When the religious beliefs of an NHS employee run contrary to trust policy, the result is often headline grabbing conflict. Louise Hunt looks at a modern day dilemma

Key points

  • Some occasions of health employees’ religious beliefs influencing their actions in the workplace have raised controversy in recent years.
  • Despite religion and belief guidance published in January many areas remain hazy.
  • Dress code rules to help combat infection control are raising concerns among some healthcare staff.

When Christian nurse Caroline Petrie was suspended from work last year for offering to pray for a patient, her story reignited the perennial debate as to where professional boundaries should lie when it comes to exercising religious beliefs in a public serving job.

Ms Petrie, who works as a community nurse for NHS North Somerset, was told by her employer that she had breached the Nursing and Midwifery Council code of conduct, which says it is not acceptable to promote personal beliefs unless invited to do so by patients or families.

Amid an outcry from faith groups and the public that she was a victim of overly sensitive political correctness, Ms Petrie was reinstated.

But it was not long before a similar incident reared its head. Nurse Anand Rao has recently been sacked by University Hospitals of Leicester trust for allegedly imposing his religious beliefs during a training exercise in which he suggested during a role play that a hypothetical patient with a short time left to live could alleviate her stress by going to church. Again the trust cited a breach of the NMC code, which it claimed the nurse had disregarded on more than one occasion.

As these cases illustrate, despite equality and diversity legislation and guidelines on religion and belief there is still ample potential for conflict between employees’ spiritual beliefs and trust policy.

Tension between regulations

“What makes these issues so interesting is that there is a balancing of rights between respecting employees’ beliefs and the ways in which beliefs may impact on their duties,” says Tina Elliott, a partner in health and social care specialist law firm Capsticks.

While employees may quite rightly start out with the view that they should not be discriminated against for their religious beliefs under the European Convention on Human Rights and the Employment Equality (religion or belief) regulations, their views may not be protected in all cases, she says.

For example, there could be a tension between the religion or belief regulations and the sexual orientation regulations among some groups who believe homosexuality is wrong. Ms Elliott describes another case of an employee seconded by Liverpool city council to a mental health trust who had given service users a Bible and offered to take them to church. Although he argued that he was expressing his religious views as part of his faith, he was dismissed, “not for his religious beliefs but for inappropriately proselytising. He hadn’t seen the boundaries”, she explains.

In religion and belief guidance published by the Department of Health in January with the aim of providing clarity for the muddy area, proselytising in the workplace is acknowledged as an area that “can cause many problems” because preaching or evangelising may be part of someone’s faith. At the same time there is a danger that non-religious people and those from other beliefs or faiths could feel harassed or intimidated by this behaviour.

“To avoid misunderstanding and complaints on this issue, it should be made clear to everyone from the first day of training or employment, and regularly restated, that such behaviour, notwithstanding religious beliefs, could be construed as harassment under the disciplinary and grievance procedures,” the guidance says. This means whatever religious or spiritual beliefs an employee holds firm they should not be promoted if they are likely to cause offence to others.

As a lawyer Ms Elliott offers this advice: “Yes, you have a right to your religious beliefs, but you have got to be a bit more careful in the workplace over pressing your beliefs on others, or where they may cut across others’ beliefs. The Caroline Petrie case does show this can be tricky. It is about respecting other people’s religious practices and finding out from the patient and relatives what is right for them and not what is right for you.”

But faith groups are concerned that equality and diversity rules and guidance could be used vindictively or misguidedly by some managers. Christian Medical Fellowship general secretary Peter Saunders, suggests that as society has become more secular there is more suspicion and hostility towards Christian values. He goes as far as arguing that some NHS managers are actively using equality and diversity legislation to discriminate against Christian staff.

“The current legislation makes it possible to discriminate because managers can simply say someone is not upholding the guidance on proselytising, for example. There is a growing trend of cases where health managers who are personally hostile to Christian values are using equality and diversity policy as a pretext for bullying and discriminating against NHS staff,” alleges Dr Saunders.

“There is another group that is afraid there will be complaints that will lead to court cases so it is far easier to get rid of the person being complained against. These cases didn’t happen 20 or 30 years ago because there was a lot more tolerance.”

In Dr Saunders’ view there is an intrinsic place for Christian values in healthcare and he would like to see more acceptance and recognition of this.

“Christian doctors have played a major part in establishing modern medicine. There has always been a strong emphasis to care for people as a whole person and not just as bodies,” he says.

He thinks that as part of providing direct clinical care to patients, staff should make an effort to understand the beliefs and worldview convictions of a patient and be able to manage these beliefs showing full respect. At the same time he does not see that Caroline Petrie did anything wrong in offering to pray for a patient.

“Appropriate enquiries about patients’ beliefs are an essential part of whole person care without which a comprehensive plan of care is less achievable. A sensitive enquiry as to whether a patient would value prayer may well be an appropriate part of a medical consultation, especially in the NHS, where some trusts actually pay spiritual healers as part of the care team.

“I think we need an NHS where it is recognised that the motivation to care for the sick among many staff, and not just Christians, comes from people’s underlying faith. If you stop them, you end up cutting off what motivates people to practise health and you will ultimately drive them from the workforce,” he says.

Uniform policy is another potential flashpoint between staff and managers on religious grounds. Last month a phlebotomist resigned because her employer Gloucestershire Hospital foundation trust had banned her from wearing her crucifix at work because it breached health and safety rules which state no jewellery should be worn as it could harbour germs. Last year a Muslim radiographer resigned from the Royal Berkshire foundation trust, arguing the new NHS-wide “bare below the elbows” policy went against the teachings of Islam.

The NHS dress code was introduced in January 2008 to help combat hospital acquired infections.

NHS Employers deputy director Alastair Henderson says: “It is important not to confuse or conflate issues that are genuinely about safety and risk, and a lot of the uniform issues are about infection control. These are very legitimate patient safety issues where trusts have a generally unequivocal right to enforce policy.”

Yet trusts come up against strong feelings against the policy from some faith groups that see it as unnecessary and as discriminatory because they believe it interferes with religious practices.

Islamic Medical Association head Majid Katme warns that many female Muslim health professionals are considering leaving their jobs because they are worried about having to show their arms in front of men.

“If I was a woman Muslim doctor I would be trying everything in my power to cover my arms,” he says.

Dr Katme argues that Muslims meticulously wash hands and arms throughout the day for prayer. He protests that “there is no single scientific evidence that a bare below the elbows policy will protect patients”.

“There are many other ways to deal with cross-infection, such as using disposable gloves, so that women don’t have to leave their jobs,” he adds.

He is also angry that Muslim medics were not consulted before the policy was introduced and calls for the NHS to be more accommodating of Muslim practices and beliefs.

“I am frankly fed up that we are being made to feel the odd one out. It’s Islamophobic and shows a lack of understanding about how we behave. We want to serve British society and Muslim women doctors are needed,” says Dr Katme.

Ms Elliott agrees that the dress code policy does have the potential to be seen as indirect discrimination. While trusts probably can justify enforcing the policy on health and safety grounds, she thinks it is wise for managers to look at individual cases and decide if the requirement is justified, for example whether the dress code has to be upheld in non-clinical areas.

No blanket answers

“Having a blanket policy may give a trust problems,” Ms Elliott says. “If you are imposing a requirement you need to know why it’s there and have a good reason for it and don’t take a policy wider than it needs to be.”

However, she adds that it is unlikely that a Christian would succeed if they claimed religious discrimination over not being allowed to wear a cross, because wearing one was a personal choice rather than a requirement of the faith. However much guidance and legislation is produced, there appear to be no hard and fast answers.

Mr Henderson says: “This is a classic example of where employment and service delivery issues interact and potentially conflict. As always it is about achieving the right balance.

“There is not one right or wrong way, it is about making the right judgement. The guidance is helpful, but what’s important is how a situation is managed on the ground.”

Trusts can best protect themselves against potential conflicts by going through organisational procedures with a fine-tooth comb to ensure any areas that are potentially discriminatory to staff or patients are picked up before problems arise.

This might seem a mammoth task, but many trusts that are developing single equality schemes, which bring together the different equality duty strands plus added provisions for religion, are already doing it (see box, below).

“The process of implementing the single equality scheme ought to help organisations become much more aware of potential discrimination issues, as well as providing real, local tools such as equality impact assessments to prevent issues from arising,” says Mr Henderson.

“Trusts that have not done this background work will be much more prone to conflicts and making bad judgements.”


NHS Employers guidance: search for single equality scheme at the NHS Employers home page

Developing a single equality scheme

Under the Equality Bill, due to come into force in April 2010, all public bodies will need to bring together the three existing duties (race, disability and gender) and extend this to gender reassignment, age, sexual orientation and religion or belief. It will also cover the legal requirements on equal pay. Public bodies will need to tackle discrimination and promote equality on all the key diversity strands.

Developing a single equality scheme is not mandatory, but it is recommended by NHS Employers, which has guidance on its website.

NHS North East has set up a religion and belief staff network, as part of developing a single equality scheme. Several of the 23 trusts across the strategic health authority have introduced the religion and belief network and others for the different equality strands.

“The religion and belief network is one way that staff’s beliefs can be supported by NHS employers in the North East,” says Lynne Lane, equality and diversity manager of the three NHS South of Tyne and Wear primary care trusts, and network facilitator.

“It aims to raise awareness of different religions and beliefs and the part they play in some staff’s lives.”

Some of the activities organised by the network include: an event to inform staff about different faiths, one-hour lunch sessions to find out about different faiths and beliefs with quizzes to see how much has been learned, and computer pop-ups to let staff know about religious dates.

“This is not just about supporting staff who are part of the network,” she adds. “It’s about raising awareness and understanding within our organisations to respect the different religions and beliefs of staff, patients and clients and also the values of people that have no religious or spiritual beliefs.”

NHS Norfolk has opted to develop its single equality scheme ahead of enforcement of the Equality Bill and is carrying out an extensive public consultation to canvass opinion on what it should include and how different groups will be affected.

This has involved the PCT investing in an independent Ipsos Mori survey, as well as working with partner organisations such as the local Race Equality Council and traveller groups, to ensure the voices of hard to reach members of the community are heard.

Director of corporate services Jonathan Cook says this approach is “more far reaching and less tokenistic” than for the development of previous equality and diversity schemes.

“We are hoping to achieve genuinely meaningful comments to set out our single equality scheme strategy,” he says.

The equality and diversity team is also working with the Race Equality Council to develop equality impact assessments that will be used to screen all board decisions and trust policy to make sure they are not discriminatory.

The trust has also made equality and diversity a mandatory part of staff training with the introduction of an e-learning package as well as on site sessions that cover areas such as how to address patients’ religious and spiritual needs in care plans.