DIVISION OF College of Townsville

TROPICAL Medicine & Campus

HEALTH & Dentistry
MEDICINE

Surgical Scrubbing Workbook

Year 3
Clinical Skills

Study Period 1, 2020

Copyright © 2020, James Cook University. All rights reserved.

Materials produced by A/Prof Nichole Harvey. Updated

by A/Prof Nichole Harvey February 2020. Reviewed by
Dr Roy Rasalam 2020.
Clinical Skills Unit
College of Medicine & Dentistry
James Cook University
Townsville, Australia

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TABLE OF CONTENTS

TABLE OF CONTENTS ................................................................................................................................................. III

STAFF CONTACTS ........................................................................................................................................................ 1
CLINICAL SKILL SESSION LECTURERS ......................................................................................................................................... 1
YEAR 3 CLINICAL SKILLS ACADEMIC SERVICES OFFICER ................................................................................................................ 1
WELCOME .................................................................................................................................................................. 2
REQUIRED PREPARATION PRIOR TO SESSION - VIDEO ................................................................................................ 2
STRUCTURE OF WORKSHOP ....................................................................................................................................... 2
REQUIRED READING ................................................................................................................................................... 2
REQUIRED VIDEO ........................................................................................................................................................ 3
RECOMMENDED WEBSITES ........................................................................................................................................ 3
GENERAL INSTRUCTIONS ............................................................................................................................................ 3
ATTENDANCE & DRESS ......................................................................................................................................................... 3
INTRODUCTION TO SURGICAL SCRUBBING ................................................................................................................. 4
LEARNING OUTCOMES ............................................................................................................................................... 4
THEATRE ATTIRE ......................................................................................................................................................... 4
NOTES ON SURGICAL SCRUBBING............................................................................................................................... 5
SKINMAN® – AN AVAILABLE OPTION FOR CLEANING HANDS ...................................................................................... 6
NOTES ON GOWNING & GLOVING .............................................................................................................................. 6
DRYING HANDS ................................................................................................................................................................... 6
GOWNING .......................................................................................................................................................................... 6
DOUBLE GLOVING................................................................................................................................................................ 7
TYING THE GOWN AT THE FRONT ............................................................................................................................................ 7
SURGICAL CONSCIENCE .............................................................................................................................................. 7
SURGICAL SCRUB CERTIFICATE ................................................................................................................................... 8
REFERENCE LIST .......................................................................................................................................................... 8
APPENDIX A ................................................................................................................................................................ 9
APPENDIX B – VISUAL STEP-BY-STEP GUIDE ...............................................................................................................11
APPENDIX C – SKINMAN® SURGICAL HANDRUB PROTOCOL .......................................................................................16

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STAFF CONTACTS
Clinical Skill Session Lecturers

Nikki Harvey (Year 3 Clinical Skills Coordinator)

P: (07) 4781 6408
E: Nikki.Harvey@jcu.edu.au
Office: Building 39 – Room 033 (ground level)

Karryn Lytton
P: (07) 4781 5571
E: Karryn.Lytton@jcu.edu.au

Robyn Hay
P: (07) 4781 6408
E: Robyn.Hay1@jcu.edu.au

Wayne Rickerby
E: Wayne.Rickerby@jcu.edu.au

Year 3 Clinical Skills Academic Services Officer

P: (07) 4781 5955

E: mbbs3@jcu.edu.au

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WELCOME
Welcome to the Surgical Scrubbing clinical skills session. This compulsory clinical skills session
runs during weeks 3-6 of study period 1. All ‘surgical scrubbing’ clinical skills sessions are run on a
Tuesday afternoons and Wednesday mornings. Please refer to the timetable for the exact date and
time of the session for your home group. One Home Group at a time will undertake the teaching
session to allow for easier access to the scrubbing sinks and increased time per student-tutor
interaction. Each student only needs to attend the session once.

This workbook contains information about the steps in gowning and gloving and the recommended
scrubbing technique as approved by ACORN (see Appendix A). As always, communication between
staff and students is very important. Please do not hesitate to contact me if you have any queries or
problems. All the best with you studies this semester and I hope you find the teaching session
informative, enjoyable and fun!

Regards, Nikki

REQUIRED PREPARATION PRIOR TO SESSION - VIDEO

Prior to your scheduled teaching session, please ensure that you have watched the surgical
scrubbing instructional video on LearnJCU, under the clinical skills tab. This is a compulsory
requirement prior to undertaking the teaching session. The surgical scrubbing, gowning and gloving
instructional video will not be re-shown in class time. There will be an assumption that all students
are fully aware of the content of this video prior to commencing the teaching session. The watching
of the video prior to the teaching session will allow you to get the most out of the one-hour face-to-
face teaching session.
Please remember to bring a copy of the surgical scrubbing certificate with you for signing by
one of the tutors.

STRUCTURE OF WORKSHOP
Students will assemble in 46-014 for a brief introduction to the session. Following the introduction,
students will divide between rooms 46-011, 46-014 and 46-010B where they will commence
undertaking a 5-minute surgical scrub under the supervision of a tutor. This will be followed by
donning a sterile gown and double gloving, using both the open and closed gloving techniques. A
tutor will be available in each room to assist students and answer questions (and of course take photos
if asked). At the completion of the session, students receive the ‘signed’ ‘Surgical Scrubbing’
certificate.

REQUIRED READING
This workshop will be largely interactive so students must read, and become familiar with this
workbook in preparation for the workshop. Please also look at the Clinical Skills ‘Readings’ list for
this topic on LearnJCU.
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REQUIRED VIDEO
Lytton, K., Harvey, N., & Gavan, A. Surgical scrubbing: Scrubbing, gowning and gloving
[Instructional Video]. Townsville, Queensland: Clinical Skills Unit, James Cook University; 2015.

The above instructional video is on LearnJCU under the Year 3 clinical skills heading. The first sub-
heading is MD3011 Clinical Skills Videos – the video is available via this channel. Please contact
Nikki Harvey if you have any problems with locating or viewing the video.

RECOMMENDED WEBSITES
Hand Hygiene Australia
https://www.hha.org.au/hand-hygiene/hha

Queensland Health: Bare Below the Elbows Initiative

https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-
prevention/standard-precautions/hand-hygeine/bare-below-elbows

GENERAL INSTRUCTIONS
Attendance & Dress
Information on the attendance process, swapping process and dress policy for clinical skills sessions
can be found under the Medicine Course Site on LearnJCU.

NOTE: Clinical dress is required, however, betadine solution will be used during the session,
therefore it is recommended you wear suitable clothing to prevent yellow staining of clothes. It is
also advisable to wear short sleeves as surgical scrubbing requires you to clean above the elbows.

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INTRODUCTION TO SURGICAL SCRUBBING
The ‘Surgical Scrub’ is the process of effectively reducing the number of transient and resident
organisms on the skin.1 The learning of this skill is essential, as the patient’s surgical outcome is
influenced by the creation and maintenance of an aseptic environment.2 Students must complete this
clinical skills session in order to have their ‘Surgical Scrubbing’ certificate signed. The surgical
scrubbing certificate is an essential inclusion for the year 4 practice portfolio and is a mandatory
requirement in all student portfolios prior to graduation. This clinical skill session is not offered in
any other year of the course, therefore it must be completed at this time.

LEARNING OUTCOMES
The student will be able to:
 Identify why surgical scrubbing is important and how this process helps to reduce the risk of
infection;
 Have an understanding of the different roles that individuals take within the theatre setting
and how these roles work together – i.e. surgeon, scrub nurse, circulating nurse
 Discuss the different cleaning solution options available and when to use them;
 Discuss what the preparation requirements are for individuals, before commencing surgical
scrubbing;
 Demonstrate the technique used for surgical scrubbing and perform a complete 5 minute
surgical scrub;
 Demonstrate the technique used for donning a sterile gown and sterile gloves;
 Identify what preparation is required prior to surgical scrubbing;
 Submit the ‘surgical scrubbing’ certificate for signing by the tutor.

THEATRE ATTIRE
Theatre attire has evolved over the centuries to what it is now. Halstead introduced the wearing of
gloves in 1889; Milulicz-Radecki recommended wearing face masks in 1897; Matron McGahey
introduced theatre attire into Australia in 1902; and disposal masks, gloves and headwear were
introduced in the 1960s and 70s.3 The most commonly worn attire is the two-piece surgical top and
pants. The clothes and footwear worn into theatre must not have been worn outside the theatre room.
Shoes are to be covered with disposal shoe protectors (figure 1) or swapped for clogs/theatre shoes
on entering the theatre environment. Hair must be covered, so please ensure you select the correct
headwear to cover your hair totally. A number of headwear options are available (figure 2).

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Figure 1

NOTE: If headwear garments need to be worn for religious reasons this can be accommodated,
providing it is freshly cleaned headwear that is put on after you arrive in the theatre changing room
and not the one you wore into the hospital. It does need to be secured inside the scrub top and a
surgical head covering still needs to be worn on top. The surgical hoods are a good option to help
cover as much of the headwear as possible. See figure 2.

Figure 2

The only acceptable jewellery in theatre is a plain wedding ring. All other jewellery is to be removed,
along with nail polish. Occasionally plain small stud earrings can be worn, but the preference is
definitely to wear no jewellery at all. Additionally, cotton bracelets worn for religious or cultural
reasons must be removed for patient safety reasons.

NOTES ON SURGICAL SCRUBBING

 First scrub of the day is 5 minutes in duration
 Subsequent scrubs are 3 minutes in duration, as cleaning of the nails can be omitted
 The antimicrobial solution is to be in contact with your skin for a period of 2 minutes
throughout the scrubbing time
 There are a number of scrubbing solution options – Iodine/Betadine; Skinman (alcohol
based); and chlorhexidine.
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  Always scrub from fingertips to elbow – one direction
 Imagine your fingers and hands as having four sides – all of which need to be cleaned
 Keep hands above elbows at all times
 Brushes are not recommended as they can cause skin damage and hence an increase in the
number of gram negative microorganisms, because of microscopic cuts on the skin surface.4
Please see Appendix A for detailed information about the requirements when performing a
preparation check and a 5-minute surgical scrub. Appendix B provides a pictorial representation of
the procedure for performing a 5- minute surgical scrub.

SKINMAN® – AN AVAILABLE OPTION FOR CLEANING HANDS

Skinman 90® is an alternate option for surgical staff who have developed compatibility issues with
other products, such as Betadine. Skinman® is an alcohol based hand disinfectant that takes
approximately 90 seconds to apply and lasts for 3 hours. It contains Vitamin E, Glycerine and
Panthenol to help protect, nourish and regenerate the skin. Only use Skinman® on visibly clean and
dry hands and allow to dry naturally. 5 (see Appendix C).

NOTES ON GOWNING & GLOVING

The below information is from the ACORN Standards for Perioperative Nursing 2010-2011
handbook.2 There is a more current version of the handbook available, however, the Standards for
Gowning and Gloving have not changed.

Drying Hands
 Use a dry corner of the towel for each hand and arm
 Dry each arm in one direction only – fingertips to elbows
 Extend arms while drying
 Do not touch scrub attire
 Discard towel in line skip when finished
 If two towels are provided, use one for each hand and arm

Gowning
 Pick up gown at folded edge and step back from the table/trolley
 Be careful to not touch another person or furniture
 Touch only the inside surface with your bare hands
 Do not allow hands to go through the cuffs of gown
 Keep elbows bent and hands above elbow level

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 Your skin is not sterile after you have scrubbed

Gowns and gloves applied correctly achieve sterility

Conducting yourself in the correct way will maintain sterility

Double Gloving

 Using two sets of gloves, usually one glove your hand size and the other ½ size bigger
 Put the larger size glove on first
 Tips for gloving:
o thumb to thumb
o Cuff to cuff
o Fingers of glove should point towards the elbow

Tying the Gown at the Front

 Tying gown: separate the two ties and hand the short tie to the assistant
 Pivot away from the assistant then take the short tie and tie up in front of the gown
 Remember to keep hands above waist

SURGICAL CONSCIENCE
Girard defines surgical conscience as involving “knowledge, self-awareness, intelligence, and the
courage to make ethical and moral decisions that benefit the patient”.6 Surgical conscience involves
understanding the principles of asepsis and infection control and being aware of one’s own location
in relation to the sterile environment and others in the sterile field.

Don’t ever be afraid to ask for guidance or help – it is not always obvious where you can stand or
what to do in theatre. It is best to ask, rather than touching something that is sterile when you may
not be sterile yourself. Always be aware of your surroundings so you are careful not to accidentally
bump into equipment or people. Of course if you do, it is important to let someone know immediately
so that if the surgical area has been contaminated it can be dealt with immediately and usually quite
easily at the time. This is not a rare event, so please be honest and let someone know immediately if
you think you may have contaminated the surgical field. Theatre staff will no doubt be watching you
fairly closely – it is not personal, it is so they can maintain a safe environment for the patient.

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SURGICAL SCRUB CERTIFICATE

Surgical scrubbing certificate can be located on LearnJCU, under the clinical skills tab/surgical
scrubbing folder.

PLEASE PRINT AND BRING WITH YOU TO THE

CLINICAL SKILLS SESSION

REFERENCE LIST

1. Scrubbing, Gowning and Gloving. Adelaide, South Australia: A Media Machine Production;
2010.
2. Australian College of Operating Room Nurses. ACORN standards for perioperative nursing
including nursing roles, guidelines and position statements 2010-2011. Adelaide, South
Australia: The Australian College of Operating Room Nurses Ltd; 2011.
3. Davies M. You are what you wear: Perioperative attire through the centuries. Journal of
Perioperative Nursing in Australia. 2017;30(2):43-49.
4. Liang QL, Mehigan S. The effects of surgical hand scrubbing protocols on skin integrity
and surgical site infection rates: A systematic review. Journal of Perioperative Nursing in
Australia. 2017;30(2):21-30.
5. Evidence Based Clinical Guidelines Co-ordinator. Surgical scrubbing, Gowning and
Gloving. website.
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionf/f_g
loving.pdf. Published 2016. Accessed 8 Feb 2018.
6. Girard N. Surgical conscience: Still pertinent. American Operating Room Nurse's Journal.
2007;86(1):13-14.

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APPENDIX A
APPROVED/RECOMMENDED SCRUBBING TECHNIQUE AS APPROVED
BY THE AUSTRALIAN COLLEGE OF OPERATING ROOM NURSES
(ACORN) 1 (p.11), 2
FIRST SCRUB 5 MINUTES
SUBSEQUENT SCRUBS 3 MINUTES

PREPARATION CHECK:

 CLEAN HANDS
 SHORT FINGERNAILS
 NO FALSE NAILS OR NAIL POLISH
 NO OPEN WOUNDS, LESIONS TO HANDS
 NO JEWELLERY ON UPPER BODY AND HANDS
 PUT ON HAIR NET/MASK AND PROTECTIVE EYEWEAR

MOST IMPORTANT POINTS WHILST SCRUBBING:

 HANDS TO BE ABOVE ELBOW HEIGHT AT ALL TIMES TO AVOID

BACKFLOW
 ANTIMICROBIAL SOLUTION TO BE IN CONSTANT CONTACT
WITH HANDS FOR A MINIMUM OF 2 MINS DURING SCRUB
 APPLY SOLUTION TO ARMS IN ONE DIRECTION WITH
CIRCULAR MOTION
 RINSE FINGERTIPS TO ELBOWS IN ONE DIRECTION ONLY –
NO BACKFLOW
 AVOID SPLASHING CLOTHING WHICH CAN CAUSE STRIKE
THROUGH CONTAMINATION
 ALWAYS USE ELBOWS TO TURN ON/OFF TAP LEVERS AND
DISPENSE SOLUTION

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 APPROVED/RECOMMENDED SCRUBBING TECHNIQUE AS APPROVED
BY THE AUSTRALIAN COLLEGE OF OPERATING ROOM NURSES
(ACORN) 1 (pp. 11-13), 2
FIRST SCRUB OF THE DAY 5 MINUTES
SUBSEQUENT SCRUBS 3 MINUTES

STEP 1 (1 minute) PROGRESSIVE

MINUTE
TOTAL
 Open and prepare a nail cleaner and scrub sponge.
Rinse hands and arms.
 Apply solution. Wash hands and then proceed to wash forearms to
2.5 cm above the elbows using circular motion. Do not return to your
hands. (30 secs) 30 SECONDS

 Leave solution on whilst cleaning nails with nail file. Clean under
running water, do not scrub fingernails.
 Rinse hands and forearms from fingertips to elbows – allow water to
1 MINUTE
run in one direction only – no backflow. (30 secs)

STEP 2 (2 minutes)

 Apply solution to the scrub sponge and clean hands & fingernails. 2 MINUTES
Visualise each finger and hand as having four sides. (1 minute)
 Once each hand is done, proceed to wash forearms to the level of
2 MINUTES,
elbows using circular motion. Do not return to your hands. (30 secs) 30 SECONDS
 Rinse hands and forearms – fingertips to elbow. (30 secs)
3 MINUTES

STEP 3 (2 minutes)

 Apply solution and wash hands thoroughly to mid-forearm. (40 secs)

 Rinse hands and forearms – fingertips to elbow. (20 secs) 4 MINUTES
 Final wash – HANDS only. (30 secs)

 Final rinse of hands and forearms – Rinse thoroughly. (30 secs)

5 MINUTES
 Proceed to gowning and gloving.

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APPENDIX B – VISUAL STEP-BY-STEP GUIDE
1. Remove jewellery, clean hands short nails 2. Cover hair and apply facemask

3. Open gown, maintaining sterile field 4. Add sterile gloves to field

5. Proceed to sink and open scrubbing brush 6. Wet hands, arms and apply betadine

7. Apply betadine up to elbows 8. Clean nails with file under running water

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9. Rinse hands and arms (fingertips to elbows) 10. Apply betadine to sponge

11. Clean each finger (4 sides) 12. Clean arms up to elbows- circular motion

13. Rinse hands and arms (fingertips to elbows) 14. Dispense betadine into hand

15. Thoroughly wash hands up to mid forearm 16. Rinse hands and arms (fingertips to elbows)

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17. Dispense betadine into hand 18. Thoroughly wash hands only

19. Final thorough rinse of both hands and arms 20. Allow excess water to drip off elbows

21. Proceed to sterile field and dry hands 22. Dry hands and arms using sterile towels

23. Pick gown up by placing hands in side folds 24. Allow gown to unfold; work arms into sleeves

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25. Allow the back of the gown to be tied 26. Open first set of gloves(keep hands in sleeve)

27. Don first set of gloves using closed technique 28. Pull sleeve to help move hand into glove

29. Open second pair of gloves 30. Don second pair of gloves

31. Once both gloves are on, tie front of gown 32. Pivot slowly and pull tie from cardboard

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33. Tie gown at front 34. You are now ready!

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APPENDIX C – SKINMAN® SURGICAL HANDRUB PROTOCOL

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