SELF/Perioperative Nursing/Donning Sterile Gown and Gloves

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Correctly donning a sterile surgical gown and gloves is an essential infection prevention skill that helps protect both patients and healthcare workers during operative and other sterile procedures. Maintaining a sterile barrier requires not only proper technique but also a sound understanding of aseptic principles and the ability to recognize and respond to contamination.

This module teaches the knowledge required to safely don a sterile surgical gown and gloves using the closed gloving technique. You will learn when sterile gowning and gloving are indicated, the equipment and supplies required, the principles of surgical asepsis, common contamination risks, and appropriate corrective actions..

By the end of this module, you will understand the principles that support safe sterile practice and be better prepared to prevent contamination before entering the sterile field.

This module is designed for trainee perioperative nurses transitioning from general nursing into the operating theatre. Learners have completed three years of general nursing training and have approximately two years of post-qualification clinical experience, with foundational knowledge of infection prevention, aseptic technique, surgical hand antisepsis, and the principles of sterility.

The module is intended for learners working in district hospitals and other resource-limited settings, where workloads may be high and supervision limited. It focuses on developing the knowledge needed to safely don a sterile surgical gown and gloves using the closed gloving technique, recognize contamination, and maintain sterility while adapting to occasional shortages of equipment, supplies, or personnel. Learners are expected to be proficient in English and have basic computer literacy to support self-directed or blended learning.

By the end of this module, you should be able to:

• Explain the purpose of sterile gowning and closed gloving in preventing surgical site infections and protecting both patients and healthcare workers.
• Identify the indications, contraindications, and pre-procedure requirements for sterile gowning and closed gloving.
• Recognize the equipment and supplies required for sterile gowning and closed gloving, including appropriate selection, inspection, and preparation before use.
• Describe the principles of surgical asepsis that govern sterile gowning and closed gloving, including sterile zones, safe positioning, maintenance of sterility, and recognition of contamination.
• Describe the correct sequence for drying the hands and forearms, donning a sterile gown, performing closed gloving, and safely removing the gown and gloves.
• Recognize common contamination points during gowning and closed gloving and determine the appropriate corrective actions when contamination occurs.
• Apply infection prevention principles to maintain sterility while working with the circulating nurse and when adapting to resource-limited clinical environments.

Sterile gowning and gloving create the final protective barrier between you and the sterile surgical field. Their purpose is to prevent microorganisms normally present on your skin, clothing, and body from contaminating sterile instruments, implants, tissues, or the surgical wound. At the same time, they help protect you from exposure to the patient's blood and body fluids.

Even after performing a thorough surgical hand antisepsis, your skin cannot be made completely sterile. Surgical hand preparation removes transient microorganisms and greatly reduces resident microorganisms, but some bacteria remain in the deeper layers of the skin and can gradually return to the surface. The sterile gown and gloves provide the physical barrier that prevents these microorganisms from reaching the patient during surgery.

Surgical site infections can result from even small breaks in aseptic technique. A brief contact between a sterile glove and a non-sterile surface, a torn glove, or a contaminated gown may introduce microorganisms directly into the operative field. Because contamination is often invisible, every member of the sterile team must assume that any break in sterility places the patient at risk until proven otherwise. Sterile gowning and gloving are therefore not simply technical tasks. They are essential infection prevention measures that protect both the patient and every member of the surgical team.

You should wear a sterile surgical gown and sterile gloves whenever you will enter or work within the sterile field during an operative or invasive procedure.

Examples include:

• Open surgical procedures.
• Procedures involving body cavities or major blood vessels.
• Procedures involving sterile implants or prosthetic devices.
• Procedures requiring direct handling of sterile instruments within the sterile field.

Any procedure where your hands or forearms may enter the sterile operative field. Even procedures that appear relatively minor, such as wound debridement, orthopedic pin removal, or surgical dressing changes performed within a sterile operative field, require sterile gowning and closed gloving whenever there is a risk of contaminating the surgical site.

The level of protection should always match the risk of contamination. If there is any doubt whether you will enter the sterile field, it is safer to gown and glove than to risk contaminating the patient.

Sterile gloves may be donned using either the closed gloving technique or the open gloving technique. The choice depends on whether a sterile surgical gown is being worn and the level of sterile barrier protection required for the procedure.

Understanding when each technique is appropriate helps ensure patient safety and maintain aseptic technique. Although both techniques have important roles in clinical practice, this module teaches only the closed gloving technique as the psychomotor skill.

Closed gloving is performed after a sterile surgical gown has been donned. Throughout the procedure, the hands remain inside the gown cuffs until the gloves have been completely applied. This prevents bare hands from contacting the outside surface of the gloves and maintains a continuous sterile barrier.

Closed gloving is the preferred technique when:

• Donning a sterile surgical gown before entering the sterile field.
• Participating as a scrubbed member of the operating room team.
• Performing open surgical procedures.
• Assisting with invasive procedures that require both a sterile gown and sterile gloves.

Advantages of closed gloving include:

• Maintains continuous protection of the sterile barrier.
• Minimizes the risk of contaminating the gloves during application.
• Prevents exposed skin from contacting the sterile glove surface.
• Provides the highest level of protection when a sterile gown is required.

Limitations of closed gloving include:

• Requires a sterile surgical gown.
• Cannot be performed before the gown has been donned.
• Requires familiarity with the technique to perform efficiently.

Because closed gloving provides continuous protection of the sterile barrier, it is considered the standard technique for gowned members of the surgical team.

Open gloving is performed without first wearing a sterile surgical gown. During this technique, sterile gloves are applied directly to the hands while minimizing contact between bare skin and the outside surface of the gloves.

Open gloving is commonly used when:

• A sterile gown is not required.
• Performing minor sterile procedures.
• Applying sterile gloves outside the operating room.
• Replacing a contaminated glove while remaining sterile, following institutional policy.

Advantages of open gloving include:

• Faster to perform than closed gloving.
• Does not require a sterile surgical gown.
• Appropriate for many minor sterile procedures.

Limitations of open gloving include:

• Greater opportunity for accidental contamination if performed incorrectly.
• Does not provide the additional protection of a sterile surgical gown.
• Is not appropriate when both a sterile gown and sterile gloves are required.

The choice between closed and open gloving depends on the procedure being performed and the level of sterile barrier protection required.

Use closed gloving whenever you have donned a sterile surgical gown and will be entering the sterile field as a scrubbed member of the surgical team.

Use open gloving only when a sterile gown is not required or when changing sterile gloves according to your institution's approved procedures.

The table below summarizes the appropriate selection of each technique.

A sterile gown and gloves do not protect against every hazard encountered during surgery.

Some procedures create a high risk of blood or body fluid splashes, bone fragments, irrigation fluid, or other infectious material. In these situations, additional personal protective equipment (PPE) may also be required, including:

• Protective eyewear or face shields.
• Fluid-resistant surgical masks.
• Waterproof aprons worn beneath the sterile gown when heavy fluid exposure is expected.
• Double gloving when recommended by institutional policy or during procedures with a high risk of glove perforation.

The exact PPE depends on the procedure, the patient's condition, and your institution's infection prevention policies.

Sterile gowning and gloving begin only after successful surgical hand antisepsis has been completed. Proper preparation before gowning helps reduce contamination, improves efficiency, and ensures that all necessary equipment is available before you enter the sterile field.

Surgical hand antisepsis removes transient microorganisms and significantly reduces resident microorganisms on the hands and forearms before donning a sterile gown and gloves. Although it greatly reduces the number of microorganisms, it does not sterilize the skin. This is why sterile gowns and gloves are still required.

Depending on local policy and available resources, surgical hand antisepsis may be performed using:

• An antimicrobial surgical hand scrub, such as chlorhexidine gluconate or povidone-iodine.
• A validated alcohol-based surgical hand rub when hands are visibly clean.
• The method used should follow your institution's infection prevention policy.

Before opening sterile supplies, confirm that:

• Your hands and forearms have been prepared appropriately.
• The correct gown and glove sizes are available.
• All sterile packages are dry, intact, and within their expiry date, where applicable.
• Sterility indicators confirm successful sterilization.
• The sterile field has been prepared.
• The circulating nurse is ready to assist with gowning if required.
• There is enough space to unfold the gown without touching non-sterile surfaces.

Preparing everything before beginning reduces unnecessary interruptions and minimizes opportunities for contamination.

Although contraindications to sterile gowning and gloving are uncommon, certain situations make it unsafe to enter the sterile field until the problem has been corrected.

You should not scrub into the sterile field if you have:

• Untreated skin infections affecting the hands or forearms.
• Open wounds, cuts, or draining lesions on the hands or forearms.
• Severe dermatitis that compromises skin integrity.
• Any illness or physical condition that prevents you from maintaining sterile technique safely.

These conditions increase bacterial shedding and may compromise glove integrity, increasing the risk of contaminating the sterile field.

If any of these conditions are present, inform your supervisor and perform a non-sterile role, such as the circulating nurse, until the condition has resolved.

You should also delay entering the sterile field if the available equipment cannot provide an adequate sterile barrier.

Examples include:

• Torn or damaged sterile gowns.
• Torn, punctured, or improperly sized sterile gloves.
• Wet or damaged sterile packaging.
• Failed or missing sterility indicators.
• Expired sterile supplies.
• Missing equipment required to perform the procedure safely.

If there is any doubt about the integrity of sterile equipment, replace it before proceeding. Remember:

If sterility is uncertain, consider the item contaminated until proven otherwise.

A sterile gown and gloves alone may not provide adequate protection for every procedure.

Additional PPE should be used whenever there is:

• Risk of heavy blood or body fluid splashes.
• Risk of aerosol generation.
• Management of patients requiring transmission-based precautions.
• Institutional policies requiring enhanced PPE.

Never proceed using only standard sterile gowning and gloving when additional protection is indicated.

Before approaching the sterile field, perform a deliberate final self-check.

Confirm that:

• Surgical hand antisepsis has been completed correctly.
• The sterile gown is intact and correctly secured.
• Both sterile gloves are intact and free from tears or punctures.
• The glove cuffs completely cover the gown cuffs.
• No contamination occurred during gowning or gloving.
• Any additional PPE required for the procedure has been applied.
• You are physically prepared to maintain sterile technique throughout the procedure.

This final inspection takes only a few seconds but may prevent contamination before patient contact begins.

Once you enter the sterile field, maintain your hands above waist level, in front of your body, and within your field of vision. Avoid contact with non-sterile objects or personnel.

If contamination is suspected at any time, stop immediately and take the appropriate corrective action before continuing.

• Sterile gowning and gloving create the final barrier protecting both the patient and the healthcare worker.
• Surgical hand antisepsis reduces microorganisms but does not sterilize the skin.
• Wear a sterile gown and gloves whenever you will enter or work within the sterile field.
• Understand the difference between closed gloving and open gloving, and select the appropriate technique for the clinical situation.
• This module teaches the closed gloving technique as the psychomotor skill.
• Select additional PPE according to the anticipated exposure risk.
• Do not enter the sterile field if skin conditions, contaminated equipment, or inadequate PPE compromise sterility.
• Perform a deliberate final inspection before entering the sterile field.
• If contamination is suspected, stop immediately and correct the problem before proceeding.

Self-assessment

Please complete the following: Sterile Handling Principles for Unopened Packs Quiz

Successful sterile gowning and closed gloving begin long before you put on the gown. Careful selection, inspection, and preparation of equipment help prevent contamination, reduce delays during the procedure, and ensure that an effective sterile barrier is maintained.

Before beginning, gather all required supplies and inspect them carefully. A missing item, damaged package, or incorrect glove size can interrupt the gowning process and may require repeating the entire procedure.

A standard sterile gown pack contains the items needed to safely don a sterile gown and prepare for closed gloving. While the exact contents vary by manufacturer and healthcare facility, most packs include:

• Sterile surgical gown
• One or two sterile hand towels
• Wrapping material that serves as a sterile work surface
• Sterility indicator confirming successful sterilization

Some facilities package sterile gloves separately, while others include them within the gown pack.

Before opening the pack, verify that it is the correct pack for the intended procedure.

The sterile surgical gown creates a protective barrier between you and the patient. It helps prevent microorganisms on your skin and clothing from contaminating the sterile field while also protecting you from exposure to blood and body fluids.

An appropriate surgical gown should:

• Provide full coverage of the torso and arms.
• Fit comfortably without restricting movement.
• Maintain its barrier properties throughout the procedure.
• Be suitable for the anticipated amount of fluid exposure.
• Once the gown has been donned correctly, only certain areas are considered sterile.

The sterile areas include:

• The front of the gown from approximately chest level to the level of the sterile field.
• The sleeves from approximately 5 cm (2 inches) above the elbows to the cuffs.
• The following areas are considered non-sterile:
• The neckline and shoulders.
• The back of the gown.
• Areas below the sterile field or below waist level.
• The axillary (underarm) region.

Understanding which parts of the gown are sterile is essential because these principles determine how you move, where you position your hands, and how you interact with other members of the surgical team.

Sterile gloves provide the final protective barrier between your hands and the sterile field. Even after surgical hand antisepsis, microorganisms remain on the skin. Gloves prevent these microorganisms from contaminating sterile instruments, tissues, and the operative site.

Sterile gloves should:

• Be the correct size.
• Fit snugly without restricting movement.
• Allow precise finger movement and tactile sensation.
• Completely cover the gown cuffs after closed gloving.
• Be free from tears, punctures, or manufacturing defects.

Selecting the correct glove size improves dexterity and reduces hand fatigue. Gloves that are too tight are more likely to tear, while gloves that are too loose reduce control and increase the likelihood of contamination during delicate tasks. Before beginning the procedure, inspect both gloves for damage and confirm that they correspond to the correct hand.

Choosing the correct size is an important part of maintaining a safe sterile barrier.

The gown should:

• Fit comfortably across the shoulders.
• Allow unrestricted movement of the arms.
• Completely cover the torso.
• Permit secure fastening without excessive tension.

A gown that is too small may restrict movement or tear during use. A gown that is too large may interfere with movement or increase the risk of contacting non-sterile surfaces.

The correct glove size should:

• Fit snugly around the fingers and palm.
• Allow unrestricted finger movement.
• Permit precise handling of instruments.
• Completely overlap the gown cuffs after closed gloving.

Never intentionally use gloves that are too large or too small simply because they are available. If the correct glove size cannot be obtained, notify the circulating nurse or supervisor before proceeding.

Every sterile package should be inspected before it is opened. Never assume a package is sterile simply because it appears unopened.

Before opening any sterile package, check for:

• Tears, punctures, or holes.
• Moisture or water damage.
• Broken or incomplete seals.
• Damaged package corners.
• Expired sterilization date, where applicable.
• A satisfactory sterility indicator confirming successful sterilization.

If any of these checks fail, the package should be considered contaminated and replaced.

Remember this important principle: When sterility is uncertain, consider the item contaminated until proven otherwise.

Healthcare facilities may use disposable gowns, reusable gowns, or both. Regardless of the type used, every gown must provide an effective sterile barrier throughout the procedure.

Disposable gowns are designed for single-patient use and are discarded after the procedure.

Advantages include:

• Consistent barrier performance.
• No need for laundering or reprocessing.
• Lower risk of wear-related damage.
• Convenient availability in many operating theatres.

Many disposable gowns include a belt card, which allows the circulating nurse to assist with securing the gown while maintaining sterility.

Reusable gowns are designed to undergo repeated cleaning, inspection, and sterilization between procedures.

Before use, inspect reusable gowns carefully for:

• Tears or holes.
• Worn or thinning fabric.
• Damaged seams.
• Failed closures or ties.

Only gowns that have completed the approved reprocessing and sterilization cycle should be used.

Reusable gowns provide an effective sterile barrier while reducing waste and lowering long-term costs. They are widely used in many district hospitals and other resource-limited healthcare settings.

Proper preparation reduces unnecessary movement and helps maintain sterility throughout the gowning process.

Before beginning surgical hand antisepsis, confirm that:

• All required supplies are available.
• The correct gown and glove sizes have been selected.
• Sterile packages are dry, intact, and undamaged.
• The sterile field has been prepared.
• The circulating nurse is available to assist when needed.
• There is sufficient space to unfold the gown safely without contacting non-sterile surfaces.

Good preparation minimizes interruptions and reduces opportunities for contamination.

Many district hospitals and low-resource healthcare facilities experience occasional shortages of equipment, supplies, or personnel. Maintaining patient safety remains the highest priority under these circumstances.

When resources are limited:

• Use approved reusable gowns when available.
• Confirm that substitute equipment meets institutional infection prevention standards.
• Inspect reusable equipment carefully before use.
• Never use damaged or visibly compromised gowns or gloves.
• If the correct glove size is unavailable, seek assistance rather than knowingly using poorly fitting gloves.
• If essential sterile equipment cannot be obtained, delay the procedure whenever clinically appropriate until safe equipment becomes available.

Resource limitations should never justify compromising the sterile barrier or placing the patient at unnecessary risk.

• Gather and inspect all required equipment before beginning the procedure.
• Understand the purpose of each item in the sterile gown pack.
• Select the correct gown and glove size before surgical hand antisepsis.
• Inspect all sterile packages for damage, moisture, broken seals, expiry dates, and sterility indicators.
• Understand which areas of the gown are sterile and which are non-sterile.
• Reusable gowns are safe when properly inspected, reprocessed, and sterilized.
• Organize equipment before gowning to reduce interruptions and contamination.
• If sterility is uncertain, consider the item contaminated and replace it before proceeding.
• Patient safety should never be compromised because of equipment shortages.

Self-assessment

Please complete the following: Sterile Gowning and Gloving Equipment Quiz

Surgical asepsis is a set of practices designed to eliminate microorganisms from the sterile field and prevent contamination during invasive procedures. Every member of the sterile team shares responsibility for maintaining sterility from the moment the sterile field is established until the procedure is completed.

Sterile gowning and gloving are only one part of surgical asepsis. They work together with surgical hand antisepsis, sterile instruments, sterile drapes, environmental controls, and proper surgical technique to reduce the risk of surgical site infections.

The following principles should guide every step of sterile gowning and gloving:

• Only sterile items should touch other sterile items.
• Sterile items that come into contact with non-sterile objects become contaminated.
• If sterility is uncertain, consider the item contaminated.
• Moisture may transfer microorganisms through sterile barriers (strike-through contamination).
• Sterility must be maintained continuously throughout the procedure.
• When contamination occurs, it should be recognized immediately and corrected before proceeding.

Maintaining sterility requires constant awareness. Because microorganisms cannot be seen, healthcare workers must assume contamination has occurred whenever aseptic principles are broken.

Knowing which areas are sterile helps you maintain an effective sterile barrier throughout the procedure.

After gowning and gloving, the following are considered sterile:

• The front of the gown from approximately chest level to the sterile field.
• The sleeves from approximately 5 cm (2 inches) above the elbows to the glove cuffs.
• The outside surfaces of properly donned sterile gloves.

These are the only areas that should contact sterile instruments, supplies, or other sterile personnel.

The following areas are considered non-sterile:

• The neckline and shoulders.
• The back of the gown.
• The axillary (underarm) region.
• Areas below waist level.
• Any damaged or visibly contaminated portion of the gown or gloves.

Understanding these boundaries helps prevent accidental contamination during movement and interaction with the sterile field.

Maintaining sterility depends not only on wearing sterile equipment but also on how you move and position yourself throughout the procedure.

During gowning and gloving:

• Keep your hands above waist level.
• Keep your hands in front of your body and within your field of vision.
• Avoid un
• necessary movements.
• Do not turn your back toward another sterile team member.
• Avoid reaching over non-sterile areas.
• Handle only sterile objects once gowned and gloved.
• Maintain an appropriate distance from non-sterile personnel and equipment.

Each movement should be deliberate and performed with awareness of the sterile field.

Maintaining sterility requires more than following the correct sequence of steps. You must also recognize when contamination has occurred and know how to respond before continuing.

Contamination can occur at any stage of gowning and gloving. Some contamination events are obvious, such as a torn glove, while others are subtle, such as lowering your hands below waist level or allowing the gown to brush against your clothing. Because microorganisms cannot be seen, any break in aseptic technique should be treated as contamination until proven otherwise.

The table below summarizes common contamination events that may occur during gowning and gloving and the appropriate response.

Not every contamination event requires repeating the entire procedure. The appropriate response depends on what was contaminated, when the contamination occurred, and whether the sterile barrier can be safely restored. Always follow your institution's policies and procedures.

Whenever contamination is suspected:

• Stop immediately. Do not continue until the contamination has been assessed.
• Identify the source of contamination. Determine whether the gown, gloves, sterile supplies, or sterile field have been affected.
• Prevent further contamination. Avoid touching additional sterile items until the problem has been corrected.
• Replace contaminated items. Replace the gown, gloves, or sterile equipment whenever sterility has been compromised.
• Communicate with the team. Inform the circulating nurse or other team members if contamination affects the sterile field or requires additional sterile supplies.

* Resume the procedure only after sterility has been restored.

Remember: If sterility is uncertain, consider the item contaminated until proven otherwise.

Many contamination events can be prevented by consistently following a few simple principles:

• Keep your hands above waist level and within your field of vision.
• Keep your hands inside the gown cuffs until both gloves have been fully applied.
• Handle the gown only by its inside surface before donning.
• Avoid unnecessary movements while gowning and gloving.
• Keep a safe distance from non-sterile personnel and equipment.
• Inspect the gown and gloves before entering the sterile field.
• Pause briefly before each major step to confirm that sterility has been maintained.

Developing these habits helps reduce contamination and improves consistency during every procedure.

Maintaining sterility is a shared responsibility between the scrubbed team and the circulating nurse.

The circulating nurse assists by:

• Presenting sterile supplies.
• Helping secure the sterile gown.
• Opening additional sterile equipment.
• Monitoring for breaks in sterile technique.

Good communication helps prevent contamination.

Before beginning gown securing:

• Confirm that both individuals are ready.
• Explain the next movement if necessary.
• Turn slowly and deliberately.
• Stop immediately if contamination is suspected.
• Clear communication protects both the sterile field and the patient.

• Surgical asepsis requires continuous maintenance of the sterile barrier.
• Only sterile items should contact other sterile items.
• Understand which parts of the gown and gloves are sterile.
• Keep your hands above waist level and within your field of vision.
• Recognize common contamination points throughout gowning and gloving.
• Immediately recognize and correct contamination whenever it occurs.
• Good communication with the circulating nurse helps maintain sterility.
• If sterility is uncertain, consider the item contaminated

Self-assessment

Please complete the following: Principles of Surgical Asepsis Quiz

Proper preparation before donning a sterile gown and gloves is essential for maintaining aseptic technique. Even if the gowning and gloving steps are performed correctly, poor preparation can compromise the sterile barrier before the procedure has even begun.

Surgical hand antisepsis is the first step in preparing for sterile gowning and gloving. Its purpose is to:

• Remove transient microorganisms from the hands and forearms.
• Significantly reduce resident microorganisms.
• Suppress bacterial regrowth during the surgical procedure.
• Reduce the risk of microorganisms contaminating the sterile field if glove perforation occurs.

Although surgical hand antisepsis greatly reduces microorganisms, it does not sterilize the skin. Sterile gowns and gloves are therefore required to provide the final protective barrier.

Depending on institutional policy and available resources, surgical hand antisepsis may be performed using:

• An antimicrobial surgical hand scrub.
• A validated alcohol-based surgical hand rub.
• The method used should follow your institution's infection prevention policy.

Note: This module assumes that you have already mastered surgical hand antisepsis. The complete technique is covered in the Surgical Hand Scrubbing module.

Proper drying is an essential step between surgical hand antisepsis and donning a sterile gown. Moisture remaining on the skin can compromise the sterile barrier by allowing microorganisms to pass through sterile materials, a process known as strike-through contamination.

Drying should begin immediately after completing surgical hand antisepsis using a sterile towel.

To dry your hands and forearms safely:

• Pick up the sterile towel without contaminating it.
• Use one end of the towel for the first hand and forearm.
• Begin at the fingertips and dry toward the elbow using one continuous direction.
• Do not retrace from the forearm back toward the hand with the same part of the towel.
• Use the unused end of the towel to dry the opposite hand and forearm using the same technique.
• Keep your hands above your elbows while drying to prevent water from running back toward the clean hands.

Using one continuous direction prevents microorganisms from being transferred back toward the hands.

Common mistakes include:

• Drying from the elbow back toward the fingertips.
• Using the same section of the towel for both arms.
• Retracing over areas that have already been dried.
• Allowing the towel to touch clothing or other non-sterile surfaces.
• Holding the hands below the elbows while drying.
• Placing the used towel back onto the sterile field.

Any of these actions may compromise aseptic technique before gowning even begins.

Before opening sterile supplies, ensure that the gowning area is properly prepared.

Confirm that:

• The sterile field has been established.
• There is sufficient space to unfold the gown without contacting surrounding objects.
• The sterile work surface is organized.
• All required equipment is immediately available.
• The circulating nurse is available to assist if needed.
• Unnecessary personnel movement around the gowning area is minimized.

Organizing the work area before gowning reduces interruptions and helps maintain sterility throughout the procedure.

Sterile supplies should be opened carefully to preserve the sterility of their contents.

Before opening any package:

• Inspect the packaging for tears, punctures, moisture, broken seals, or damage.
• Confirm that the sterility indicator has changed appropriately.
• Verify that the package has not expired, where applicable.

When opening sterile packages:

• Open the wrapper slowly to avoid contaminating the contents.
• Avoid reaching over sterile items.
• Touch only the outside of the package unless you are already scrubbed.
• Place sterile contents onto the sterile field without contaminating them.

If a sterile item touches a non-sterile surface or there is any doubt about its sterility, it should be considered contaminated and replaced.

Before lifting the gown, identify its correct orientation and ensure there is adequate space for it to unfold safely.

When preparing the gown:

• Hold it by the inside surface at the neckline.
• Keep the outside sterile surface away from your clothing and surrounding equipment.
• Confirm that the gown is the correct size.
• Inspect the gown for visible damage or defects.
• Allow the gown to unfold naturally under its own weight.

Do not:

• Shake the gown open.
• Snap the gown forcefully.
• Allow the gown to touch the floor or nearby equipment.

Using gravity to unfold the gown minimizes unnecessary air movement and reduces the risk of contamination.

Before beginning closed gloving, prepare the gloves so they can be donned smoothly without unnecessary manipulation.

Confirm that:

• The gloves are the correct size.
• The right and left gloves are correctly identified.
• The glove package has been opened correctly onto the sterile field.
• The gloves are positioned for easy access.
• There are no visible tears or manufacturing defects.

Good preparation reduces unnecessary handling and helps maintain the sterile barrier during closed gloving.

Immediately before picking up the sterile gown, pause and perform one final readiness check.

Confirm that:

• Surgical hand antisepsis has been completed.
• Your hands and forearms are completely dry.
• All sterile supplies are available and intact.
• Sterility indicators have been checked.
• The sterile field is prepared.
• The correct gown and glove sizes have been selected.
• There is sufficient space to unfold the gown safely.
• The circulating nurse is ready to assist.

Taking a few moments to complete this mental checklist reduces interruptions, improves efficiency, and helps prevent contamination before gowning begins.

• Proper preparation is essential before donning a sterile gown and gloves.
• Surgical hand antisepsis reduces microorganisms but does not sterilize the skin.
• Dry the hands and forearms from the fingertips toward the elbows using one continuous direction.
• Use separate sections of the sterile towel for each arm.
• Organize the sterile work area before opening supplies.
• Inspect every sterile package before use.
• Allow the gown to unfold naturally without shaking it.
• Prepare the gloves before beginning closed gloving.
• Perform a final readiness check before picking up the sterile gown.

Self-assessment

Please complete the following: Preparation Before Gowning Quiz

Closed gowning and gloving is the process of donning a sterile surgical gown followed immediately by the closed gloving technique before entering the sterile field. During this process, the hands remain inside the gown sleeves until both gloves have been completely applied.

Rather than thinking of gowning and gloving as separate tasks, they should be viewed as one continuous process in which each step prepares for the next. Following the correct sequence helps the procedure proceed smoothly while minimizing unnecessary handling of sterile items.

The sequence consists of:

1. Don the sterile gown.
2. Insert both arms into the gown sleeves.
3. Position the first sterile glove.
4. Apply the first glove.
5. Position and apply the second glove.
6. Make any necessary glove adjustments.
7. Secure the gown.

Perform a final inspection before entering the sterile field. Understanding this sequence before performing the procedure makes the technique easier to learn and helps identify errors when they occur.

Each step of closed gowning and gloving depends on the previous one. Changing the order can interrupt the procedure or make it more difficult to maintain sterility.

For example:

• The gown must be donned before closed gloving can begin.
• Both hands remain inside the gown sleeves until the gloves have been completely applied.
• The gloves should be adjusted only after both gloves have been donned.
• The gown should be secured only after the gloves have been applied correctly.
• The final inspection should be completed before approaching the sterile field.

Following a consistent sequence also improves efficiency. Repeating the same order every time reduces unnecessary movements, makes it easier to recognize mistakes, and helps develop safe habits through practice.

Correct glove positioning is one of the most important preparations for successful closed gloving. Proper orientation allows each glove to be applied smoothly with minimal handling.

Before applying each glove, confirm that:

• The correct glove has been selected for the appropriate hand.
• The palm of the glove faces the palm of the receiving hand.
• The glove fingers point toward the shoulders.
• The glove cuff is aligned with the end of the gown sleeve.
• The glove can be grasped easily without unnecessary repositioning.

Taking a few seconds to position the gloves correctly often prevents errors later in the procedure.

During closed gloving, the glove is drawn over the end of the gown sleeve while the hand advances into the glove. Both actions occur together as one coordinated movement.

When correctly applied:

• The glove should fit comfortably.
• Finger movement should be unrestricted.
• The glove should not be twisted.
• The glove should require only minimal adjustment after application.
• The same process is repeated for the second glove.

Smooth, deliberate movements are generally more successful than attempting to complete the procedure quickly.

After both gloves have been applied, minor adjustments may be needed to improve comfort and hand function.

Appropriate adjustment includes:

• Seating the fingers correctly within the gloves.
• Removing minor wrinkles that interfere with movement.
• Confirming that the gloves fit comfortably.
• Verifying that the glove cuffs fully overlap the gown sleeves.

Once these adjustments have been completed, avoid unnecessary handling of the gloves before beginning the procedure.

After both gloves have been donned, the gown is secured according to the design of the gown being used.

Many disposable gowns include a sterile belt card attached to one waist tie. The belt card allows the circulating nurse to assist with fastening the gown without touching the sterile surface of the gown.

After the belt card has been transferred, the waist ties are secured according to the manufacturer's instructions and institutional policy.

Reusable gowns may use fastening systems that differ from disposable gowns. Depending on the manufacturer, reusable gowns may have reusable waist ties, fabric belts, or other closure mechanisms.

Although the fastening system may differ, the gown should always be secured according to institutional policy while maintaining the sterile barrier.

Learning to recognize common technical problems makes the procedure easier to perform consistently and helps reduce unnecessary interruptions.

Recognizing these technical problems during practice helps develop a smoother and more efficient technique before performing the procedure in the clinical setting.

• Closed gowning and gloving should be viewed as one continuous sequence.
• Perform each step in the same order every time.
• Correct glove positioning makes application easier and reduces unnecessary handling.
• Smooth, deliberate movements are more effective than rushing.
• Different gown designs may use different fastening systems.
• Recognizing common technical problems helps improve consistency and efficiency during practice.

Self-assessment

Please complete the following: Closed Gowning and Gloving Sequence Quiz

Removing a sterile gown, gloves, and other personal protective equipment (PPE) is the final stage of maintaining infection prevention after a procedure. Although the sterile field no longer needs to be preserved, contaminated surfaces of the gown and gloves may carry blood, body fluids, or microorganisms that can expose healthcare workers, patients, or the surrounding environment.

The goal of removal is to avoid transferring contaminants from used PPE to your skin, clothing, or nearby surfaces.

Safe removal requires controlled movements, attention to hand placement, and adherence to your institution's infection prevention policies.

Just as gowning and gloving follow a specific sequence, PPE should also be removed in an appropriate order.

Removing items in the wrong sequence may:

• Contaminate clean clothing or exposed skin.
• Transfer microorganisms from contaminated PPE to the hands.
• Increase environmental contamination.
• Increase the risk of occupational exposure.

Although removal sequences may vary slightly between institutions depending on the PPE used, they are designed to minimize contamination at every stage. Always follow your institution's approved procedures.

Successful PPE removal depends on recognizing which surfaces should be considered contaminated.

In general:

• The following should be considered contaminated after patient care:
• The outside surface of the gloves.
• The outside front of the gown.
• The sleeves of the gown.
• Any area visibly contaminated with blood or body fluids.

The following are generally considered cleaner surfaces used during removal:

• The inside surface of the gown.
• Internal gown ties.
• Areas specifically designed to be handled during removal.

During removal, avoid touching contaminated surfaces whenever possible.

Gloves are usually the most contaminated item of PPE because they come into direct contact with the patient, instruments, and body fluids.

When removing gloves:

• Avoid touching your bare skin with the contaminated outside surface.
• Remove the gloves using an approved glove removal technique.
• Contain the contaminated glove inside the remaining glove whenever possible.

Dispose of gloves immediately into the appropriate waste container. Once gloves have been removed, perform hand hygiene according to institutional policy.

After glove removal, the sterile gown should be removed carefully to prevent contamination of clothing or exposed skin.

When removing the gown:

• Handle the gown using the inside surface whenever possible.
• Pull the gown away from the body slowly.
• Turn the contaminated outside surface inward as the gown is removed.
• Roll or fold the gown inward before disposal or reprocessing.

Avoid vigorous movements that may disperse contaminants into the surrounding environment.

Additional PPE may include:

• Eye protection.
• Face shields.
• Surgical masks.
• Respirators.
• Waterproof aprons.

Because the degree of contamination varies, these items should be removed according to institutional policy.

When removing additional PPE:

• Handle reusable equipment only by designated clean areas.
• Avoid touching the front surfaces whenever possible.
• Dispose of single-use items appropriately.
• Send reusable equipment for cleaning and disinfection according to local procedures.

Proper disposal and reprocessing are important parts of infection prevention.

Single-use items should:

• Be discarded immediately after use.
• Be placed into the correct waste stream according to local policy.

Reusable gowns and reusable eye protection should:

• Be placed in designated containers.
• Be transported for cleaning, inspection, and reprocessing.
• Never be mixed with clean supplies.

Correct disposal protects healthcare workers, environmental services personnel, and future patients.

Hand hygiene is the final step after removing PPE.

Although gloves reduce contamination, microorganisms may still be transferred to the hands during glove removal.

After removing all PPE:

• Perform hand hygiene immediately.
• Follow institutional policy regarding hand washing or alcohol-based hand rub.
• Ensure hands are completely clean before touching clean equipment or leaving the patient care area.

Hand hygiene completes the infection prevention process.

• PPE removal should minimize contamination of the healthcare worker and surrounding environment.
• Follow the approved removal sequence used by your institution.
• Handle contaminated PPE carefully and avoid unnecessary movements.
• Turn contaminated gown surfaces inward during removal.
• Dispose of single-use items appropriately.
• Send reusable items for approved reprocessing.
• Perform hand hygiene immediately after removing PPE.

Self-assessment

Please complete the following: Removal of Sterile Equipment Quiz

Healthcare workers in district hospitals and other low-resource settings may occasionally encounter shortages of sterile supplies, equipment, or personnel. These situations require careful decision-making to maintain patient safety while making the best use of available resources.

Although practices may need to be adapted, the fundamental principles of aseptic technique should never be abandoned. Safe adaptation means modifying how care is delivered without compromising the sterile barrier or increasing the patient's risk of infection.

When resources are limited, always ask:

• Can sterility still be maintained?
• Does this adaptation comply with institutional policy?
• Does this adaptation increase the patient's risk of infection?
• Is there a safer alternative?

Patient safety should always guide clinical decision-making.

When supplies are limited, priority should be given to equipment that directly maintains the sterile barrier.

Examples include:

• Sterile surgical gowns.
• Sterile surgical gloves.
• Sterile hand towels.
• Sterile drapes.
• Properly sterilized instruments.

Whenever possible:

• Gather all required equipment before beginning.
• Avoid opening unnecessary sterile supplies.
• Use supplies efficiently without unnecessary waste.
• Report shortages early so replacement supplies can be obtained.

Good planning helps reduce delays and unnecessary consumption of sterile supplies.

Many healthcare facilities rely on reusable surgical gowns and other reusable equipment to reduce costs and improve sustainability.

Reusable equipment may be safely used provided it has:

• Been cleaned according to institutional procedures.
• Been inspected for damage.
• Successfully completed the approved sterilization process.
• Been stored appropriately before use.

Before using reusable gowns:

• Inspect the fabric for tears, holes, thinning, or damaged seams.
• Confirm that ties and fasteners remain functional.
• Verify that sterility indicators are satisfactory where applicable.

A properly reprocessed reusable gown provides an effective sterile barrier comparable to many disposable gowns.

Occasionally, required equipment may not be immediately available.

Examples include:

• Incorrect glove sizes.
• Shortages of sterile gowns.
• Delayed sterilization of reusable equipment.
• Limited availability of sterile towels.

When shortages occur:

• Inform the circulating nurse or supervisor promptly.
• The scrub nurse may need to arrange gown and gloves supplies in advance before scrubbing so that minimal assistance is required afterward
• If glove sizes are scarce, the closest fit should be chosen rather than attempting to reuse gloves, which compromises both dexterity and sterility.
• Determine whether appropriate sterile alternatives are available.
• Delay the procedure if essential sterile equipment cannot be obtained and the patient's condition permits.

Follow institutional contingency plans whenever available. Shortages should never be managed by knowingly using damaged or non-sterile equipment.

Resource limitations often require greater coordination among members of the surgical team.

Effective communication helps the team:

• Anticipate equipment shortages.
• Prioritize available resources.
• Minimize unnecessary opening of sterile supplies.
• Coordinate the preparation of reusable equipment.
• Maintain patient safety despite operational challenges.

Reporting shortages early allows the team to identify solutions before the procedure begins.

Every shortage, contamination event, or equipment failure provides an opportunity to improve future practice.

Healthcare facilities should:

• Report recurring equipment shortages.
• Document damaged or defective equipment.
• Monitor contamination events.
• Review opportunities to improve sterilization, storage, and inventory management.
• Participate in quality improvement initiatives that strengthen infection prevention.

Continuous improvement benefits both healthcare workers and future patients.

• Patient safety remains the highest priority when resources are limited.
• Adapt clinical practice without compromising the principles of aseptic technique.
• Prioritize equipment that maintains the sterile barrier.
• Properly reprocessed reusable equipment is a safe and sustainable option.
• Never use damaged, expired, or non-sterile equipment because of shortages.
• Early communication helps the surgical team respond effectively to limited resources.
• Reporting equipment shortages and contamination events supports continuous quality improvement.

Self-assessment

Please complete the following: Adapting Sterile Gowning and Gloving to Resource-Limited Settings Quiz

Cumulative Assessment

Please complete the following: Cumulative Assessment