d care (Xa = 17.63, dr= 9, p = 0.039).
Factors Influencing Glove Choice Tables 3 and 4 list the frequencies and rankings for responses to the question, " H o w influential are the following factors g o v e r n i n g y o u r choice of glove type to use in w o u n d care?" A m o n g all nurses, type of w o u n d , exposed bone, and imm u n o s u p p r e s s i o n were the three m o s t influential factors in glove choice. Nurses' responses were rank ordered b y institution and the profiles were compared. The resulting profiles were similar a m o n g the four hospitals but differed from the V N A sample (Table 4). Visiting nurses ranked the availability of gloves as more influential than did hospital nurses. Physician preference, w h i c h was a m o n g the least influential factors for hospital nurses, was a m o n g the m o s t i n f l u e n t i a l for V N A nurses. Profiles of influence also differed between registered nurses and licensed vocational nurses. Licensed vocational nurses ranked the following factors as significantly more influential than did registered nurses: agency policy (Ha = 29.31,df= 15,p = 0.015), glove availability (X2 = 37.13, df = 15, p = 0.001), and "the w a y I was taught in school" (X2 = 38.87, df = 15, p = 0.0007).
Organizational Policy The final question in the survey tested nurses' knowledge regarding the nature
No gloves (%) 0.1
4 0,6
Clean gloves (%) 22 10 34 66 57 13 14
Sterile gloves (%) 17 76 41 18 23 73 75
Variable (%) 61 14 25 12 19 14 12
Table 2. P e r c e n t a g e of t h e t i m e nonsterile ( c l e a n ) g l o v e s a r e used to c h a n g e dressings b y a g e n c y t y p e a n d t y p e of w o u n d Type of wound Wound care in genera/ Acute wounds Wounds requiring packing Intact incision (surgical)
Exposed orthopedic wounds Chronic wounds Tunneling wounds Purulent wounds Pressure ulcers
Acute care patients (%, n = 693) 20%
Home care patients (%, n = 30) 67%
8% 69% 13%
57% 90% 24%
11% 32% 56%
70% 80% 100%
of their own institutional w o u n d care policy for packing w o u n d s (Table 5). The five agencies' policies are identified in the table by the asterisks. Only three of the five agencies had written policies governing glove choice, and all specified sterile gloves. Only 297 of 723 nurses (41%) correctly guessed their respective agencies' policies. More than 20% admitted that they were u n a w a r e of their a g e n c y ' s w o u n d care policy regarding sterile glove use. \
DISCUSSION This survey extends the w o r k of Stotts and colleagues, 9w h o reported on American nurses' w o u n d care practices. Their sample comprised members of the WOCN, and our sample comprised staff nurses. As in the research reported b y Stotts and associates, 9nearly half of our study sample were baccalaureate prepared. The average length of experience was also similar (14.8 years vs 19.4 years). Participants in our investigation were neither advanced practice nurses nor w o u n d care specialists (e.g., certified w o u n d care nurses or ET nurses), and 6% of the current participants were licensed vocational nurses. Our study population was therefore likely
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Table 3. Frequencies for responses to the question, " H o w influential are the following factors in g o v e r n i n g your c h o i c e of sterile or nonsterile gloves?"
Response frequencies (%) Motivating influences Length of time since surgery Size of wound Amount of drainage Type of drainage Type of dressing Type of wound Exposed bone, tendon, etc. Immunosuppression of patient Cleanliness of surroundings Availability of gloves Agency policy Physician preference Research findings Way I was taught in school
Little or none 33.80 39.80 32.60 26.70 13.20 6.30 4.00 4,10 27.70 55.10 16.10 23.10 14.00 16.70
Some to average 21.60 23,40 21.50 18.60 12.40 ' 6.40 1.70 3.80 24.20 18.70 22.90 21.10 28.80 28.00
Moderate to very 53.60 40.80 48.40 54.70 74.40 87.00 94.30 92.20 48.20 26.20 61.00 55.80 57.20 55.30
Table 4. Rankings for responses to the question, " H o w influential are the following factors in g o v e r n i n g your c h o i c e of sterile or nonsterile gloves?"
Response rankings grouped by agency
Exposed bone Immunosuppression Type of wound Type of dressing Agency policy Research finding Way I was taught Physician preference Type of drainage Cleanliness of surroundings Amount of drainage Time since surgery Wound size Availability of gloves
Total (n = 723) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Community hospital I (n= 133) 1 2 3 4 7 9 6 10 5 8 11 12 13 14
Community hospital 2 (n= 91) 1 2 3 4 6 5 9 7 8 10 11 12 13 14
to share some b u t n o t all of the practice p a t t e r n s r e p o r t e d b y Stotts a n d associates. 9 For example, differences b e t w e e n acute a n d h o m e care n u r s e s were m u c h greater in our i n v e s t i g a t i o n t h a n in that of Stotts a n d associates2 In addition, acute care n u r s e s in our s a m p l e were b e t w e e n two a n d seven times more likely to choose sterile gloves in the care of chronic w o u n d s than were home care nurses from our study p o p u l a t i o n or n u r s e s i n the overall s t u d y p o p u l a t i o n of Stotts a n d colleagues. 9 R e s p o n s e s from the staff n u r s e s par-
University hospital 3 (n = 342) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
VNA (home care; n=30) 1 3 5 6 4 8 11 2 12 7 14 9 13 10
Veterans hospital 4 (n= 127) 1 2 3 4 6 7 5 11 9 8 12 10 13 14
ticipants in our s t u d y closely r e s e m b l e d Stotts a n d c o l l e a g u e s ' s a m p l e of W O C N m e m b e r s 9 w i t h r e s p e c t to the u s e of n o n s t e r i l e t e c h n i q u e for e x p o s e d orthopedic w o u n d s and among i m m u n o s u p p r e s s e d p a t i e n t s . A c u t e care a n d h o m e care n u r s e s i n this s t u d y u s e d n o n s t e r i l e gloves 13% a n d 24% of the time, comp a r e d w i t h W O C N m e m b e r rates of 14% a n d 33%. W O C N m e m b e r s indicated that i m m u n o s u p p r e s s i o n caused them to limit n o n s t e r i l e t e c h n i q u e from 16% to 29% of the time, w h e r e a s the n u r s e s i n our
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Table 5. Response t a b l e for the question, "Our a g e n c y policy for p a c k i n g w o u n d s requires,,." Response categories
Sterile Either--nurse choice No policy Clean I do not know
1 2 3 4 5
Community hospital I (%,n= 133)
Community hospital 2 (%,n=91)
University hospital3 (%,n= 342)
VNA (home care; %, n=30)
Veterans hospital 4 (%,n= 127)
67 6 3* 5 19
50 9 2* 16 22
61" 4 2 0 24
7" 3 0 72 17
63" 5 0 4 27
*Actual agency policy,
sample identified immunosuppression as second in i m p o r t a n c e to e x p o s e d orthopedic wounds as a motivating factor in the selection of gloves. In both studies, acute care nurses were more likely to choose sterile rather than nonsterile t e c h n i q u e than were nurses in outpatient settings. Only one of the seven wound care situations listed in our survey d e m a n d e d sterile procedure (exposed orthopedic wounds), however, so it is likely that u n n e c e s s a r y use of more expensive sterile supplies often occurs. This conclusion is even more compelling because 41% of our respondents (n = 296) indicated a preference for using sterile gloves when dressing a purulent w o u n d (Table 1).
Clinical Implications If practice were guided by research, we would have expected to find more than 57% of this sample reporting the use of clean procedure for dressing pressure ulcers. Our findings show that some agencies have done a better job than others in educating nurses with regard to the AHCPR guidelines. The message has not yet reached practicing nurses. In addition, if practice were guided by research, we would have expected to find a high number of nurses using clean gloves in the care of pressure ulcers. In contrast to this expectation, 43% of the sample chose something other than clean gloves for pressure ulcers, despite scientific evidence and AHCPR guidelines ~ (Table 1). The results of this survey illustrate the variability in practice that occurs when nursing practice is not guided by research. When science fails to provide guidance for w o u n d care practice, nurses must choose their practice standards from a range of authorities. Within this sample, the authorities most often identified were past practice and the educational expe-
rience. Agency policy proved to be among the weakest influences on practice. One puzzling finding was that home health care nurses rated "physician preference" as the second strongest determinant of glove choice, particularly because home care nurses are customarily regarded as more independent in their nursing practice. It is possible that the perception of independence only reflects independence from agency control, not from the physician. The inaccuracy with which nurses in all five agency settings perceived their agency's wound care policies is remarkable. Nurses from only two hospitals (University and Veterans Affairs) were able to correctly state their agency's glove policy correctly more than half the time (61% and 63%, respectively). In the remaining three agencies, more than 90% of respondents gave incorrect answers. In all five agencies, there was a high degree of concordance between actual practice and nurses' assumption of wound care policy. It is possible that with regard to some nursing activities, such as w o u n d care, nurses seldom deviate from patterns they learned during their basic education. A majority of nurses (385) indicated that "the way I was taught in school" influenced them "moderately" or "very much." If lessons learned in basic nursing programs become persistent templates for future behavior, then the importance of teaching w o u n d care methods that reflect the current state of the science is a p p a r e n t . In our i n v e s t i g a t i o n , an inverse relationship between the influence of basic education and the amount of professional education was observed. Nurses p r e p a r e d at baccalaureate or higher level tended to rate this influence lower than did licensed vocational nurses and associate degree nurses. These findings suggest that nursing practice patterns may be resistant to modi-
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ficationby policy change. Merely publishing changes within a policy may not be sufficient to effect a corresponding change in nursing practice. Health care agencies need to review more than the soundness of their clinical policies. They also need to compare the compatibility of these policies with nurses' practice patterns and their philosophic or theoretic orientations. For example, if an agency wished to change wound care policy so that nonsterile technique would be substituted for sterile in certain wound care procedures, it is entirely likely that the agency would see no reduction in sterile supply use. There would be no reduction unless a substantial attempt toward reeducating the staff and subsequently monitoring clinical practice were made.
Economic Implications Most nurses chose sterile procedure, the safest and most conservative approach. Although sterile practice is considered the safest practice in w o u n d care, it also remains the most expensive.
dence suggesting that additional environmental and personal factors exert considerable influence. Variables that affect practice patterns include health care setting, degree of professional education, type of w o u n d care under consideration, and n u r s e s ' experiential background. Some evidence suggests that methods learned during initial education may limit nurses' ability to modify their practice later in their careers. If this is true, then attempts to modify practice through policy change alone may not be sufficient to overcome resistance to change. Instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can adapt to new practices and clinical policies. More research is needed to examine these factors and their influence on the clinical change process. Cost-effectiveness and soundness of practice pattern are extremely i m p o r t a n t in establishing sound clinical policy. Without consequent behavioral change, however, the potential benefits of these practice changes may never occur.
Limitations This exploratory survey of wound care practice among staff nurses was limited to five health care agencies. A larger, more geographically diverse sample might show more or less variation among agencies and settings. The use of five health care facilities in one metropolitan area of the country represents a limitation of our investigation. Another limitation of our study lies in the content and form of selfreport measures. Because there were no existing survey forms capable of capturing the themes we wished to explore, we relied on an untested survey instrument designed for this study. In an effort to limit the length of the questionnaire and keep the study's focus relatively broad, we necessarily left out a level of detail that u n d o u b t e d l y would have expanded knowledge about w o u n d care in certain areas.
SUMMARY We found greater variation in w o u n d care practice with respect to sterile technique than has been previously reported. As reported in earlier studies, issues such as patient risk factors and w o u n d type weigh heavily in the choice of sterile or clean gloves. Our study also found evi-
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