CLINICAL
References
Ayliffe, G.A.J. et al (1988) Hand
disinfection: a comparison of
various agents in laboratory
studies and ward studies.
Journal of Hospital Infection;
11: 226–243.
HMSO (1974) The Health and
Safety at Work Act.
London: HMSO.
Nursing and Midwifery Council
(2004) The NMC Code of
Professional Conduct:
Standards for conduct,
performance and ethics.
London: NMC.
PRACTICAL PROCEDURES
Handwashing
author Annette Jeanes, MSc, RGN, DipN, DipIC,
is consultant nurse infection control, University
College Hospitals, London.
The NMC Code of Professional Conduct (2004)
states that ‘you must… act to identify and minimise
risk to patients and clients’. The Health and Safety
at Work Act (1974) places a duty on workers to
avoid or reduce risk if technically possible.
Handwashing is a simple and effective infection
control intervention.
When to wash hands
Fig 1. Palm to palm
Hands should be washed:
l When they are visibly soiled;
l Before an aseptic or sterile procedure;
l When they feel dirty or sticky;
l Following frequent applications of a
decontaminant gel.
Hands may also be washed before and after
patient contact or putting on gloves. If hands are
not soiled or sticky, a decontaminant rub or gel
may be used. Where handrubs are not available,
the hands should be washed.
Johnny Zygo
Anatomy and physiology
28
All humans have bacterial flora on their skin,
although the quantities present vary (Price, 1938).
The bacterial flora on the hands can be divided
into two groups:
l Transient;
l Resident.
Resident flora are found on the surface of the skin
and under the superficial layers (stratum corneum).
They live and multiply on the hands. A common
example is Staphylococcus epidermidis. Resident
bacterial hand flora are unlikely to cause infections
on the skin surface but may be problematic if they
enter wounds or body cavities.
Transient bacterial flora are frequently acquired
from contact with surfaces, substances or people.
An example is Staphylococcus aureus. They may or
may not colonise the hands and are more easily
removed by handwashing than resident flora.
Transient flora may be pathogenic and cause
health care-associated infections.
The aim of handwashing is to remove transient
and some resident flora to prevent transmission of
pathogenic micro-organisms to patients. The action
of friction (rubbing hands together and drying with
a towel) and the effect of soap and water remove
debris and micro-organisms. Scrubbing should be
avoided as this may damage the skin.
Fig 2. Right palm over left dorsum and left palm over
right dorsum
Fig 3. Palm to palm, fingers interlaced
NT 5 July 2005 Vol 101 No 27 www.nursingtimes.net
keywords n Handwashing n Infection control n Procedures
Preparation
Fig 4. Backs of fingers to opposing palms with fingers interlaced
Taylor (1978) found that the handwashing
techniques of health professionals were often
inadequate, and training is therefore useful.
Posters are a good reminder of the correct
technique and the importance of handwashing.
In clinical settings, sinks should be at the correct
height for professionals to stand while
handwashing. Elbow or wrist action taps should be
adjusted for easy operation.
A foot-operated lidded bin is preferable. Liquid
soap and disposable towels should be wallmounted near the sink.
In the community, health professionals may have
to adapt to the available facilities, possibly carrying
a supply of disposable towels and liquid soap.
In some settings, facilities and supplies may be
more restricted but the general principles are the
same. It is important not to contaminate hands
from the operation of the taps or waste bin.
Nails should be kept clean and short, and
varnish or other decorations avoided. Abrasions or
cuts should be covered with a waterproof plaster.
Prior to washing the hands, rings, bracelets and
wristwatches should be removed, and long
sleeves rolled up.
Keep it clean
References
Price, P.B. (1938) The
bacteriology of normal skin:
a new quantitative test applied
to a study of the bacterial flora
and the disinfection action of
mechanical cleansing. Journal
of Infectious Diseases; 63:
301–318.
Taylor, L.J. (1978) An evaluation
of handwashing techniques.
Nursing Times; 74: 3, 108–110.
The procedure
Fig 5. Rotational rubbing of right thumb clasped in left palm and
vice versa
Fig 6. Rotational rubbing, backwards and forwards, with clasped
fingers of right hand in left palm and vice versa. Wrists are
similarly rubbed
NT 5 July 2005 Vol 101 No 27 www.nursingtimes.net
If a patient or relative is present, explain that you
are going to wash your hands. Turn on the water
and check the temperature is comfortable. Wet
hands under running water.
l Apply soap or detergent to the palms of the
hands and rub palms together vigorously (Fig 1);
l Place the right palm over top of the left hand
and rub. Repeat this with the left hand over the
right hand (Fig 2);
l Place palms together and interlace fingers and
rub. Link fingers so that the backs of fingers are
against the opposite palm and rub (Fig 3);
l Place the fingertips in the palm of the opposite
hand, rotate and rub. Repeat this for the other
hand (Fig 4);
l Grasp the right thumb with the left hand, rotate
and rub. Repeat with the opposite thumb (Fig 5);
l Grasp the left wrist with the right hand. Rotate
and rub. Repeat this for the other wrist. (Ayliffe et
al, 1988) (Fig 6);
l Rinse hands thoroughly, holding them downwards;
l Turn off taps with elbows or wrists. If this is not
possible, use a disposable paper towel to touch
the tap while turning it off;
l Dry hands thoroughly using as many disposable
paper towels as necessary. Place used towels in a
foot-operated waste bin.
This entire procedure normally takes 15–30
seconds. A longer surgical scrub will require extra
soap or detergent. n
This article has been double-blind
peer-reviewed.
For related articles on this subject
and links to relevant websites see
www.nursingtimes.net
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