Journal of Patient Safety and Infection Control

: 2021  |  Volume : 9  |  Issue : 1  |  Page : 8--12

Qualitative observational assessment of the recommended hand rubbing technique amongst young healthcare workers at an academic hospital

Mazin Barry1, Raghad Alotaibi1, Farah Alotaibi2, Lama Alotaibi3,  
1 Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, , Saudi Arabi
2 Division of Emergency Medicine, King Abdulaziz Medical City, Riyadh, , Saudi Arabi
3 Division of Dermatology, Prince Sultan Military Medical City, Riyadh, , Saudi Arabi

Correspondence Address:
Dr. Mazin Barry
Division of Infectious Diseases, King Saud University Medical City, College of Medicine, King Saud University, P. O. Box 2925, Riyadh 11461
Saudi Arabi


Background: Hand hygiene (HH) is a major cornerstone in preventing hospital-acquired infections. The recommended six-step alcohol-based hand rubbing (ABHR) technique has not been qualitatively evaluated amongst young healthcare workers (HCWs) before. Methods: A cross-sectional observational study at an academic hospital was conducted in 2018; data collectors observed HCWs voluntarily perform ABHR, observing for the quality of the six steps of HH and recording the duration, and if they performed accessory removal then recorded total qualitative scores. Results: Three hundred and seventy-seven young HCWs were qualitatively observed, the mean age of participants was 24.1 years, 49.1% were female, only 10 (2.7%) completely fulfilled all six steps, 97.35% of HCWs had inadequate hand surface coverage and 69.23% did not achieve sufficient timing. The median scores, out of 12, for 3rd-, 4th- and 5th-year medical students, were 6.4, 7.2 and 7.5, respectively, while medical interns scored 7.4 and medical residents scored 7.5 (P = 0.016). Participants with previous HH training sessions scored higher with mean scores of 7.4 versus 6.3 (P ≤ 0.001). Conclusion: The quality of ABHR practised by young HCWs lacked the appropriate coverage of full hands surface coverage and inadequate duration of time, special training and follow-up on the quality of ABHR technique for HCWs early in their career is warranted.

How to cite this article:
Barry M, Alotaibi R, Alotaibi F, Alotaibi L. Qualitative observational assessment of the recommended hand rubbing technique amongst young healthcare workers at an academic hospital.J Patient Saf Infect Control 2021;9:8-12

How to cite this URL:
Barry M, Alotaibi R, Alotaibi F, Alotaibi L. Qualitative observational assessment of the recommended hand rubbing technique amongst young healthcare workers at an academic hospital. J Patient Saf Infect Control [serial online] 2021 [cited 2022 Dec 6 ];9:8-12
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Hospital-acquired infections (HAIs) have a major impact on patient safety, morbidity and mortality.[1],[2],[3],[4],[5] It is estimated that HAI affects 5%–15% of hospitalised patients and up to 37% of patients admitted to intensive care units in some reports.[6] Prevalence of HAI is reported differently in different countries but is not directly associated with hand hygiene (HH) quality reports.[7],[8],[9],[10],[11],[12],[13],[14]

Healthcare workers (HCWs), including medical students, medical interns and post-graduate residents, play a pivotal role as transporters of microorganisms on their hands.[15],[16] Evidence-based models for improved HH practices indicate that suboptimal technique is a major factor of hand transmission during patient care.[17] It is well established that proper HH with soap and water or with alcohol is the most important precautionary measure to prevent HAI.[15],[18],[19] Alcohol-based hand rubbing (ABHR) is promoted by the World Health Organization (WHO) as the gold standard of HH based on its microbiological removal efficacy, the time it takes, easy accessibility and lower skin irritation in comparison to hand washing, unless hands are visibly soiled.[15],[19],[20] Wearing hand rings and accessories were also found to increase the risk of contamination.[21]

Effective HH requires proper frequency and technique. The 'Five Moments of Hand Hygiene' are recommended by the WHO for every patient encounter, with proper technique. An efficient HH technique requires removing accessories, applying an adequate amount of alcohol solution, preforming the six steps to guarantee good coverage of the hand surfaces and sufficient time for rubbing and drying.[15] After applying a palmful of the product in a cupped hand, covering all surfaces, the six subsequent steps include: (1) rub hands palm to palm, (2) right palm over left dorsum with interlaced fingers and vice versa, (3) palm to palm with fingers interlaced, (4) backs of fingers to opposing palms with fingers interlocked, (5) rotational rubbing of left thumb clasped in right palm and vice versa and (6) rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once HCW hands are dry, they are considered safe for pateint examination. The proper duration of the entire procedure should be 20–30 seconds.[15]

Overall compliance of HCWs with the Five Moments of HH is varied and has been studied extensively,[22],[23] however, the technique of ABHR has rarely been studied in clinical settings, especially amongst young HCWs including medical students, medical interns and post-graduate residents, who typically rotate all over hospital departments. No qualitative evaluation has been conducted to assess the quality of ABHR in these subsets of HCWs; we conducted a qualitative assessment of the six steps practised by this group.


A cross-sectional observational study was performed between 1 August 2018 and 30 September 2018 at King Khalid University Hospital (KKUH), a tertiary care academic hospital, in Riyadh, Saudi Arabia. The study was approved by its Institutional Review Board (IRB: E-17-2678). Our pre-defined primary outcome was to evaluate the quality of the six steps of ABHR in terms of technique and duration amongst a subgroup of young HCWs defined as medical students in their clinical years which in our university are 3rd–5th year, medical interns and post-graduate residents. The minimal estimated sample size was 318 participants selected randomly from the three different strata: 166 students, 48 interns and 105 residents. Presuming 50% of study population would be familiar with alcoholic-based hand rub, bearing with the finite population correction factor, 80% power and 95% confidence interval. Convenience sampling was used to include 3rd-, 4th- and 5th-year medical students in clinical years attending hospital wards. Interns and residents rotating at KKUH were also included in the study. Students in their 1st and 2nd years of medical education were excluded. Residents from specialities that have no direct contact with patients were also excluded. We evaluated the quality of ABHR by direct observation by the researchers in an academic hospital and since it did not interfere with HCWs' daily practice and their environment, the possibility of the Hawthorne effect was reduced. Prior to observational data collection, data collectors were trained with practise sessions that included observation and scoring of different scenarios with different mistakes until they were accurate for at least 6 consecutive times. Three data collectors recruited participants, after obtaining their informed written consent; participants were asked to complete a short survey that included demographic data, year of training and previous attendance of any HH training session in their career.

Next, participants were asked to voluntarily perform ABHR. Data collectors observed the participant's technique and recorded their scores. For each of the six steps of ABHR, two points were allocated for each appropriately performed step, one for incomplete step and zero for any missed step. For steps that include bilateral poses, two points were allocated if the technique was performed properly on both hands, one if performed only on one hand or inappropriately on both hands, and zero if not preformed. The maximum possible score was 12 and the lowest was 0. The total duration was documented, 20–30 s or more was considered sufficient, while <20 s was considered insufficient. Accessory removal was also recorded. Finally, feedback regarding the six steps of ABHR was given to all participants.

Data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 22 (SPSS Inc., Chicago, IL, USA). Chi-squared and Fisher's exact tests were used for categorical variables. P < 0.05 was considered statistically significant.


Four hundred and two candidates were approached, out of which 377 (93.8%) agreed to participate, 220 (58.3%) were medical students in their clinical years, 50 (13.3%) were medical interns and 107 (28.4%) were post-graduate training residents. The mean age of participants was 24.1 ± 2.5 years, 50.9% were male and 49.1% were female. Other participant characteristics are shown in [Table 1].{Table 1}

Only 10 (2.7%) participants fulfilled all the six steps of ABHR completely. Out of a perfect score of 12, the median scores for 3rd-, 4th- and 5th-year medical students were 6.4, 7.2 and 7.5, respectively, while medical interns scored 7.4 and post-graduate residents scored 7.5 (P = 0.016). Junior residents in their 1st year of training scored higher than seniors in their 2nd or 3rd year (P = 0.001). The quality of each of the individual six steps did not differ between all study participants [Table 2].{Table 2}

Participants who had previously attended HH training sessions during their career scored higher than those who did not attend any training sessions, with mean scores of 7.4 versus 6.3 (P ≤ 0.001), respectively, with a significantly higher quality in step 2: palm over back with fingers interlaced and step 6: rotational rubbing, backwards and forwards with clasped fingers [Table 3].{Table 3}

Sufficient timing was achieved by 116 (30.8%) or a third of participants. Removal of rings and accessories was performed by only half of the study participants who wore them. Compliance with specific steps was best for the first step of palm-to-palm rubbing (99.2%), while the fourth step of backs of fingers to opposing palms with fingers interlocked had the lowest compliance (13.3%).


In this study, we used the six steps of ABHR recommended by the WHO to evaluate the quality of HH amongst young HCWs focusing on medical students, medical interns and post-graduate residents. We found that almost 97% of our study participants had inadequate ABHR technique, which is extremely high, and almost 70% did not achieve sufficient timing duration of HH to ensure efficient antimicrobial activity. Despite the possibility of a positive impact of the Hawthorne effect from direct observation, this effect would have overestimated their HH quality rather than underestimate it. Poor quality of ABHR was especially illustrated with completely missing the fourth step of backs of fingers to opposing palms with fingers interlocked, as more than three-quarters of study participants missed this step.

There are little data on the quality of ABHR technique practised by HCWs; a recent study in Korea observed insufficient converge of hand surface by more than 90% of HCWs.[24] Fingertips and tips of the nails were the most commonly missed areas in studies that used a florescent substance to evaluate HH.[25],[26],[27],[28] A review by Tschudin-Sutter et al. on HH amongst HCWs found that the lowest rate of compliance to different HH steps was the fourth step of ABHR amongst both doctors and nurses, which is similar to our findings.[29] A recent study suggested that a new and less complex ABHR technique that includes only three steps instead of six may help alleviate the problem, the technique showed sufficient hand surface coverage in experimental settings and suggested it may be a better method to be used if further reports show the same results in clinical settings.[30]

No previous studies have focused on young HCWs such as medical students, medical interns and post-graduate residents; this group of HCWs, who are classically more distributed within hospital wards and clinics, has higher potential to act as vectors for HAI.

Some of the study limitations include it being based in one academic centre, which limits its generalisation; no florescent substance was used to evaluate participants' hands; furthermore, there is a probability of observation and observer bias, which we tried to limit by special training sessions of observer's pre-study.


The quality of ABHR practised by young HCWs seems to lack the full and appropriate coverage of all hand surfaces and might serve as a medium for HAI. Further efforts are warranted to emphasise the appropriate technique of ABHR and early introduction of mandatory HH training with emphasis on the 6-step technique of ABHR, especially in academic hospitals with high flow of young HCWs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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