Why is hand hygiene so difficult to learn?

We often hear complaints that the World Health Organization (WHO) hand hygiene 6-step technique is too difficult to learn and hard to remember. Studies show that compliance with technique can be as low as 15-18% (Tschudin-Sutter et. Al., 2015). Children tend to have the same reaction when they first begin learning how to tie their shoelaces. However, with repeated practice and feedback they eventually master the task. When it comes to hand hygiene, inappropriate teaching methods are at fault for hand hygiene being perceived as too complex. Too often hand hygiene is taught as “knowledge” rather than as a “skill”. Hand hygiene is a psychomotor skill that critical for patient safety. Therefore, it needs to be taught correctly or students and healthcare workers are being set up to fail

A Psychomotor Skill

Neuroscience tells us that we need to practice a psychomotor skill daily for 2 to 4 weeks to “automate” the skill. We should be able to perform the skill without conscious thought. Therefore, it is much better to have very short bursts of training separated by sleep rather than one long “massed” training session. This is because our brains consolidate motor learning while we are asleep. As hand hygiene is a psychomotor skill, it is not feasible to learn the correct technique in a single training session. We need to build a habit in hand hygiene, and this requires repeated training supported by feedback, just like when we learned to tie our shoelaces.

Training to Proficiency in the WHO Hand Hygiene Technique

In a study with Yale School of Medicine, we examined the effectiveness of hand hygiene training.
To measure how much training is required to learn the WHO hand hygiene technique we designed a study to train students until they could demonstrate the technique from memory. The student population was a group of 42 Physicians Assistant students who were attending their 5-day induction training course in YALE Medical School. A SureWash GO device was used to deliver identical short burst training with feedback to each student and to objectively evaluate their technique. The results of the study were that it took 32 hand hygiene practice sessions that took a total of 23-minutes over 5 days to achieve proficiency.

The key take-away message from this study is that the effectiveness of hand hygiene training is dependent on the number of times training is provided. If we want healthcare workers to retain the skill of hand hygiene, we can’t expect them to do so after a single training session. They need to be provided with regular training over multiple days to achieve proficiency. They also need the ability to train with feedback on their proficiency during each practice session.

Read to the full study with Yale School of Medicine here: https://journals.sagepub.com/doi/pdf/10.1177/2382120519867681

In Summary

We started this article off by asking why is it so difficult to learn the WHO 6 step technique. The answer is, we have always been teaching it wrong. The traditional classroom session learning approach is not affective to learn the skill of hand hygiene. However, we understand that providing repeated training to staff is time consuming and may not be achievable. This is where technology can come into play, saving infection preventionists time from both a training and administrative perspective.


Tschudin-Sutter, S., Sepulcri, D., Dangel, M., Schuhmacher, H., & Widmer, A. (2015). Compliance with the World Health Organization Hand Hygiene Technique: A Prospective Observational Study. Infection Control & Hospital Epidemiology, 36(4), 482-483. doi:10.1017/ice.2014.82