Guidance on uniforms and work wear
Aimed at those who undertake nursing care and their employers, this guidance sets out information on issues related to selecting, wearing and decontaminating uniforms or clothing worn when caring for patients. It can be applied to all settings in which health care takes place, and for any clothing worn when undertaking patient care activities.
Guidance on uniforms and work wear
Introduction
The professional image presented by nursing staff significantly contributes to the way in which nursing in general is regarded by colleagues, patients and the public. In recent years there has been much debate about uniforms and their desirability. For instance, while uniforms give nurses a recognisable identity that helps to promote public trust and confidence, some patients may negatively view uniforms as intimidating symbols of authority. Moreover, because the general public associates nurses' uniforms with the risk of infection, this can result in complaints and reduced confidence in the nursing profession when staff are seen in uniform outside of the workplace. Nurses and their employers need to keep these issues in mind. If its not appropriate to wear a uniform in certain situations, then each health care workers clothing should still meet certain essential requirements.
General principles
Uniform or clothing must be smart, safe and practical. It should:
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provide the wearer with mobility and comfort be durable enough to withstand decontamination (laundering) contribute to identification for security purposes (for example, a security coded name badge)
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project a professional image to encourage public trust and confidence contribute to the corporate image that nurses, and their employers, wish to present
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be designed with a client group in mind, reflecting the type of work undertaken take into account staff safety issues.
Organisational requirements
Health care organisations must help their staff to comply with essential good practices with regard to uniforms. Risk assessments and cost benefit considerations need to be addressed, and clear policies and guidance set out for staff.
Legal requirements
Health and Safety at Work Act (1974) and Management of Health and Safety at Work Regulations (1999) The Health and Safety at Work Act (1974) outlines the general duty of employers to protect staff at work and implement safe systems of work, while the Management of Health and Safety at Work Regulations (1999) require employers to carry out risk assessments. These duties extend to the type of uniform worn, and the decision as to whether a uniform is actually needed. For instance, in some areas of the UK, community nurses feel less vulnerable to attack if they are not in uniform when visiting patients. Personal Protective Equipment at Work Regulations (1992) The Health and Safety Executive definition of personal protective equipment (PPE) encompasses: ...all equipment (including clothing affording protection against the weather) which is intended to be worn or held by a person at work and which protects him against one or more risks to his health or safety. HSE INDG174(rev1) 08/05. While the PPE definition does not extend to general nursing uniforms, where the main objective is to project a corporate image, it does include specific work wear items designed to protect the user against a specific health risk, such as exposure to blood/body fluids in the operating theatre environment. For this reason aprons, gloves, and goggles or visors, may be considered to be PPE items. Workplace (Health and Safety and Welfare) Regulations (1992) These regulations stipulate that where an employee has to wear special clothing (such as a uniform) for the purpose of work, then suitable and sufficient changing facilities should be made available. In addition, where special clothing has to be worn, secure facilities for storing the personal clothing should be available. Where work is strenuous, dirty, or could result in contamination of the skin by harmful or offensive materials, showers should be provided.
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The Workplace Regulations (1992) also require that temperatures in workplaces should be set to provide reasonable comfort, without the need to wear special clothing. Additional clothing, such as cardigans, should not be worn during direct patient contact. Manual Handling Operations Regulations (1992) This guidance states that clothing should form a part of the assessment process. Work clothing should be well-fitting and restrict movement as little as possible. Health and Social Care Act (2008) (England only) The Health and Social Care Act (2008) contains a code of practice on the prevention and control of healthcare associated infections (HCAI) and related guidance. Under compliance criterion 2, which sets out the standards organisations are expected to meet for minimising the risk of HCAI the code states that uniform and work wear policies ensure that clothing worn by staff when carrying out their duties is clean and fit for purpose. Organisations are also required to ensure that policies enable good hand hygiene practices; for example, by keeping the hands, wrists and lower arms free from jewellery.
Guidance on patient and staff safety
Department of Health (2004) Standards for better health (England only) This document establishes the core standards for NHS patients in England and outlines the requirement that patient safety must be enhanced by the use of health care processes, work practices and systematic activities that prevent or reduce the risk of harm to patients. Health care organisations need to keep patients, staff and visitors safe by using systems that ensure a reduced risk of infection for patients. There is a particular emphasis on the high standards of hygiene and cleanliness needed to achieve year-on-year reductions of infection rates.
Moving and handling of patients
The type, frequency and extent of patient handling will affect the choice of uniform and this should be considered in any risk assessment. Belts, buckles, jewellery and badges can restrict movement and may lead to patients being injured during care, particularly in paediatrics and heavy work.
Hats can interfere with free movement when performing patient handling techniques, and should not be worn in locations where nurses need to move and handle patients. Minimum standards should embrace the following points:
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any uniform must allow unrestricted movement at the shoulder, waist and hips (options include dresses with shoulder vents and skirt pleats, culottes or trousers, tunic tops or polo shirts)
postures, like bending and reaching, should be undertaken without compromising the dignity of the nurse or patient
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wearer comfort is key, especially if work is being undertaken in a warm environment clothing fabric must withstand laundering at the correct temperature required for thermal disinfection for infection control fabric containing Lycra or polyester may not endure thermal disinfection processes
footwear should be comfortable shoes should be non-slip, have enclosed toes and provide support while sandals, clogs or shoes without heel support may not be deemed suitable when undertaking patient handling
the special needs of pregnant staff should be assessed and advice obtained from the occupational health service.
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Infection control issues
Studies show that uniforms may become contaminated by potentially disease-causing bacteria, including Staphylococcus aureus, Clostridium difficile, and glycopeptideresistant enterococci (GRE). Although it has been suggested that uniforms act as a reservoir or vector for transmission of infection in hospitals, no evidence is currently available linking the transmission of bacteria to patients (Wilson et al., 2007). Although studies investigating nurses uniforms have identified that contamination occurs, it is estimated that one-third of the organisms present originated from the actual wearer themselves as a result of their normal bacterial skin flora being in contact with the uniform (Wilson et al., 2007). Maximum contamination occurs in areas of greatest hand contact, for example, pockets, cuffs and apron areas (Babb, 1983; Wong, 1991; Loh, 2000), and potentially causes the re-contamination of washed hands. However, it is important to note that all clothing worn by all staff (for example, doctors, therapists and cleaners) has the potential to become contaminated via environmental micro-organisms, or those originating from patients or the wearer, and that nurses uniforms are not unique in that respect. This reinforces the need to ensure all clothing worn by staff in all clinical areas is fit for purpose and able to withstand laundering. The wearing of rings is known to be associated with higher numbers of bacteria on the hands and can affect the effectiveness of hand hygiene techniques (Salisbury, 1997). This effect is pronounced if stoned or multiple rings are worn. The wearing of plain wedding rings is considered acceptable, and staff should be encouraged to manipulate rings during hand washing to ensure the skin under the rings is cleaned.
The professional image presented by nursing staff is an important component in the way nursing in general is regarded by colleagues, patients and the public
Guidance on uniforms and work wear
Minimum organisational standards
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Written organisational policies for work wear and uniform laundering must be available, agreed, and approved by the infection control team or director of infection prevention and control (DIPC) and staff side organisations (for example, unions).
To support compliance and reinforcement, all staff should be made aware of dress code/uniform standards before they commence employment. This should also include information on initiatives such as bare below the elbows, headwear and facial hair such as beards/moustaches.
There must be sufficient uniforms provided so freshly laundered clothing can be worn for each shift or work session. This should include consideration of the needs of bank and agency staff.
Organisations should have a clear and transparent process for determining how uniform numbers are allocated based on their risk assessment (see the Legal requirements section of this document).
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Uniform fabrics must be capable of withstanding water temperatures of at least 60C. Processes for access to spare clothing, if staff clothing items become contaminated (for example, splashed with blood and/or body fluids), should be included in uniform policies together with guidance on where staff can access showers if required.
There must be access to a laundry disinfection service for visibly/excessively contaminated uniforms or agreement about safe alternative arrangements (for example, the disposal and replacement of contaminated items).
If routine laundering facilities are not available, an organisation must advise staff what it considers to be appropriate in these circumstances as stipulated in local policy.
Developmental standards
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Acute health care settings should provide laundering facilities for staff uniforms, so staff are able to change out of uniforms after work and have clean uniforms available for each shift.
Uniform or clothing must be smart, safe and practical. It should project a professional image to encourage public trust and confidence.
Guidance on uniforms and work wear
Minimum professional and personal standards
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Where facilities are available, staff must change out of their uniform promptly at the end of a shift and before leaving their place of work.
Hand hygiene must be performed before contact with patients regardless of whether contact with uniform fabric has occurred.
Uniforms should be carried separately from other items clean and dirty uniforms must not be transported together.
Hand washing clothing items is ineffective and unacceptable and should not be undertaken. Physically soiled uniforms should receive a machine sluice (rinse) cycle first, prior to the main wash, in order to avoid washing items by hand.
Entering commercial premises in uniform/clothing should be avoided where possible. Local policies should dictate circumstances that are acceptable, for example, community nurses fillingup cars, collecting prescriptions for patients.
Community staff should work with their employers to develop a suitable policy that meets community working needs.
Staff must follow an organisations dress code and guidance on the wearing and laundering of uniforms.
Staff should not wear jewellery (note plain wedding bands are acceptable); fingernails should be short and free of nail varnish (false nails are unacceptable) and hair should be worn neatly in a style that does not require frequent re-adjustment (Pratt et al., 2007). It is the responsibility of individual organisations to determine a local definition of what constitutes jewellery and what is acceptable, taking into account religious, cultural and infection control needs.
The use of protective clothing, including aprons, gloves, gowns and masks must be based on an assessment of risk of transmission of micro-organisms to the patient or to the carer, and to the risk of contamination of the healthcare practitioners clothing and skin by patients blood and body fluids, secretions or excretions (Pratt et al., 2007). Aprons and gloves should not be worn routinely by staff, just in case of need. Organisations should ensure they have adequate supplies of protective clothing available in appropriate sizes so staff can access them when required.
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Suggested content for uniform and work wear policy/guidance
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An organisations expectations, in relation to professional appearance and identification, must be explicit.
The responsibilities for ensuring adherence to uniform policy is maintained must be made clear at both senior and local levels.
Local policy should be agreed and approved by the infection control team/DIPC/risk management committees.
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Local policy should be agreed in partnership with staff and local trade union representatives. Laundering facilities must be defined. Where no facilities are provided, alternative arrangements must be detailed.
Guidance on the changing facilities provided or which areas of the health care setting are felt suitable to be used by staff for the purposes of changing.
If laundry facilities are not provided, guidance should be made available on handling and decontaminating socially soiled uniforms. The guidance should include: wash temperature use of detergent drying/ironing storage and transport of uniforms.
Guidance on practices to enable good hand hygiene, for example, bare below the elbows and the wearing of personal alcohol hand gel dispensers.
An organisational definition of jewellery to support hand hygiene, together with professional standards and guidance on appropriate hairstyles and the wearing of jewellery.
Routine frequency for when the uniform should be changed and circumstances where the uniform should be changed immediately (this should include emergency procedures in the event of contamination with blood or body fluids).
Guidance on what additions are acceptable (for example, jackets, coats, cardigans when these can and cannot be worn) and thermal disinfection requirements.
Guidance on adaptation to comply with religious beliefs, while maintaining good practice in infection control (for example, beards, use of head wear, skin coverage, wearing of bracelets and wedding bands).
Guidance on uniforms and work wear
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Reference should be made to other relevant policies, including the appropriate use and disposal of protective clothing such as plastic aprons, and the policy on the wearing of theatre clothing scrubs, masks, hats etc.
Information on how compliance with uniform and dress code standards will be monitored and non-compliance dealt with.
Further advice can be obtained from local infection control teams and trade union representatives. For additional country specific guidance on uniforms see: Wales Chief Nursing Officer website (Welsh uniform guidance currently being developed) Scotland NHS Interim Dress Code. Available at: [Link]/Publications/2008/08/interimdresscode (accessed 08/04/09) (Web) Northern Ireland Northern Ireland Regional Infection Control Manual: Uniforms. Available at: [Link]/principles/documents/[Link] (accessed 08/04/09) (Web).
Tax relief
Tax relief is not applicable if your employer provides laundry arrangements, or if you chose not to use these facilities. However, nurses can claim tax relief in respect of laundry costs where they have to pay for laundering their uniform. Copies of the form and more information is available from RCN Direct on 0845 772 6100 or your local Inland Revenue office.
Nursing students
Practice placement providers and universities must include a sufficient number of uniforms, provided at no cost to the nursing student, to ensure a clean uniform is available for each clinical duty. This must include an equal number of tops and trousers, if these are worn in place of dresses. Free laundry facilities must be made available, with an allowance to cover laundering costs where individuals have to do their own laundry, or where the uniforms provided are not suitable for a particular placement. Suitable and sufficient changing facilities and secure facilities to store personal clothing must be made available at workplaces.
Bank and agency staff
Bank and agency staff must be aware of, and comply with, the specific uniform policy in place at each location they work.
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References and further reading
Babb JR, Davies JG, Ayliffe GA (1983) Contamination of protective clothing and nurses uniforms in an isolation ward, Journal of Hospital Infection, 4, pp.149-157. Department of Health (2004) Standards for better health, [Link] Department of Health (2006) Code of practice for the prevention and control of healthcare associated infections, London: DH Department of Health (2009) The Health and Social Care Act 2008: Code of practice for the NHS on the prevention and control of healthcare associated infections and related guidance, London: DH. [Link]/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093762 Department of Health, Social Services and Public Safety (2008) Northern Ireland Regional Infection Control Manual: Uniforms, Belfast: DHSSPS. Available at: [Link]/principles/documents/[Link] (accessed 08/04/09) (Web). Hambraeus A (1973) Transfer of Staphylococcus aureus via nurses uniforms, Journal of Hygiene (London), 71, pp.799-814. Hambraeus A, Ransjo U (1977) Attempts to control clothes-borne infection in a burns unit, Journal of Hygiene, 79, pp.193-202. Parliament (1974) Health and Safety at Work Act 1974, London: HMSO. Loh W, Ng VV, Holton J (2000) Bacterial flora on the white coats of medical students, Journal of Hospital Infection, 45, pp.65-68. Manual Handling Operations Regulations 1992, London: HMSO. National Health Service Executive (1995) Hospital laundry arrangements for used and infected linen, HSG(95)18. NICE Clinical Guideline 2 (2003) Infection control: Prevention of healthcare-associated infection in primary and community care, [Link] Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives, London: NMC. Perry C, Marshall R, Jones E (2001) Bacterial contamination of uniforms, Journal of Hospital Infection, 48, pp.238-241. Personal Protective Equipment at Work Regulations (1992), Health and Safety Executive Series,
Guidance on uniforms and work wear
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London: HMSO. (A short guide to the regulations (1992) can be downloaded from [Link]/pubns/[Link]) Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, et al. (2001) The epic project: Developing national evidence-based guidelines for preventing healthcare associated infections. Phase 1: guidelines for preventing hospital-acquired infections, Journal of Hospital Infection, 47, (Supplement) S3S4. Pratt RJ, Pellowe C, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C and Wilcox MH (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England, Journal of Hospital Infection, 65, (Supplement), S3-S4. Royal College of Nursing (2005) Uniform approach: Key points for nursing staff, London: RCN. Publication code: 002 723 Salisbury DM, Hutfilz P, Treen LM, Solin GE, Gautam S (1997) The effect of rings on microbial load of health care workers hands, American Journal of Infection Control, 25, pp.24-7. Scottish Executive (2002) The Watt Group Report, A review of the outbreak of salmonella at the Victoria Infirmary. Scottish Office (2008) NHS Interim Dress Code July 2008, Edinburgh: Stationery Office. Available at: [Link]/Publications/2008/08/interimdresscode (accessed 08/04/09) (Web). Speers R, Shooter RA, Gaya H, Patel N (1969) Contamination of nurses uniforms with Staphylococcus aureus, The Lancet, 2(7614), pp.233-235. Wilson J, Loveday P and Pratt R (2007) 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), Journal of Hospital Infection, 66, pp301-307. Wong D, Nye K, Hollis P (1991) Microbial flora on doctors white coats, British Medical Journal, 303, pp.1602-1604. Workplace (Health, Safety and Welfare) Regulations 1992, Health and Safety Executive Series, London: HMSO.
May 2009, second edition Published by the Royal College of Nursing 20 Cavendish Square, London, W1G 0RN [Link]
Publication code 002 724
Supported by an unrestricted educational grant from Proventec Healthcare Innovators in integrated hygiene and infection prevention solutions
