PPE Donning And Doffing

Historical Context & Motivation

The concept of personal protective equipment (PPE) in healthcare settings evolved alongside our understanding of how infectious diseases are transmitted. Long before germ theory was established, practitioners noticed that physical barriers seemed to reduce the spread of plague and other epidemic diseases. The formal integration of PPE into clinical practice accelerated dramatically during the twentieth century as microbiology revealed the mechanisms of contact, droplet, and airborne transmission. Today, standardized donning and doffing procedures represent one of the most critical competencies for licensed practical and vocational nurses, directly impacting patient safety outcomes and clinician well-being.

Despite decades of guidelines, studies consistently show that self-contamination during doffing occurs in up to 40% of observed removal episodes when proper technique is not followed. This raises a central question for every nursing student: how can a structured, evidence-based sequence for putting on and removing PPE minimize cross-contamination and protect all parties involved in patient care?

Core Principles of PPE Use

Effective PPE use rests on a set of foundational principles that guide clinical decision-making. The practical nurse must understand not only which items of PPE to select but also why the sequence matters, how each component addresses a specific transmission route, and when hand hygiene must be performed within the process. These principles apply across all isolation categories—contact, droplet, and airborne—and form the backbone of infection prevention competency tested on the NCLEX-PN examination.

Donning Sequence — Visual Guide

The CDC-recommended donning sequence follows a specific order designed to create an unbroken barrier between the clinician and potentially infectious material. The mnemonic "G-M-E-G" (Gown → Mask → Eyewear → Gloves) captures the standard sequence. Each step builds upon the previous one, ensuring that the most external—and therefore most contaminated during patient care—layer is applied last. The following diagram illustrates this stepwise progression from hand hygiene through final glove application.

As illustrated above, the donning sequence begins with thorough hand hygiene—either soap and water for a minimum of 20 seconds or an alcohol-based hand rub (ABHR). The gown is applied first because it covers the largest surface area of the body and must be secured before subsequent items are layered over it. The mask or respirator comes next, seated firmly against the face with the nosepiece molded to the bridge of the nose; for an N95 filtering facepiece respirator, a user seal check must confirm that no air leaks around the edges. Eye protection—goggles or a face shield—is placed over the mask to shield mucous membranes of the eyes. Finally, gloves are pulled on and their cuffs extended over the gown's wristbands, ensuring no gap exists between glove and gown.

Doffing Sequence — The Critical Phase

If donning is about building a barrier, doffing is about dismantling it without breaching sterility. Research published in the American Journal of Infection Control demonstrates that the removal phase accounts for the majority of self-contamination events, particularly when healthcare workers rush or deviate from the prescribed order. The CDC outlines two acceptable doffing sequences: one involving a combined glove-and-gown removal and one involving separate removal. Both sequences share the same cardinal rule—gloves, which are the most heavily contaminated item, must always come off first, and the mask or respirator, which protects the airway, is always removed last, after exiting the patient's room or anteroom.

Standard Doffing Sequence

1. Step 1 — Remove gloves: Using a glove-in-glove technique, grasp the outside of one glove near the wrist and peel it away, turning it inside out. Hold the removed glove in the still-gloved hand, then slide fingers under the wrist of the remaining glove and peel it off over the first glove, creating a contained bundle. Dispose in the designated waste receptacle.
2. Step 2 — Perform hand hygiene.
3. Step 3 — Remove goggles or face shield: Handle only by the headband, earpieces, or temples—never touch the front surface. Place reusable items in the designated receptacle for reprocessing.
4. Step 4 — Remove gown: Unfasten ties at the neck and waist. Pull the gown away from the body, touching only the inside surfaces. Roll the contaminated exterior inward and dispose.
5. Step 5 — Perform hand hygiene.
6. Step 6 — Remove mask or respirator (outside the room): Grasp the bottom elastic or ties first, then the top, and pull the mask away from the face. Do not snap the elastic. Discard immediately.
7. Step 7 — Perform hand hygiene.

An alternative method endorsed by the CDC is the simultaneous glove-and-gown removal technique, in which the nurse grasps the front of the gown and pulls it forward, turning the gown and gloves inside out together as they are peeled off. This reduces the number of hand-to-contaminated-surface contacts, though it requires careful practice to execute without inadvertently touching the outer surface. Regardless of which technique is used, the sequence always concludes with mask removal outside the room followed by hand hygiene.

PPE Classification by Isolation Precaution

The selection of PPE components is not arbitrary; it is dictated by the type of transmission-based precautions required for a given patient. Standard Precautions form the baseline and are applied for every patient encounter where exposure to blood, body fluids, secretions, excretions, non-intact skin, or mucous membranes is anticipated. On top of Standard Precautions, one or more transmission-based categories may be layered depending on the pathogen's identified or suspected mode of spread. The table below maps each isolation category to its required PPE, common clinical examples, and the rationale for each barrier.

Worked Example — Clinical Scenario

The following scenario walks through the complete decision-making and procedural process a practical nurse would follow when entering and exiting the room of a patient on airborne and contact precautions. This scenario integrates PPE selection, donning, patient interaction, and doffing into a single clinical narrative.

Common Errors & Best Practices

Observational studies of healthcare workers reveal consistent patterns of PPE misuse that elevate infection risk. Understanding these common errors—and the evidence-based practices that prevent them—is essential for NCLEX-PN preparation and safe clinical practice. The following table contrasts frequent mistakes with their corresponding best-practice corrections.

Connection to Advanced Infection Prevention Concepts

While the NCLEX-PN examination focuses on the fundamental donning and doffing procedures covered in this lesson, practical nurses should be aware that PPE competency exists within a broader framework of infection prevention science. As healthcare delivery becomes more complex and emerging pathogens continue to challenge existing protocols, several advanced concepts build upon the foundational skills reviewed here.

As practical nurses advance in their careers, they may encounter situations that demand these more sophisticated approaches. The COVID-19 pandemic, for example, forced many facilities to implement crisis-capacity N95 reuse strategies that would have been unthinkable under normal supply conditions. Understanding why the standard protocols exist—and the infection transmission principles that underpin them—equips the nurse to adapt thoughtfully when circumstances require deviation, always under the guidance of the facility's infection preventionist and in accordance with the most current CDC recommendations.

Practice Problems

Lesson Summary