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Unfairness laid bare – exclusive dress codes

20200079 thedoctor March issue 19
WILEY: The requirements of faith and hygiene can be met with more sensitive NHS clothing guidance (image: Emma Brown)

The NHS has committed to changing dress codes which have left Muslim women doctors feeling harassed. Jennifer Trueland reports

When Emma Wiley asked Muslim women to share their experiences of bullying and harassment in the NHS, she did not expect their top concerns would turn out to be dress codes.

Yet the stories women shared about their discomfort, about being rudely challenged, about changing their careers, being subjected to racist ‘jokes’ – and even, in one case, having a heart attack – made her realise how serious the issue was.

‘I thought they would talk about things like appraisals and line management,’ says Dr Wiley, a consultant microbiologist in south London. ‘But they actually started talking about dress codes and it was a surprise to me that this was the main theme that came out.

‘People were saying they wanted to leave the hospitals where they were working because of difficult experiences with dress codes, such as feeling they were constantly under scrutiny. People told me they wanted to change career paths because of it – moving towards general practice [rather than hospital medicine], and they told me how they felt – that they were uncomfortable coming to work because they felt that somebody was always watching them to see if they were compliant and so on.’

This reaction had a particular resonance for Dr Wiley – both as a microbiologist with a strong interest in infection control, and as a Muslim woman (who wears a hijab) who wants more discussion of, and sensitivity to issues related to faith in the health service. So she decided to do something about it, campaigning for more inclusive dress-code policies.


Uniform policy

Four years after that initial inquiry – and with help from the BMA – NHS England has committed to producing updated dress-code guidelines. Dr Wiley hopes it will help raise awareness about the issues and potential consequences of ill-thought-out or ‘blanket’ dress codes, and the need to apply them sensitively.

A spokesperson for NHS England confirmed to The Doctor that updated information had been developed after a range of stakeholders (including the BMA) requested a revision of the 2010 Department of Health Uniforms and Workwear Guidance, especially relating to ‘bare below the elbows’ and ‘hand hygiene’ policies.

‘NHS England and Improvement have worked with a range of stakeholders and medical providers to revise the voluntary guidelines around uniforms and dress policy for NHS Employers including medical staff,’ a spokesperson says. ‘This is expected to be finalised before the end of the financial year.’

20200079 thedoctor March issue 19

The new dress policy will be aimed at all NHS employers and employees working with patients in the NHS, and aims to be inclusive and meet the needs of a diverse workforce.

For Dr Wiley, it’s a welcome step forward in a campaign which has occupied much of her time for several years. After the initial feedback about dress codes, she and colleagues conducted some formal research (with the help of the British Islamic Medical Association) which was published in BMJ Open in 2017. This found that there was a lack of consistency on dress codes and how they were applied, particularly regarding the wearing of the hijab and ‘bare below the elbows’.

It notes that although NHS Employers advocates careful consideration of religious belief and avoiding discrimination for those who wear hijabs, in practice, many staff members reported bad experiences. Some women reported being challenged by staff, while others felt they had no choice but to avoid working in surgical specialties.


Placements missed

Dr Wiley has heard many stories from staff, including doctors, who have felt discriminated against. ‘The worst case was a lady who was a chaplain – she didn’t have much direct patient contact in that she wasn’t doing procedures or anything like that. She didn’t want to be bare below the elbows for faith reasons [as a Muslim]. Her line manager, who was the senior chaplain, was really unhelpful – things really escalated and she felt physically threatened by him. She was an older lady and she went home that evening and had a heart attack.’

In addition, Dr Wiley reports that students told her they had missed out on placements, particularly in surgical theatres, because there was no accommodation of their faith.

‘They were being told that nobody had ever asked for this before, and everybody else was OK with it. So they were left feeling isolated, and that’s really difficult when you’re young.’

The bare below the elbows policy, although well-known, is not based on evidence and is often applied inflexibly.

‘Once the policy had been written and the ink had dried, it was almost as if there was no coming back,’ she says. ‘The critical thing should be having engagement with policy makers at an early stage so that key stakeholder groups are consulted. Because once it’s in the system, it’s very hard to tackle, certainly at an individual level.’

She would like to see a range of options available both to organisations and individual healthcare workers. This might include specific products such as disposable sterile sleeves (pictured above) to wear on arms, or disposable hijabs, which some employers have introduced. But it should also include recognition that while there is strong evidence that good hand washing prevents infection, this is not the case for bare below the elbows.

Feedback on disposable hijabs, for example, from those who work in theatres, is that many actually want the breathability and feel of a cloth fabric. ‘[The hijab] is fine in terms of infection control as long as it’s washed at 60 degrees,’ she stresses. ‘But we need to have a range of options. It’s important that we allow trusts options, and women options too.’


Long campaign

She is delighted that the guidance will soon be published. ‘It’s been a long campaign and has taken many woman hours,’ she laughs.

‘For me, I hope that it’s the beginning of something. I hope that it’s the beginning of Muslim women being at the table and being able to speak out, and have their voices heard as equal to everybody else.

‘I want to thank the BMA for putting its weight behind this – the team has been fantastic over what’s been a very long journey.’

BMA council chair Chaand Nagpaul (pictured below) says the updated guidelines are desperately needed to ensure consistent and inclusive policies.

‘For doctors with faith-based clothing practices, it shouldn’t be the luck of the draw whether their employer has a supportive policy. Doctors of all faiths must feel welcomed at work,’ says Dr Nagpaul.

Chaand-Nagpaul-3 GPC chair 2015 16x9

‘We have lobbied for the publication of this guidance for over two years, but our work won’t stop here – we need to ensure that every trust has a dress-code policy that adheres with the guidance.’

Read Dr Wiley's blog


‘Blunt and tactless’

Doctors share their experiences with Dr Wiley of how they have been made to feel uncomfortable in the clothes they wear to work

As a junior doctor working in a hospital placement, Zeinab Ahmed was surprised and upset to be challenged for having covered arms – when she was nowhere near a patient. Infection control and patient safety is a priority for her, but so is her faith as a practising Muslim.

‘One day at work a health professional asked me to “roll up my sleeves” and remain bare below elbows although I was not in direct contact with a patient and was in a hallway on the ward. Despite explaining this, I was told bluntly and tactlessly that keeping my arms covered was not a religious commitment and I must adhere to being bare below elbows at all times even if not involved in direct patient care.’

Dr Ahmed, who is now training to be a GP, spoke to her clinical supervisor, explaining that she wanted to adhere to infection control guidelines, but also to express her faith.

‘I am fortunate that he was understanding and supported me in a fair way with safe patient care in mind, where I was allowed to cover my arms when I am not involved in direct patient care,’ she adds.

Another doctor, who wants to remain anonymous, describes how she was made to feel in the wrong for raising concerns.

‘I used to quite regularly wear shalwar kameez to work, but around the time of the London bombing, I came into work to have a colleague say to me “you could be hiding a bomb under that thing”. I do try not to be oversensitive to clumsy comments but I mentioned this to my consultant. He was quite annoyed [with me] and told me that “this department isn’t racist”, even though I hadn’t even made that accusation. I have never worn Indian clothes to work again.’


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