- The objectives: patient safety, public confidence, staff comfort
- The evidence base
- Good practice for uniforms and workwear
- Appendix A – Direct patient care activity
- Appendix B – Advice from Muslim Spiritual Care Provision (MSCP) in the NHS
- Appendix C – Additional legal context
- Appendix D: References
Publications approval reference: 001559 / C0078
Date: 2 April 2020
Uniforms and workwear: guidance for NHS employers
In 2007 the Department of Health published Uniforms and Workwear: An evidence base for developing local policy. This publication supports the specific requirements of the Health and Social Care Act 2008 Code of Practice relating to uniform and workwear policies, and the need to ensure that they support effective hand hygiene. This was updated in 2010 to include key equality and diversity measures to accommodate faith groups.
NHS England and NHS Improvement are publishing this revised guidance to ensure it is more accessible and inclusive to NHS employers and NHS employees. This is a joint initiative with key stakeholders, led by NHS Employers, including the British Medical Association (BMA), University College London Hospitals NHS Foundation Trust (UCLH), Healthcare Infection Society, The Infection Prevention Society and the British Islamic Medical Association. We would like to thank all the stakeholders involved in the revision of the guidance.
Whilst the development of local uniform policies and dress codes remains the responsibility of individual organisations, this guidance aims to ensure we support the drive in the NHS for a more inclusive and culturally responsive NHS for our staff, patients and carers. We want the guidance to support our NHS staff and workforce in the wide range of careers and opportunities that the NHS has to offer including medical, nursing, midwifery and the allied health professions. It will also help all NHS organisations to produce local polices on dress codes which are inclusive and consider the needs of all staff.
The guidance is also accompanied by a range of resources, good practice examples, blogs and infographics which you can find on the NHS Employers website.
Since its publication Uniforms and workwear: An evidence base for developing local policy has been widely adopted throughout the NHS. A range of comments and feedback have been received from employers and staff as local policies have been implemented. This revised guidance takes account of the feedback and offers further advice on dealing with some of the equality, faith and cultural issues associated with workwear.
The revised guidance contains no significant changes but offers some new and updated examples of good and poor practice of uniform and work wear. It reaffirms the principles set out in the original guidance with a focus on how staff should be dressed during direct patient care activity. A definition of direct patient care activity is set out in Appendix A.
The guidance provided is general and workwear requirements for specialised roles and tasks have not been considered in any level of detail. It addresses the interaction between infection control requirements relating to uniform and workwear and the public sector Equality Duty, with specific consideration given to the needs of faith groups.
Personal protective equipment (PPE) requirements, provisions relating to the use of hazardous materials and occupational health requirements, alongside wider infection control and health and safety obligations, are not addressed within this document and must be considered and addressed by individual organisations in accordance with legislation and regulations listed in Appendix C.
Effective hygiene and preventing infection transmissions are absolutes in all healthcare settings. Although there is no conclusive evidence that uniforms and workwear play a direct role in spreading infection, the clothes that staff wear should facilitate good care practices and minimise any risk to patients. Uniforms and workwear should not impede effective hand hygiene and should not unintentionally come into contact with patients during direct patient care activities. Similarly, nothing should be worn that could compromise patient or staff safety during care, for example any nails products, rings, earrings other than studs, and necklaces. Local policies may allow a single plain metal ring, such as a wedding ring.
Patients and the wider public should have complete confidence in the cleanliness and hygiene of their healthcare environment. The way staff dress is an important influence on people’s overall perceptions of the standards of care they experience. Uniforms must be clean at all times and professional in appearance. In addition, although there is no evidence that wearing uniforms outside work adds to infection risks, public attitudes indicate it is good practice for staff to change at work or cover their uniforms as they travel to and from work.
Patients and visitors also like to know who staff are the care team. Uniforms and name badges can help with this.
As far as possible, subject to the overriding requirements of patient safety and public confidence, staff should feel comfortable in their uniforms. This includes being able to dress in accordance with their cultural practices (see Appendix B). For example, although exposure of the forearm is a necessary part of hand hygiene during direct patient care activity (see Appendix A) the local uniform codes should allow for covering of the forearm at other times.
The 2007 guidance was informed by two extensive literature reviews conducted by Thames Valley University (TVU1 and TVU2), and practical research on washing of uniform fabrics carried out at University College London Hospital (UCLH). It also incorporated recommendations from the Hand Hygiene Task Force (HHTF).
TVU1: a literature review of evidence around the role of uniforms in the transfer of infections and effectiveness of laundry methods in removing contamination.
TVU2: a literature review of evidence on how uniforms affect the image of individuals and the organisations they work for, and the importance that people attach to this.
UCLH: practical work to establish the effectiveness of domestic and commercial laundering methods in removing micro-organisms from uniform fabrics.
HHTF: the guidance includes recommendations from the Healthcare Infection Control Practices Advisory Committee and Hand Hygiene Task Force: Morbidity and Mortality Weekly Report 2002; 51 (No. RR-16).
Legislation affecting uniforms and workwear has two main areas of focus:
- A primary concern with health and safety, along with the requirement to prevent the spread of infections.
- Employment equality for staff in terms of age, disability, gender, sexual orientation, race and ethnicity, religion or belief, and protection of human rights.
The way in which local policies are designed and implemented can minimise the risk of any challenge to uniform and workwear codes. The key factors are:
- clarity of meaning supported by practical examples of what is required
- consistency in the application and observance of dress codes
- robust reasons for each requirement of the policy.
Employers should consult with staff on uniform and workwear policies and keep them under regular review. Legislation that deals specifically with uniforms and workwear in healthcare settings is listed in Appendix C.
Responsibilities of NHS organisations should be included as currently the emphasis is on individual healthcare workers. Organisations should:
- Have local uniform policies in place and monitor compliance with these.
- Provide enough uniforms for staff to have clean uniforms for every shift to avoid daily washing (including students).
- Procure uniforms in line with sustainable procurement strategies, utilising natural fibres where possible to ensure staff comfort (particularly important in relation to menopause and peri-menopause).
All elements of the washing process contribute to the removal of micro-organisms on fabric. Detergents (washing powder or liquid) and agitation release any soiling from the clothes, which is then removed by sheer volume of water during rinsing. Temperature also plays a part.
Scientific observations and tests, literature reviews and expert opinion as stated in the 2007 suggests that:
- There is little effective difference between domestic and commercial laundering in terms of removing micro-organisms from uniforms and workwear
- Washing with detergents at 30ºC will remove most Gram-positive micro-organisms, including methicillin-resistant Staphylococcus aureus (MRSA)
- A ten minute wash at 60ºC is sufficient to remove almost all micro-organisms. In tests, only 0.1% of any Clostridioides difficile spores remained. Microbiologists carrying out the research advise that this level of contamination on uniforms and workwear is not a cause for concern
These are recommended good practices based on evidence from the literature reviews, testing and effective hand hygiene procedures.
|Wear short-sleeved tops and do not wear white coats during patient care activity.||Cuffs at the wrist become heavily contaminated and are likely to come into contact with patients.||TVU1, TVU2|
|Change immediately if uniform or clothing becomes visibly soiled or contaminated.||Visible soiling may present an infection risk and will be disconcerting for patients.||TVU1, TVU2|
|Dress in a manner which inspires patient and public confidence.||People may use appearance as a proxy measure of professional competence.||TVU2|
|Change into and out of uniform at work or cover uniform completely when travelling to and from work.||There is no evidence of an infection risk from travelling in uniform, but many people perceive it to be unhygienic.||TVU1, TVU2|
|Wear clear identifiers.||Patients like to know the names and roles of staff who are caring for them.||TVU1|
|Wash uniforms and clothing worn at work at the hottest temperature suitable for the fabric (trusts should take this into account before purchasing uniforms that can only be washed at low temperatures or are dry clean only).||A wash for ten minutes at 60ºC removes almost all micro-organisms. Washing with detergent at lower temperatures – down to 30ºC – eliminates MRSA and most other micro-organisms.||UCLH|
|Clean washing machines and tumble driers regularly, in accordance with manufacturer’s instructions.||Regular cleaning and maintenance will protect the machine’s washing efficiency. Dirty or underperforming machines may lead to contamination of clothing, although there is no published evidence that this presents an infection risk.||UCLH|
|Have clean, short, unvarnished fingernails.||Clean nails are hygienic and look professional. Long nails are harder to keep clean and are a potential hazard.||HHTF|
|Tie long hair back off the collar.||Patients prefer to be treated by staff who have tidy hair and are smartly presented.||TVU2|
|Go shopping in uniform or engage in other activities outside work.||Even though there is no evidence of infection risk, people perceive there is one.||TVU2|
|Wear false nails during patient care activity.||False nails harbour micro-organisms and make effective hand hygiene more difficult.||HHTF|
|Wear any jewellery, including a wrist-watch, on the hands or wrists during direct patient care activity (local policies may allow a plain ring such as a wedding ring).*1||Jewellery and watches can harbour micro-organisms and make effective hand hygiene more difficult.||HHTF|
These are examples of good practice which need no evidence base. They simply serve the three objectives of patient safety, public confidence and staff comfort.
|Wear soft-soled shoes, closed over the foot and toes.||Closed shoes offer protection from spills and dropped objects. Open shoes risk injury or contamination for staff. Soft soles reduce noise in wards.|
|Have at least enough uniforms available for staff to change each day.||Enables staff to start each day with a clean uniform.|
|Put on a clean uniform at the start of every shift.||Presents a professional appearance.|
|Do not overload the washing machine.||Overloading the machine will reduce wash efficiency.|
|Wash heavily soiled uniforms separately.||Separate washing will eliminate any possible cross-contamination from high levels of soiling and enable the uniform to be washed at the highest recommended temperature.|
|Use posters or other visual aids to show who wears which uniform.||Patients and their visitors like to know who is looking after them. Uniforms will help them identify who they may wish to speak to.|
|Where, for religious reasons, members of staff wish to cover their forearms or wear a bracelet when not engaged in patient care, ensure that sleeves or bracelets can be pushed up the arm and secured in place for hand washing and direct patient care activity.*||Hand hygiene is paramount, and accidental contact of clothes or bracelets with patients is to be avoided.|
|Headscarves must be worn unadorned and secured neatly.
In surgical theatres:
|Headwear, for example, turbans and kippot, veils (Christian or niqab) and headscarves are permitted on religious grounds, provided that patient care, health and safety, infection control and security and safety of patients or staff is not compromised.
The outline for Headwear, builds on the Dress Codes and Uniform policy developed and implemented by University College London Hospital NHS Foundation Trust (UCLH), May 2018.
*In a few instances, staff have expressed a preference for disposable over-sleeves – elasticated at the wrist and elbow – to cover forearms during patient care activity. Disposable over-sleeves can be worn where gloves are used, but strict adherence to washing hands and wrists must be observed before and after use. Over sleeves must be discarded in exactly the same way as disposable gloves.
|Wear neckties/lanyards (other than bow-ties) during direct patient care activity.||Ties have been shown to be contaminated by pathogens and can accidentally come into contact with patients. They are rarely laundered and play no part in patient care.|
|Carry pens, scissors or other sharp or hard objects in outside breast pockets.||They may cause injury or discomfort to patients during care activity. They should be carried inside clothing or in hip pockets.|
|Wear jewellery while on duty other than a smooth ring or plain stud earrings.||Necklaces, long or hoop earrings and rings present possible hazards for patients and staff.|
|Wear numerous badges.||One or two badges denoting professional qualifications or memberships may be acceptable. Any more looks unprofessional and may present a safety hazard.|
|Dress untidily and in an unprofessional manner.||Patients and visitors may equate untidy appearance with low professional competence and poor hygiene standards.|
Care of a patient provided by a staff member may involve any aspect of healthcare of a patient, including examination, treatment, sample collection, etc., so any activity that involves direct patient care as per the WHO 5-moments.
This includes activity in the following settings:
On the ward
- In the patient bedspace
- In any activity that involves patient contact
In out-patient clinics
- Any activity that involves patient contact, for example:
- examining patients
- wound care
- collecting samples for testing
In treatment and minor surgical procedure rooms
- At all times when patients are being treated.
In clinical areas with specific dress requirements
- In operating theatres
- In intensive/critical care units
- In A&E departments
Hand hygiene during direct patient care activity requires washing/disinfection*
- Before patient contact
- Before aseptic tasks
- After risk of body fluid exposure
- After patient contact and after contact with a patient’s surroundings
*Based on the My 5 moments for Hand Hygiene © World Health Organization 2009. All rights reserved.
Exposure of the forearms is not acceptable to some staff because of their Islamic faith. In response to these and other concerns, the MSCP convened a group including Islamic scholars and chaplains and multi-faith representatives, as well as Department of Health policy-makers and external experts in infection prevention. Based on these group discussions, the MSCP prepared a list of recommendations to ensure that local dress code policies are sensitive to the obligations of Muslims and other faith groups whilst maintaining equivalent standards of hygiene.
It is recommended that these changes are agreed with local infection prevention and control teams and equality and diversity steering groups and implemented into local trust policy
- Uniforms may include provision for sleeves that can be full length when staff are not engaged in direct patient care activity.
- Uniforms can have three-quarter length sleeves.
- Any full or three-quarter length sleeves must not be loose or dangling. They must be able to be rolled or pulled back and kept securely in place during hand-washing and direct patient care activity.
- Disposable over-sleeves, elasticated at the elbow and wrist, may be used but must be put on and discarded in exactly the same way as disposable gloves. Strict procedures for washing hands and wrists must still be observed.
Use of hand disinfection gels containing synthetic alcohol does not fall within the Muslim prohibition against natural alcohol (from fermented fruit or grain).
Individual organisations should take account of the following legislation and regulatory guidance (which falls outside the scope of this guidance) when drafting organisational policies on uniform and workwear requirements, the transmission of infection and health and safety, principally:
The Health and Safety at Work Act 1974 (‘HSWA’), Sections 2 and 3:
The HSWA is the primary piece of legislation covering occupational health and safety in Great Britain. Section 2 HSWA concerns risks to employees and Section 3 concerns risks to persons other than employees affected by work-related activities.
The Control of Substances Hazardous to Health (COSHH) Regulations 2002
The control of occupational exposure to biological agents in the healthcare setting is covered by the COSHH Regulations.
The Management of Health and Safety at Work Regulations 1999
These regulations generally make more explicit what employers are required to do to manage health and safety under the Health and Safety at Work Act 1974 and provide general principles of prevention. They require employers to undertake a risk assessment of the health and safety implications, on employees and others who may be affected, of work-related activities.
Personal Protective Equipment at Work Regulations 1992
These regulations set out an employer’s duties concerning the provision and use of personal protective equipment (PPE) at work. The definition of PPE includes specific workwear items designed to protect the user against health risks such as exposure to blood or bodily fluids. For this reason, aprons, gloves, googles and visors may be considered to be PPE items.
Provision and Use of Work Equipment Regulations 1998
These regulations place duties on entities that own, operate or have control of work equipment (including PPE) to manage risks from that equipment.
Workplace (Health, Safety and Welfare) Regulations 1992
These regulations stipulate that where an employee has to wear special clothing (for example, a uniform) for the purposes of work, then suitable and sufficient changing facilities are to be made available to them along with secure facilities to store personal clothing. Where work is strenuous, dirty or could result in contamination, showers must be provided.
Manual Handling Operations Regulations 1992
The Manual Handling Operations Regulations stipulate that work clothing should be well-fitting and hinder movement and posture as little as possible.
Helping Great Britain work well: A new health and safety system strategy (2016)
The Health and Safety Executive strategy for improving health and safety in the workplace.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
These regulations set out the requirements that all providers must reach in order to be registered with the Care Quality Commission. Regulation 12(2) (h) details that providers must assess the risk of, prevent, detect and control the spread of infections including those that are health care associated.
The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance
This requires that uniform and workwear policies ensure the clothing worn by staff when carrying out their duties is clean and fit for purpose. This guidance provides that particular consideration should be given to items of attire that may inadvertently come into contact with the person being cared for and that uniform policies should specifically support good hand hygiene.
The Human Rights Act 1998
The Human Rights Act 1998 incorporates into UK law the rights contained within the European Convention of Human Rights. The Act imposes direct obligations on public authorities to ensure that Convention rights are protected. Courts and employment tribunals must interpret UK legislation, where possible, in a manner consistent with Convention rights. Article 9 of the Convention protects freedom of thought, conscience and religion and Article 14 of the Convention prohibits discrimination, including on religious grounds.
Equality Act 2010
The Equality Act 2010 provides legal protection from discrimination in the workplace and in wider society. It replaced previous anti-discrimination laws with a single Act, making the law easier to understand and strengthening protection in some situations. It prohibits discrimination and harassment in respect of protected characteristics, which includes religion or belief. The Equality and Human Rights Commission has issued revised guidance (June 2018) on Religion or belief: dress codes and religious symbols, including specific questions addressing religious dress and health and safety policies.
Public sector Equality Duty (PSED)
Section 149 of the Equality Act 2010 created a single public sector equality duty covering all strands of discrimination law. Authorities are required to have regard to three matters when exercising this duty: (1) eliminating conduct that is prohibited by the Equality Act 2010; (2) advancing equality of opportunity between those who share a protected characteristic and people who do not share it; (3) fostering good relations between those who share a protected characteristic and those who do not share it.
The Constitution sets out rights for patients, public and staff. It outlines NHS commitments to patients and staff, and the responsibilities that the public, patients and staff owe to one another to ensure the NHS operates fairly and effectively. Amongst other matters it emphasises patient safety and rights of patients to be cared for in a clean, safe, secure and suitable environment. Employers should also be aware of the provisions of equality and diversity legislation. Guidance on this issue is available on the NHS Employers website.
- British Medical Journal (BMJ) Open research paper on a cross-sectional study investigating experiences of female Muslim medical health professionals on bare below the elbows (BBE) policy and wearing headscarves (hijabs) in Theatre: Malik, A., Qureshi, H., Abdul-Razaqk H., Yaqoob, Z., Javaid, F., Esmail, F.,
- Wiley, E., Latif, A,. (2019) “I decided not to go into Surgery due to Dress Code”. A cross-sectional study investigating experiences of female Muslim medical health
- Professionals on bare below the elbows (BBE) policy and wearing headscarves (hijabs) in theatre. BMJ Open
Employers should also be aware of the provisions of equality and diversity legislation.