Journal of Nursing Education

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BRIEFS 

Fish or Fowl: Nursing's Ambivalence Toward its Symbols

Sally B Hardin, RN, PhD; Denise W Benton, RN, PhD

Abstract

If the symbols of a culture or civilization reflect the essence of its existence, which professional symbols would nursing choose to leave to posterity in a time capsule? Ordinarily, symbols and traditions seek to create a degree of conformity within a group supporting a form of equilibrium and implying a shared culture (Duncan, 1961). As nursing becomes ever more diverse, can we share meaningful symbols; or does "nursing" mean such disparate things to nurses themselves, that our common (traditional) symbols are now obsolete?

These and other questions began to be raised when one of us was recently doing research observations in a variety of large midwestern hospitals. A most striking observation was that it was impossible to teU who represented which field by either his/her dress or even behavior. In some instances, social workers, dieticians, medical technologists, doctors, x-ray technicians, lab workers, and nurses all dressed similarly. Whether in scrub suits, lab coats or nondescript combinations of white and pastels, the degree of homogenization was so confusing, one can only imagine its effect on patients! Out of curiosity, we decided to try to find out more about this state of affairs.

We approached the problem by developing and distributing a questionnaire on nursing symbols to all faculty of a large college of nursing and by surveying a random sample of all schools of nursing in the state of Illinois. Forty-one of Illinois' 83 accredited nursing programs were contacted with a fairly equal distribution among diploma, associate degree, and baccalaureate programs.

A total of 59 faculty questionnaires were returned; the faculty members represented 24 diploma schools, 39 baccalaureate schools, and one junior college, and were graduated from their basic programs between 1937 and 1976. We asked the schools and faculty about their current use of several identifiable symbols of nursing.

Without exception, those faculty who had attended diploma schools had worn caps as students; five of those schools are still in operation and continue to require that students wear caps. Among those faculty who attended baccalaureate schools, most never wore caps. Those who did, no longer saw a cap as a mandatory part of a nursing uniform. Most respondents attributed the "cap decision" to policies of either nursing administration or their school's faculty, although four faculty credited God or Florence Nightingale with having created this policy! Faculty also said that now students or student-faculty committees determined whether to retain or abolish the nursing cap in their former schools. Interestingly, they felt that some programs demonstrated an ambivalence toward the traditional cap by still requiring that it be worn for graduation, or school pictures, even though it is no longer a mandatory part of the school uniform.

The faculty felt that the cap has been abandoned for a variety of reasons. Like Hughes and Proulx (1979), they cited inconvenience, expense and bother of upkeep, discomfort, and other less tangible reasons, such as the cap's being a symbol of subservience or the belief that it creates an undesirable professional distance between patient and nurse. A touch of irony was shown by several faculty who disagreed that a cap was a symbol of subservience, but felt it had lost its status appeal: "Nowadays, so many hospital staff wear caps as a status symbol that the cap has lost its symbolic value for an RN."

On the pro side of the question, several faculty leaned toward tradition. Some cited sentimental reasons, others noted that the ambiguity of our current professional insignia leaves many patients in doubt as to our identity. Amplifying this theme, one said:

It is spooky to receive health care services from health…

If the symbols of a culture or civilization reflect the essence of its existence, which professional symbols would nursing choose to leave to posterity in a time capsule? Ordinarily, symbols and traditions seek to create a degree of conformity within a group supporting a form of equilibrium and implying a shared culture (Duncan, 1961). As nursing becomes ever more diverse, can we share meaningful symbols; or does "nursing" mean such disparate things to nurses themselves, that our common (traditional) symbols are now obsolete?

These and other questions began to be raised when one of us was recently doing research observations in a variety of large midwestern hospitals. A most striking observation was that it was impossible to teU who represented which field by either his/her dress or even behavior. In some instances, social workers, dieticians, medical technologists, doctors, x-ray technicians, lab workers, and nurses all dressed similarly. Whether in scrub suits, lab coats or nondescript combinations of white and pastels, the degree of homogenization was so confusing, one can only imagine its effect on patients! Out of curiosity, we decided to try to find out more about this state of affairs.

We approached the problem by developing and distributing a questionnaire on nursing symbols to all faculty of a large college of nursing and by surveying a random sample of all schools of nursing in the state of Illinois. Forty-one of Illinois' 83 accredited nursing programs were contacted with a fairly equal distribution among diploma, associate degree, and baccalaureate programs.

A total of 59 faculty questionnaires were returned; the faculty members represented 24 diploma schools, 39 baccalaureate schools, and one junior college, and were graduated from their basic programs between 1937 and 1976. We asked the schools and faculty about their current use of several identifiable symbols of nursing.

Without exception, those faculty who had attended diploma schools had worn caps as students; five of those schools are still in operation and continue to require that students wear caps. Among those faculty who attended baccalaureate schools, most never wore caps. Those who did, no longer saw a cap as a mandatory part of a nursing uniform. Most respondents attributed the "cap decision" to policies of either nursing administration or their school's faculty, although four faculty credited God or Florence Nightingale with having created this policy! Faculty also said that now students or student-faculty committees determined whether to retain or abolish the nursing cap in their former schools. Interestingly, they felt that some programs demonstrated an ambivalence toward the traditional cap by still requiring that it be worn for graduation, or school pictures, even though it is no longer a mandatory part of the school uniform.

The faculty felt that the cap has been abandoned for a variety of reasons. Like Hughes and Proulx (1979), they cited inconvenience, expense and bother of upkeep, discomfort, and other less tangible reasons, such as the cap's being a symbol of subservience or the belief that it creates an undesirable professional distance between patient and nurse. A touch of irony was shown by several faculty who disagreed that a cap was a symbol of subservience, but felt it had lost its status appeal: "Nowadays, so many hospital staff wear caps as a status symbol that the cap has lost its symbolic value for an RN."

On the pro side of the question, several faculty leaned toward tradition. Some cited sentimental reasons, others noted that the ambiguity of our current professional insignia leaves many patients in doubt as to our identity. Amplifying this theme, one said:

It is spooky to receive health care services from health care personnel wearing no identifying insignia. I remember in a student health service that went mod giving my health history to someone in jeans with a top that looked like men's underwear. I might have been more comfortable giving my health history to an identifiable plumber. I questioned the person in jeans and underwear about her identity and learned she was a nurse. Tb some patients the good old cap may have conveyed an aura of nurseliness and nurturance that was comforting.

From the survey of Illinois nursing schools, Table 1 shows the information we found about current uniform-cap policies. The schools reveal an ambivalence similar to that reported by faculty. While more schools, especially baccalaureate, are abandoning caps, they are frequently still required for official functions (teas, graduation, class pictures). Moreover, two schools reported having official "capping" ceremonies, even though the cap was rarely, if ever, worn by students.

Table

TABLE 1THE USE OF CAPS IN ILLINOIS NURSING SCHOOLS

TABLE 1

THE USE OF CAPS IN ILLINOIS NURSING SCHOOLS

Table

TABLE 2THE USE OF SCHOOL PIN IN ILLINOIS NURSING PROGRAMS

TABLE 2

THE USE OF SCHOOL PIN IN ILLINOIS NURSING PROGRAMS

Symbols can allow individuals within a group not only to feel that they are a part of the group, but also to feel distinguished within a group (Gusfield, 1961). Our respondents felt that the cap and lamp are universal nursing symbols for the public; but that the cap and pin are specifying or individuating symbols within the profession. A school pin, although much less likely to represent "nurse" to the general public, was given priority by faculty as an individuating symbol. All faculty reported that their school had given them nursing pins as a part of graduation. One intentional or unintentional function of an individuating symbol, like the pin, may be to promote the school it represents. One faculty member wrote: "I used to advertise my school with cap and pin - not any more. Do other nurses feel that way?"

Apparently they do, especially if they are nursing faculty. When asked whether they wore their school pins, most faculty said "never" or "not any more" indicating that they no longer "practice in clinical areas and/or wear uniforms." A few said they wear the pin only on their uniforms or on a lab coat while working in clinical areas.

While nonchalance toward the pin is likely to occur among academic faculty, students are less inclined to give it up. The survey of nursing school policies about pins shows that virtually every nursing program (including two newer collegiate programs who have decided against the cap) has maintained the pin (Tables 2 & 3). Although some schools do not make the purchase of the pin mandatory (especially with the increasing cost of gold), all reported that just about every student purchases one.

Table

TABLE 3A DESCRIPTION OF NURSING SCHOOL PINS IN ILLINOIS

TABLE 3

A DESCRIPTION OF NURSING SCHOOL PINS IN ILLINOIS

In general, the pins were described as gold with white, blue, or red (in that order) and had a variety of symbols, ranging from crosses, caducei, and lamps, to Maslow's Hierarchy of Needs Triangle (Carbary, 1971).

Students reportedly take on the attitudes of or "model" faculty in proportion to the length of their educational experience (Crocker & Brodie, 1974). If such is the case, then it seems that students could become increasingly confused about the value of nursing symbols the longer they are exposed to the variety of nursing symbols and faculty attitudes toward them. The wide variety of faculty attitudes toward nursing symbols was reflected in the returned questionnaires. Responses varied from full-page, single-spaced, typed essays on the importance of nursing symbols, to a blank sheet inscribed with merely two words: "Silly Discussion." Along the same lines, another respondent (perhaps lightly jabbing the researcher?) answered the question about what factors affected whether caps should be worn: "The main one (factor), probably was not enough intellectual stimulation to keep their minds off the fact whether caps should or shouldn't be worn." Another wrote "How important is the cap to the actual performance of any particular nurse? In my opinion, it has no bearing on performance."

Nurses themselves may know why they abandon or retain symbols, but those reasons may not be as clear to patients, students, or other health care professionals. In previous research, one medical student identified her belief that professionalism is largely a matter of attitude and said: "You can tell the nurses who aren't professional because they don't wear caps. It's a matter of pride in what you are and what you're doing. Without that, you're not a professional."

We would venture that one reason certain symbols, like the cap, may be abandoned is an effort to homogenize the various levels of education in the profession, at least at the staff nurse level. However, it may be that new and different symbolic heirarchies of dress are developing between nursing leadership and the rank and file. Asked to identify the present symbols of nursing, one respondent wrote: "Caps and uniforms for ADs, diplomas, and baccalaureates; white lab coats, beepers, and stethescopes (p.m.) for MSNs; and tailored suits for PhDs."

Many faculty and administrators of the educational programs identified lab coats as an evolving nursing symbol; the stethoscope, usually pastel, and always draped casually around the neck, was also frequently cited. One nurse lamented: "It is too bad that there isn't one more meaningful symbol that could replace the cap - like the doctors' caduceus."

Several schools seem to have taken a step in precisely that direction by claiming a modified caduceus as their own; it has been combined with lamps, caps, or in one case, a large "N."

While our survey answers some questions about the demise of some nursing symbols and the emergence of others, questions still remain. There seems to be an ambivalent pull between tradition and pride, and between what nursing has been and those who feel new roles demand new autonomous symbols. Having gone from veils and petticoats to lab coats, stethoscopes and caducei, could it be that nursing is attempting to solve its identity crisis by identifying with the aggressor?

Nursing is a highly and increasingly diverse field, which utilizes such a wide variety of both work skills and settings that it seems an almost hopeless effort to single out certain symbols with which most nurses would identify. Many of the reported objections to retaining some symbols (caps and uniforms, for example) have their basis in clearly practical reasons such as discomfort, inefficiency, and constriction of movement. The vast majority of objections, however, are ideologically based and represent nursing's revolt against its traditional image. To the extent that such revolt is accompanied by well-articulated alternatives, it is admirable. To the extent that it represents simply disillusionment with the reality of nursing or the coveting of another profession's prestige, without any attempts to change that reality, is less admirable. In the latter case, our own confusion creates distress and confusion in the minds of our co-workers and patients. If we wish to be different from our tradition, then we must first discriminate which aspects of the role we choose to change and then educate ourselves and the public regarding the meaning of these changes. Just as playing "dress up" when we were younger did not make us nurses, so now playing "drees up - other" will not make us "other" unless we also change.

References

  • Carbary, L. (1971, December). Nursing school pins are priceless possessions. R.N. , pp. 27-30.
  • Crocker, L., & Brodie, B. (1974). Development of a scale to assess student nurses' views of the professional nursing role. Journal of Applied Psychology, 59, 233-235.
  • Duncan, H. (1961). Symbols and social theory. New York: Columbia Press.
  • Gusfìeld, J.R. (1961). Symbolic crusade. Urbana, IL: University of Illinois Press.
  • Hughes, E., & Proulx, J. (1979, August 16). You are what you wear. Hospitals, pp, L13-118.

TABLE 1

THE USE OF CAPS IN ILLINOIS NURSING SCHOOLS

TABLE 2

THE USE OF SCHOOL PIN IN ILLINOIS NURSING PROGRAMS

TABLE 3

A DESCRIPTION OF NURSING SCHOOL PINS IN ILLINOIS

10.3928/0148-4834-19840401-11

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