JDC discussion paper on uniforms November 2008

A number of employers across the UK have recently brought in uniform policies for junior doctor employees where previously no uniform had been worn or where the wearing of long-sleeved white coats had been abandoned for reasons of infection control. The types of uniforms imposed have been various, including short-sleeved white tunics to be worn over normal clothes, scrubs, full tunics and polo shirts.

Employers have explained that the new uniforms are essential in order to improve infection control and to enhance corporate image. Some have even argued that, from their own sample studies, patients prefer to see doctors in uniforms. They argued that junior doctors would feel more respected when wearing uniforms and have improved confidence. In the majority of cases, these uniform policies have been brought in without agreement from junior doctor employees. In addition, policies often only apply to junior doctor employees rather than all grades of medical staff.

Several questions arise from the introduction of these policies and the JDC has been asked for its general views on this matter. This short paper aims to discuss the key points arising from the introduction of uniforms for junior doctors, and is based on discussions amongst JDC members, other BMA work in this general area, Department of Health policy documents and academic literature. This paper is only intended to provide a general overview of the area: we hope that future work by the BMA’s Board of Science will be able to provide a more in-depth review of the evidence base.

Department of Health literature
In September 2007, the Secretary of State for Health announced that a new ‘bare below the elbows’ policy would be introduced for clinical staff in NHS acute trusts in order to improve infection control in hospitals. Coupled with this was the publication of ‘Uniforms and workwear’ (Department of Health, 2007), which was an attempt to give examples of good practice to employers on dress codes for staff and the wearing and laundering of uniforms, where uniform policies were in place. The paper was based on two literature reviews by Thames Valley University (Wilson et al, 2007 and Loveday et al, 2007, both discussed below), and included a number of recommendations for employers. The list of recommendations can be found in guidance for consultants from the BMA Central Consultant and Specialists Committee (2007).

Neither the ‘bare below the elbows’ policy, nor the ‘Uniforms and workwear’ paper was an encouragement to employers to implement uniform policies for staff where previously there were none. Neither the Department of Health website nor the NICE website carry material that specifically recommends the wearing of uniforms as a method of infection control. In ‘The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections’ (Department of Health, 2008), uniforms are only mentioned twice:

“Duty to provide and maintain a clean and appropriate environment for healthcare:
An NHS body must, with a view to minimising the risk of HCAIs, ensure that: … uniform and workwear policy ensure that clothing worn by staff when carrying out their duties is clean and fit for purpose.”

“Linen, laundry and dress:
Particular consideration should be given to items of attire that may inadvertently come into clinical contact with a patient. Uniform and dress code policies should specifically support good hand hygiene.”

Scientific evidence relating to uniforms
Employers who have implemented a uniform policy for junior doctors have argued that uniforms are essential for infection control. As discussed above, there is no evidence that this is supported by either the Department of Health or NICE. More importantly there is little evidence for this in the academic literature.

Much scientific research in this area has in fact been from a slightly different angle: research has attempted to find out whether or not the wearing of uniforms encourages the transmission of micro-organisms. However, according to Wilson et al (2007), there have been no scientific studies that show micro-organisms are transferred from uniforms to patients in clinical situations. The study also goes on to say that uniforms should not be considered as a substitute for protective clothing, recommending that “plastic aprons or other personal protective clothing must be used to protect uniform/work clothing from contamination during patient care activities.” A study by Loveday et al (2007) agrees and concludes that “traditional uniforms and other clothing worn for patient care should be viewed as work attire and not as patient or personal protective clothing”. If there is an acknowledged need for staff to wear protective clothing, for any reason including infection control, disposable plastic aprons and gloves should always be provided.

BMA guidance for staff on healthcare associated infections (HAIs) also notes that, from the scientific evidence available, the unnecessary wearing of aprons, gowns and masks in everyday clinical settings is not recommended (BMA Board of Science, 2006).

As there is little evidence to support employers’ claims about uniforms and infection control, the JDC agrees with the CCSC’s view that uniform policies “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.”

Views of junior doctors
In addition to questions over the validity of claims about the importance of uniforms for infection control purposes, junior doctors are chiefly concerned over the effect of uniforms on their professional identification. Many believe that the wearing of a uniform, where not clinically necessary, undermines their professionalism. As Loveday et al (2007) found, patients “judge professionalism and trustworthiness of practitioners based on the clothes they wear”. The paper goes on to say that:

“a feature of the literature surrounding nurses’ and doctors’ uniforms is the importance attached to enabling patients and staff to easily recognise the role, experience and seniority of an individual practitioner often indicated by particular colours and accessories, many of which have historical associations”.

Junior doctors are concerned that patients may view a doctor in uniform as just another corporate NHS body, rather than seeing them as the authoritative leader of the delivery of their care.

Junior doctors are also concerned about unnecessary trust expenditure on uniforms (the RCN estimates that on average a nurse’s uniform costs between £12 and £20) and many feel that the importance placed on uniform policies by trusts could lead to over-reliance on this as a method of infection control.

However, many junior doctors, particularly those in certain specialties such as Emergency Medicine, like to wear a uniform for a number of reasons including:

•It prevents their own clothes from being spoiled at work;
•They do not need to buy ‘work clothes’
•The uniform may be appropriate for the clinical area in which the doctors work
It may be the case that some uniform policies will receive support from junior doctors, depending on their detail and their implementation.

Policy implementation
Perhaps the most important part of the discussion on uniforms is how local policies are developed and implemented. A large number of issues need to be considered by trust managers and junior doctors if a reasonable policy, which can be supported by staff, is to be introduced:

•Before anything is drawn up, any uniform policy must be discussed in its very early stages, in detail, with junior doctor representatives in the trust, with the LNC, and with the BMA locally. Without buy-in from potential uniform-wearers, a uniform policy is likely to be difficult to implement successfully.
•Questions for management and staff to consider jointly:
– Is a uniform clinically appropriate? In some areas a uniform may be useful and the need well-supported by staff e.g. Emergency Departments, Intensive Care Units
– Is the uniform design appropriate? Does it clearly identify the wearer as a doctor? How will patients be able to distinguish between a doctor, a nurse, a physiotherapist etc? This is very important. It will reduce confusion between staff groups, and also between staff and patients.~
– Which specialties will wear the uniforms? Which grades of doctors? Will the consultants be wearing them? If only junior doctors are expected to wear the uniforms, how is this justified?
– What sanctions will be imposed if doctors do not comply with the policy?
– What facilities for changing will be provided? Lockers and changing areas are essential. A mandatory policy for uniform wearing must also include changing a secure storage facilities.
– What footwear and outerwear (e.g. cardigan, sweater) can be worn with the uniform?
– Where exactly must the uniform be worn? There should be clear rules – on wards only, in out-patients, on the way to/from work, in the hospital canteen etc. Will doctors have to change if they move from one area to another? What effect will this have on efficiency and working time?
– How will the uniforms be laundered ? If the policy is for home-laundering can staff still access hospital laundering when uniforms are heavily soiled?
– If the employer is determined to implement uniforms, it is their obligation to provide them to employees. How many changes of uniform will be issued? A clean uniform is required each day, and many junior doctors could work for 12 days straight. How will doctors be able to obtain a new set? How often can they get them?
– Will there be access to spare uniforms if a doctor’s uniform becomes contaminated?


1.BMA Board of Science (2006), ‘Healthcare associated infections: a guide for healthcare professionals’, February 2006, British Medical Association.
2.BMA Central Consultants and Specialists Committee (2007), ‘Uniforms and dress code for doctors: guidance from the Central Consultants and Specialists Committee’, December 2007, British Medical Association.
3.Department of Health (2008), ‘The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections’, January 2008.
4.Department of Health (2007), ‘Uniforms and workwear: an evidence base for developing local policy’, September 2007.
5.HP Loveday, JA Wilson, PN Hoffman and RJ Pratt (2007), ‘Public perception and the social and microbial significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review’, British Journal of Infection Control, September 2007, Vol 8, No 4.
6.JA Wilson, HP Loveday, PN Hoffman and RJ Pratt (2007), ‘Uniform: an evidence review of the microbial significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England)’, Journal of Hospital Infection, 2007, Vol 66, pp 301-307.

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