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Aseptic technique: evidence-based

approach for patient safety

Rosemary M Preston

The fact that there is a relationship between the standards of aseptic technique
performance and the rise in hospital infection rates has been suggested by the
Department of Heaths (DoHs, 2004) Winning Ways document. This literature review
considers how the aseptic technique is performed in the UK, and examines the nature
of ritualistic and evidence-based practice underpinning this skill-based procedure.
The findings have identified an emerging glove culture and continuing poor
hand-hygiene practices.The alternative clean technique is also adopted widely in
clinical practice which confuses the aseptic theorypractice gap.While it is hard to
pinpoint an actual time or event that causes infection, it is unlikely nurses will ever
become involved in litigation as a result of a poorly performed aseptic technique.
However, the review concludes that nurses should not become too complacent. It briefly
considers how performance of the aseptic technique can be improved, through creative
educational strategy, applied risk assessment and clinical audits of nurses practices.
Key words:  Infection control  Nursing: role  Patients: welfare






n recent months, questions concerning

hospital-acquired infections (HAIs) have
dominated both the professional and
national news media. The Winnings Ways
report, issued by the Department of Health
(DoH, 2004), describes how methicillin-resistant Staphylococcus aureus (MRSA)-type infections have increased by 3.6% in England for
the year 20022003. One of the actions outlined in this report, pledged that clinical teams
will demonstrate consistently high standards of
aseptic technique in practice to help reduce
these rates of infections.
Unfortunately, 1 year after its publication, it
has been reported by Hartley (2005a) that the
aseptic technique is still not being carried out
to a high standard across the country. This adds
to the growing concern about HAIs in the UK.
This concern is being addressed by the Chief
Nursing Officer, Christine Beasley, in her call
for improving aseptic techniques in managing
wounds and surgical sites (DoH, 2005).
Unfortunately, Hartley (2005a) reported that
practitioners themselves say the aseptic technique is not what it should be in some places.
According to Michalopoulos and Sparos
(2003), this may be related to a theorypractice
gap. However, Hallett (2000) argues the problem may result from confusion and complacency in professional practice. Certainly, the
Government is concerned enough to
announce that an Essence of Care benchmark
on the aseptic technique is soon to be drawn
up and published (Hartley, 2005a). This will
encourage practitioners to use the same terminology and working principles that will promote best practice and standardize the
technique across the whole of the UK.
In the current climate, health care requires
nurses to be able to apply the best evidence to
their practice. Gilmour (2000) argues that
infection control policies should be based on
evidence rather than ritual. Research should
Rosemary M Preston is Senior Lecturer, Preregistration
Programme, Postregistration Programme, Postgraduate
Programme, University of Luton
Accepted for publication:April 2005

Cover picture: Bacterial contamination of hands, showing areas of the skin that are often left contaminated after washing.


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British Journal of Nursing 2005.14:540-546.


promote the practice of risk assessment to
minimize the incidence of cross-infection.
However, if general principles of asepsis are not
being practised to a high enough standard
(Hartley, 2005a), is there evidence to suggest
why this might be happening? This review of
the literature examines ritualistic and evidence-based practice in relation to the education and practice of the aseptic technique, as
well as its implications for patient safety.

Principles of the aseptic technique

The aim of the aseptic technique is to prevent
the transmission of microorganisms to wounds,
or other susceptible sites, to reduce the risk of
infection (Bree-Williams and Waterman, 1996;
Xavier, 1999). However, pathogenic microbial
contamination continues to be identified as a
problem when practitioners carry out aseptictype procedures (Ward, 2000; Michalopoulos
and Sparos, 2003; Myatt and Langley, 2003). In
a survey conducted in two major hospitals in
Greece, nurses demonstrated a sound knowledge of the aseptic principle when questioned,
but 15.6% of nurses were found to have contaminated their hands during the procedure
(Michalopoulos and Sparos, 2003).
Bree-Williams and Waterman (1996) and
Hallett (2000) have both observed that a failure
to use the aseptic technique correctly could be
responsible for problematic and intractable infections such as MRSA. For example, BreeWilliams and Waterman (1996), in their
observational study, found that 33% of nurses
contaminated their hands and equipment during
the aseptic tachnique procedure. This was found
to be a result of a number of factors, ranging
from making the procedure more complicated
than required, to poor skill in handwashing,
glove technique and use of non-touch principles
in handling sterile equipment and instruments.
In assessing attitudes towards the aseptic
technique, Hallett (2000) found that nurses discussed the concept of aseptic technique in
fatalistic terms. This was a small qualitative
study involving community nurses, who
expressed a belief that asepsis was virtually
impossible to achieve in reality. While this
result may only have significance in a community setting, Hallet (2000) was concerned
about the degree of ambivalence and uncertainty around infection control in wound care,
particularly as it could be related to how practitioners are originally taught the aseptic technique, combined with a failure to adopt new
skills and techniques safely as they emerge in
professional practice. As Hallett (2000) concluded, if there is no research evidence to support the aseptic procedure then it is not

surprising if the practice is becoming obsolete

for some nurses.
Therefore, is the aseptic technique always
necessary? According to Gilmour (2000) and
Weaver (2004), performing an aseptic technique requires sterile equipment, gloves and
fluids, and non-touch actions of the nurse.
This will help to minimize spread of potential
pathogens to other sites, wounds or self. It is
also important for nurses to be able to account
for their actions at all times. This means being
able to demonstrate a sound knowledge and
practice in maintaining a sterile field
(Gilmour, 1999; Xavier, 1999; Nursing and
Midwifery Council (NMC), 2002; Weaver,

political factors that may impinge on their

everyday working environments and expected
working practices.

Teaching clean technique vs aseptic

Over the past 10 years, a move towards a clean
technique has been identified (Gilmour, 1999;
Williams, 1999; Michalopoulos and Sparos, 2003).
A clean technique adopts the same aims as the
aseptic technique but uses clean rather than sterile
gloves. It is also less ritualistic and relies on less
hand-washing intraprocedure, but continues to
utilize sterile equipment and fluids as appropriate
for individual patients needs (Gilmour, 2000).










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2004). Gilmour (2000) goes on to argue that
despite its ritualistic nature (of being a formal
procedure that is followed consistently), the
aseptic technique (Table 1), is an effective
infection control strategy.
However, in an observational study of
healthcare practitioners in two accident and
emergency departments, Al-Damouk et al
(2004) found that there was poor compliance
with good-practice guidelines for the aseptic
technique. This study was conducted in the
UK and New Zealand and it showed UK doctors rate of compliance to be as low as 27%.
Although it was accepted that a compromise in
standards of asepsis in very sick patients would
be likely to occur, this low figure contrasted
sharply with New Zealands doctors who
scored 58%. This result could imply that both
nurses and doctors in the UK may have
become confused and complacent about the
term aseptic in their everyday practice. It may
also be the result of the differences in how
professional practitioners are trained in the
UK, combined with other sociocultural and

Parker (2000) observed that the clean technique was an alternative approach when dealing
with some chronic wounds using non-sterile
solutions such as tap water for irrigation (Riyat
and Quinton, 1997; Hollinworth and Kingston,
1998). Therefore, it must be asked whether the
nurses in Halletts study (2000) believed they
were doing the best they could when adopting
this alternative approach. For example, one Fgrade sister in the study commented she didnt
really believe in this clean-aseptic procedure
she did the best she could. This may be why
she and her colleagues felt the aseptic technique
had become virtually obsolete in their community practice. If so, it could be a reason why
nurses in other practice areas are similarly confused about when to apply the clean or aseptic
approaches for a range of aseptic-type procedures (Table 2).

Reinforcing aseptic technique

The complex issues surrounding the acceptable
standard for performing the aseptic technique


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British Journal of Nursing 2005.14:540-546.

continues to pose a challenge for all professional

healthcare practitioners. Evidence-based practice
can be difficult to implement in infection control as most professionals tend to base their practice on experience or expert opinion (Ward,
2002). It is usual to find nurses and doctors who
have both a lack of knowledge of the evidence
available and an unwillingness to change their
behaviour based on new evidence (Davey, 1997;
Ward, 2000; Myatt and Langley, 2003).
The aseptic technique is one area of professional practice in which ritual can be recognized from when to wash hands and don
gloves, to opening the sterile packages, and
performing procedures such as care of intravenous cannulae (Dougherty, 2000), or wound












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care (Wilson, 2003). Successive studies on
wound care (Filetoth, 2003; Michalopoulos
and Sparos, 2003), hand hygiene (Patel, 2004;
Rickard, 2004) and glove use (Ross, 1999)
have been well reported in the last 5 years.
For example, both Filetoth (2003) and
Michalopoulos and Sparos (2003) reported on
the need to improve aseptic technique practice
in wound care to reduce the rates of wound
infection. In handwashing practices, both Patel
(2004) and Rickard (2004) have reviewed the
various factors which inhibit good handwashing
techniques and have offered suggestions on how
professionals can be helped to improve their
performance. In glove selection and technique,
Ross (1999) reported on an audit that identified
that practitioners were using gloves inappropriately and that latex sensitivity was becoming a
problem for healthcare workers.This report also
highlighted the importance of risk assessment
for glove use in the healthcare setting.

The motivation to look at research and

explore new methods to improve skill-based
care is recognized to be a focus for ongoing
postregistration education (Ford and Koehler,
2001; NMC, 2002; Preston, 2004). In maintaining good standards for the aseptic technique, this
should involve revisiting the skills of handwashing, glove selection and technique, maintaining a
sterile field with use of non-touch principles
and developing risk-assessment protocols that
encompass safety issues for both the professional
practitioner and patient (Bree-Williams and
Waterman, 1996; Ford and Koehler et al, 2001;
Michalopoulos and Sparos, 2003).

Learning to visualize microbial

As suggested by Rickard (2004), one of the
reasons for non-compliance in the aseptic
technique is because the individual cannot see
the microorganisms with the naked eye. The
relationship between contamination, colonization and infection is not easy for the average
professional to perceive in practice, and it can
take many days for an infection to develop
(Wilson, 2003). This makes it harder to pinpoint the actual time, occasion or event that
caused the infection. To help overcome this
lack of awareness in practice, Ford and Koehler
(2001), for example, provided an educational
session for their staff that used colourful pompoms with parachutes to represent microbial
fallout. This helped staff to realize the location
of contamination on their equipment, the
patient and their hands while performing the
aseptic technique. Talcum powder or pillow
feathers have been used in a similar way.
Another visual aid useful for raising awareness of microbial fallout is to follow a simple
hand-hygiene exercise as reported by Aspock
and Koller (1999). This involves using a
creamy-coloured dye which is applied to
gloved hands and which are then washed with
soap and running water and dried using standard paper towels. The aim is to see the distribution of dye on the gloves following this
handwash procedure. Parts of the hands that
are frequently left contaminated with the soapy
dye (Griffiths, 2002) are the palms, between
the fingers and outer edge of the thumb. This
type of exercise can allow practitioners to
refine their handwashing technique to a higher
standard of performance.

Learning to wash hands effectively

The relationship between poor hand hygiene
and infection risks has been well documented
(Merchant, 2001; Griffiths, 2002; Rickard,
2004). Hartley (2005b) reported intensive care


unit (ICU) nurses would need to wash their

hands every 3 minutes to ensure patient safety.
This was based on an observational study conducted at the University College London
Hospital and the Royal Free Hospital, London.
This study identified 534 handwashing opportunities in a 26-hour observation period, i.e. one
every 3 minutes. It was interesting to note that
the nurses scored a low 29% for handwash compliance for the total number of opportunities
observed.The findings also conveyed the importance of washing hands when moving between
different parts of the patients body and ventilator, e.g. so that colonization and spread of
MRSA was kept to a minimum. Although ICU
is a specialist area, the issue of handwashing
techniques, as well as timing and frequency, is
often viewed as the major causal link in HAIs
(Dunford, 1997; Rotter, 2001;Weaver, 2004).
In relation to the aseptic technique, effective
handwashing practice is essential even if gloves
are worn at some stage in the procedure. Swales
(2003) identified that hands should be washed
before and after wound care, and also after
removal of gloves if worn. Pittet (2001) notes
that nurses often forget to do handwashing at
these times or devote too little time to wash
and dry their hands in an appropriate manner.
Bree-Williams and Waterman (1996) highlighted that contamination of gloves occurred
because hands were still wet when attempting to
apply the gloves. Further, good quality soap, towel
and wash-basin facilities continues to be a problem in ensuring compliance (Hampton, 2003).
When undertaking handwashing as part of
the aseptic procedure how many units still have
no elbow or foot-controlled taps? This means
nurses cannot safely mix hot and cold water
and turn the taps off without recontaminating
their washed hands. It would also be interesting
to investigate if practitioners use the foot pedals on waste bins or lift the bin lids with their
hands instead as this may pose a risk activity
leading to higher rates of HAIs. Clearly, there
is a need for all practitioners to conduct risk
assessments of the facilities they have available.
Any concerns raised by practitioners, such as
the risks posed by poor design, should be
heeded and action taken as a matter of high
priority in the healthcare setting.

Alcohol gels
The use of hand gels and alcohol rubs are an
additional aid to promoting hand hygiene
(Rickard, 2004).These have proved to be effective in reducing the time it takes to effect
decontamination of the hands compared with
using soap, water and paper towels (Jones et al,
2000; Bissett, 2002; Pittet, 2002; Patel, 2004).

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Rickard (2004) discovered that in an average

8-hour shift, nurses could spend a total of
45 minutes, or 15% of their work activities,
devoted to hand-hygiene practices. The use of
alcohol, waterless-base rubs reduces the time
spent on this activity.
However, inservice education emphasizes that
these rubs are only effective on hands that have
no visible signs of soiling (Bissett, 2002; Patel,
2004). Further, the efficacy of these rubs were
questioned by Kramer (2002), who found that
where the application time was 816 seconds,
this would increase the likelihood of cross-contamination. In this study, the researchers tested
the antimicrobial efficacy of 10 gels and four
rinses on the contaminated hands of 15 volunteers. This showed that a rub time of at least
30 seconds is needed to meet acceptable standards for successful hand decontamination.
Rickard (2004) also reported other reasons
for poor hand decontamination. He highlighted issues involving both complacency and
avoidance factors related to skin problems,
workload and lack of time, poor facilities and
materials and disagreement with hospital protocol and training regulations.
Traditionally, it has been accepted that
increasing the amount of training and education
is the best strategy to take if compliance in hand
hygiene is to improve. Unfortunately, writers
like Gould (2000) have found that despite many
innovative strategies being forwarded in educational programmes, hand- hygiene behaviour
continues to be poorly applied. As Rickard
(2004) concludes, future strategies could involve
empowering patients to question practitioners
hand-hygiene practice, improve hand-hygiene
facilities, and create local ownership of any
problems identified. These problems can be
assessed locally through regular risk assessment,
research, and feedback of infection rates.

Learning to select clean or sterile

gloves using a risk-assessment
Nurses are now expected to wear gloves for all
procedures to protect not only the patient, but
also themselves from infection (Hampton,
2002; Yip and Cacioli, 2002). Unfortunately,
this practice has promoted a distinct behavioural culture, where nurses use gloves inappropriately for a number of tasks such as
conducting clinical observations and assisting
patients with feeding, where risks to either
patients or themselves are not identified
(Infection Control Nurses Association, 1999;
Raybould, 2001). In the Health and Safety
Commission (1999) report, Control of
Substances Hazardous to Health Regulations:







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Approved Codes of Practice, it is suggested that

risk assessment should follow specific guidelines related to the barrier efficacy for the type
of gloves selected. Unfortunately, this is an area
where the theorypractice gap is well documented (Gould and Chamberlain, 1997;
Curran, 2000; Rourke et al, 2001).
For example, Curran (2000) reported on reasons for an outbreak of the hepatitis B infection in a group of patients who were all
diabetic. Practitioners were found to be using
gloves to protect themselves from blood-borne
infections when conducting blood glucose
monitoring. However, it was discovered that
these practitioners had failed to understand the
risk posed to their patients by not changing
their gloves between each procedure. This was
how successive diabetic patients were found to
have become infected.
In addition, Hampton (2002) has highlighted
the lack of understanding in relation to the
health risk of developing latex sensitivity,
assessing permeability (virus leaking) risks of
both polyvinyl and latex gloves material, and
recognizing the high costs and wastage
involved when using gloves inappropriately in
the healthcare setting.


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In the case of acute wound care and urinary

catheterization, for example, Hampton and
Collins (2002) and Haberstich (2002) advocate
that sterile gloves should always be worn.
However, they also acknowledge that there are
some practice environments where the risk is
assessed as low for some chronic wounds, such
as chronic leg ulcers when managed in the
patients home, as well as other sterile procedures. Both OToole (1997) and Gottrup et al
(2001) support this view of adapting the aseptic procedure to a clean technique for these situations and of using clean non-sterile gloves
and sterile equipment and fluids (but including
tap water when applicable).
Unfortunately, the technique for safely
applying sterile gloves has been shown to be of
a low standard. In relation to applying clean
gloves, there appears to be no research on techniques for their application and it is left to the
practitioner to adapt the technique taken for
applying sterile gloves to minimize the risk of
contamination. Aspock and Koller (1999) give
a clear explanation of how to apply and
remove sterile gloves correctly in their simple
hand-hygiene exercise (Table 3). This is an
important skill, as Bree-Williams and

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Waterman (1996) found 33% of nurses put
gloves on incorrectly, which could have led to
glove contamination. Further, nurses often
selected the wrong glove size and some tried
to apply gloves while hands were still wet.
In a different study, Davey (1997) found there
was also some confusion relating to when
gloves should be applied in the aseptic procedure. Some nurses did not know that the
wound dressing could be removed with the
sterile wastage bag to avoid contaminating their
hands, thus reducing the need for an extra pair
of gloves or forceps (see Table 1). Parker (2000)
supported the need for hands to be washed
after glove removal.This will remove any bacterial growth from the hands that might have
occurred during glove use or on their removal.
Hampton (2002) also considers that it is possible for virus particles to leak through latex
and polyvinyl gloves. For example, while
nurses are performing wound care the amount
of exposure to exudates and blood can be
high, even in chronic wounds. It is, therefore,
important that even with gloves, non-touch
principles are used when assessing, cleansing
and redressing wounds (see Table 1). Gloves can
become perforated or the permeability altered
if they come into contact with chemical agents
like alcohol-hand gels.
As Jones et al (2000) argued, these gels have
not been tested on latex material, only human
skin.Therefore, the culture behaviour observed
in some nurses, who apply hand gels to disinfect gloves during the aseptic procedure, or
even between patients, as reported by Curran
(2000), is not recommended. If gloves become
soiled or contaminated, they should be
removed, hands washed or disinfected with an
alcohol rub, and dried well before fresh gloves
are applied. Only in this way can the nurse
ensure patient safety is maintained.

Aseptic technique: improving patient

It was reported in the DoH (2004) document, Winning Ways, that the UK has one of
the highest HAI rates in Europe. Urinarytract infections are reported at 23%, with
wound infections 9% and blood infections at
6% (DoH, 2004). Certainly from the patients
perspective, this equates to an alarming risk
to his/her safety, ranging from posing a threat
to his/her life, to a longer stay in hospital
with increased NHS costs, loss of personal
earnings and, for some, long-term disability
(Myatt and Langley, 2003).
According to Myatt and Langley (2003),
MRSA colonization and infection is considered to be endemic in NHS hospitals, with

critical care units identified as the highest risk

areas. However, in all clinical environments,
this review has highlighted the need to question basic aseptic principles when performing
a range of clinical procedures, whether these
are involving wound care, administration of
drugs, urinary catheterization or blood-glucose monitoring.
In practice, both the clean and aseptic technique (Gilmour, 2000; Parker 2000) appear to
be used synonymously, but often without
recourse to risk assessment. Poor hand
hygiene, incorrect glove selection and technique and a failure to use non-touch actions
when manipulating sterile equipment are areas
which need most attention. Such failures indicate a problematic theorypractice gap that
was identified by Michalopoulos and Sparos
(2003). However, this is further compounded
by an observed rise in glove culture (Hallett,
2000; Raybould 2001).
Risk assessment is not routinely carried out
before glove usage, and it has been observed by
Curran (2000) that some nurses wear the same
pair of gloves for multiple tasks. For example,
some nurses do not always change gloves
between patients when performing some clean
procedures such as blood-glucose monitoring
(Curran, 2000; Rourke et al, 2001). Regular
audits of practice behaviour and educational
support programmes are needed to resolve
some of these behavioural issues. Action plans
should be drawn up for nurses to follow if
standards of performance are found to be poor.
While the introduction of alcohol-based hand
disinfectants has significantly reduced hand-contamination risks (Patel, 2004), poor practice in
its application can negate its efficacy. Nurses
should recognize that this practice only meets
high enough standards if they apply the disinfectants for at least 30 seconds (Kramer, 2002).
Applying hand disinfectants to gloved hands is
not recommended (Jones et al, 2000) as these
chemicals have not been tested on latex or synthetic glove material, only human skin. Risk
assessments on type of gloves (latex or
polyvinyl), equipment, lotions and exposure risk
to blood and wound exudates, should be completed as a universal precaution for all aseptic
procedures (Weaver, 2004). This should guide
nurses to adopt safer principles when using
gloves and to enhance hand-hygiene practice.
It should be noted that aprons and uniforms
are easily contaminated and can be a reservoir
for cross-infection. Callaghan (1998) and
Pearson et al (2001) have both concluded that
plastic aprons should be changed between
patients and always before performing an aseptic or clean procedure. It is also recommended

(Callaghan, 1998) that uniforms are changed

daily and, if laundered at home, should be
washed at a high temperature of 60C. From a
personal observation, the wearing of rings,
including wedding bands, should be considered
a source of pathogenic contamination if worn
during aseptic-type procedures.

Patient safety when performing the aseptic
technique is of the highest importance.
Considering the relationship between contamination, colonization and infection is not easy
for the nurse to perceive in practice.This makes
it harder to pinpoint the actual time, occasion
or event that caused the infection. While drug
errors are more easily identified (Preston,
2004), errors in applying the aseptic technique
are more difficult to prove in law.Therefore, it is
unlikely that nurses will be involved in some
form of litigation as a result of a poor performance leading to HAI (Oxtoby, 2003).
However, nurses should not be complacent
about this area of their practice. It is recommended that all nurses use risk-assessment protocols, attend educational updates, and conduct
regular audits in their practice areas. Such
strategies should promote ownership of the
problems identified in their practice and
improve the standard of aseptic technique performance. This will not only have benefits in
promoting the safety and wellbeing of the
patients, but also provide a safe environment for
student nurses to learn and practice this skill in
a safe and competent manner.
Al-Damouk M, Pudney E, Bleetman A (2004) Hand hygiene
and aseptic technique in the emergency department. J
Hosp Infect 56(2): 13741
Aspock C, Koller W (1999) A simple hand hygiene (practice
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Bissett L (2002) Can alcohol hand rubs increase compliance
with hand hygiene? Br J Nurs 11(16): 10727

The practice of aseptic technique is causing
concern for patient safety.
Glove culture is emerging as a threat
to controlling infection risks.
Poor hand hygiene practices continue
to be observed.
Hand disinfectants are only effective
if applied for longer than 30 seconds.
Risk assessment should precede all aseptic
technique procedures.
Education strategies are needed
to visualize microbial fallout.


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British Journal of Nursing 2005.14:540-546.

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British Journal of Nursing, 2005,Vol 14, No 10

British Journal of Nursing 2005.14:540-546.