Clinical Policy Handbook

Policy for Documentation of Health and Non-Health Credentials

The College of Nursing and Health Sciences (CNHS) uses a Third-Party Vendor to manage documents related to nursing clinical requirements. Communication from the nursing program regarding clinical requirements and credentials is disseminated through email.

Students are responsible for reading all CNHS communications throughout the calendar year.

• Requirements and timelines apply to all students: including students who are enrolled in a clinical course, students who are not enrolled in a clinical course, and students who will enroll in a clinical course.
• Students are subject to CNHS/UMass Dartmouth disciplinary actions if expected credentials are not met by the predetermined deadline.

Students are expected to comply with the following requirements:

1. Establish an account with the third-party vendor as directed at the student's expense
2. Complete all clinical requirements as directed.
3. Upload all documents and credentials related to clinical requirements per schedule.
4. Meet all timelines and deadlines as outlined by the CNHS
5. Contact the third-party vendor help desk with any questions or concerns with your individual profile.
6. Contact the CNHS staff if unable to resolve concerns, issues, or questions with the third-party vendor staff.

General Clinical Policies

1. Immunization
   All students who are admitted to UMass Dartmouth CNHS must comply with the Massachusetts Department of Health Immunization Laws for Healthcare Workers available and 244 CMR 6.04 (3) MA Board of Nursing.
   
   Initial health immunization records are managed by Student Health Services on admission to UMass Dartmouth. Sophomore, Junior and Senior Traditional BS students, ABS, and RN-BS track students have additional health related requirements as delineated by the nursing program, clinical agencies, and Massachusetts Department of Public Health. In the summer preceding each year in which nursing students are enrolled in a clinical "NUR" course(s), information about health-related requirements, including immunizations, will be sent to you from the College. Traditional BS and ABS students must complete the required requirements and submit the completed forms to the third-party vendor as instructed. Students will not receive a clinical assignment in a clinical course until the health/immunization requirements have been met. Failure to meet health/immunization requirements may result in a failing grade in the course.
   
   The clinical instructor for each section of a clinical "NUR" course will exercise the authority to defer clinical assignment until the student completes the stipulated health related requirements. Protracted delay could result in the student's inability to meet course outcomes within that semester. If you have any questions about health services, forms, or health insurance, please call the College (508-999-8586)
2. Cell phone use
   The inappropriate use of cell phones is not permitted in the clinical setting. Inappropriate use is defined by clinical faculty and may vary by clinical setting. Prohibited activities include: texting, social telephone calls, telephone use during pre/post conferences, use of social networking, and photography of any kind. Phones should be set to "vibrate" or "off" while in the clinical setting. In any case of cell phone use, if the policy of the clinical institution is more prohibitive than the policy of the University of Massachusetts Dartmouth, the policy of the clinical setting shall supersede the University of Massachusetts Dartmouth policy.
3. Cardiopulmonary Resuscitation (CPR) Certification Requirement
   Students are required to be certified in Basic Life Support for Health Care Providers (CPR and AED) by the American Heart Association prior to the beginning of each academic year in which they enroll in clinical courses. A copy of the certification must be submitted per instructions. Students without this certification may not attend clinical.
   • Courses are offered by American Heart Association, local hospitals, local community groups, and the UMass Dartmouth Public Safety Office. The course that students must take is CPR for Health Care Providers from the American Heart Association.
   • It is suggested that students take a CPR Course through the recommendation of the student support staff. You will then be certified in time for Fall clinical courses. Check with the Student Support Staff for specific times and dates.
   • Students are required to submit all necessary documentation per instructions by the established deadline in order to attend clinical experiences. Students will receive a clinical warning and will not be able to participate in clinical until all documentation is uploaded to the 3rd party vendor.
4. A requirement imposed by one of our largest clinical settings for all employees and student affiliates is a ten (10) panel urine screening (for drug use) conducted once before the first agency clinical course. Typically, this will be required in the fall of the Sophomore year.
5. Basic students entering the Sophomore year, Senior year, ABS and RN Students will be subject to a Criminal Offender Check (CORI) in the State of Massachusetts. Students must submit the permission form prior to the start of clinical sessions. Should a CORI check result in a positive finding (evidence of a criminal record,) the report will be reviewed by the Dean and the student will be required to submit a written explanation of the criminal offense, the outcome and subsequent activity. The Dean will determine if the student may continue in the program. The outcome of the Dean's deliberation cannot be appealed. Additionally, during senior mentorship, some facilities require a national criminal background check. This may result in an additional charge for students at these facilities.
6. All students must wear the official student uniform when in the clinical agency. The faculty may make alterations in requirements as appropriate to the clinical activity. At all times students are to present themselves in a professional manner.
7. All students must read and understand the clinical information and policies related to infection control and exposure contained in this handbook.
8. Students are responsible to provide their own transportation to clinical agencies.

Note: The following contains more detailed information about each of the policies referenced above. (Rev. 6/98, 6/99, 6/00, 6/01, 6/04, 8/09, 3/12, 4/15, 12/20)

CORI/SORI Policy

For CNHS students and potential applicants to the CNHS

In order for a student to be eligible to participate in an academic, community, clinical program or internship that involves potential unsupervised contact with children, the disabled, or the elderly, the student will be required to undergo a Criminal Offender Record Information (CORI) check and/or a Sex Offender Registry Information (SORI) check and the possibility of fingerprinting per clinical agency policy. An additional cost may be incurred per clinical agency policy. Students found to have certain criminal convictions or pending criminal actions will be presumed ineligible to participate in clinical activities. The CNHS is authorized by the Commonwealth's Criminal History Systems Board, pursuant to Massachusetts General Laws, Chapter 6, Sections 167-178B, to access CORI records. The CNHS shall refer to regulations issued by the Commonwealth's Executive Office of Health and Human Services, 101 Code of Massachusetts Regulations 15.00-15.16, as guidance when assessing student CORI records. Sex Offender checks shall be performed pursuant to Massachusetts General Laws, Chapter 6, Sections 178C-178P.

For information regarding the CNHS's CORI/SORI check process, please contact the Dean of CNHS or designee.

For mentorship students, there may be an additional expense for clinical agency mandated CORI.

Please note: The CNHS is obligated to comply with our contracted agencies’ CORI policies. Therefore, this information is subject to change. CORI forms are submitted per annual instructions. Students are responsible for providing all required information by specified deadlines. (Rev. 9/10, 3/12, 8/12 4/15)

Policy Regarding Bloodborne Pathogens

To prevent transmission of bloodborne pathogens in healthcare settings

The increasing prevalence of blood borne pathogens increases the risk that health-care workers will be exposed to blood/body fluids from patients infected with bloodborne pathogens, especially when blood and body-fluid precautions are not followed for all patients. Thus, this document emphasizes the need for healthcare workers to consider all patients as potentially infected with bloodborne pathogens and to adhere rigorously to
infection-control precautions for minimizing the risk of exposure to blood and body fluids of all patients.

The Center for Disease Control and Prevention (CDC) has issued guidelines regarding occupational exposure to bloodborne pathogens (including HIV, Hepatitis B and Hepatitis C). The College of Nursing and Health Sciences has adopted the following policies in conformity with CDC guidelines.

The following policies are your first line of defense against HIV, Hepatitis B and Hepatitis C, but also against all bloodborne pathogens:

1. Body substances of all clients are to be considered infectious.
2. Handwashing is the major preventive technique. It should be used:
   1. Prior to and following any patient contact.
   2. Immediately, if contact with any body substance onto the skin or mucous membranes occurs.
   3. After removing contaminated gloves, gowns, or equipment.
3. Needles should not be recapped or broken; deposit in a puncture-resistant container.
4. Gloves should be worn if contact with body substances is anticipated. These include:
   1. Handling of blood, urine, feces, vaginal drainage, saliva, tears, amniotic fluid, breast milk, or wound drainage, including wet dressings and laundry.
   2. When potential contact with body substances is anticipated (IVs, irrigations).
   3. When carrying body substances in containers (bedpans, urinals, specimen containers).
5. Added precautions should be taken if splashing of body substances is anticipated, or if contact with eyes or mouth is expected (masks, goggles, gown).
6. Students should be knowledgeable of the nature and risks of body substance transmitted diseases, the mode of transmission, and the appropriate preventive techniques.
7. Students with cuts, sores or other broken skin areas on their hands should not be in direct contact with patients. Clinical instructor must be notified immediately to determine if clinical practice can be carried out by wearing gloves or by applying an occlusive dressing.
8. Any needle-stick injuries with contaminated needles, cuts with contaminated sharp objects, body substance splashes or contact with mucous membranes should be managed following CDC guidelines. Clinical instructor must be notified immediately. Immediately wash area, report to agency, and refer to the ED for treatment of exposure. Occupational health referral will be made by ED provider and follow
   up with occupational health and University Health Services. Documentation of exposure will be required.
9. Spills of body substances should be immediately cleaned from the surface using soap and water then follow agency policy. Gloves should be worn during cleaning and hands washed when gloves removed. The agencies recommended bactericidal cleaning procedure should be followed.

The following principles should also be recognized:

1. Blood and body fluids transmitted diseases are not transmitted by ordinary contact with patients (bathing, feeding, or touching). They are not transmitted through the air.
2. Blood and body fluids guidelines are for the protection of patients as well as the health care worker.
3. Gloves must be worn when it can be reasonably anticipated that the student may have hand contact with blood, other potentially  infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures and when handling or touching contaminated items or surfaces.
4. When needed equipment or supplies are not available in the clinical area, the instructor should use his/her judgment as to how the student should proceed.
5. After caring for a patient, students should not put hands to face, especially eyes or mouth, prior to washing hands.
6. Students are accountable for the correct implementation of the above procedures.
7. Students are responsible for reviewing agency procedure/policy manual.

(Rev. 6/98, 6/99, 6/00, 5/05, 8/09)

Bloodborne pathogen policy signature sheet

Annual clinical requirement which is part of the annual clinical requirements that are managed by a third-party vendor.

(Rev 6/98, 6/99, 6/02, 5/05, 8/09, 2/12)

Clinical, On-Campus Clinical, Simulation and Lab Attendance Policy Statement

Students are expected to attend all scheduled clinical experiences, including Clinical, On-Campus Clinical, Simulation and Lab experiences. Attendance consists of arriving on time, dressed according to the dress code for that experience, and prepared to work. Any absence must be reported to the appropriate faculty, the agency and preceptor (if applicable) prior to the time the students are expected to arrive (as stated in the course syllabus). Student absences due to extenuating circumstances (see definition) will be considered on a case-by-case basis.

Extenuating circumstances

Unforeseen events such as an auto accident, deaths in the immediate family or personal illness which requires a student to be absent from class or clinical may be viewed as an extenuating circumstance. In the case of such events, the student must notify faculty members as soon as possible. Vacations, weddings, doctor appointments, studying for an exam, childcare issues, job interviews, working, etc. are not considered extenuating circumstances as these are not unforeseen events. Students wishing to claim extenuating circumstances will be asked to provide documentation of the condition that led to absenteeism. The presence of extenuating circumstances does not guarantee that a student will be exempted from this attendance policy.

Absences

If a student demonstrates patterns of behavior that includes tardiness and absences, they will be placed on clinical warning and are at risk of failing the course. The student is required to establish a remediation plan with the course faculty and may be required to complete an activity, assignment, or clinical hours as decided by the course faculty

Student clinical absence with notification

1. The student must notify their clinical faculty a minimum of 1 hour before the beginning of their clinical experience or as directed in the course syllabus.
2. With the first clinical absence, the student is required to complete an activity, assignment, or clinical hours as decided by the course faculty.
3. If a second clinical absence occurs; the student is required to complete an activity, assignment, or clinical hours as decided by the course faculty and establish a remediation plan with the course faculty and department chairperson.
4. If a third clinical absence occurs (or more); the student will meet with the Course faculty, department chairperson and/or Assistant/Associate Dean to review/update the remediation plan and is at risk of failing the course.

Student clinical absence without notification (no call, no show)

1. The first no call no show will result in clinical warning and remediation plan that includes an activity, assignment, clinical hours, and/or a deduction in overall course grade as decided by the course faculty (as indicated in course syllabus)
2. The second no call no show, will result in failure of the course.

Tardiness

Tardiness is defined as arrival to the designated clinical unit or meeting place any time after the designated start of clinical. In the event the student anticipates clinical tardiness, the faculty must be notified prior to the beginning of the clinical day.

1. If a student is more than 1 hour late to clinical the incident will be counted as an absence, the student may be sent home from the clinical site, and they may be required to complete and activity, assignment, or clinical hours as decided by the course faculty.
2. Two or more incidences of tardiness will result in a clinical warning and remediation plan and the student may be required to complete an activity, assignment, or clinical hours as decided by the course faculty.

(Approved by Fac Org March 26, 2018)

Undergraduate Clinical Warning Policy and Procedure Policy Statement

A clinical warning is an official written notice to the student given by the clinical instructor for unacceptable clinical performance or behavior (see Definition below). “Clinical” includes simulated learning activities (Sim Lab); laboratory learning activities (Lab); and clinical agency learning  activities.

Purpose

Consistent application, documentation, and record retention of a Clinical Warning.

Definition

A student receives a clinical warning when performance or behavior in the clinical setting is below the level expected for a student at his/her current level of training as defined in the clinical evaluation tool, and if continued, could result in failure of the clinical course.

Procedure

When an instructor determines that the clinical performance or behavior of a student merits a clinical warning, the following procedures will be implemented.

1. The clinical instructor:
   1. notifies the student verbally on the clinical practice day and states the specific reason for the clinical warning.
   2. notifies the clinical coordinator within 24 hours of the occurrence.
   3. schedules a conference (face-to-face) with the student and clinical coordinator, to occur within two (2) working days, for discussion of the unacceptable performance and/or behavior. The clinical coordinator may meet with the student in lieu of the clinical instructor in order to adhere to the 48-hour period.
   4. gives the student a written copy of the clinical warning which will include:
      1. a description of the unacceptable performance and/or behavior;
      2. mutual assessment of the causative factor(s)
      3. mutually determined goal(s)/remediation action plan and expected time frame for achievement of same; and
      4. a section for evaluation of the action plan on the expected date of achievement.
2. The clinical instructor, the course coordinator, and the student are required to sign the conference interaction indicating their participation in the above steps (Clinical Warning form).
3. The clinical faculty will retain the original copy of the Clinical Warning until the end of the semester. All completed forms will be retained in the office of the Assistant/Associate Dean of Undergraduate Studies, and a copy will be provided to the student.
4. Depending on the issue/problem, the student receiving a clinical warning may be required to satisfactorily complete remediation in the clinical lab and Simulation Center before returning to their clinical setting.
5. Remediation in the Clinical lab and Simulation Center does not count as a clinical day; make-up of any missed clinical day is per the course syllabus.
6. If the student is unable to successfully remediate within the timeframe, the student will be subject to failure of the clinical course.
7. Students with two or more warnings during the program of study are subject to disciplinary action up to and including dismissal from the program upon review by the Assistant Dean/Dean.

Responsibility

• Clinical Instructor
• Clinical Coordinator
• Assistant/Associate Dean of Undergraduate Studies

Attachment(s)

Clinical Warning Form (PDF)

(Approved by Fac Org 10/25/17)

Guidelines for Mentorship Placement in the College of Nursing ABS Program

All students in the ABS Program will be expected to complete NUR 457 in their final fall semester. To provide learning opportunities to prepare the students for professional generalist nursing practice, mentorship placements will be found on an acute adult health unit, outpatient setting, or at a long-term care facility.

If requesting alternative placement, the student must submit a recommendation request form to his/her academic advisor no later than May 1 of the spring prior to mentorship.

Alternative placement criteria for advisor

*Students must meet the following requirements to be considered for alternative mentorship placement. Alternative clinical placements are not guaranteed even if requirements are satisfied due to limited availability of placement and proctoring in alternative areas.

• Cumulative GPA at time of application submission: 3.7
• Achieve at least 95% in all clinical rotations prior to mentorship including NUR 255, NUR 331, and NUR 327.
• Achieve at least a Level 2 on all ATI proctored exams including NUR 250, NUR 330, and NUR 326.

*If you have received a clinical warning for any reason, you will be ineligible for an alternative placement.

(Approved by Fac Org 10/18/18)

Expectations of lab and clinical agency

• Shoes: Students should wear one of the following: a professional nursing shoe that is fully closed without air vent openings or sling back, pair of well-kept cross trainers, running shoes, clogs or walking shoes in white, black, or brown. (update approved by Faculty Org. 2/23/2015)
• Socks & stockings: Clean socks or stockings must be worn. You are not allowed to wear shoes without socks or stockings.
• White lab coat: Three-quarter or waist-long lab coats are appropriate. Ample pocket space is desirable. UMass Dartmouth
  emblem patch attached to the left sleeve, near the shoulder.
  • UMass Dartmouth name pin is to be worn on the left chest of your lab coat. Both are available for purchase
    through the UMass Dartmouth Bookstore.
• UMass Dartmouth Name Pin: To be purchased through the UMass Dartmouth Bookstore and worn at all clinical experiences. The name pin is to include the student's first name and last initial.
• Optional navy scrub jacket: The optional navy scrub jacket will be offered as an optional uniform item by the campus bookstore and will be embroidered with the UMassD College of Nursing logo. The navy scrub jacket may be worn with the navy-blue scrub uniform. (Approved by Fac Org 05/13/24)
• Optional navy fleece Jacket: The optional navy fleece jacket will be offered as an optional uniform item by the campus store and will be embroidered with the UMassD College of Nursing logo. The navy fleece jacket may be worn in addition to the student’s community clinical uniform (navy blue polo and tan scrub pants), which is worn for community, pediatrics, and service learning courses. (Approved by Fac Org 05/13/24)

Hospital-based and CNHS-based clinical days (including assessment, skills, and SIM labs)

UMass Dartmouth College of Nursing uniform unless otherwise instructed by your clinical faculty.

UMass Dartmouth CNHS nursing uniform

The UMass Dartmouth College of Nursing and Health Science nursing program school uniform is available for purchase through the University of Massachusetts Dartmouth Bookstore. All students are required to purchase the following:

• Sophomores
  • One navy UMass Dartmouth CNHS uniform top.
  • One pair of unisex navy uniform pants
• Junior & Seniors
  • There is a minimum of 2 clinical days each week. Recommend: One (or two) navy UMass Dartmouth CNHS uniform tops. One (or two) pair of unisex navy uniform pants
• Psych Clinical Agency
  • One (or two) navy polo UMass Dartmouth CNHS uniform top.
  • One (or two) pairs) of khakis
• ABS Track: Recommend two navy UMass Dartmouth CNHS tops and navy unisex uniform pants. Uniform is to be neat and clean (ironed if needed).
• Equipment
  • Wristwatch with sweep second hand. Any brand of watch is acceptable. A waterproof watch is recommended.
  • Stethoscope
  • Bandage scissors
• Shoes: Students should wear one of the following
  • a professional nursing shoe that is fully closed without air vent openings or sling back
  • pair of well-kept cross trainers, running shoes, clogs or walking shoes in white, black, or brown.
    (update approved by Faculty org. 2/23/2015)
• Socks & stockings: You are not allowed to wear shoes without socks or stockings.
• Student identification: It is required that you be legally identified as a student nurse. Always introduce yourself by name and title (“Student Nurse”) when entering a nursing unit and/or patient's room.
  • Note: Faculty will advise the student of additional guidelines that are specific to the clinical agency or nursing unit.
• Agency/hospital badge: Students may be issued a clinical agency “student identification” badge. This badge is to be worn visibly at all times while on hospital/agency property. Badges are to be returned to your clinical instructor at the end of your clinical experience.
• UMass Dartmouth name pin: Worn at all clinical experiences

(approved by Faculty org. 2/23/2015)

Brigham and Women’s Hospital and Mass General Brigham (effective Jan. 31, 2024)

Nursing Academic Placement Policy

Clinical students must complete the mandatory Health Stream training requirement for onboarding at Brigham and Women’s Hospital and Mass General Brigham. Students will not be allowed to attend clinical mentorship placements until they complete the training assignments.

Southcoast Personal Appearance Policy (effective 2022)

Title: Personal appearance
Policy number: SHS-ADM-HR-7.04
Policy date: August 7, 2000
Effective date: August 7, 2000
Revision dates: May 22, 2007, May 17, 2016, November 2020, August 22, 2022
Revision effective: May 22, 2007, June 8, 2016, July 15, 2021, August 26, 2022

Purpose

The purpose of this policy is to provide guidelines so that employees and volunteers are aware of the requirements to dress in a way that promotes and professional appearance and establishes trust, comfort and confidence while providing care in a safe environment.

Policy

Employees represent the first impression of Southcoast’s brand to patients and visitors. This policy outlines dress and grooming expectations to promote a confident, respectful, and consistent professional image throughout the organization. Employees are expected to utilize the guidelines outlined in this policy. Department Leadership (DL) may establish additional requirements regarding uniforms, safety apparel or specific clothing appropriate to their work setting. Departmental standards are subject to review and approval by Human Resources (HR).

Definitions

• Patient care areas: Locations where patients are present, such as hospitals, physician practice offices, urgent care centers and patient homes visited by Visiting Nurse Association (VNA) staff (this includes common/public areas in these locations).
• Staff members: All employees, employed providers, medical staff, and volunteers.
• Business casual: Attire that projects a professional image while also allowing employees to work comfortably in their work area.

Procedure

1. Appropriate Work Attire
   1. Identification Badges: Southcoast Health System (SHS) issued ID badges are part of each employee’s required attire. It must be worn and clearly visible with the picture side out. The badge must be located at shoulder height (not at waist or belt level) so that it is easy to read by patients, visitors, and other  Employees. Badges must be in good condition and current information is required.
   2. Professional Appearance Standards
      • Business casual dress is permitted throughout the organization. Clothing should be neat, clean, wrinkle-free and in good condition (no holes or tears). Employees are expected to be mindful of the business and location of their work on any given day and comply with the appearance requirements of that department or entity. Employees are expected to exercise good judgement around what dress is appropriate for the circumstances.
      • DL are responsible for guiding employees as to appropriate dress for their work environments, including but not limited to, approved use of neat and clean jeans and sneakers.
      • Employees who work at non-patient care locations and who travel to locations where patients are present are expected to conform to the dress code when at patient care locations.
   3. Shoes and Legwear
      • Patient Care Areas: For safety and public health reasons, stockings or socks are required to be worn in areas where regular direct patient care is necessary or required; open-toed shoes are not permitted.
      • Non-Patient Care Areas: Except in the case of safety or public health reasons as determined by the manager, dress sandals/open-toed shoes and clogs are permitted.
      • Leggings and tight-fitting pants must be worn with a top/shirt which reaches mid-thigh.
   4. Hair: Hair, including natural or protective hairstyles beards and mustaches should be kept clean and neat. Anyone who provides direct patient care, works with food, or handles sterile equipment, must comply with all safety protocols concerning hair or hair covering.
   5. Jewelry and Other Accessories: Jewelry and body piercings are acceptable and must be worn in a way that does not present a safety hazard. Lanyards are a safety hazard and should not be worn in any patient care locations.
   6. Fingernails: To comply with hand hygiene requirements fingernails should be less than one-fourth inches (¼”) in length. Nail enhancements are prohibited for staff involved in direct patient care or the preparation of sterile or at-risk supplies. Anything other than traditional polish is considered an enhancement. Please see Infection Prevention Policy (SHS-CLI-INF- 006).
   7. Tattoos: Tattoos and other body art are generally permitted. They will not be permitted to be visible during work if they are potentially offensive based on racial, sexual, religious, ethnic characteristics or attributes of a sensitive protected nature.
2. Professional Casual Wear
   1. SHS Department Directors may allow employees to dress more casually at certain times, provided attire is neat and complies with the guidelines listed below. Employees are always expected to present a professional appearance at all times, even with this casual dress provision. Exemptions will not be permitted.
   2. The following dress is not permitted at SHS:
      • Jeans (in Patient Care locations).
      • Mini-skirts or dress/skirt with high slits.
      • Spandex pants.
      • T-Shirts unless SHS branded (T-shirts are discouraged in all Patient Care locations).
      • Graphics/messages on clothing.
      • Midriffs, strapless, low-cut, or revealing clothing.
      • Tank tops (sleeveless blouses or dresses are permitted).
      • Flip-flops or beach sandals.
      • Faded, frayed or torn clothing.
      • Hooded sweatshirts and sweatpants.
      • Hats, bandanas, or inappropriate head coverings (except for medical, safety or religious reasons, or as part of a uniform).
3.  Uniforms
   1. Several SHS departments require uniforms to be worn as their departmental dress standard. In departments where consistency of dress is important based on contact or visibility with patients and visitors and thus, personal attire would not be appropriate, uniforms are provided by SHS. If, due to the nature of work performed in the department there is an expectation that clothing may be soiled, ripped, or torn, uniforms are provided by SHS.
   2. Employees who are required to wear uniforms are expected to adhere to the Personal Appearance Standards outlined above and maintain uniforms in good condition in order to present a professional appearance. SHS issued scrubs should only be worn on days the employee is working.
   3. Departments that require uniforms will provide a basic supply to employees. Employees may purchase additional uniforms.
   4. While in contact with the public outside of SHS facilities when wearing a uniform, employees should be aware of their surrounding and circumstances as they are representing SHS and their profession.
   5. Departments that require uniforms be worn, but not permitted to be taken from the premises for health and safety reasons, will provide employees ten (10) minutes of paid time at the beginning and end of each shift for changing.
4. Responsibilities and Accountability
   1. Leaders must review departmental standards with the employee at the time of hire or transfer. Leaders are responsible for the following:
      • Ensure staff members meet the standards for professional appearance and for determining if the safety of an employee or others is jeopardized by the employee’s appearance/dress. Coordinate and distribute uniforms, where appropriate.
      • Take corrective action when employees do not comply with the SHS Personal Appearance Policy and consult with HR in accordance with the Corrective Action/Disciplinary Measures Policy. Employees who are dressed inappropriately for work should be sent home to change.
      • Collect and return the ID badge of employees within their unit/department to the Director of Security upon termination of employment.
   2. Employees must
      • Adhere to the Personal Appearance Standards outlined in this policy and present an appearance that is professional, positive and inspires the confidence of our patients and partners.
      • Wear their ID badges while on SHS premises, update the badge when there is a change in name, title or department, report lost or stolen badges to their supervisor and the Public Safety Department immediately, and return the badge upon termination of employment to their Department Director.
      • Maintain and return assigned uniforms to their Department Director upon termination of employment.

*SHS reserves the right to interpret the provision of this policy and modify or terminate this policy at any time at its sole and exclusive discretion.

*Employees who are part of a collective bargaining unit should consult with the relevant collective bargaining agreement for applicability of this policy.

Attachments: None

References:

• MA CROWN Act

Cross-References:

• SHS-ADM-HR-4.40, Corrective Action/Disciplinary Measures
• SHG-HR 4.26, Employment
• SHS-ADM-HR-4.28, Employment Exit Interviews
• SHS-ADM-HR-8.14, Worker’s Compensation
• SHS-CLI-INF-006-Hand Hygiene

Prepared by
Beth Barker, Vice President, Human Resources

Approved by:
Rayford Kruger, MD
President and Chief Executive Officer

Lauren De Simon Johnson
Sr. Vice President, Human Resources

St. Anne’s Dress Code/Personal Appearance Policy (effective 2020)

Dress code/Personal Appearance Policy
Department: Human Resources
Policy number: HR 06
Origination date: 3/3/20

Policy

While it is recognized that dress and grooming are a matter of personal taste and culture, Steward expects all employees to be well-groomed and to comply with standards in order to maintain a professional appearance and to promote infection control. Employees should remember that they represent Steward Health Care, and the image they project should always be professional, discrete, and in good taste. In applying and enforcing this
policy, supervisors are expected to exercise good reason and judgment and should consult with Human Resources if guidance is needed.

Scope

This policy is applicable to all Steward Health Care System employees. In addition to this policy, supervisors may advise employees of specific dress or uniform requirements of individual departments.

Procedure

1. Responsibilities
   1. It is the responsibility of all covered employees to abide by the provisions of this policy and to support the professional image of Steward.
   2. Individual departments may develop stricter dress guidelines or require a uniform, providing that they do not conflict with this policy and are reviewed and approved in advance by the Human Resources department. In maintaining such standards, Human Resources will be most concerned that requirements of the workforce member’s department are met and the department policies are non-discriminatory in terms of race, color, religion, sex or gender, age, disability, national origin, ancestry, sexual orientation, military status, or any other legally-protected category.
   3. It is the responsibility of the Department Manager or Supervisor to ensure that all terms of this policy are applied with consistency and fairness.
   4. It is the responsibility of the Human Resources department to resolve any questions or disputes relative to application and interpretation of this policy. When appropriate, the Department Manager or Supervisor, in conjunction with Human Resources, may send the employee home to change. If an employee is sent home to change his or her clothes, the time spent doing so will not be considered time worked for purposes of calculating pay earned by the employee.
   5. Definition of appropriate clothing is clothing of modest cut and style that benefits a clinical and business setting. Management is the ultimate arbiter of appropriate attire.
   6. All covered employees are expected to follow the departmental and general dress guidelines. Continued failure to comply with this policy may result in corrective action, up to and including termination of employment.
2. The following guidelines and definitions are provided:
   1. For clerical or administrative positions not involving direct patient contact:
      1. Business casual dress is appropriate for all positions. This includes tailored pants, skirts or dresses, collared shirts, and solid or printed tops, blouses, or lightweight sweaters.
      2. For clerical and administrative positions on the nursing floors, scented hair care products, lotions, perfumes, and/or colognes are strictly prohibited due to sensitivity and allergies.
      3. Jewelry should be kept to a minimum.
      4. Every effort should be made to keep body tattoos and body piercings covered with an exception for minimal ear piercings.
   2. For employees working in clinical areas:
      1. Employees must wear closed toe shoes with a solid upper covering (no holes on the top or sides of the shoe) and flexible non-slip sole. In addition, athletic shoes with an outwardly curved sole or unattached heel are not safe and, therefore, not acceptable in either clinical or
         non-clinical areas.
      2. Employees working in clinical areas are prohibited from wearing or bringing into the workplace, natural or artificial scents/fragrances, including perfumes, aftershave, lotions, scented candles, or similar items that are perceptible to others. Smoke odors are not allowed at any time, as these odors may be offensive or harmful to patients and their visitors, and/or to co-workers.
   3. For all employees, good personal hygiene is required, including bathing and good grooming.
      1. Identification Badges must be worn in clear sight and above the waist.
      2. Clothing must be neat, clean, and in good repair.
      3. Long hair is to be secured either behind the head or pinned up when performing patient care duties or any duties that pose a risk of harm to themselves or patients such as food services, sterilization, and building maintenance.
      4. Minimal fragrance, lotions, scented hair products, etc., may be worn unless the department manager indicates that, due to an employee allergy or sensitivity, a restriction must be made.
      5. Fingernails should be clean and trimmed, with no ragged edges. Clinical employees are prohibited from wearing artificial nails.
      6. Open toed shoes may be worn, when/where appropriate, by non-clinical employees.
      7. Sandals of any kind, including wearing socks with sandals are not allowed.
      8. Prohibited items include, but are not limited to, the following:
         1. Any tight, low-cut, or sheer clothing or any top that ends above the waist.
         2.  Shorts.
         3. iii. Cargo pants, leggings, stretch pants, or sweatpants.
         4. Any ripped denim garments.
         5. Tank tops or any top with spaghetti straps.
         6. Sweatshirts, jackets, or vests with non-hospital or non-Steward logos.
         7. Flip flops.
         8. Hats, except when working in departments that require hats for sanitary or other purposes (including, but not limited to the kitchen and sterile areas).
      9. Certain items, while appropriate for patient care areas, such as scrubs and sneakers, do not present the professional image that Steward is committed to maintain for individuals in nonclinical roles. Individual department heads will make determinations as to the appropriateness of such attire. In general, scrubs and sneakers are not appropriate for non-clinical areas.
3. Exceptions
   1. Any exceptions to the dress code policy may only be made with the permission of the Department head in conjunction with Human Resources and will be made for legitimate business reasons on a case-by-case basis only.

Review and approval

The following Steward Health Care System personnel originated and approved this policy:

Date: 3/3/20
Contact: Executive Vice President, Human Resources
Approved by: Corporate Human Resources, Steward Clinical Excellence Committee
Description: New

Saint Anne’s Hospital Hospital Addendum

System policy has been adopted with the following variation:

Uniforms:

1. Individual departments may specify a particular style and/or color of uniform which will be loaned to the employee and must be returned to the hospital upon termination.
2. Registered Nurses, Patient Care Assistants (including Nursing Assistants, Health Unit Coordinators, Patient Care Techs, Emergency Room Techs and Paramedics), Physical Therapists, Phlebotomists, Respiratory Therapists, Occupational Therapist, and Speech Therapists working in patient care areas must adhere to the color and style of scrub top and bottom designated for their position.
3. The designated uniform jacket offered by the hospital is the only form of cover-up that may be worn. Employee may wear a white long sleeve top underneath the designated scrub top.
4. Positions where a particular color and/or style are not required, employees must purchase and maintain their own work attire. The hospital may take action in response to violations of the dress code policy. An employee may be sent home to change, or a lab coat or scrubs may be provided for the scheduled shift. Repeated violations of the policy may result in disciplinary action, up to and including termination.

Review and approval

The following Steward Health Care System personnel originated and approved this policy:

Date: 8/13/20
Contact: Human Resources Director
Approved by: Does not Require Policy Committee approval. Follows HR approval process for Non-Regulatory HR policies.
Description: New Steward policy adopted