Healthcare personnel (HCP) attire is an aspect of the medical profession steeped in culture and tradition, according to Gonzalo Bearman, MD, MPH. “Apparel and appearance of HCPs have been linked with significant symbolism and professionalism, but we’ve recently increased our awareness of the potential role of attire in the transmission of healthcare- associated infections (HAIs).” HCP apparel can be contaminated with potential pathogens, but the role of clothing in the transmission of these microorganisms to patients has not been established. This has made it challenging to create generalizable, evidence-based recommendations on attire for non-operating room HCP.

The Society for Healthcare Epidemiology of America (SHEA) recently analyzed available data on this topic and issued a guidance paper with reasonable recommendations for HCP attire. “The SHEA recommendations should not be viewed as a consensus guideline or as a standard of care,” explains Dr. Bearman, who was lead author of the paper and is a member of SHEA’s guidelines committee. “Instead, it’s intended to help acute care hospitals develop or modify policies relating to HCP attire.”


The SHEA article evaluated and summarized the literature around the perception of both patients and HCP regarding attire in relation to professionalism and the potential risk for transmitting microorganisms. It also assessed the evidence for contamination of HCP attire and the potential for it to contribute to the transmission of pathogenic microorganisms in hospitals. In addition, a survey of the SHEA membership and SHEA Research Network was conducted to learn more about the policies related to HCP attire that are currently in place in members’ institutions.

“Bare Below the Elbow” & White Coats

The concept of “bare below the elbows” (BBE) is an important aspect to consider in HCP attire. BBE is defined as wearing short sleeves and no wristwatches, jewelry, or ties during clinical practice. The SHEA paper recommends that facilities consider adopting a BBE approach during inpatient care as a means of offering a supplemental infection prevention policy (Table 1). “BBE can be a good adjunct to support infection control practices, but the optimal choice of alternate attire— such as scrub uniforms or other short-sleeved personal attire—remains undefined,” says Dr. Bearman.

SHEA also outlined several practices to be considered regarding the use of white coats. For hospitals that mandate the use of white coats to establish a professional appearance, HCP should have two or more coats available and have access to convenient and economical means to launder these coats, such as on-site, institution-provided laundering at no or low cost. Coat hooks should also be provided so HCP can remove their white coats prior to contact with patients or the immediate environment.

In a review of patient and healthcare provider perceptions of HCP attire and HAI transmission risk, findings suggested that professionalism may not be contingent on the traditional white coat. “Patients usually preferred formal attire, including white coats, but these preferences appear to have little impact on patient satisfaction and confidence in HCP,” says Dr. Bearman. Patients were unlikely to perceive the potential HAI risks of white coats or other clothing but seemed willing to change their preferences of HCP attire when they were made aware of these risks.

Other Helpful Attire Practices

The SHEA recommendations also outlined other HCP attire practices with regard to laundry, footwear, and shared equipment. Apparel worn at the bedside should ideally be laundered after daily use, but home laundering can help eliminate bacteria if hot water wash cycles are used, preferably with bleach. Shoes should be closed toe and low heeled and have non- skid soles. Any shared equipment should be cleaned between patient visits. The SHEA paper offered no general guidance on prohibiting specific items but noted that items coming into direct contact with patients or the environment should be disinfected, replaced, or eliminated.

“By implementing these practices—in addition to other HAI measures—it’s possible that we can reduce the spread of many HAIs in hospitals,” says Dr. Bearman. Importantly, these practices should be voluntary and accompanied by a well-organized communication and education effort that is directed at both HCP and patients.

Future Research: Attire & Infections

With limited evidence surrounding the knowledge about HCP attire and its effect on infections, several recommendations were made to steer future studies (Table 2). “With better data on the actual role played by HCP attire in the transmission of pathogens, we hope to learn more about its true impact on the burden of HAIs in the future,” Dr. Bearman says. “This information may help guide interventions to further reduce the transmission of HAIs in hospital settings.”