Hand Washing for CNAs: Step-by-Step Guide and Exam Tips

Hand washing is the most fundamental skill in nursing assistant practice. It is how you protect patients, protect yourself, and stop bacteria and viruses from spreading between people or surfaces. In a clinical setting, you wash your hands dozens of times per shift, before and after every patient contact, before putting on gloves, and after removing them.

Hand washing is the only skill that appears on every single NNAAP (National Nurse Aide Assessment Program) skills examination. While the other four skills on your exam are drawn randomly from a larger pool, hand washing is always tested. That makes it the single most important skill to get exactly right on exam day.

Why This Skill Matters on the CNA Exam

The NNAAP skills exam uses a standardized checklist. The evaluator watches you perform the skill and marks whether you completed each required step in the correct order. For hand washing, that checklist includes specific behaviors like fingertip direction, scrubbing duration, and how you handle the faucet at the end. Missing even one critical step can result in a failing score for the entire skill.

Because hand washing appears on every exam, it is also evaluated at the start and end of every other skill you perform. Your evaluator is watching your hand hygiene throughout the entire exam, not just during the designated hand washing skill. Getting this right early in the day sets a strong tone for everything that follows.

If you fail the hand washing skill, you may still pass the overall exam if your other skills score high enough, depending on your state's testing provider. However, a poor hand washing score often signals to evaluators that your infection control habits need work across the board. Check your state's testing provider for the exact pass/fail criteria in your area.

What You Need

• A sink with running water
• Liquid soap or bar soap
• Paper towels
• A trash receptacle near the sink

Step-by-Step: Hand Washing

1. Approach the sink without touching it. Keep your clothing away from the sink edge. If the sink or faucet handles may be contaminated, use a paper towel to turn on the water. Adjust the temperature to warm. Water that is too hot can damage your skin over time and may cause you to rush through the process.
2. Wet your hands with fingertips pointing down. Hold your hands under the running water with your fingertips lower than your wrists. This allows dirty water to flow away from your body and off your fingertips rather than running back up toward your forearms. This direction matters and the evaluator will be watching for it.
3. Apply soap to all hand surfaces. Pump enough liquid soap to cover your palms, the backs of your hands, between your fingers, and your wrists. A small amount is not enough to clean thoroughly.
4. Rub your palms together. Use a circular motion to create a lather across both palms. This is the starting point before you move to the less obvious surfaces.
5. Scrub the back of each hand. Place one palm flat on the back of the other hand and rub. Switch hands and repeat. The backs of your hands touch surfaces constantly and are easy to forget during handwashing.
6. Interlace your fingers and rub between them. Lace the fingers of one hand between the fingers of the other and rub back and forth. Bacteria accumulate in the spaces between fingers because those areas rarely get enough friction during a quick rinse.
7. Clean under your fingernails. Rub the fingernails of each hand against the opposite palm in a scratching motion. This dislodges debris and pathogens that collect under the nail edge, which is one of the most commonly missed areas during hand washing.
8. Scrub your wrists. Wrap one hand around your opposite wrist and scrub in a circular motion, then switch sides. The wrist is often missed entirely, but it is part of the NNAAP hand washing checklist.
9. Continue scrubbing for at least 20 seconds. The CDC and NNAAP both require a minimum of 20 seconds of scrubbing. If you are unsure how long you have been scrubbing, count to 20 slowly or hum Happy Birthday twice. The 20 seconds starts after you apply the soap, not when you turned on the water.
10. Rinse with fingertips still pointing down. Return your hands to the running water with fingertips lower than your wrists, the same position as when you wet them. Rinse from the wrists toward the fingertips so contaminated soap and water run off your hands and not back up your forearms.
11. Dry from fingertips toward wrists. Take a clean, dry paper towel and pat starting at your fingertips. Move toward your wrists as you dry. This order ensures you are not dragging germs back toward clean skin you already dried.
12. Turn off the faucet with the paper towel. Use the same paper towel you dried with (or a fresh one) to grip the faucet handle and turn it off. The faucet handle was contaminated when you turned it on. Touching it with your now-clean hands would immediately re-contaminate them.
13. Discard the paper towel without touching the trash can. Drop or push the paper towel into the trash. Do not use your clean fingers to lift a lid or push a flap. If the trash can requires a hand to open, use your elbow or the paper towel to avoid contact.

What the Examiner Looks For

• Fingertips are pointing downward during both the wetting and rinsing steps
• Soap is applied before scrubbing begins
• All hand surfaces are scrubbed: palms, backs of hands, between fingers, under nails, and wrists
• Scrubbing continues for a minimum of 20 seconds
• Drying goes from fingertips toward wrists, not the reverse
• The faucet is turned off using a paper towel, not bare hands
• The trash can is not touched with clean hands after discarding the paper towel
• The sink and surrounding surfaces are not touched with clothing

Common Mistakes to Avoid

• Scrubbing for less than 20 seconds. This is one of the most common reasons students fail the hand washing skill. Count deliberately. Twenty seconds feels longer than you expect when you are nervous in an exam setting.
• Pointing fingertips up during rinsing. Holding your hands with wrists below the fingertips causes dirty rinse water to run toward your wrists and forearms rather than off your fingertips. Always keep fingertips lower than wrists throughout.
• Touching the faucet with clean hands. Many students turn off the faucet by hand out of habit. Practice using the paper towel every single time so it becomes automatic before exam day.
• Skipping the wrists or between fingers. Students who are anxious about time often rush through these areas. The evaluator is specifically watching for them. Slow down and scrub every surface.
• Not cleaning under the fingernails. This step is on the checklist and is easy to forget because most people skip it in everyday handwashing. Make it a deliberate habit during practice.
• Touching the trash can after discarding the towel. Even pushing a lid open with your fingertips counts as recontamination. Practice the discard motion until it is smooth and hands-free.

Printable Practice Checklist

Use this checklist when practicing with a partner or in front of a mirror. Check off each step as you complete it.

1. Turned on water with paper towel if needed; adjusted to warm
2. Wet hands with fingertips pointing down
3. Applied soap
4. Rubbed palms together
5. Rubbed back of each hand
6. Interlaced fingers and scrubbed between them
7. Cleaned under fingernails
8. Scrubbed wrists
9. Scrubbed for at least 20 seconds total
10. Rinsed with fingertips pointing down
11. Dried from fingertips toward wrists with paper towel
12. Turned off faucet using paper towel
13. Discarded paper towel without touching trash can

The best way to build confidence with hand washing is to practice it in a real clinical setting. If you are not yet enrolled in a training program, browse CNA programs by state to find options near you.

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