Four hand hygiene moments and a colleague who uses gloves instead
You are on clinical placement in a 20-bed surgical ward of a district hospital, working the morning shift with a staff nurse. Over about 40 minutes you see the following. (1) She enters the side room of a patient with diarrhoea confirmed as Clostridioides difficile wearing gloves, and on leaving removes the gloves and uses alcohol-based hand rub. (2) She uses alcohol rub before touching the intact skin of the next patient. (3) You are asked to set up for a simple dry dressing on a healing abdominal wound; the trolley has sterile gloves, a bottle of alcohol rub with no date or label, and there is no soap at the sink. (4) At the next bed the patient's cannula site has bled and her hands become visibly contaminated. (5) She tells you, 'I do not need to clean between these two patients because I wore gloves.' Alcohol rub stock is low: 250 mL left for the rest of the shift.
1. For moments 1, 2 and 4, say what is correct and what is wrong, and explain the reason in each case.
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Moment 1 is wrong at the exit step. Gloves protect her, not the patient, and C. difficile spores survive alcohol. She must wash with soap and water, with friction, after glove removal, because the mechanical action removes spores that alcohol cannot kill. She is also relying on gloves alone for entering the room, which is acceptable only if hand hygiene follows.
Moment 2 is correct. Alcohol rub before touching a patient is one of the five moments, and intact skin does not demand soap and water. The exception is when hands are visibly soiled or the patient has a spore-forming organism.
Moment 4 is wrong if she reaches for rub. Visible contamination with blood means soap and water first, because rub does not remove organic matter and blood. She should wash, dry with a paper towel, then use rub if she is going on to a procedure. Blood also means she should check for skin breaks and report any exposure.
Reasoning: the decision is driven by two questions - are the hands visibly soiled, and is a spore-former involved - not by whether gloves were worn.
2. In moment 3 you cannot do proper hand hygiene at that sink and the rub bottle is unlabelled. What do you do, and why?
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Do not start the dressing yet. The steps:
- Do not use the unlabelled or undated bottle. You cannot tell whether it is the correct product, whether it has been topped up and contaminated, or whether it is out of date; an unlabelled bottle cannot be defended if there is an infection.
- Get a labelled, in-date bottle from the treatment room stock, or move to a sink that has soap and paper towels. For a dressing on a healing wound, clean hands followed by sterile gloves are needed.
- Tell the staff nurse or the nurse in charge that the ward sink has no soap and the trolley bottle is unlabelled, and ask for it to be replaced. This is a stock and audit issue, not a personal one.
- Perform hand hygiene, then open the sterile pack, then put on sterile gloves without touching the outside of the gloves.
- If no clean option exists at all, stop and escalate rather than proceed with a dressing you cannot do safely.
Reasoning: low stock is a supply problem, never a reason to lower the standard; the patient's wound is the direct risk, and an unlabelled bottle is a system failure that should be recorded so it is fixed.
3. How do you respond to her statement in moment 5, and what do you do if she repeats the practice?
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Answer in the moment but privately. In front of the patient, say only something neutral such as, 'I will clean my hands before I touch him,' and model the correct action; do not correct her in front of the patient, because it undermines her and frightens the patient.
Then speak to her where you cannot be overheard: 'Gloves are not a substitute for hand hygiene - the five moments still apply, so I am cleaning between patients even when I have worn gloves.' Keep it about the standard, not about her character.
If she repeats it, the duty to protect patients outweighs loyalty to a colleague. Raise it with your placement supervisor, the infection control nurse or the ward in-charge, describing what you saw and when, not your opinion of her. If there is an infection control link nurse, that is the right person. Write it in your reflective portfolio as a learning event without naming the nurse, because the portfolio may be read by others.
Reasoning: hand hygiene between patients is a patient safety duty for every worker, and a student who stays silent shares the risk; escalation is a professional act, not disloyalty.