(DOH) Uniform and Workwear - East Lancashire Hospitals NHS Trust

Equality Impact Assessment
Uniforms and Workwear: Guidance on uniform and
workwear policies for NHS employers
Introduction
1. Equality Impact Assessment (EqIA) is a tool aimed at improving the
quality of local services by ensuring that local bodies systematically
consider the actual or potential impacts of their policies and practices
on certain communities and population groups. Organisations are
required to take action to mitigate or eliminate the negative impacts
and maximise the positive impacts or opportunities for promoting
equality.
Policy Aim
2. This EqIA looks at the impact of the Department of Health's revised
uniform and workwear guidance. The guidance is good practice
guidance only. It aims to deliver to NHS employers an evidence base
(and examples of good and poor practice), to allow the development of
local policy on the wearing and laundering of uniforms. This should
lead to an improvement in public confidence that the NHS is taking the
issue of infection control seriously. The guidance is not prescriptive,
except in respect of wearing uniforms that encourage good hand
washing and do not include functionless items of clothing.
Results of initial screening of Uniform & Workwear
Guidance
Negative impact
Age
Gender
Ethnicit
y
Disabili
ty
Religio
n and
belief
Sexual
orientat
ion
Does the policy
represent any
problems or barriers
to any community or
group?
Yes No No No No No
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Is any group of
people excluded as a
result of this policy?
Does the policy
worsen existing
discrimination and
inequality?
Does the policy have
a negative effect on
community relations?
Positive impact
No No No No No No
No No No No No No
No No No No No No
Age
Gender
Ethnicit
y
Disabili
ty
Religio
n and
belief
Sexual
orientat
ion
Does the policy have
a significant positive
impact on equality by
promoting equality of
opportunity?
Does the policy have
a significant positive
impact on equality by
eliminating
discrimination?
Does the policy have
a significant positive
impact on equality by
eliminating
harassment?
Does the policy have
a significant positive
impact on equality by
promoting good
community relations?
Does the policy have
a significant positive
impact on equality by
promoting positive
attitudes towards
disabled people?
Does the policy have
a significant positive
No No No No Yes No
No No No No No No
No No No No No No
No No No No Yes No
No No No No No No
No No No No No No
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impact on equality by
encouraging the
participation of
disabled people?
Does the policy have
a significant positive
impact on equality by
considering more
favourable treatment
of disabled people?
Does the policy have
a significant positive
impact on equality by
promoting human
rights?
No No No No No No
No No No No No No
The evidence
3. The Department's original uniform and workwear guidance was
published in September 2007. On reviewing the equality screening (in
December 2007 and March 2010), we reconsidered the impact of the
guidance in respect of disability, age, gender and sexual orientation. As
the guidance simply identifies good practice and does not offer specific
rules beyond wearing uniforms that encourage and support effective
hand hygiene and hand-washing we feel that the policy had a neutral
impact in respect of disability, ethnicity, gender and sexual orientation.
There seemed to be a possible issue in relation to age, as older people
may prefer to dress more formally. The guidance should help trusts
make informed decisions on such areas, although final resolutions will
still be made locally.
4. It is recognised that some uniforms are in apparent conflict with the
dress codes of specific religions or cultures (eg head coverings,
jewellery, long sleeves etc). In particular, there is evidence that
adopting 'bare below the elbows' has presented difficulties for some
Muslim female healthcare workers and students. Indeed, it has been
reported that some staff had had such difficulty with those dress code
provisions as to find that they could no longer continue in their jobs.
5. The Department therefore worked jointly with the Muslim Spiritual Care
Provision in the NHS (MSCP*) to consider these concerns. The
outcome is that the guidance contains examples of how local dress
code policies might be further developed such that individuals are able
to align religious and cultural obligations with infection control
responsibilities without compromising patient safety. We take the view
that it is likely to provide a significant positive impact on equality by
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promoting equality of opportunity and by extension, on promoting
good community relations.
*The Muslim Spiritual Care Provision in the NHS, hosted by the Muslim Council of Britain in
partnership with the Department of Health , is a resource and contributing in recruiting, training
and empowering Muslim Chaplains in the health service.
Based on the information set out above I have decided that an equality
impact assessment is necessary.
Signed: Dr Elizabeth Jones
Business area: CNO-D Date: 12th March 2010
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UTitle and description of the policy
6. The uniform and workwear guidance is a collection of evidence to help
trusts devise their own local policies on laundering and wearing
uniforms and on other aspects of a dress code. The guidance remains
an exact fit with the requirements of the Health and Social Care Act
2008 Code of Practice for the prevention and control of infections. The
Code charges trusts with establishing uniform and dress code policies
that specifically support good hand hygiene. The Department's Clean
Safe Care strategy has demonstrated that effective screening, sensible
prescribing, high standards of cleanliness and effectiveU hand hygieneU
are all vitally important in the fight against infection
UThe Evidence Base
7. The publication of revised uniform and workwear guidance does not
involve the development of new national policies – instead it continues
to support trusts in the development of their own policies. We have
tried, where possible, to keep the guidance evidence-based and flexible
to allow for local implementation. This allows trusts to include specific
equality issues within their own policy, as relevant to their community.
8. In producing the original guidance, we commissioned two systematic
literature reviews to examine:
• The evidence around uniforms and workwear as a possible
source of infection, and around the antimicrobial effect of
laundry processes.
• the importance attached by patients, staff and the public, to the
concept of uniforms in healthcare.
9. This has now been published (as two separate reviews) in peerreviewed
journals as referenced below.
• J.A. Wilson, H.P. Loveday, P.N. Hoffman, R.J. Pratt, Uniform: an
evidence review of the microbiological significance of uniforms
and uniform policy in the prevention and control of healthcareassociated
infections. Report to the Department of Health
(England). Journal of Hospital Infection (2007) 66, 301e307
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• HP Loveday, JA Wilson, PN Hoffman, RJ Pratt; Public perception
and the social and microbiological significance of uniforms in the
prevention and control of healthcare-associated infections: an
evidence review. British Journal of Infection Control. September
2007 Vol. 8 No. 4
10. We are satisfied that no further evidence has since emerged to
challenge the findings in these reports.
11. We have also established that the findings of the empirical research
that was commissioned in 2007, to study the effects of various wash
temperatures on removal of micro-organisms from uniform fabric,
remains valid
12. We have consulted NHS Employers to ensure that no new evidence
has come to light that conflicts with any of the previous
recommendations
UWhat the evidence shows
UDisability, gender, race, sexual orientation
13. As indicated previously, we feel that the policy has a neutral impact in
respect of disability, ethnicity, gender and sexual orientation. It is not
considered that any further information is needed. The literature
reviews and the advice of NHS employers' expert reference group are
sufficient. NHS Employers provides specific guidance via its website
and this is available to trusts.
UAge
14. On reviewing the policy of ' no tie, it remains possible that there is a
differential impact on older members of staff if there is truth in the
assertion that older people dress more formally. We feel that there is
no need to revise the guidance as this is an issue that can be handled
locally.
UReligion and belief.
15. We remain satisfied that there are issues of hygiene (including hand
washing) and public expectation (eg the role of uniforms in enhancing
public confidence) that have implications for uniforms in respect of
religion and belief
16. There is evidence that wearing of hand or wrist jewellery compromises
the undertaking of effective hand hygiene. The guidance therefore
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makes it clear that it is poor practice to wear any jewellery, including a
wristwatch, on the hands or wrists during direct patient care activity.
However, the Department is aware that there will be instances where,
for religious reasons, members of staff may wish to wear a bracelet
(for example the Sikh Kara) when they are not engaged in direct
patient care activities. The guidance recognises that in these
circumstances it is good practice to ensure such bracelets can be
pushed up the arm and secured in place for hand washing and direct
patient care activity. These references have been shared with
organisations representing Hindu and Sikh interests and no objections
have been raised.
17. There is good evidence, from the previously referenced systematic
literature reviews, that effective hand hygiene reduces the risk of
infection, and wearing long sleeved clothes compromises its
achievement.
18. Whilst the phrase 'bare below the elbows' never appeared in the
Department's original 2007 uniform and workwear guidance, it is the
tag line by which it has become known. The Department has become
aware that in certain cases, where trusts have adopted dress codes
that literally require staff to be 'bare below the elbows' at all times, it
has presented difficulties for a minority of Muslim female healthcare
workers and students.
19. It is acknowledged that the majority of NHS trusts have been able to
use the original guidance to devise policies that take account of local
factors without conflicting with religious requirements and for the
majority of staff, being bare below the elbows during direct patient
care activity has not presented any significant difficulty. However, in
some cases, the local interpretation of what constitutes 'direct patient
care activities' has caused some problems.
20. The Department worked jointly with the Muslim Spiritual Care Provision
in the NHS to address some of the concerns expressed by female
Muslim healthcare workers and students. The result has been a
revision to the existing guidance to address the issues around the
practical aspects of implementing a dress code. This is achieved in part
by providing a specimen definition of, and clarity of terms used in
relation to, 'direct patient care activity'. This should help by more
clearly defining the precise areas where staff should observe dress
codes when performing patient care duties involving direct patient
contact or within the patient's close environment.
21. The revised guidance also now identifies some adaptations to local
dress codes that might be adopted to ensure they are more sensitive
to the requirements of different religious groups and that can be
accommodated without compromising patient safety or staff dignity.
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22. The guidance recognises that a very small number of staff have
expressed the view that for them the strong preference is to use
disposable over-sleeves to cover forearms during direct patient care
activity. The guidance therefore recognises that such over sleeves can
be worn where gloves are used. It cautions that strict adherence to
washing hands and wrists must be observed before and after use and
that over-sleeves must be discarded in exactly the same way as
disposable gloves.
23. The guidance also makes it clear that decisions on the adoption of any
of the measures outlined should be taken in conjunction with clinical
managers and the infection prevention and control team and form part
of the trust's policies.
Challenges and opportunities
24. The MSCP reported that some Muslim female staff had been so
negatively affected by 'bare below the elbows' dress codes as to find
they could no longer continue in their current roles, This has caused
disquiet among Muslim female healthcare workers, medical students
and trainees.
25. We consider that the provision of further guidance for trusts about
practical steps that can be taken to ensure patient safety without
compromising religious or cultural beliefs is a very positive step. We
also consider that the local consideration, approval and adoption of
such practical steps can have a beneficial effect on recruitment. We are
satisfied that this can be achieved without compromising the principles
of ensuring that uniform and dress codes should support good hand
hygiene.
Equality Impact Assessment
26. A negative impact is unlikely and we believe the risk of adverse effect
is small. The guidance has been kept deliberately flexible and evidence
based that NHS trusts can develop their own policies to take account of
local circumstances.
27. On reviewing the policy of 'no tie' it is possible that there is a
differential impact on older members of staff - but only if there is truth
in the assertion that older people prefer to dress more formally. We
felt there was no reason to revise the guidance as this is an issue that
can be handled locally.
28. The MSCP has identified a number of practical steps in relation to the
guidance that trusts might take to ensure patient safety without
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compromising religious or cultural beliefs. We feel that the provision of
this statement means that the potential for a differential impact on
members of particular religious groups has been removed.
29. We recognise that elements of the additional guidance could be seen
to be introducing differing requirements for those to whom 'baring
below the elbows' presents no significant problem. We have considered
the implications of this possibility but concluded that the overall
purpose of the guidance, to ensure patient safety by adherence to
good hand hygiene, is not prejudiced by the additional dress options
that have now been identified.
30. The guidance has the clear potential to have a positive effect. This is
by firstly having a significant positive impact on promoting equality of
opportunity, and secondly, by promoting good community relations.
Next steps
31. The available evidence continues to suggest that patients and the
public use the personal appearance of staff as a way of judging
competence - both in respect of the individual and in terms of the NHS
as a whole.
32. There is little evidence that uniforms are a significant source of
infection, but the belief persists amongst the public that they are.
There is clear evidence that hand hygiene is compromised by hand and
wrist jewellery, and by clothing that prevents the wrist being included
in hand hygiene. There is also evidence that cuffs become heavily
contaminated.
33. The Health Act 2008 Code of Practice for the prevention and control of
infections includes a requirement that trusts should have local uniform
and dress codes polices in place that specifically support good hand
hygiene. The Care Quality Commission assesses providers against their
compliance with this provision. The outcome of those assessments
becomes a matter of public record and has a definite impact on the
public's confidence that trusts are taking infection control seriously.
34. We are confident that this issue is of sufficient importance to need
central good practice guidance. It will be for trusts to define their own
local policies.
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