The nursing uniform has evolved into a traditional image of nurses and serves as a way for patients and other health care professionals to identify a nurse in the hospital setting. The public's perception of nurses influences nursing image in the community and affects patient decisions when seeking care. The culture of an organization is affected by factors such as safety and appearance that can directly be linked to the nursing uniform and patients' perceptions of professionalism (Spragley & Francis, 2006). Nursing administration is faced with the difficult task of constructing policies and procedures that dictate uniform standards and acceptable behaviors that promote a positive image for the profession. Clear descriptions of professional expectations would provide clinical educators with objective guidelines to promote a professional work environment and improved professional image for the discipline.
The first nursing uniforms were documented in the 1860s during the time of Florence Nightingale and the Crimean War. Nightingale was a nursing pioneer whose tireless efforts during the war to improve sanitation and hygiene practices drastically reduced death rates of soldiers. Nightingale and the first nursing apprentices trained and practiced in the St. Thomas Hospital in London wearing floor length dresses with long sleeves, an apron, and bonnet. These traditional uniforms were adorned with colored embroidery that differentiated rank between nurse and servant. These uniforms were worn until the first and second World Wars, when the role of nurses was intensified to assist in the treatment of the growing number of wounded soldiers. The long dresses were shortened due to impracticality and hindrance of safe practice in the work environment (McDonald, 2014).
Cantanzaro (2013) stated that the origination of the National Health Service in the United Kingdom in 1948 created stricter sanitation standards and regulations on laundering of hospital linens. These changes created financial challenges for hospitals, causing shortening of the uniform skirt and removal of shoulder and neck ties. Between 1950 and 1970, nurses added colored belts on their uniforms to signify rank and facilitate identification of the nurse in the clinical arena. Cotton aprons and hats were transitioned in the 1980s to disposable variations as awareness of infection control heightened. Even stricter uniform regulations were implemented in the 1990s that eliminated belts to reduce risk of patient injury. Due to the lack of role differentiation with the elimination of the colored belts, colored piping was used on the uniform around collars, shoulder, and pockets. At the end of the 1990s, uniforms morphed into the modern-day tunic top and pants, commonly called scrubs. This final transition has sustained due to improved comfort and functionality. An increase in male nurses has also forced creation of a uniform that is gender neutral. Minor adjustments have been made to the styles and colors of the tunic top and pants, but the overall image of the traditional scrubs has remained (Catanzaro, 2013).
The nursing uniform has evolved over time but has remained critical to nursing image. A study by Clavelle, Goodwin, and Tivis (2013) presented patients with images of nurses in a variety of uniforms, and “patients rated a white uniform with a stethoscope around the neck as significantly more professional than other uniforms” (p. 172). Cleanliness and neatness of uniforms were also deemed more important to patients than color. The study concluded the purposes of the nursing uniform included minimizing risk of infection, respecting cultural practices of staff and patients, and creating a professional appearance for nurses (Clavelle et al., 2013).
Recent research efforts have acknowledged the importance of a professional nursing image, but standardization of policies and procedures across health care facilities has not emerged, creating inconsistencies across the discipline. Consistent characteristics of “knowledge, specialization, intellectual and individual responsibility, and well-developed group consciousness” have been identified and contributed to the development of nursing as a profession and its progress into the realm of professionalism (Akhtar-Danesh et al., 2013, p. 249). Professionalism includes elements of dress, attitude, communication, knowledge, and personal behavior that have contributed to the professional image of nursing (Rezaei-Adaryani, Salsali, & Mohammadi, 2012).
Subjects and Method
Educators are faced with the unique challenge of teaching nurses about professional standards that are not clearly defined across the discipline. Five separate conversations were held with nurses who ranged in age from 46 to 74 years. These nurses graduated from their individual nursing programs between the years of 1977 to 1995. Their years of experience ranged from 21 to 39 years in practice. The purpose of these conversations was to explore the evolution of the nursing uniform and its effects on perceptions of professionalism. Nurses who have witnessed uniform changes over time have personal life experience that may explain the reasons for these changes and how nursing and perceptions of professionalism have been affected. Max van Manen developed human science research that linked lived experiences with practical situations through personal descriptions and recall of events (Magrini, 2012). Through analysis of data collected through these conversations, emerging themes are extracted to promote universal understanding of issues related to the lived experiences of nurses.
Conversations were centered around three structured open-ended questions concerning the evolution of the nursing uniform and the opinions of the nurses regarding the potential impact of the uniform on patients' perceptions of professionalism. The first question asked participants to describe their nursing uniforms worn during school. The second question asked their opinion about why uniform styles and colors have changed over the years. The final question asked whether participants thought the changes in uniform appearance have affected patients' perceptions of professionalism. Individual conversations took no longer than 10 minutes and were audiotaped for accuracy. Data were transcribed and analyzed line by line using van Manen's approach to identify emerging themes regarding the nursing uniform and professionalism.
The first question answered by participants was to describe their nursing uniforms while in nursing school. All participants wore pressed clean dresses with aprons. The dress for three participants was white, one was pale blue with white pinstripe, and the final was maroon to match the colors of the university. White stockings and white shoes were mandatory requirements for all. A white nursing hat was required in the clinical setting for three participants; two participants wore a hat when taking their formal composite nursing pictures. Participants stressed the theme of white in relation to cleanliness of appearance.
The second question participants answered involved their thoughts on why uniform styles and colors have changed over the years. One participant identified an increased need for comfort. The emerging theme for uniform evolution emphasized changes in the mindset of younger generations of nurses and their aversion to the white uniform and tradition in nursing. One participant felt members of the younger generation were not traditional but trendy and did not want to wear white; another acknowledged that white showed stains and was more difficult to keep clean. Another participant expressed that uniform changes have occurred due to nurses' lack of desire to look professional.
The final question participants answered addressed what affect these changes have had, if any, on patients' perceptions of professionalism. The overwhelming theme was the uniform changes have affected how patients perceive professionalism in nursing. Four of the five participants described how the shift from white to colored scrubs creates confusion for patients when identifying the nurse, given that most members of the health care team wear scrubs in the clinical arena. A specific incident cited involved one participant being asked whether she was the nurse or the nursing assistant. One participant expressed the traditional image of a nurse included a white uniform, whereas another acknowledged the increasing patient population of older adults who traditionally identify the nurse by the color white. Two participants stressed that white uniforms have historically been associated with professional nurses. Another participant thought the white uniform fostered higher standards of nursing care: improved cleanliness and handwashing, tidiness in patient rooms, attention to detail, and increased pride in the care provided to patients.
Implications for Future Research
Future research is warranted to further define a professional image for nursing. Larger sample sizes of nurses from across the nation can be interviewed to identify uniform trends and how changes have influenced perceptions of professionalism. Male nurses can provide unique perspectives on their unchanged uniform style of tunic top and pants by sharing personal experiences with patient reactions to uniform color changes and whether this has affected patient perceptions of professionalism. Future research should investigate perceptions of the Millennial generation as trends shift in socially acceptable norms and professional expectations. Members of the Millennial generation have not witnessed uniform evolution, so they can provide insight into other potential phenomena that influence professional nursing image.
Future research is needed to investigate the concepts nurses and patients consider important in promoting a professional image. A professional nursing image has been linked to uniforms but includes other concepts such as presence, communication, education, professional affiliations, caring behaviors, ethical practice, and overall attitude of the nurse, all contributing to increased professionalism in the discipline. Investigation of these concepts can foster deeper understanding of professional image and expectations that will unify the profession and promote professionalism in nursing. Clear expectations can help health care administrators develop policies and procedures that allow educators to teach nurses professional behaviors that improve nurse–patient relationships, maximize interdisciplinary teamwork, and promote positive patient outcomes.
Professional image in nursing is not clearly defined but is often linked to nursing uniforms. The results of these discussions validate the link between the nursing uniform and its influences on perceptions of professionalism. Professional nursing image needs to be further investigated to assist educators in teaching and role-modeling professional behaviors. A deeper understanding of a professional nursing image would allow hospital administrators to create well-defined policies and procedures that clearly outline professional expectations to enhance the culture of the organization, as well as improve patient outcomes. A unified approach to professionalism can improve interdisciplinary relationships and foster professional nursing behaviors that continue to promote a professional image of nursing.
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