Intended for healthcare professionals


Are YOU getting naked?

BMJ 2008; 336 doi: (Published 12 April 2008) Cite this as: BMJ 2008;336:s129
  1. Karen Hebert, F2 doctor
  1. 1Bristol


A sign adorning the door of an NHS clinical investigation unit reads, “Are you NAKED below the elbows? Do not enter if you are not.” This is one of the most obvious results of the Department of Health’s Bare Below the Elbows campaign. Karen Hebert investigates nakedness, loss of watches, and the impact on professional appearance

Farewell humble white coat

The white coat remains a symbol for the medical profession, closely followed by the stethoscope. The wearing of white coats originated in the 19th century. Ironically, they were introduced in order to prevent cross contamination on the wards. They heralded an era in which improved understanding of hygiene meant that hospitals were no longer synonymous with death. At the time doctors were also receiving particularly bad press as scientists repeatedly proved their cures to be useless. Doctors realised that the future of medicine lay in science and turned to the laboratory to provide new answers. Aiming to win back public trust doctors wore a white coat in an attempt to show their allegiance with modern science.1 More recently, elderly patients were shown to favour doctors wearing a white coat, as it made the doctor easy to identify.2 (Although one can certainly walk around a hospital and find many staff in a white coat who aren’t doctors.) White coats have fallen out of favour over the past decade, however, as fears about infection have grown, and providing clean white coats daily has been thought to be too impractical. Few doctors mourn their loss, believing them to be hot and uncomfortable, although some women do miss the storage space.

Bare below the elbows

The final death toll sounded for the white coat with secretary of state for health Alan Johnson’s statement, “I’m determined that patient safety, including cleanliness, should be the first priority of every NHS organisation. This will set guidelines on clothing that will help ensure thorough hand washing and prevent the spread of infections. This is a clear signal to patients that doctors, nurses, and other clinical staff are taking their safety seriously.”3 His statement described a new “bare below the elbows” policy that would be nationally enforced from January 2008. This specified that staff should wear “short sleeves, no wrist watch, no jewellery and allied to this the avoidance of ties when carrying out clinical activity. The traditional doctors’ white coat will not be allowed. The new clothing guidance will ensure good hand and wrist washing.”

In December 2007 the BMA’s central consultants and specialists committee voiced concerns. “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.”4

Evidence base

In December 2007 an anonymous general practitioner sent in a query to the National Library for Health’s primary care question answering service. “re ‘Bare below the elbows’ policy. What is the evidence for this, specifically is there any for primary care?” The answer given was as follows, “We searched the NLH Library and the TRIP and Medline databases but found no guidelines or studies in support of clinical healthcare staff (primary or secondary care) adopting a ‘bare below the elbows’ policy.”

Indeed in the Department of Health’s working group on uniforms and laundry it is clearly demonstrated that “there is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection.”5

Professor Didier Pittet, director of the infection control programme at the University of Geneva, discussed the available evidence. “Hospitals’ hand cleansing by healthcare workers is the most important and most effective strategy to reduce cross transmission from patient to patient and from the environment to the patient. It reduces healthcare associated infection and associated morbidity and mortality. It also contributes significantly to reduce the reservoir of multiresistant bacteria.

“Whether asking healthcare workers to be bare below the elbow as a dress code for clinical staff in hospitals would participate in helping healthcare workers to improve compliance with hand hygiene remains to be proven. Thus, the recommendation by the UK health secretary to either banish the traditional white coat or to ensure that white coats are short sleeved is interesting, but certainly not based on evidence. Although it makes sense, it remains to be proven whether it would be useful or not in the long term.

“My comments are similar regarding the use of watches on healthcare workers’ wrists. Also similar is the recommendation that doctors’ ties may be capable of transmitting infections. Whether doctors’ ties, as well as any part of the surrounding environment of patients and healthcare workers, are colonised with micro-organisms remains again to be proven. Those items have never been proven to be responsible for infection or even micro-organism cross transmission in hospitals. In fact, provided that the healthcare workers would clean their hands immediately before touching their patients, infection will not be cross-transmitted.”


This very lack of evidence base has resulted in grumblings among some doctors. They feel that such drastic and strict policies should be based on evidence and that attention and funding is being detracted from the areas that would be more effective in reducing infections.

In a letter to the BMJ, Henderson and McCracken argue for the clinical value of a wristwatch—with Henderson declaring his competing interests to be, “Henderson likes to wear a wristwatch.” Henderson, a specialist registrar in plastic surgery, explains, “My main concern is that there are much more important infection control issues, like bed overoccupancy, which are being conveniently ignored. Why ban wristwatches but not wedding rings? What about stethoscopes, pens, pagers?”6

This concern is echoed by the BMA’s Dr Vivienne Nathanson, head of BMA science and ethics. “It is very important to emphasise that clean hands, bare elbows, and short sleeves are only one aspect of preventing and controlling infection. A coordinated approach addressing all the relevant factors, for example, dress code, bed occupancy, hygiene in hospital, and isolation policies, is most likely to be successful.”

Appearance’s sake

The Department of Health’s working party state that dress makes an impression. “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.”5

Possibly as a result, some trusts have gone one step further and implemented formal dress policies for clinical staff. NHS staff are being informed that adherence to “bare below the elbows” policies and formal dress codes are a contractual obligation.

Some doctors, however, feel that these policies are making them look less professional. Henderson says, “The other issue is that of maintaining a professional appearance, which I believe is extremely important, and which is proving to be difficult for male doctors in particular.”

Dr Nathanson warned any new guidelines on dress code must be “practical, realistic, and sensitive to different religious groups.” The Islamic Medical Association explained the issues. “Covering the arms is as a part of the hijab—modesty of the practising Muslim woman is to cover all the body except the hands and face. However, we believe that all the efforts should be done by female medics in the hospitals to comply with all hygiene regulations in the hospitals especially in washing the hands and the arms repeatedly and after seeing the patients.

“Alternative hygiene measures can be arranged to implement the regulations and prevent any cross infection while fitting in with the Muslim culture and needs—such as the provision of long disposable gloves to the elbows.

“Uncovering of the arms to the elbows and repeated washing can be done in single sex female wards with no men around without any problem,” proposed Dr A Majid Katme, the association spokesman.

But ultimately Loveday sends out a grave warning. “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.”7

The ironic last word

Professor Pittet had one last comment. “There are a number of reports worldwide of a very significant, if not dramatic, reduction in healthcare associated infection following hand hygiene promotion strategies where doctors and nurses were still wearing long sleeved white coats. This is what you call ‘the evidence.’ It would be unfortunate if, in the UK, healthcare staff and, in particular, infection control practitioners would lose their time by monitoring compliance with short sleeves or with doctors’ ties instead of investing their precious time in securing efficient hand hygiene promotion strategies according to worldwide recommendations and, in particular, spending their time to educate healthcare workers and monitoring their practices using recommended tools instead of monitoring the sleeve length and the presence/absence of a tie around a doctor’s neck.”

Food for thought next time you notice your wrists being scrutinised in a “hand audit.”


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