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Patient and hygiene benefits of using blue pillowcases for head pillows

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Using blue pillowcases for head pillows to differentiate them from pillows used for other body areas has benefits in terms of hygiene and patient satisfaction, as shown by a small-scale trial at an acute trust


In healthcare, pillows are used not only to support patients’ heads, but also other body parts; as a result, patients can have more than one pillow on their bed. If all pillows are covered in pillowcases of the same colour, there is no way of knowing what they have been used for and with which area of the body they may have been in contact. This poses a risk in terms of hygiene and quality of care. The author trialled the use of blue pillowcases for pillows used for the head on two inpatient wards at The Royal Wolverhampton NHS Trust; here, she explains how she went about it and what was achieved.

Citation: Haywood K (2019) Patient and hygiene benefits of using blue pillowcases for head pillows. Nursing Times [online]; 115: 8, 34-35.

Author: Katie Haywood is practice education facilitator, The Royal Wolverhampton NHS Trust.

  • This article has been double-blind peer reviewed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)


 In healthcare, pillows are used both for comfort and positioning, and to support the head as well as other body parts; patients may have one or more depending on their needs. I first came across the use of blue pillowcases for head pillows when I worked as a nurse in New Zealand – in Maori culture, the head is sacred and, as such, should not come into contact with items that have touched other areas of the body (Waitemata District Health Board, 2003). Using blue pillowcases for head pillows and white pillowcases for all other pillows helps to differentiate them, which promoted hygiene and patient-centredness, and respected Maori cultural beliefs.

Trialling blue pillowcases

In May 2015, an 11-day trial was carried out involving 10 beds on two inpatient wards in my trust. Blue pillowcases were used for head pillows; white pillowcases continued to be used for pillows in contact with other body areas (Box 1). I had developed a standard operational procedure to guide staff – instructions were given to ward managers and staff at ward meetings, and an information leaflet was available for patients.

Box 1. Using colour in healthcare

Colour can improve an environment aesthetically and influence people’s psychological and physiological state (Ghamari and Amor, 2016); it can be used therapeutically as a healing agent. Blue has a calming influence, which is why it is traditionally used in hospitals. In colour therapy, it is linked with relaxation and healing.

I visited the wards daily to support staff and liaise with patients and visitors. Speaking to them enabled me not only to adopt a personable approach, but also to gain a deeper insight into their views. At the end of the trial, I gave feedback forms to 35 staff, 10 patients and 10 visitors to explore their views on the practice in terms of hygiene, patient-centredness and reassurance about care. Staff were also asked whether the practice affected their workload. Everyone was asked whether blue pillows should be adopted permanently.

In addition to the trial of blue pillows, I also audited how pillows moved around a patient’s bed over a 24-hour period (Box 2). This was conducted for two patients who had only white pillowcases. Box 3 features an example of how mixing up pillows can pose a hygiene issue.

Box 2. Auditing the movement of pillows

Two patients were invited to take part in the audit and provided with white pillowcases only, which were labelled to enable them to be tracked. The position of each pillow was checked and charted every two hours over a 24-hour period. I found that pillows moved around the bed and came into contact with all areas of the body. In one patient, they did a whole circuit, moving from the head, down to the feet and back to the head.

Box 3. How mixing up pillows can pose a hygiene risk

While presenting my project to the estates team, one its members staff told me what he had witnessed when visiting his mother in hospital the night before. “She was in bed and asked to use the commode. She was helped onto the commode but complained it was digging into her legs. The nurse took the pillow from the bed and squeezed it between her legs and the commode. When my mother had finished, the nurse helped her back into bed and put the pillow back under her head. I didn’t think anything of it until now.”

Positive feedback

I received 18 out of 20 responses from patients and visitors, and all 35 from staff. All staff thought using the blue pillowcases for head pillows improved hygiene, provided patient-focused care and should become permanent practice; it did not create additional workload. All patients and visitors thought the practice was more hygienic and should be adopted permanently. Staff noted that patients slept better and were much more settled at night. Patients said they “slept much better”, “the pillows were more comfortable”, and they were pleased to know only their heads went on the blue pillow. They also made positive comments about the choice of colour.

The overall feedback was that the practice enhanced quality of care, by reassuring patients that the pillow on which they rested their heads had not been used for any other purpose. The 12 Essence of Care benchmarks set out by the Department of Health (2010) explore best practices in making patients feel comfortable, safe, reassured, confident and welcome in their care environment. Using pillowcases of a different colour appears to support that.

Estates, purchasing and supply

During the project, I discovered that any decision regarding supply and laundering of pillowcases lay with the trust’s estates’ services department, so I had to present my project to them and gain their authorisation and support. I now know how much linen our trust uses each year, how often it is collected and delivered, how much it costs to hire, and the requirements for laundering.

For the trial, we had to source high-quality pillowcases that would withstand heavy use and the laundering process. We decided to purchase them ourselves, as it would have been more expensive to obtain them through our supplier. They could not be washed with our regular linen because our supplier could not wash colour items separately, so we had to use independent laundry services and ensure they met requirements such as a minimum wash temperature of 71°C. Purchasing and laundering pillowcases for the trial cost £600. It was the first time in my nursing career that I was involved with purchasing and supply.

Trust-wide practice

After the first trial, a larger one was conducted in June 2016 at one of the trust’s smaller hospital sites, chosen because it had an independent linen supplier that could meet our requirements. This allowed us to extend the use of blue pillowcases to nearly 100 inpatient beds.

Today, blue pillowcases for head pillows is a trust-wide practice across its 910 inpatient beds – and blue pillowcases are provided and laundered as part of our new linen contract. Linen services at the trust have supported the project, acting quickly to ensure stock was available and calculating how many blue and white pillowcases to supply to different clinical areas. Some require a larger proportion of blue pillowcases, as they have a faster turnover of patients who mostly use one pillow only, whereas those areas where patients stay longer and have more complex conditions need a mix that is more balanced.


The most difficult part of the project was finding out about the logistics of the linen process, laundry procedures, suppliers, procurement and finance. The easier parts were informing ward staff (nurses, doctors, therapists, healthcare support workers and housekeepers) about the project and gaining their support, and developing resources for them. It was amazing how some took ownership of the project in their area. The project has now been in place for over four years and appears to have had a positive impact on the quality of care. 

Key points

  • Using the same pillows for the head and other body parts poses a hygiene risk 
  • In some cultures - for example, the Maori culture - the head is sacred and should not be in contact with items that have touched other body parts
  • Covering head pillows with blue pillowcases allows staff to differentiate them from other pillows
  • Blue pillowcases for the head reassures patients about the quality of care they receive
  • The colour blue has calming properties and blue pillowcases may improve patients’ sleep
  • Acknowledgements – The author would like to thank Cheryl Etches, chief nurse at the time of the project, for supporting it from the outset, and her previous managers Lynne Fieldhouse and Lorna Southan and her colleagues at the nurse education team for their support. She would like to give special thanks to her nursing colleagues on the trust’s dementia and oncology wards and at West Park hospital for seeing the project through; to Pete Gibbons and his assistant Laura Roberts, without whom the project would not have been possible; to Julie Burgess and her housekeeping team; and to Jeanette Roberts who modelled the blue pillowcase. Last but not least, she would like to thank Aotearoa for touching her soul.
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