Proper handwashing technique: a restaurant observation

Picture of Jasminka Criley, MD, FACP, FHM

Jasminka Criley, MD, FACP, FHM

President and CEO, Indelible Learning
Associate Clinical Professor of Medicine, UCLA School of Medicine

Observing handwashing of others in public restrooms reveals many examples of poor handwashing technique.

People do not know proper hand washing technique.

Or do they?

Even if they know proper hand washing technique, it does not seem they are implementing it, at least not regularly or consistently.

When I tell people that we have been creating a handwashing learning game, an app to improve people’s hand washing technique, and upgrade their health habits, I often hear them telling me: “I always wash my hands,” or “I always use hand sanitizer to wash my hands.” What they mean to say is they are already doing it or that they at least pay attention to it.

That is good, but does doing it mean doing it well?

Does “doing it” mean “my hands are now clean?”

The only way to wash your hands well is by doing it properly.

Doing it properly means more than washing for 20 seconds as often recommended. Doing it well means being aware of things you touch around you that are potentially contaminated, and washing your hands, well, mindfully.

Are you aware of how you wash your hands?

Are you aware how you wash your hands at all times?

If you touch poop or other soiled material, you would probably be aware that you need to wash your hands well. Immediately. But what if you are distracted?

What if you touch a door handle in the restroom that someone else with poop on their hands touched before being able to get to the water faucet? In that case, you would not know that you got that dirty material on your hands, too.

In both cases, you do not wash your hands thoroughly, you might still have some of that “soiled material remnants” on your hands. If that “soiled material” came from a person with infectious diarrhea, you might get infectious diarrhea, too.

During, as well as after the pandemic, we made a number of personal observations while visiting restaurants, hotels, healthcare facilities and even educational institutions that confirmed our prior observations: even with a good will, and good intentions to wash their hands, people often do not do it well.

Here is only one example (from a restaurant, a common place many people go to) that illustrates our prior observations:

A woman comes out of the restroom. She is beautifully groomed with a long hair, impeccable makeup, and fashionable outfit. As she goes to the sink to wash her hands after using the toilet, this is what she does:

  1. First, she holds her mobile phone in her hand (which she was using while on the toilet) and puts it on the counter.
  2. Then, she looks at herself in the mirror, checking her hair and her makeup. She touches her right eye to fix her artificial eyelashes.
  3. She opens the water using the faucet handle, and washes her hands, rubbing palms while continued to look at herself in the mirror. And somewhat, rubbing the back of her hands. She has beautiful long nails with flawless nail polish.
  4. She turns off the faucet.
  5. She dries her hands.
  6. She picks up her phone and looks at it.
  7. She again inspects her face and her makeup.
  8. Then, she opens the bathroom doors and exits.

How did she do?

Let’s analyze her steps:

  1. She used her cellphone while on the toilet.
    1. Where did she hold her phone if she needed to wipe herself? On the floor? In her hand?
    2. Did some of the “stuff” get on her phone?
  2. She went to the sink area and placed her phone on the bathroom counter.
    1. How clean is her phone now, I wonder?
    2. Will she clean it before picking it up again?
    3. How clean was the counter in the publicly shared bathroom?
    4. If the counter is not clean, is she adding to the number of germs on her phone?
    5. If she got some germs on her phone while using the toilet, did she let some of those germs spread on the counter?
    6. If someone comes after her and touches the same counter, will they pick up some of these germs, too?
  3. She touched her eye before she washed her hands.
    1. Did she spread some of the germs she potentially had on her hands, before washing them, onto her eye? If she did, does it matter?
  4. She turned on the faucet with her hands after using the toilet.
    1. Were those hands dirty and did she spread some germs on that faucet handle too?
    2. Did she contaminate her hands again, after turning off the faucet with hers now seemingly clean hands?
    3. Will the next person that touches that same faucet handle get those germs on their hands now?
  5. Handwashing duration:
    1. She washed her hands for about 20 seconds.
    2. According to CDC guidelines, that is sufficient for handwashing.
    3. Unfortunately, the duration of handwashing does not determine (and is not correlated with) the quality of handwashing.
    4. Let’s look closer at how she washed her hands.
  6. Handwashing technique: she was washing her hands automatically, without even thinking about it.
    1. She washed her palms thoroughly.
    2. She washed the back of her hands, somewhat.
    3. She did not wash in between her fingers.
    4. She did not wash her fingertips.
    5. She did not wash the area around her nails (which were long).
    6. She did not wash her thumbs.
    7. She had jewelry on her wrists and did not wash her wrists either.
  7. She rinsed her hands.
  8. She turned off the faucet with her clean hands.
    1. Did she get additional germs from the faucet handle on her hands?
  9. She dried her hands which was good, but then threw the paper away too soon.
  10. She picked up her phone from the counter (with clean hands).
    1. How clean are her hands now?
  11. She touched her eyes and face again (did she transmit some germs onto her face?).
  12. She opened the restroom doors touching the restroom door handle with her bare hands.
    1. How clean was that handle?
    2. Did her potentially newly contaminated hands (from faucet handle and/or her dirty phone) transmit additional germs to the door handle?

She went out to the real world, hugging, touching her friends, eating, drinking, and living her life happily. Could she have gotten sick from missing any of the above hand washing steps?

What was her Handwashing Score?

Turn on clean running water 1
Wet hands under water 1
Apply soap 1
Scrub PALMS 1
Scrub BACK of left hand 1
Scrub BACK of right hand 1
Scrub BETWEEN fingers 0
Scrub THUMB of left hand 0
Scrub THUMB of right hand 0
Scrub NAILS of left hand 0
Scrub NAILS of right hand 0
Scrub FINGERTIPS of left hand 0
Scrub FINGERTIPS of right hand 0
Scrub WRIST of left hand 0
Scrub WRIST of right hand 0
Rinse 1
Dry hands with a clean towel 1
Turn off water with a towel 0
Handwashing score 8

She did 8 out of 18 total hand washing steps.

In relation to the 12-handwashing scrubbing steps she did only 3 out of 12 steps (she washed her palms and backs of her hands only).

It is easy to see how even well-meaning people do not do a good enough job washing their hands. In our example, she had good intentions. If asked, she would honestly say that she washed her hands or that she always washes her hands.

But, doing it the way she did it, she missed so many proper hand washing steps. That technique that she demonstrated in real life while missing some hand washing steps, might potentially contribute to spreading germs to others.

That point is extremely important especially in our efforts to combat some diseases like infectious diarrhea (notoriously easy to spread Norovirus being one of them).

In addition to Norovirus, some other pathogens that we transmit via diarrhea and dirty hands include: E. coli, Salmonella, Shigella and others.

Dirty hands can also transmit germs from a upper respiratory infections, like the common cold, the flu or RSV.

Any of these germs could have been spread this way from incompletely washed hands. Even clean hands that touch something dirty can undo the best of hand hygiene efforts.

While advising people to wash their hands for 20 seconds might have been a good initial public health strategy, more could be done.

We need to teach people healthy habits including how to wash their hands properly. Ideally, we would start proper hand washing instruction at an early age. That includes practicing all hand washing steps, especially handwashing scrub steps.

While teaching children is extremely important, adults might need a refresher and reminder too. as demonstrated in only one example shared in this story. People are capable of learning more and learn better. Let’s not underestimate people’s ability to learn.

What are your observations about how people wash their hands at home, work, in hotels, restaurants, airports, universities, hospitals or other public places? Are they doing it well? What could they do even better?