Guna Reddy-Kolanu: Cultural problems with the “bare below the elbows” policy

Guna Reddy-KolanuThe NHS should, as its name suggests, be a service which caters to the health of the nation.  Britain, as a nation, has a rich and deeply international history. With the benefits of internationalism have come complexities of addressing the needs of a multicultural population.  To achieve this not only does it need to attend to the population it serves but it must also acknowledge the cultures of the staff who are its servants. 

An area where this has been a challenge in daily practice is in the implementation of the “bare below the elbows” policy aimed at potentially reducing the spread of infections in hospitals.  In 2008 the potential problems were highlighted in the Nursing Times concerning a Muslim radiographer quitting over the policy, and by the Telegraph with regard to Muslim medical students refusing to follow the policy. Both of these pieces ignited strongly felt opinions with a tension between professional duty of hygiene and religious belief regarding rules of modesty.

To provide solutions the department of health document “Uniforms and Workwear: Guidance on uniforms and workwear policies for NHS employers” relayed advice given by muslim spiritual care provision in the NHS.  The advice was an amalgamation of the thoughts of Islamic scholars, chaplains, multi faith representatives, department of health policy makers, and experts in infection prevention.  The recommendations were:

  • Uniforms may include provision for sleeves that can be full length when staff are not engaged in direct care activity.
  • Uniforms can have three-quarter length sleeves.
  • Any full or three-quarter length sleeves must not be loose or dangling.  They must be able to be rolled or pulled back and kept securely in place during hand washing and direct patient care activity.
  • Disposable over sleeves, elasticated at the elbow and wrist may be used but must be put on and discarded in exactly the same way as disposable gloves.  Strict procedures for washing hands and wrists must be observed.

These are recommendations and the document states that the development of local uniform policies and dress codes remain the responsibility of individual organisations and that incorporating these recommendations into trust policy would have to be agreed in conjunction with clinical managers and local infection prevention teams.

This issue is likely to be raised increasingly frequently with Muslims representing 4% of the European population and with the worldwide growth rate of Islam being greater than that of the world population. In order to prevent problems trusts need to formulate a clear and justifiable policy.

The arguments against the provision of over-sleeves are the financial costs and an assumption that staff may not use them or change them between patients.  Commercially available over sleeves cost about 5 pence per pair, which is less than a pair of disposable gloves. Thus it seems unlikely that trusts would incur significant costs in providing them. With regard to their appropriate use, just as hand washing has become part of the culture in healthcare it seems reasonable to assume that over sleeve use could. The monitoring of their use would be part of the infection control teams existing methods of monitoring hand hygiene.

As Islam requires ablutions to be taken 5 times a day and advises on the need for hand washing before and after many daily activities, it is difficult to deny the importance given to hygiene.  Within the scientific literature there is only one study demonstrating that wrist (not hand) washing is improved by a bare below the elbows policy.  There is no evidence that improved wrist hygiene reduces healthcare associated infections.  Indeed one study suggests that the public perception is that being bare below the elbows is less hygienic than full sleeves.

Given the limited evidence of the benefits of being bare below the elbows and the availability of Department of Health guidance of alternatives, it seems appropriate that trusts should at least consider the feasibility of the use of over-sleeves.  Trusts that place greater importance on clear simple messages and zealously flaunt their “Zero Tolerance Policies”  are in danger of disenfranchising significant parts of the community.  Providing solutions that demonstrate respect and sensitivity to staff and patients are simple ways to inspire creativity and tolerance in the NHS.