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What should doctors wear?

BMJ 2008; 337 doi: (Published 24 September 2008) Cite this as: BMJ 2008;337:a938

Rapid Response:

‘Bare below the elbow dress code’ and ‘Good practice guide’ could be the answers.

As early as in 1995, the Department of Health (DH) identified that
the provision of adequate laundry services is a fundamental requirement of
direct patient care which would in turn contribute to its commitment to
meet the Patient’s Charter standard of quality service (Department of
Health, 1995).

The DH (2007) Working Group on Uniforms and Laundry has stated that
there is no conclusive evidence that uniforms (or other work clothes) pose
a significant hazard in terms of spreading infection. The dress code
should not only apply to the doctors in the hospital, but should apply to
all the other health care professionals and patients as well. The working
group also drew conclusions using a combination of expert opinion,
literature reviews and scientific study, that a properly designed and
operated laundry services do contribute to the removal or killing of micro
organisms on linen. Dilution and flushing is the main contributor and
washing the fabric for ten minutes at 600 C is sufficient to remove most
of the micro-organisms. The use of detergent will facilitate washing at
lower temperatures to remove organisms (MRSA is removed completely
following a wash at 300 C. The study also found that there was no
difference in effectiveness between commercial and domestic laundering.

The evidence was drawn from literature reviews carried out by Thames
Valley University (TVU) and the empirical research findings of University
College London Hospital NHS Trust (UCLH). Based on this the DH has devised
a set of good practice and poor practice examples.

The good practice advice includes the following measures:

•Dress in such a way that inspires the public confidence.

•Cuffs are likely to become contaminated and more likely to come in
contact with patients and therefore it is advised to wear short sleeved
shirts and blouses, and for the same reasons not to wear the ‘white coat’.

•Although there is no evidence to suggest that there is an infection
risk from travelling in uniform, it is advised to change into and out of
uniform at work in order to not to undermine the patients’ confidence in
the National Health Service (NHS).

•Patients wish to know who is caring for them therefore it is advised
to wear a clear identifier (name badge and or uniforms).

•Visible contamination and soiling of uniforms are not only an
infection risk but also is likely to affect patient confidence and
therefore it is advised to change uniforms immediately when soiled or

•Patients prefer their carers with short or tidy hair and a neat
appearance and therefore it is advised to tie long hair back off the

•Long nails are harder to clean and can present a poor appearance and
therefore keep fingernails short and clean.

The identified poor practice includes the following:

•Go shopping or for similar activities in uniforms would likely
undermine the patient’s confidence. No evidence to suggest that there is
an infection risk.

•Wearing false nails for patients’ direct clinical care.

•Wearing hand or wrist jewellery as it may harbour micro organisms.

The advised commonsense practice:

•Wear soft-soled (to prevent noise) and closed-toe footwear (to get
protection from spillage).

•Maintain professional appearance by changing into clean uniforms at
the start of each shift and cover all tattoos where these are extensive
and deemed offensive.

•Using posters and other aide-memoires to show what each uniform
means will help patients and their families to identify their carers.

•Wearing too many badges and adornments may result in injury to the
patients and make the carers look unprofessional.

•Neck ties (bow-ties exempted) are rarely laundered but worn daily,
and are likely to harbour pathogens and therefore it is advised not to
wear them during direct clinical care.

•Using breast pockets to carry pens/scissors etc, may result in
injury when caring for patients and therefore it is advised to use hip

•Wearing sloppy clothes might indicate lack of professional pride and
poor personal standards.

•Wearing excessive jewellery not only makes it unprofessional but may
be hazardous. Wedding rings are allowed. Where earrings are worn, they
should be studded.

Not all staff needs to wear uniforms, and it seems unlikely that
uniforms are a significant source of cross-infection. Nevertheless, 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.

There is insufficient evidence to suggest that the uniforms are a
significant source of infection. There is evidence that the cuffs do
become heavily contaminated. There is a definite evidence to suggest that
the hand hygiene is compromised by hand and wrist jewellery and the type
of clothing that prevents the effective hand washing (Department of
Health, 2007 a).


Department of Health (1995) HSG (95)18: Hospital laundry arrangements
for used and infected linen[Internet] . London. Department of Health
Publication. Available from<
[Accessed on 24th of September 2008].

Department of Health. (2007) NHS Next UNIFORMS AND WORKWEAR An
evidence base for developing local policy. London. Department of Health
Publication. Page 6.

Department of Health. (2007 a) Download Equality Impact Assessment -
Uniform Guidance. London. Department of Health Publication.

Competing interests:
None declared

Competing interests: No competing interests

26 September 2008
Anthony V B Bathula
Staff Grade Doctor
Dr Swapna Alexander, Dr Gouri Kumar
Glan Clwyd Hospital, Rhyl, North Wales. LL22 5UJ