SELF/Perioperative Nursing/Surgical Scrubbing

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This training module prepares healthcare workers to safely enter a sterile environment by performing effective surgical hand antisepsis. Learners will develop the knowledge and psychomotor skills needed to eliminate transient microorganisms, reduce resident microorganisms on the hands and forearms, and prevent contamination before participating in sterile procedures. The module emphasizes infection prevention, systematic surgical scrubbing technique, contamination avoidance, appropriate use of antiseptic agents, and safe transition from the scrub sink to the operating room while maintaining asepsis.

The target learner is a trainee theatre nurse with 3 years of general nursing training and 2 years of post-qualification clinical experience transitioning into perioperative nursing practice.

The learner is already familiar with basic infection prevention, routine hand hygiene, and aseptic principles but requires structured practice in surgical scrubbing technique, sterile positioning, contamination avoidance, and transition into the sterile operating room environment

A theatre trainee practicing in a resource-limited setting, characterized by a critically constrained infrastructure. This learner must navigate systemic challenges including chronic instrument and supply shortages, severe understaffing, and a high-volume workload within an overcrowded and inadequately equipped clinical space.

By the end of this module, you will be able to:

• Describe the purpose of surgical scrubbing in reducing transient microorganisms, lowering resident microorganisms, and preventing surgical site infections.
• Explain nail, jewelry, skin integrity, and personal protective equipment (PPE) requirements before surgical scrubbing.
• Identify the antiseptic agents commonly used for surgical scrubbing and explain their appropriate use.
• Explain the correct sequence, directionality, and principles of surgical scrubbing, including contamination prevention throughout the procedure.
• Demonstrate safe practices for maintaining asepsis while moving from the scrub sink to the operating room.
• Describe appropriate adaptations to surgical scrubbing practices in low-resource settings while maintaining infection prevention principles.

Surgical scrubbing, also called surgical hand antisepsis, is a systematic process used to eliminate transient microorganisms and reduce resident microorganisms on the hands and forearms before participating in a sterile procedure. It is performed immediately before entering the sterile environment to reduce the risk of transferring microorganisms into the surgical field.

Unlike routine hand hygiene, surgical scrubbing combines mechanical friction with an antimicrobial scrub solution to achieve a much greater reduction in microbial burden. Although resident microorganisms cannot be eliminated completely because they live within the deeper layers of the skin, their numbers can be significantly reduced through effective surgical hand antisepsis.

The goal of surgical scrubbing is not to sterilize the skin. Instead, it reduces microorganisms to the lowest practical level while preserving skin integrity and preventing contamination before entering the sterile environment.

Every member of the surgical team has the potential to introduce microorganisms into the operative field. Even when sterile gowns and gloves are worn, microorganisms remaining on the hands may contaminate the sterile field if gloves become damaged or microscopic defects develop during surgery.

Proper surgical scrubbing reduces the microbial burden before participating in a sterile procedure, lowering the likelihood that microorganisms will reach the patient. This helps prevent surgical site infections (SSIs), which remain one of the leading causes of postoperative illness worldwide.

In low-resource settings, preventing infection is especially important because access to advanced wound care, microbiology services, and effective antibiotics may be limited. Preventing contamination before surgery is therefore safer and more effective than treating infection after it occurs.

Microorganisms found on the hands are broadly classified into two groups.

Transient microorganisms are acquired through contact with patients, equipment, and the environment. They remain on the surface of the skin and are readily removed through proper hand hygiene.

Resident microorganisms normally live within the deeper layers of the skin. They cannot be completely eliminated, but their numbers can be greatly reduced by surgical hand antisepsis.

Mechanical friction removes dirt, debris, and transient microorganisms, while antimicrobial scrub solutions reduce resident microorganisms and suppress their regrowth during surgery.

Understanding this difference helps explain why surgical scrubbing follows a systematic sequence and why proper technique is essential.

Healthy skin is an important part of infection prevention. Before beginning the surgical scrub, inspect your hands and forearms for cuts, dermatitis, skin infections, or other conditions that may interfere with effective scrubbing.

Fingernails should be short, smooth, and clean because microorganisms readily accumulate beneath long or irregular nails. Artificial nails and acrylic extensions should not be worn because they create microscopic spaces that harbor bacteria and fungi that cannot be completely removed during scrubbing.

Current evidence suggests that intact nail polish on short, natural nails does not significantly increase bacterial counts. However, chipped or peeling nail polish should not be worn because damaged polish creates surfaces where microorganisms accumulate and interferes with effective cleaning.

Jewelry, watches, and bracelets must be removed before scrubbing. These items trap moisture and microorganisms, prevent complete cleaning of the skin beneath them, and may damage sterile gloves during surgery.

Repeated surgical scrubbing throughout the day may dry or irritate the skin. Maintaining healthy skin through institution-approved skin care practices helps preserve the effectiveness of surgical hand antisepsis.

Several principles apply throughout the surgical scrub regardless of the antiseptic agent or scrub method used.

The scrub progresses in one continuous direction, beginning with the fingertips and hands and moving toward the forearms and elbows. Once a cleaner area has been completed, the scrub should not return to it because microorganisms from a less clean area may be transferred back onto previously cleaned skin.

Throughout the scrub and rinse, the hands should remain above the elbows so water flows from the cleanest area toward the less clean area. Contact with the sink, taps, clothing, or other non-sterile surfaces should be avoided because it may contaminate the scrubbed hands.

Whether using a timed scrub or a counted-stroke method, every movement should be systematic, deliberate, and consistent to ensure complete coverage of all hand and forearm surfaces.

Self-Assessment

Please complete the following: Surgical Scrubbing Quiz

Before performing a surgical scrub, you must wear the appropriate personal protective equipment (PPE). PPE protects both the patient and the healthcare worker by reducing the risk of contamination before entering the sterile environment. Hair, skin flakes, respiratory droplets, and body fluids can all carry microorganisms that may contaminate the operative field if appropriate PPE is not worn.

Putting on PPE before scrubbing ensures that you do not need to touch your face, hair, or clothing after your hands have been disinfected. Once surgical scrubbing begins, adjusting PPE or touching non-sterile items contaminates the hands and may require repeating the scrub.

PPE complements surgical scrubbing but does not replace it. Surgical hand antisepsis and appropriate PPE work together to reduce the risk of surgical site infections and protect the surgical team from exposure to blood and body fluids.

The exact PPE requirements vary according to the procedure and local policy, but healthcare workers performing surgical scrubbing should normally wear:

• Theatre scrubs with sleeves ending above the elbows ("bare below the elbows") to allow complete scrubbing of the forearms.
• Surgical cap that completely covers all scalp hair and ears where required by institutional policy.
• Surgical mask that fully covers both the nose and mouth.
• Eye protection, such as goggles or a face shield, whenever splashes or sprays are anticipated.
• Disposable or reusable apron, when indicated by the procedure or local policy to protect against fluid contamination.
• Appropriate theatre footwear, such as dedicated theatre shoes, clogs, or boots that are clean and suitable for the operating theatre.
• Radiation protection apron, when procedures involve fluoroscopy or other sources of ionizing radiation.

Each item serves a specific purpose. Wearing PPE correctly before approaching the scrub sink minimizes the risk of contaminating the hands after scrubbing has begun.

PPE should be applied in a logical order before entering the scrub area. Begin by putting on clean theatre scrubs. Hair should then be completely secured beneath the surgical cap. Next, apply the surgical mask, ensuring it completely covers the nose and mouth and fits securely around the face. If eye protection is required, put it on after the mask to ensure the mask fits properly. Finally, put on the apron if it is required for the planned procedure.

Once PPE has been correctly applied, avoid adjusting the cap, mask, or eye protection after beginning the surgical scrub. If PPE becomes displaced or requires adjustment after scrubbing has started, correct the problem according to institutional policy before proceeding, as touching the face or PPE with scrubbed hands contaminates the hands.

Before turning on the water, ensure that everything needed for the surgical scrub is available and functioning properly. This reduces unnecessary interruptions and helps maintain focus throughout the procedure.

Prepare and check the following:

• Appropriate antimicrobial scrub solution.
• Functional scrub sink with adequate water supply.
• Comfortable water temperature and moderate water flow.
• Timer or clock, if using the timed scrub method.
• Sterile scrub brush or nail cleaner, if required by local protocol.
• Sterile gown and gloves prepared on a clean trolley if these are to be donned immediately after scrubbing.

Gathering all required supplies before beginning allows the scrub to proceed smoothly without leaving the scrub area or touching non-sterile objects.

Limited resources should never compromise the principles of infection prevention. Where disposable PPE is unavailable, reusable caps, goggles, aprons, and face shields may be used provided they are cleaned, disinfected, or sterilized according to institutional policy before reuse.

If waterproof gowns or disposable aprons are unavailable, locally available reusable protective garments that can be effectively cleaned between cases may be used. Where timers are unavailable, the counted-stroke method provides a reliable alternative for maintaining consistent scrub duration.

Sterile nail brushes may not always be available. Brushless surgical scrubbing with an approved antimicrobial solution is acceptable where recommended by local policy. Reusable brushes should never be reused between patients without appropriate cleaning and sterilization.

Before every scrub, inspect PPE for damage such as torn masks, broken face shields, cracked goggles, or loose ties. Replace defective equipment before beginning the scrub whenever possible.

The goal is to adapt equipment to available resources while maintaining the principles of aseptic technique and patient safety.

Self-Assessment

Please complete the following: Protective Equipment for Scrubbing Quiz

Surgical scrubbing combines mechanical friction with an antimicrobial scrub solution to remove transient microorganisms and reduce resident microorganisms. The antiseptic solution used should be effective against a broad range of microorganisms while remaining safe for repeated use on the skin.

The two most commonly used antimicrobial scrub solutions are:

• Chlorhexidine gluconate (CHG) 4% – provides rapid antimicrobial activity with prolonged residual action. Because CHG continues suppressing bacterial growth after the scrub is completed, it is widely used for repeated surgical procedures.
• Povidone-iodine (PVP-I) 7.5–10% – provides broad antimicrobial activity but has less persistent residual activity than chlorhexidine. It remains an effective alternative where chlorhexidine is unavailable or contraindicated.

Some facilities use alcohol-based surgical hand rubs containing 60–90% alcohol with chlorhexidine or another persistent antiseptic. These products may be used according to institutional policy when hands are not visibly soiled and after any required initial hand washing.

The choice of antiseptic should follow institutional policy, product availability, patient safety considerations, and any known allergies or sensitivities among healthcare workers.

Several methods are used to perform surgical hand antisepsis. Regardless of the method used, the principles of complete coverage, systematic technique, and contamination prevention remain the same.

Timed Scrub The timed method requires each stage of the scrub to be performed for a predetermined length of time. Many institutions perform a longer scrub at the beginning of the operating list and shorter scrubs between subsequent procedures, although the exact duration varies according to local policy and the manufacturer's instructions for the antiseptic product.

Counted-Stroke Method Instead of timing the scrub, some institutions count a predetermined number of strokes over each anatomical surface. This method provides consistency when timers are unavailable and is particularly useful in low-resource settings.

Alcohol-Based Surgical Hand Rub Where approved by institutional policy, alcohol-based surgical hand rubs may be used after initial hand cleaning when the hands are not visibly soiled. The product should be applied in sufficient volume to keep the hands and forearms wet for the contact time recommended by the manufacturer while covering every surface systematically.

Regardless of the method used, every anatomical surface must receive adequate friction and antimicrobial exposure.

A successful surgical scrub depends on following the same systematic sequence every time.

The scrub begins with the fingernails and fingertips, where microorganisms are most heavily concentrated. It then progresses to the fingers, interdigital spaces, thumbs, palms, backs of the hands, wrists, forearms, and finally to approximately 2–3 inches (5–8 cm) above the elbows.

Each anatomical area should be completed before progressing to the next. Once the scrub has moved to a less clean area, it should not return to a cleaner area. This one-way progression prevents microorganisms from being transferred back onto previously scrubbed skin.

Whether using a timed or counted-stroke method, each scrub cycle should follow this same continuous sequence.

Effective surgical scrubbing depends on both mechanical friction and complete coverage. Mechanical friction loosens dirt, oils, skin debris, and microorganisms from the skin surface, allowing the antimicrobial solution to act more effectively. Simply applying antiseptic without adequate friction may leave microorganisms behind.

Every surface of both hands and forearms must be cleaned deliberately. Areas that are commonly missed include:

• Fingertips
• Nail folds and cuticles
• Thumbs
• Interdigital spaces
• Palmar creases
• Backs of the hands
• Wrists
• Distal forearms

Developing a consistent routine helps ensure that no surface is overlooked. Performing the same sequence during every scrub reduces variability and improves patient safety.

Maintaining the correct direction of movement is one of the most important principles of surgical scrubbing.

During scrubbing, movements always progress from the fingertips toward the elbows. During rinsing, water should flow in the same direction—from the fingertips toward the elbows—without reversing direction.

Hands should remain above the elbows throughout both scrubbing and rinsing. This allows water carrying microorganisms to flow away from the cleanest part of the upper limb.

Avoid:

• Moving from the elbows back toward the hands.
• Moving the arms back and forth through the running water.
• Allowing the hands to fall below the elbows.
• Touching the sink, taps, clothing, or surrounding surfaces.

Maintaining correct directionality throughout the procedure helps preserve the effectiveness of the surgical scrub.

Many breaks in surgical scrubbing occur because the sequence is rushed or performed inconsistently rather than because of inadequate antiseptic solution.

Common errors include:

• Skipping anatomical areas.
• Inadequate friction during scrubbing.
• Using insufficient antimicrobial solution.
• Rushing the scrub or shortening the required contact time.
• Reversing direction by returning from the forearms to the hands.
• Allowing the hands to drop below the elbows.
• Touching the sink, taps, clothing, or surrounding surfaces.

Failing to complete all required scrub cycles according to local protocol.

These errors increase the likelihood that microorganisms remain on the skin or that clean hands become recontaminated before entering the operating room.

Developing a slow, systematic routine helps prevent these mistakes and improves consistency throughout every surgical scrub.

Self-Assessment

Please complete the following: Surgical Scrubbing Technique Quiz

After completing the required surgical scrub cycles, thoroughly rinse the hands and forearms to remove all antimicrobial solution. The rinse should follow the same direction as the scrub—from the fingertips toward the elbows—allowing water to flow away from the cleanest areas.

During rinsing:

• Keep your hands above your elbows at all times.
• Allow water to flow in one continuous direction.
• Do not move your hands or arms back and forth through the running water.
• Avoid touching the scrub sink, taps, or surrounding surfaces.

Moving the hands back toward the running water or lowering them below the elbows may carry microorganisms from the forearms back onto the hands, compromising the effectiveness of the surgical scrub.

The rinse should remove all residual soap while preserving the reduced microbial burden achieved during scrubbing.

Once rinsing is complete, turn off the water without contaminating the scrubbed hands or forearms.

The method used depends on the scrub sink design:

• Foot-operated taps should be closed using the foot pedal.
• Elbow-operated taps should be closed using the elbows.
• Automatic sensor-operated taps require no physical contact.
• Where none of these systems are available, follow your institution's approved method for avoiding contamination.

Never use your scrubbed hands to turn off manual taps.

After the water has been turned off, continue holding your hands above your elbows and away from your body.

Completing the surgical scrub does not mean the procedure is finished. The reduced microbial burden on your hands can be lost immediately if they become contaminated before entering the operating room.

After leaving the scrub sink:

• Keep your hands together and above the level of your elbows.
• Hold your hands away from your body.
• Avoid touching your clothing, face, mask, cap, walls, doors, equipment, or other non-sterile surfaces.
• Move directly to the operating room without unnecessary delays.

Maintaining this hand position allows any remaining water to drain from the fingertips toward the elbows while minimizing the risk of contamination.

Many operating rooms require the scrubbed healthcare worker to pass through one or more doors before reaching the sterile gowning area.

Whenever possible:

• Ask another team member to open the door.
• If assistance is unavailable, use your back or shoulder to push the door open if this is consistent with local policy.
• Never use your scrubbed hands to push or pull doors.
• Proceed directly to the designated sterile preparation area.

Continue protecting the hands until the next stage of sterile preparation begins.

Despite careful technique, contamination may occasionally occur before entering the operating room.

Examples include:

• Touching the scrub sink or taps with the hands.
• Touching clothing, the face, mask, cap, walls, or doors.
• Allowing the hands to fall below the elbows.
• Accidentally brushing against another person or non-sterile equipment.
• Contact with any non-sterile surface.

If contamination occurs before entering the sterile environment, the surgical scrub should be repeated according to institutional policy. Continuing with contaminated hands increases the risk of introducing microorganisms into the operative field.

Recognizing contamination promptly and taking corrective action is an essential part of maintaining aseptic technique.

Healthcare facilities differ in the design of their operating suites and scrub areas. In some settings, the scrub sink may be located immediately outside the operating room, while in others, staff may need to walk a greater distance after scrubbing.

When the transfer distance is longer:

• Plan your route before beginning the scrub.
• Minimize unnecessary movement and conversation.
• Avoid crowded areas whenever possible.
• Ask another team member to assist with opening doors if available.
• Maintain correct hand position until you reach the sterile preparation area.

Although facilities and equipment may differ, the principles remain unchanged: protect the scrubbed hands from contamination until sterile preparation continues.

Self-Assessment

Please complete the following: Transition to the Operating Room Quiz

Healthcare workers practicing in low-resource settings frequently face shortages of equipment, supplies, running water, or personnel. These challenges should never compromise the fundamental principles of surgical hand antisepsis. While equipment and techniques may need to be adapted, the objectives remain the same:

• Remove transient microorganisms.
• Reduce resident microorganisms.
• Prevent recontamination before entering the sterile environment.
• Maintain patient and healthcare worker safety.

When resources are limited, adaptations should be evidence-based, follow institutional policy whenever possible, and preserve aseptic technique rather than simply making the procedure faster or easier.

Many healthcare facilities may not always have access to every item used during surgical scrubbing. Appropriate alternatives can often be used without compromising infection prevention.

If chlorhexidine gluconate (CHG) is unavailable, povidone-iodine may be used according to institutional policy. If one product causes skin irritation or allergy, an approved alternative antimicrobial agent should be selected whenever possible.

Routine use of sterile nail brushes is no longer recommended by many infection prevention guidelines because excessive brushing may damage the skin and increase bacterial colonization. When local policy requires a sterile brush, use it only as directed. Where nail brushes are unavailable or not routinely used, perform thorough cleaning of the nails using the approved brushless technique and antimicrobial scrub solution.

When timers are unavailable, use the counted-stroke method recommended by your institution. Following the same systematic sequence each time is more important than relying on a clock alone.

If running water is temporarily interrupted, follow your institution's contingency plan. Surgical scrubbing should only be performed using an approved method that maintains infection prevention standards. Improvised washing methods that cannot ensure adequate rinsing and contamination control should not be used.

Personal protective equipment shortages may occur in resource-limited facilities. Adaptations should always prioritize healthcare worker and patient safety. Reusable items such as theatre caps, eye protection, aprons, and dedicated theatre footwear may be used provided they are cleaned, disinfected, or sterilized according to institutional policy before reuse.

Before every procedure:

• Inspect reusable PPE for cleanliness and integrity.
• Replace damaged masks, goggles, or face shields whenever possible.
• Ensure reusable protective equipment has been appropriately processed before use.

Do not modify or reuse single-use PPE unless specifically permitted by institutional or national guidance.

Busy operating theatres often require staff to prepare for several procedures in succession. Working efficiently helps maintain patient flow, but efficiency must never compromise aseptic technique.

Developing a consistent routine improves both speed and accuracy. Preparing equipment before beginning the scrub, following the same scrub sequence every time, and minimizing unnecessary interruptions all reduce the risk of contamination.

Avoid rushing through the procedure or shortening the required scrub sequence simply because the operating theatre is busy. A missed step or contaminated hand may result in surgical site infection, delays, or the need to repeat the entire scrub.

The effectiveness of a surgical scrub is lost if the hands or forearms become contaminated before entering the sterile environment.

Repeat the surgical scrub according to institutional policy if you:

• Touch the scrub sink, taps, clothing, walls, doors, or other non-sterile surfaces.
• Lower your hands below your elbows during or immediately after the scrub.
• Interrupt the scrub and perform another activity that contaminates your hands.
• Experience any event that compromises aseptic technique before entering the operating room.

Recognizing contamination promptly and repeating the scrub when necessary protects both the patient and the surgical team. Never continue to a sterile procedure if you believe the scrubbed hands have become contaminated.

Self-Assessment

Please complete the following: Adapting Surgical Scrubbing in Low-Resource Settings Quiz

Staff shortages and space limitations demand foresight. The scrub nurse should open gowns and gloves before approaching the sink, reducing dependence on assistance after drying. With fewer colleagues available to catch errors, maintaining posture, avoiding unnecessary movement, and moving directly from sink to gowning area become even more critical. These adaptations preserve the intention of the scrub—maximal microbial reduction and protection of the sterile field—even when the ideal tools or support are not present.

Contamination occurs whenever microorganisms are transferred from a non-sterile source to a clean or scrubbed surface. During surgical scrubbing, contamination may occur before, during, or immediately after the scrub.

Even if the scrub has been performed correctly, touching a non-sterile object or allowing contaminated water to flow back onto the hands can compromise the effectiveness of the entire procedure.

Maintaining asepsis requires continuous awareness from the moment preparation begins until you reach the operating room.

Several common actions can contaminate scrubbed hands and forearms.

These include:

• Touching the scrub sink or faucet with scrubbed hands.
• Touching clothing, masks, caps, eyewear, or the face after scrubbing has begun.
• Allowing the hands to fall below the elbows.
• Splashing contaminated water from the elbows back toward the hands.
• Brushing against walls, doors, equipment, or other personnel.
• Leaving the scrub area to retrieve forgotten equipment after beginning the scrub.
• Interrupting the scrub to answer phones, adjust equipment, or perform other non-sterile tasks.

Being aware of these risks helps prevent accidental contamination.

Maintaining sterile technique requires consistency throughout every stage of the procedure.

During the scrub:

• Keep the hands above the elbows.
• Progress from the fingertips toward the elbows without reversing direction.
• Apply adequate friction to every anatomical surface.
• Avoid touching non-sterile objects.

During rinsing:

• Allow water to flow from the fingertips toward the elbows.
• Do not move the hands back through the running water.
• Do not touch the sink or surrounding surfaces.

During transfer to the operating room:

• Keep the hands elevated and away from the body.
• Avoid unnecessary movement or conversation.
• Allow another team member to open doors whenever possible.
• Proceed directly to the sterile preparation area.

Maintaining these principles throughout the entire process helps preserve the effectiveness of surgical hand antisepsis.

Healthcare workers should immediately recognize situations that compromise asepsis.

Examples include:

• Accidental contact with a non-sterile surface.
• Touching the face or adjusting PPE after scrubbing.
• Lowering the hands below the elbows.
• Contaminating the sterile brush during use.
• Splashing water from the forearms back onto the hands.
• Forgetting part of the scrub sequence and attempting to return to a previously scrubbed area.

Recognizing these events promptly allows corrective action to be taken before patient safety is affected.

If contamination occurs before entering the sterile environment, stop immediately and follow institutional policy.

Depending on the nature of the contamination, this may include:

• Repeating the affected portion of the scrub if permitted by local policy.
• Repeating the entire surgical scrub.
• Replacing contaminated equipment or supplies.
• Reporting repeated contamination events if they indicate a systems issue or equipment problem.

Never continue to a sterile procedure if you believe your hands or forearms have become contaminated.

Patient safety always takes priority over saving time.

Self-Assessment

Please complete the following: Preventing Contamination Quiz

Cumulative Test

Please complete the following: Final Summative Assessment Surgical Scrubbing