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Do dress codes lead to discrimination?

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Bare below the elbow policies are coming into direct conflict with religious beliefs. Helen Mooney reports

Last week a Muslim healthcare professional left her agency post at the Royal Berkshire Hospital Trust in Reading, claiming she had been forced out because she refused to bare her arms.

The trust argued that the radiographer had known about its ‘bare below the elbows’ policy for staff in clinical areas when she began working there in June.

This is the latest in a series of incidents in which infection control policies and religious beliefs have clashed in the healthcare environment.

In February female medical students at Liverpool’s Alder Hey children’s hospital objected to rolling up their sleeves when washing their hands and removing arm coverings in theatre. Similar concerns have been raised by medical students at the universities of Leicester and Sheffield.

According to Islamic law, a woman should cover her arms, including the wrist, at all times except in front of close relatives.

However, Yunus Dudhwala, minority faiths adviser to the College of Healthcare Chaplains and multifaith manager at Newham University Hospital Trust, suggests an element of personal choice. ‘Not all Muslim female clinicians wear wrist-length Islamic uniform and this will not pose a problem for that group – and a point of clarification, this does not make them bad Muslims,’ he said.

‘It will be a problem for those Muslim females who may ask to cover their arms as they strictly adhere to wrist-length Islamic uniform,’ he added.

All the trusts in question operate a policy based on current government guidelines.

In September 2007 health secretary Alan Johnson announced that from January 2008 all hospitals would be required to adopt a new dress code of short sleeves and no wristwatches or jewellery when providing patient care. He said this would ‘ensure good hand and wrist washing’.

Clare Edmonton, the Berkshire trust’s director of human resources, backed the policy.

‘It reduces the risk of cross-infection from clothing or items of jewellery, it ensures that staff wash or gel their hands
and wrists thoroughly, and is also a visible reassurance to the public that we take infection control seriously,’ she said.

However, scientific evidence does not support a link between clothing and infection.

Only weeks before Mr Johnson announced his ‘bare below the elbows’ policy, the government received the findings of a review it had commissioned on the issue of uniforms and infection control. As reported by NT last year, researchers from the Health Protection Agency and Thames Valley University assessed all literature on the subject.

The research found that ‘although it has been hypothesised that contaminated uniforms are a potential vehicle for the transmission of pathogens, no studies demonstrated the transfer of micro-organisms from uniforms to patients in the clinical situation’.

Judy Potter, president of the Infection Prevention Society, said that the research findings supported her own opinion.

‘Uniforms are no more likely to carry microbes than any other item of clothing,’ she said.

Non-clinical staff come into contact with patients but they are not expected to roll up their sleeves, she suggested.

So why did the government go ahead with such a strict policy?

In the main it was in response to ever-increasing negative publicity about the dramatic rise in HCAIs. The government hoped to allay the fears of the general public, which had made a link between uniforms and infection, whether or not there was actual evidence to substantiate the theory.

The Department of Health went as far as to admit this in its guidance document Uniforms and Workwear, which states: ‘There is no conclusive evidence that uniforms pose a significant hazard in terms of spreading infection.’

It continues: ‘There is evidence that sleeves become contaminated with micro-organisms. However, a causative link between this contamination and subsequent patient infection has not been established.’

But it goes on to say that ‘it seems that the public believe there is a risk’ and that ‘both infection control and public confidence should underpin a trust’s uniform policy’.

Ms Edmonton said that both the trust’s chaplain and imam supported the ‘bare below the elbows’ policy and believed it to be ‘an acceptable professional requirement for everyone who works in the trust’s clinical areas’.

But it has attracted criticism from others with strong interests in both healthcare and religion.

Dr Majid Katme, a representative of the Islamic Medical Association, said: ‘There is absolutely no scientific basis for what they are trying to do.’

Mr Dudhwala said he thought there was a strong case for the policy to be challenged on the ground of issue of religious discrimination and human rights. ‘I think trusts should be looking at other options rather than implementing a blanket policy and taking a dictatorial stand on this – it is forcing staff to choose between a profession they love and a religion they love,’ he said.

He added that the Department of Health should issue further guidelines to clarify the situation. ‘The government’s guidance
is quite vague – trusts need to look at other options, like allowing staff to wear three-quarter length sleeves or longer gloves,’ he said.

Mr Dudhwala has written widely on the subject and has come up with a range of measures that trusts could adopt to satisfy both the government guidance and religious requirements (see box).

But for now, the debate looks set to continue, with separate NHS Employers guidance adding to the controversy. Trusts should take a ‘sensitive approach’ to implementing dress codes, the guidance states and adds that ‘if a rule is likely to conflict with an employee’s religion or belief, then there must be clear evidence to demonstrate objective justification’.

Possible circumventions of ‘bare below the elbow’ policy to meet NHS and religious needs

  • Full sleeves are allowed to be worn at all times except during clinical procedures with a patient and during handwashing, where sleeves will have to rolled up to three-quarter length between the wrist and the elbow.

  • Trusts can formulate a policy that incorporates no sleeves below the elbow in clinical areas and provide disposable sleeves for those who might want to use them to cover their arms.

  • Trusts can introduce a policy which allows three-quarter length sleeves and provides the option of disposable gloves to cover the rest of the arm.

  • Organisations can devise a policy that incorporates no sleeves below the elbow but makes available for those who wish to cover their arms separate sleeves that are worn from the shoulder to the wrists that are easy to roll up and can be laundered with uniforms.



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Readers' comments (2)

  • I do believe that every person has a right to religion and to practising their religious beliefs however, reguardless of relgious beliefs and the lack of research reguarding infection control and cross contamination from uniforms, I feel that the profession as a whole including doctors, midwifes and any other professional dealing with patients should adhere to hospital policies and wear short sleaved uniforms to show the public and patients that we are dedicated to infection control, especially in this very public arena where C. Diff and MRSA are constantly in the media. the profession should be minimising any cross contamination where possible and if this means wearing short sleaves then we should do this it does not mean that we are telling staff to leave their beliefs at the door when they come in to work but work and practising religious beliefs cannot always work together.

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  • For many years this issue has not been a problem with nurses. When you start nurse training there are many things that you know you should not wear. It has always been that hair should be tied back whether you are male or female. No nail polish should be worn. Sleeves on the uniforms were short. If you don't want to comply with this you have no bussiness becoming a nurse. This is just another religious ploy from the minority to change the British way of life.

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