Deconstructing the six-step hand rubbing technique for healthcare staff: a mixed-methods investigation of efficacy,...

A six-step technique is recommended for applying alcohol-based hand rubs (ABHRs) in health care. However, evidence supporting the effectiveness of individual steps is limited and healthcare workers' (HCWs)' compliance is low, potentially due to low acceptability or feasibility or inadequate training. This study evaluated the effectiveness of the six-step hand rubbing technique for healthcare staff with consideration of microbiological efficacy, acceptability and feasibility.

A mixed-method design was used. Data were collected in two stages between 2017 and 2020. Stage 1 used a Latin square design with a modified EN 1500 procedure to compare the six-step technique with six variations omitting one step each, for bacterial load reduction and hand surface coverage (N = 35). Stage 2 was a cross-sectional online survey of the acceptability and feasibility of using the six-step hand rubbing technique in clinical practice (N = 78).

Omitting step 4 (backs of fingers) resulted in significantly lower bacterial load reduction than with the full six-step technique (P = 0.001). Omitting step 1 (palms) or step 2 (dorsa) resulted in significantly lower hand coverage than with all other technique variations (P ≤ 0.001). Stage 2 participants perceived the six-step technique as acceptable and feasible, with step 1 as the most acceptable and feasible step.

Step 4 contributed most to bacterial load reduction, and steps 1 and 2 were key for hand coverage. HCWs should continue using the six-step technique, with efforts to improve compliance with individual steps. Future research should investigate the effects of altering step sequence and the contribution of individual steps during handwashing with soap and water.