Deconstructing the 6-Step handrubbing technique for healthcare staff: a mixed-methods investigation of efficacy, acceptability and feasibility

Background: A 6-step technique is recommended for applying alcohol-based handrubs (ABHR) in healthcare. However, evidence supporting the effectiveness of individual steps is limited, and healthcare workers’ compliance is low, potentially due to low acceptability or feasibility, or inadequate training. This study evaluated the effectiveness of the 6-step handrubbing technique for healthcare staff with consideration of microbiological efficacy, acceptability and feasibility.<br/><br/>Methods: A mixed-method design was used. Data were collected in two stages between 2017-2020. Stage 1 employed a Latin square design with a modified EN 1500 procedure to compare the 6-step technique to 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 6-step handrubbing technique in clinical practice (n=78). <br/><br/>Results: Omitting step 4 (backs of fingers) resulted in significantly lower bacterial load reduction compared to the full 6-step technique (p=0.001). Omitting step 1 (palms) or step 2 (dorsa) resulted in significantly lower hand coverage compared to all other technique variations (p≤0.001). Stage 2 participants perceived the 6-step technique as acceptable and feasible, with step 1 as the most acceptable and feasible step.<br/><br/>Conclusion: Step 4 contributed most to bacterial load reduction, and steps 1 and 2 were key for hand coverage. Healthcare workers should continue using the 6-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.<br/>