Uniform and dress code for doctors


Guidance from the Central Consultants and Specialists Committee
December 2007

Following the recent well publicised outbreaks of MRSA and Clostridium difficile, various demands and claims have been made about how doctors’ dress might be regulated with a view to improving hospital infection rates. On 17 September, the Secretary of State for Health, Alan Johnson, issued a press release which contained a promise to introduce a range of measures in NHS hospitals in England including a ‘bare below the elbows’ dress code for those involved in clinical activity in all acute trusts by January 2008.

This was supported by a paper which gave some information on which the Department of Health expects local policies to be based. Accordingly the policy is for local discussion and negotiation and we expect that LNCs will have a central role in this. LNCs should consider urgently what measures would be needed in their hospitals in order to allow consultants to comply with these sensible moves. However the policy must be seen as a corporate image and identity issue, for negotiation, rather than an infection control issue which LNCs are asked to agree without question. Although this currently relates to England, it may be picked up by the devolved nations in future.

Further details are available on the Department of Health website.

One result of this announcement is that a small number of Trusts are already looking at implementing new policies which incorporate new responsibilities for staff regarding infection prevention and control into job descriptions.

The CCSC is particularly concerned that the Secretary of State’s ‘bare below the elbows’ policy is not supported by demonstrable scientific evidence and was issued hastily in response to an intense period of media focus on the issue. The CCSC and the wider BMA support evidence backed policies aimed at fighting infection rates in hospitals but believes that such policies should be introduced on the basis of clear evidence and in partnership with clinicians locally. If such policies are to be meaningful and effective, it is vital that consideration be given to what supporting resources might be necessary. Specifically, thought should be given to who might be responsible for the provision of the facilities necessary to enable NHS workers to meet the new regulations.

One of the important findings in the literature reviews underpinning this move was that patients want to know who is treating them and that they judge the professionalism and trustworthiness of doctors based on the clothes that they wear. LNCs should ensure that whatever local policies are implemented, assist in maintaining a professional appearance.

This briefing paper summarises some of the evidence and guidance for employers and employees considering introducing new polices such as those applying to the wearing and laundering of uniforms and hand hygiene. Information has been collated from two sources, the first of which, from the Department of Health, underpins this move.

‘Despite the limited amount and quality of the evidence, the general public’s perception is that uniforms pose an infection risk when worn inside and outside clinical settings. This is reinforced by media comment and a lack of clear, accessible information and may have a damaging effect on the relationship between professionals and patients and the public image of healthcare workers. There is no good evidence to suggest uniforms are a significant risk, that home laundering is inferior to commercial processing of uniforms or that it presents a hazard in terms of cross-contamination of other items in the wash-load with hospital pathogens. It is essential that the evidence is considered in a balanced way and not over-emphasised in the development of uniform policy and that the general principles of infection control are stressed.’ (Loveday et al, September 2007)

Sources:
1. Department of Health, (17 September 2007), ‘Uniforms and Workwear: An evidence base for developing local policy’

2. BMA Board of Science, (February 2006), ‘Healthcare associated infections: A guide for healthcare professionals’, (pp.9-10)

Uniforms and workwear: An evidence base for developing local policy
Conclusions for employers:
    • There is no conclusive evidence that uniforms (or other work clothes) are a significant source of cross-infection.
    • The public believe there is a risk, and dislike seeing hospital staff in uniform away from the workplace.
    • A ten-minute wash at 60C is sufficient to remove most micro-organisms
    • Using detergents means that many organisms can be removed from fabrics at lower temperatures. MRSA is completely removed following a wash at 30C
    • There is no conclusive evidence that commercial laundering is more or less effective than domestic laundering in removing micro-organisms.
    • The way staff dress will send messages to the patients they care for, and to the public.
    • It is sensible for trusts to consider what messages they are trying to convey, and to advise on dress codes accordingly.
    • Both infection control and public confidence should underpin a trust’s uniform policy, but the two are not necessarily interchangeable.
Good practice examples (based on literature reviews and empirical evidence)
It is good practice to:
    • Dress in a manner which is likely to inspire public confidence.
    • Wear short-sleeved shirts/blouses and avoid wearing white coats when providing patient care.
    • Change into and out of uniform at work.
    • Cover uniform completely when travelling to and from work.
    • Wear clear identifiers (uniform and/or name badge).
    • Change immediately if uniform or clothes become visibly soiled or contaminated.
    • Tie long hair back off the collar.
    • Wash uniforms at the hottest temperature suitable for the fabric. (Trusts may also wish to take in to account the ‘washable’ nature of clothing when making purchasing decisions).
    • Clean washing machines and tumble driers regularly and maintain according to manufacturer’s instructions.
    • Keep finger nails short and clean.
It is poor practice to:
    • Go shopping or undertake similar activities in public.
    • Wear false nails for direct patient care.
    • Wear hand or wrist jewellery/wristwatch (a plain wedding ring may be acceptable).
Common sense examples of good and poor practice
It is good practice to:
    • Wear soft-soled, closed toe shoes.
    • Provide sufficient uniforms for the recommended laundry practice (more uniforms may be needed where the trust carries out the laundry).
    • Change into a clean uniform at the start of each shift in order to avoid overloading wash uniforms separately from other clothes.
    • Cover tattoos where these are extensive or may be deemed offensive.
    • Use posters or other aide-memoires to show what each uniform means.
It is poor practice to:
    • Wear numerous badges or other adornments.
    • Wear neck-ties (other than bow-ties) when providing patient care.
    • Carry pens/scissors etc in outside breast pockets.
    • Wear uniform sloppily – e.g. cardigan on duty, or uniform dress without hosiery.
    • Wear excessive jewellery (necklaces, visible piercings and multiple earrings). Where earrings are worn, they should be plain studs).
Healthcare associated infections: A guide for healthcare professionals

Hand hygiene
Effective hand hygiene is the single most important intervention in infection control: Bibliographic references
Any LNC which expresses an interest in the bibliographic references should contact the secretariat who will send the PDFs by return.

J.A. Wilson, H.P. Loveday, P.N. Hoffman and R.J. Pratt, (Aug. 2007), Journal of Hospital Infection, Vol.66 No. 4, ‘Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England)’ (pp.301-306)

HP Loveday, JA Wilson, PN Hoffman, RJ Pratt, (Sept 2007), British Journal of Infections Control, Vol. 8 No.4, Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review (pp.10-21)

© British Medical Association 2008

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