Transdisciplinary Teamwork

In 1987 Clare O’Hagan, the founder of Therapy Professionals Ltd attended the World Congress of Physical Therapy and heard a lecture by Carol Davis on Transdisciplinary Teamwork.  From that moment Clare wanted to develop such a team.  It wasn’t until 1997 when she got the opportunity.  It was a slow process to start with as the disciplines were struggling to work in a multidisciplinary way.  By the early 2000’s the team was humming and her dream was realised.
 
Below is Carol Davis’s article on transdisciplinary teamwork.

Philosophical Foundations of Interdisciplinarity in caring for the Elderly:  or, the willingness to change your mind.
 
Carol M Davis, Ed. D Associate Professor
Department of Physical Therapy, Sargent College, Boston University, Boston, MA 02215, USA.
 
INTRODUCTION
 
Medicine alone rarely, if ever, meets all of most patients’ needs. Other health professionals assume the responsibility of caring for patients’ multiple other needs with a common goal of the highest level of independent function, thus the greatest quality of life possible, for each person.
 
When health professionals from many disciplines attempt to work together in caring for the elderly patient, the end product of this effort can have various characteristics.  This paper examines the characteristics of various outcomes, and describes what factors enhance the process.  Finally the suggestion is made that the processes of interdisciplinary or transdisciplinary result in the best possible outcome of care for the patient.
 
THE CONTINUUM TOWARD TRANSDISCIPLINARITY
 
Few health care professional students in the United States receive adequate training in learning how to work well with others for the good of patients.  Indeed, young beginning practitioners often feel more than stressed in simply maintaining access to their own professional knowledge and skill.  Learning to work with others takes place on a continuum of growth that can be described in the following model:
 
Unidisciplinary
Feeling confident and competent in one’s own discipline
 
Intradisciplinary
Believing that you and other fellow professionals in your own discipline can make an important contribution in care
 
Multidisciplinary
Recognising that other disciplines also have important contributions to make 
 
Interdisciplinary
Willing and able to work with others in the joint evaluation, planning and care of the patient
 
Transdisciplinary
Making the commitment to teach and practice with other disciplines across traditional disciplinary boundaries for the benefit of the patient’s immediate needs. (United Cerebral Palsy 1)
 
The increasing effectiveness of each of these processes can be illustrated with the help of the following case example.
 
An 85-year-old patient is admitted to the geriatric evaluation unit with a cerebral vascular accident with right hemiplegia, hemianopsia, and aphasia.  He is accompanied by his 78-year-old wife.  They had been living together at home prior to his stroke one month ago.  Since that time the patient was in the hospital for resolution of his acute problem, then transferred to a nursing home for careful nursing care until he stabilised.
 
Mr Walker was a tailor and lives on a modest social security income.  His wife receives no social security.  Their finances are assisted by monthly cheques from their son who lives in another state 1000 miles away.  Mr Walker is diabetic.  Mrs Waker is quite well but very lonely without her husband of 60 years.  They were active in the Methodist church but were driven to church each Sunday before Mr Walker’s stroke, as neither could drive any longer.
 
Mr Walker’s physician illustrates unidisciplinarity and intradisciplinarity as he evaluates the patient upon admission to the hospital. He believes that his discipline of internal medicine is very suited to the care of this patient, but his area of expertise in gastrointestinal cancer restricts his confidence that he can uncover and treat Mr Walker’s circulatory problem to resolve it adequately.  Thus, he requests his colleague in internal medicine who is a cardiac specialist to see the patient as well.
 
Multidisciplinarity occurs as he writes the order for the patient to be seen by the physical therapist, occupational therapist, speech therapist, the psychologist, the social worker and the nutritionist.
 
When this group of practitioners evaluate the patient and plan their care, all separate from each other, communicating only by way of the patient’s record, they are practicing multidisciplinarity.  Just as in a ‘jar of jelly’ beans, the end product of care is no more than the sum total of all the parts.
 
Patients complain about multidisciplinary care when they say, “I’m not answering that question one more time!”.  Or, “I’ll only give blood once today – you people get together and figure out which one of you is going to stick me and when.”
 
Practitioners complain about multidisciplinary care when the goal of the physical therapist to increase Mr Walker’s endurance in ambulation is thwarted by the nurse who ties him in bed so he cannot get up and walk around for he might fall.
 
Interdisciplinarity can be recognised as superior to the aforementioned when it’s working well.  In the Journal of Medicine and Philosophy Maurice de Wachter offers five steps to interdisciplinarity (De Wachter 2):

1. One starts by accepting the “methodological epoch”.    Each person agrees to abstain from approaching the topic along the lines of his or her monodisciplinary method alone.
2. The entire team tries to formulate, in an interdisciplinary way, the global   question, acknowledging all aspects of the patient’s problem and all disciplines required to solve it. 
3. One translates the global question into the specific language of each participating discipline.
4. Answers to this global question (translated to each discipline) are constantly checked for relevance with regard to the overall global question. 
5. One agrees upon a global answer, which must not be produced by any one particular discipline but rather integrates all particular answers available.

 
Thus, interdisciplinary process is composed of more than just several health professionals gathered around a table to discuss Mr Walker.  Each sits down and, in essence, brackets his or her professional-discipline identity, places it to the side and assumes the new identity of “team member.”

This act of bracketing is critical to the success of interdisciplinarity.  Just as in algebra or language analysis, brackets serve the purpose of setting aside, without destroying, what is bracketed.  In other words, identity as a physical therapist, for example, is available to me and, indeed, informs my contribution to the team, but I do not allow it to keep me from hearing the reports of other team members and helping to decide on a team goal and plan of care for this patient.  In short, each of us sits down at the table and listens to the others with a willingness to allow others to change our minds.  In this way the very best of all possible plans is agreed upon.  Unlike the “jar of jelly beans”, the product of this effort is larger than the sum of all the parts.  Indeed, ideally professional boundaries are transcended and flow into each other with ease, much like the colours of a rainbow.

Finally, transdisciplinarity represents the highest progression in the process of patient care.  Hospice care illustrates this process quite adequately.  Health professionals teach each other, the patient and the patient’s family how to perform aspects of care reaching beyond professional boundaries with the immediate need of the patient being foremost.  If the physical therapists arrives to work with a patient at home and learns she has not yet taken her pain medication, she doesn’t wait for the nurse to arrive to give it, nor the husband to make the toast to take with it. She does it herself.  Likewise she teachers the nurse, husband and volunteers how to help the patient move about in bed and walk to the bathroom.
 
Integrated, smooth, coordinated congruent care with the patient’s immediate needs at the centre of the effort marks transdisciplinary care.  Individuals come together without territorial professional boundary needs to guide their role and responsibilities.  This is what makes it the highest form of care.

Transdisciplinary care is a mature and humble way of being in the world.  Factors which interfere with interdisciplinary and transdisciplinary care include:

• lack of personal commitment in the process
• lack of personal commitment to accepting the risk of bracketing one’s professional role
• feelings of insecurity that are revealed in the need for clear territorial boundary roles
• lack of shared values
• lack of skill in interpersonal interaction
• perception of threat from other team members (Darling 3)

 
Factors that enhance interdisciplinarity and transdisciplinarity are the opposite of these limiting factors.  Central to these two processes is a mature, secure, self-confident practitioner with excellent skills in communication and teaching who primarily values that the patient’s needs be met regardless of who meets them.  The making of such persons takes time and commitment to the beauty and value of the rainbow.
 

What is Osteoporosis?

Osteoporosis is a condition in which the bones become fragile and break more easily.  This is because calcium and bone tissue, the major building blocks of bone, are being lost.  Bones are denser on the outside and have an open honeycomb structure on the inside.  When calcium and bone tissue are lost, the outer shell becomes thin and the ‘honeycomb’ develops larger holes.  This weakens the bone, which is then more likely to break.  The process of bone loss begins from about the age of 35 onwards as part of the normal ageing process.

Osteoporosis is very common and is a major cause of skeletal problems worldwide.  About one third of women in Australia and New Zealand will suffer fractures by the time they reach their seventies.  Osteoporosis is also found in men, but is much less common.
 
How is Osteoporosis caused?
 
There are different stages of bone changes throughout life.  The first stage occurs up to the age of 35 when bone reaches its maximum strength.  From 35 years of age onwards, there is a slow loss of bone strength in both sexes.  In women the fall in oestrogen levels at menopause leads to loss of bone calcium and structure over several years.  In younger women, oestrogen is important in preventing calcium being lost from the bones.
 
How do you know if you have Osteoporosis?
 
You often show no sign of osteoporosis until you have a fall and break a bone.  Breaks are more common in the bones of the spine, the hip and the wrist.  These breaks can occur even after a minor fall.   In the spine osteoporotic fractures lead loss of height and acute episodes of back pain.  These vertebral crush fractures give a forward tilt or bend to the spine producing the ‘Dowager’s hump’ appearance and preventing the maintenance of posture.
 
Who is at risk of Osteoporosis?
 
There are a number of factors that make you more likely to develop osteoporosis.  Some of these factors you may be able to alter while others you cannot.
 
You are more likely to develop osteoporosis if you:

• have little calcium in your diet, for example you eat or drink few dairy products (eg milk, cheese, yoghurt).
• exercise less than 3 times a week
• smoke cigarettes
• or have a high intake of caffeine or alcohol (more than 2 alcoholic drinks daily).

You are also at higher risk of osteoporosis if you:

• are of European or Asian descent
• are short. thin and small-boned
• have a mother or grandmother who developed osteoporosis
• have had the menopause before the age of 45 or had your ovaries removed
• or if you have taken corti-costeroid preparations, such as prednisone, for a long time for rheumatoid arthritis or asthma.

However, these risk factors may not be a completely reliable guide to your individual risk of osteoporosis.  Your bone density (but not bone structure) can be measured if you or your doctor is concerned about your risk.

What can you do to reduce the risk of Osteoporosis?
 
The best way to prevent osteoporosis is to reduce your exposure to the risk factors mentioned.  These include maintaining an adequate calcium intake, avoiding high intakes of alcohol and caffeine, and stopping smoking.  Dairy foods, such as cheese, milk and yoghurt, are the best sources of calcium and you should aim for 3 serves daily.  Each of the following is roughly equivalent to 1 serve: 1 (250 ml) glass of milk; a 200 g tub of yoghurt: or a 35 g piece of cheese.
 
If you are experiencing or have just experienced the menopause, your doctor may decide to give you hormone replacement therapy.  This replaces the oestrogen that your body no longer produces and helps prevent the loss of calcium from the bones.
 
Weight bearing exercise such as walking, jogging, tennis, golf, dancing and bowls helps to maintain bone strength.

What can be done to treat Osteoporosis?
 
If you are in pain your doctor may prescribe pain relievers and muscle relaxants.  Bed rest may be useful initially and a back brace may also be of help.  Gentle exercise, such as walking, can help to improve bone strength.
 
You may also be given medicine, which can help prevent bones losing their strength.  These medicines include calcitriol, the active form of Vitamin D, anabolic steroids, hormone replacement therapists and calcium supplements. Please refer to your doctor if you have any further questions.

Bathing:
 
Avoid sitting in the bath for the first six - eight weeks.  If 
you do not have a shower we will order a bath board 
for you and you will be instructed how to get in and out of 
the bath.

Showering:
​
We can arrange for you to have a high shower stool in order to take weight off the operated leg and to reduce the chance of falling
​

               The Car
 
               Follow your
               surgeon’s advice
               about driving

Stairs  NB  Good leg (leads) up to heaven.  Bad leg (leads down) to hell.
 
Sports/Hobbies
Check with your surgeon before restarting active sports or hobbies ie cycling, gardening, bowls.
 
Sexual Activity
Ensure any sexual activity does not place any strain on your operated hip and that your hip 
doesn’t bend greater than 90º for at least three months post-operatively.
 
Home Help
If you require assistance with meal preparation and/or home help ask your hospital nurse. 

If you need advice on equipment contact us at Therapy Professionals as our friendly Occupational Therapist can help.  Just contact us:
 
                        Phone:           03 377 5280               
                        Email:             admin@tpl.nz
                        Website:         www.therapyprofessionals.co.nz

                                 Forward lean                                         Wrist turns                                       Finger spreads
                        Rest elbows on thighs near the knees.                       Sitting upright with arms hanging loosely.        Rest forearms on desk top or thighs.  
                         Let hands hang loosely,  Relax shoulders..               Turn hands around one way until                        Stretch fingers apart as if trying to make
                         Breathe deeply in the base of lungs.                          gentle stretching is felt.  Hold                              them longer.  Hold stretched for 3 counts then
                        Stay relaxed in this position for 6-8 breaths.             that position for the count of 5.                          relax hand for the count of 5.   Repeat 3 times.
                                                                                                                  Repeat 3 times in each direction.

                                 Arm shakes                                          Head turns                                   Shoulder circles
                 Sitting upright, drop shoulders into a.             With slight chin tuck, turn head to one                       Sitting upright , hang arms by sides.  Roll 
                            relaxed position. Let arms hang                      side then to the other.  Hold for the count           shoulders in a backward direction.  
​                 loosely.  Gently shake wrist and arms            of 5 at the end of each turn.  Repeat 5                        Repeat 10 times.
                           to the count of 5.  Repeat 3 times.           times in each direction.

                       Side stretch                                  Flexor stretch                                         Extensor stretch
   Sitting upright hold onto the seat with one hand.          Hold one arm straight out in front, palm up.               Rest one elbow on desk top with the thumb
  Place the other hand on top of head and gently tip        Hold the front of the fingers with the other hand.       of this hand near your nose.  Resting the other
​  head over to this side.  Hold for the count of 5.              ​Keeping fingers straight bend the wrist back.             hand on the back of the first hand, bend the first
  Repeat 5 times each side.                                                   into; a definite gentle stretch is felt in the                    hand forward until a definite gentle stretch is felt
                                                                                                   forearm and wrist.  Hold for 10 ​counts,,                       over the back of the wrist.  Hold for 10 counts, then
​                                                                                                  then  relax stretch,  Repeat 3 ​times.                               relax,  Repeat 3 times.

If you are experiencing pain or discomfort doing your job out friendly physiotherapists and occupational therapists can help. Just contact us
 
                                    Phone:  03 377 5280                                           Email:  admin@tpl.nz

Seating people comfortably

Many elderly and disabled people in care sit for long periods of time.  Some are able to move themselves while others are not able to move without assistance.
 
For those of us caring for the elderly and disabled we need to think carefully about how we seat those in our care. We need to consider things like:

• posture
• pressure relief
• potential mobility

 
Good posture is important to prevent back pain, encourage mobility, assist swallowing and prevent chest infections. When choosing a chair for a client it needs to be supportive to prevent them from slumping over. 
 
When sitting for long periods of time without being able to adjust your position, circulation to areas on a person’s bottom, legs and back can be cut off causing discomfort and, if left, pressure sores.

When sitting for long periods of time without being able to adjust your position, circulation to areas on a person’s bottom, legs and back can be cut off causing discomfort and, if left, pressure sores. 

​Pressure relief is important. Some chairs have pressure relief features built into them; we recommend these, especially for people who are unable to change their position. Alternatively pressure cushions can be used.  
 
Air filled pressure cushions (Rohos) can be problematic.  They can be slippery causing a person to slide forward into a slumped posture.  A slumped posture is uncomfortable, can make it hard to swallow and breathe effectively and take part in activities. The cushions raise the height of the seat, which may cause the feet to dangle, leading to discomfort under the thighs.  While sitting it’s important to have feet on the floor or a footrest.
 
For more information on pressure injuries follow this link.
https://www.therapyprofessionals.co.nz/uploads/4/9/5/2/49523375/skin_injuries_caused_by_pressure.pdf
 
Keeping people mobile as long as possible is in everyone’s best interests.  If you are caring for someone who can still stand themselves up or better still walk safely, it’s important you choose a seat that encourages them to stand and get out of easily. This means their feet must be flat on the floor, the chair has armrests at the right height to push up from and the seat surface is firm enough to wriggle forward.

​The ideal seat for a person, maintains an upright posture with their bottom back in the chair and hips at a 90 degree angle. The chair needs to support the spine, thighs with a gap behind the knees and the armrests should support the arms with relaxed shoulders.  Feet need to be flat on the floor or supported on a footstool.

For more information on choosing a seat follow this link https://www.therapyprofessionals.co.nz/uploads/4/9/5/2/49523375/choosing_a_comfy_armchair__.pdf
 
If you need some help seating the elderly or disabled in your care our friendly Physiotherapists and Occupational Therapists can help just contact us at Therapy Professionals.
 
                Ph:      03 3775280                            Email:           admin@tpl.nz
 
 

Arthritis

Most of us have heard of arthritis, however, did you know there are about 140 different types of arthritis?  The most common are Osteoarthritis, Rheumatoid Arthritis and Gout.
 
The causes of the different types of arthritis vary, however, the thing they have in common is there is an inflammatory response in the joints causing swelling, pain, stiffness and joint damage. Arthritis can affect all age groups with the elderly being most affected, generally with Osteoarthritis.

Osteoarthritis

Osteoarthritis is caused by ‘wear and tear’ on the joints cartilage. Cartilage is on the end of our bones protecting our bones from damage, it act like a cushion. Over time the cartilage breaks down and may completely go. Injuries to joints often accelerate the breakdown of joint cartilage.  It generally affects the feet, hands, knees, hips and lower back. Most people over 65 will have some osteoarthritis.

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease, which means the immune system attacks the tissues of the body - in this case the linings of the joints.  It also affects other parts of the body.  There may be periods where the disease is active or not active and it may burn itself out after a number of years.
 
It affects all age groups - in childhood rheumatoid arthritis is called juvenile arthritis

​Gout 

In gout uric acid crystals form in and around the joints, commonly around the big toe, and may move to the knees, elbows, wrists, and fingers.  It causes excruciating pain and swelling.  Uric acid is a by-product of digesting a protein called purine, which the body isn’t excreting.  Being overweight, genetics, taking certain medications, sugary drinks, alcohol, eating too much liver, meat and seafood, and existing kidney disease may cause uric acid to stay in the body.  An attack can come on suddenly. To prevent joint and kidney damage, it needs to be treated quickly. 

Treatments

The aim of treatment is generally to reduce the swelling, pain and damage to the joints.

​For more information:

https://www.arthritis.org.nz/forms-of-arthritis/
https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/arthritis
https://www.healthline.com/health/arthritis

If you need help to get mobile, exercise or you need dietary advice our friendly physiotherapists and dietitians can help just contact us.
​
                        Ph:   (03) 377 5280        Email:           admin@tpl.nz

​Food for a Healthy Heart

It's never too late to look after your heart, improve your health, and get the most out of life. Here are some guidelines to help you choose the best foods for your heart:
 
​Fruit and Vegetables 
Have fruits and/or vegetables at every meal and for most snacks. 
 
Grains and Starchy Vegetables

• Select whole grain breads or high-fibre breakfast cereals, in place of white bread and low fibre varieties. 
• Have a baked potatoes or kumara instead of deep-fried chips.
• Swap white flour for wholemeal.
• Just eat one grainy or starchy food at each meal

Protein – meat, poultry, legumes, fish, seafood and eggs

• Include a protein in one or more meals each day.
• Cut fat off meat and chicken
• Drain the fat of tinned products
• Steam, grill or pan fry fish and seafood
• Add legumes to meat dishes they make the meat go further

 
Dairy Products

• Have low-fat milk, and milk products.
• Eat reduced fat cheeses
• Select a plain unsweetened yoghurt over sweet baking

Drinks

• Drink plenty of fluids each day, particularly water
• Have unsweetened tea and coffee with low fat milk
• Have soda water instead of fizzy drinks and fruit juices.
• Keep your alcohol consumption down

 
General tips

• When cooking limit sugar or salt 
• Choose ready-prepared foods, snacks and drinks low in saturated fat, sugar and sodium. 
• Avoid butter, deep-fried and fatty foods 
• Have sweet bakery products or pastries and fruit juices only occasionally.

If you are struggling to change your diet Therapy Professionals friendly Dietitian can help just contact us.
                                                Phone: 03 377 5280                      Email: admin@tpl.nz

Are My Elderly Parent’s Coping?

As our parents move in to Shakespeare’s ‘Sixth stage of man’ many of us in our middle age are busy with our careers and bringing up children.  We often take our parents for granted and forget they are ageing.  If we see them regularly, we may not notice subtle changes or if we live elsewhere and rarely see them, we may get a shock at their decline between visits.  Compounding this, most parents don't want to be a 'bother' and aren't good at telling their adult children they need help.
 
It can be a shock to see our parents slowing down and not coping. We may have no idea how to deal with their changing state. Some of us respond by ignoring or minimising the situation, while others will behave more like a bossy parent.  More often than not, even with the best intentions, we don't know when and how to respond. 

In my experience with my own mother and observing others it's best to start talking with your parents early in their retirement, and keep talking about all the different scenarios that may happen as they age, good and bad.  For each scenario, find out the options for care or help and discuss these with your parents. Most importantly, find out what they want to happen in each case.

​It may help to start by arranging a power of attorney, and who will be responsible for their health, welfare and finances should they become incapable of making those decisions.  A change in the ability to manage one’s affairs could happen suddenly after a health event, like a stroke, or slowly as a result of dementia.  It’s best to be prepared.
 
Become informed with your parents on how ageing may affect them and how they may look after themselves to extend their independence and enjoyment of life.  There is plenty of information on the Internet to help with this.  I suggest you look at local reputable resources.
 
Regularly check in with your parents, and ask them if there is anything they are struggling with.  If so, discuss alternative ways of managing the problem area. Be observant, and if you notice there has been a change in, say, the standard of house keeping, tactfully discuss this with them.  Again, it is helpful if you've discussed at an earlier time how to manage these changes and how best to broach the subjects with them.

Changes you may notice include, a drop in:
 

• household cleanliness and tidiness
• household and garden maintenance
• personal hygiene and grooming
• weight and lack of food in the fridge and cupboards
• bills being paid on time 
• managing trades people and technology

 
It is well worth having these hard conversations with your ageing parents as it helps take some of the stress out of their decline and allows you to more readily enjoy their final years.
 
If your parents are struggling at home our friendly therapists may be able to help them maintain their independence. Just contact us at Therapy Professionals 
 
Ph:                              03 3775280
Email:                        admin@tpl.nz

 
‘The sixth age shifts
Into the lean and slipper’d pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well sav’d, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion;
Sans teeth, sans eyes, sans taste, sans everything.’
 
William Shakespeare – As you like it.  “The seven stages of man.”
                      
                   

It's Mental Health Awareness Week 

21 September – 27 September.  
Mental Health Awareness Week is run each year by the Mental Health Foundation and it's more timely than ever. This year's theme is Reimagine Wellbeing Together – He Tirohanga Anamata.  It’s time to reflect on how we can all improve our mental health.

The five ways to wellbeing guide

Five Ways to Wellbeing is a set of five simple, evidence-based actions which can improve wellbeing in everyday life. 

Background
​
The Five Ways to Wellbeing was introduced to Aotearoa New Zealand in 2009 as part of Mental Health Awareness Week, building on work done by the New Economics Foundation (NEF) for the UK Government. 
​
This paper aims to develop confidence in organisations and workers that their communication of the messages is supported by best practice, built upon good understanding of the evidence and reflects a consistent national approach. The Mental Health Foundation has commissioned a review of how the Five Ways to Wellbeing has been implemented in Aotearoa since 2009. Further information and practical tips on how to use the Five Ways is available on the website. ​

Prevent the spread of cold and flu with regular hand washing
 
In the mid 19th Century Ignaz Semmelweis and Florence Nightingale pioneered hand washing as prevention against the spread of infection.  This simple practice revolutionised health care and public health.  It is  still as important today as it was then.
 
Hand washing is the most effective means of preventing the spread of infection, including winter colds, and flu.  
 
Hand washing needs to be done before:

• eating or preparing food

 
and after:

• sneezing, coughing or blowing your nose or a child’s.
• gardening or playing outside
• contact with animals
• going to the toilet or changing nappies
• looking after sick people

 
Hand washing is not just putting a little soap on your hands and running them under the tap.  It requires soap that froths, cleaning all the surfaces of the hands for at least 20 seconds.
 
The following 7 steps for good hand washing are: 

Step 1:           Turn on taps; adjust water temperature to desired heat.
Step 2:            Wet hands under running water.
Step 3:            Apply soap to palm of hand (use a soap that froths up well)
Step 4:            Ensure contact of soap with all surfaces for at least 20 seconds, refer to the
                        following:

​                           a)  Palm to palm                 b) Right palm over left back                 c) Palm to palm fingers
                                                                                   of hand and vice versa                           interlaced.                                        

                               d) Backs of fingers to        e)  Rotational rubbing of            f) Rotational rubbing, backwards and
                                         opposing palms with          right thumb clasped                   forwards with clasped fingers of right
                                         fingers interlocked.             in left palm and vice                   hand in left palm and vice versa.  
                                                                                        versa.

Step 5:           Rinse hands thoroughly for about 20 seconds, as long as it takes to sing Happy
                        Birthday through twice.
Step 6:           Dry hands thoroughly with clean towel or paper towel.
Step 7:           Where possible turn taps off with elbows or paper towel (avoid hand contact with
                        taps and door handles).
 
NB      Any broken skin areas should be covered with a dressing.            
 
 
Hand washing technique
(Aycliffe et al, 1978, Lawrence 1985)