Item one: A uniform approach?

Resolution submitted by the RCN Association of Nursing Students

That this meeting of RCN Congress calls on RCN Council to lobby the Government to follow the example of Scotland, Wales and Northern Ireland and introduce a national uniform for all English NHS clinical staff to promote the professional image of health care workers and ensure patients can easily identify the staff caring for them

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Damian Ronksley of the RCN Association of Nursing Students introduced the resolution, stating that there is increasing evidence that a national uniform in England would help create a professional image of nurses and health care assistants.

He demonstrated the confusion that patients in England experience, where the uniform of a nurse in one trust may be similar to that of a domestic worker in a neighbouring trust. He stated his belief that a national uniform would 'enhance interpersonal relationships between nurses and patients'. Additionally, he feels this would have security benefits, since a national uniform would only be supplied to NHS organisations. He added that laundering uniform in hospitals would improve the public perception of the hygiene of nursing uniforms, as 'no one wants to think they are being cared for by a nurse in a dirty uniform'.

The resolution was seconded by Glyn Scott of the RCN Practice Education Forum. From his experience, patients were unable to identify his role from the uniform he has worn. If he was wearing a national uniform, Glyn feels he would be more readily trusted by patients and relatives, who would find it easier to accept him as a professional.

Neil Thompson and Andrew McGovern expressed their concerns on the grounds of cost. Hamish Kemp and Jeremy Fowler felt that in a learning disability nursing environment, patient care may be compromised by nurses wearing a uniform. Lisa Lester followed this by explaining that in her role as a community mental health nurse it is intrinsic to her role that she can visit patients without wearing a uniform.

Following a point of order by Sylvia Thomas, a proposal was passed to add the words 'where appropriate' to the end of the resolution.

Results of the vote

For - 322 - 76.12%
Against - 101 - 23.88%
Abstain - 13

Background

There is increasing evidence around the UK that a national uniform for clinical NHS staff helps to promote a more professional image of nurses and other health care staff. Patients can easily identify who is caring for them at any one time — too often similar uniforms can confuse patients, making it difficult for them to differentiate between a matron, nurse, doctor, nursing student or health care assistant in different organisations.

The debate at Congress should provide an opportunity for delegates from Scotland to feed back their views on implementation of the national uniform protocol in their country — the advantages and disadvantages, and the implementation process itself — and from Wales and Northern Ireland about the coming implementation - potentially helping to shape and influence policy in England.

It is suggested that national uniforms will help promote professional appearance and patient confidence but also enhance security as, certainly in Scotland's case, any supplier will be limited to only supplying the uniforms to the NHS.

There has been much attention in the media focusing on the risk of infection posed by uniforms. Studies investigating nurses' uniforms have identified that contamination occurs, but it is estimated that many of the organisms present originated from the actual wearer themselves as a result of their normal bacterial skin flora being in contact with the uniform (Wilson et al., 2007). Maximum contamination also occurs in areas of greatest hand contact, for example, pockets, cuffs and apron areas (Babb, 1983; Wong, 1991; Loh, 2000). It is important to recognise that the presence of bacteria is not confined to uniforms and any clothing worn by all staff will reflect the bacterial flora of the wearer or the environment. The risk to patients however is negligible and there is no evidence is currently available linking the transmission of bacteria to patients (Wilson et al 2007). The critical intervention to reduce transmission of infection within clinical environments is hand hygiene which must always be undertaken prior to patient contact regardless of whether staffs are uniform wearers.

It is important therefore that the rationale for a national uniform reflects the need to uphold the professional image and confidence in nurses, and not perpetuate public and patient anxiety in relation to healthcare associated infections which is not upheld by scientific evidence.

With that in mind, employer responsibilities to provide adequate numbers of uniforms made from suitable materials to withstand frequent washing, and the provision of changing facilities are key areas for debate.

The national uniform - for nursing, AHP and support staff will be rolled out across Scotland in 2009 and will, according to Scottish Government -

Promote a coherent NHS Scotland corporate image
Enable the procurement of better quality garments which are more appropriate for staff needs
Make it easier for members of the public to identify staff

The Welsh Assembly Government have stated that an All Wales Nursing Uniform should be introduced on a phased basis. They have agreed to undertake further work to determine the design of the uniform and the process of introduction. The adoption of 'smart scrubs' for all ward nursing staff should be considered. Much of the thinking was around enabling patients to recognise the level of nursing staff they were speaking to i.e. sister, staff nurse, and student and there is a call for a clear distinction in design. It is not yet clear if that will be extended to other professions.

Northern Ireland is also about to roll out a national uniform which it is envisaged that implementation would occur on a phased basis throughout 2010/11 and 2011/12, following a 6-month manufacturing lead time for delivery of the uniforms.

Uniform policies do suggest that all uniforms should be short sleeved which may have implications for some with specific religious beliefs and which has been raised as a potential issue for staff members who may in the past have self-harmed and been left with scars.

The RCN Uniform guidance first published in 2005 has been updated in the light of recent evidence and it is hoped will be published in April 2009. The focus of the revised guidance reflects the importance of professional image and public confidence. Employer responsibilities under the Workplace (Health and Safety and Welfare) Regulations (1992) are highlighted as key factors for assisting nurses working in inpatient settings to not wear uniforms outside of the hospital environment through the provision of changing facilities.