Hatfield, Linda A. PhD, NNP-BC; Pearce, Margaret MSN, FNP-BC; Del Guidice, Mary MSN, RN, CENP; Cassidy, Courtney MSN, RN; Samoyan, Jean BSN, RN; Polomano, Rosemary C. PhD, RN, FAAN
The public’s image of registered nurses (RNs) is important. Historically, the iconic depiction of the RN was the white uniform.1 This uniform identified the individual as an educated, licensed nurse responsible for the direct care of patients. Research suggests that today’s nonstandard nursing uniforms adopted by direct care RNs and organizations do not present a professional image and contribute to patient, family, and other healthcare provider’s inability to identify the RN among other care providers and thus acknowledge the RNs’ contributions to patient care.1-4 This article evaluates the strength of evidence from peer-refereed studies examining the effect of a standardized uniform style and color for RNs.
For more than a decade, nurses have outperformed other professions in Gallup Poll ratings for trust and ethics.5 Creating a professional, confident, trusting, and therapeutic relationship with patients and families depends, in part, on the interpretative images that nurses portray.6,7 Although the Gallup Poll suggests the recent trend to nonstandard nursing uniforms has not appeared to affect the public’s perception of nursing as a prestigious profession, many patients acknowledge the connection between a uniform and the nurse.8
There is a paucity of research to guide nurses and executives toward a standard style and color representing the universal beliefs and values of the profession. Differing styles and colors of clothing worn by direct care RNs within a single organization perpetuate the role ambiguity. Moreover, few studies have focused on the development and implementation of dress code policies and their impact on patient and family satisfaction. This integrative review evaluates the strength of evidence from peer-refereed studies reflecting the impact of a standardized uniform style and color for RNs.
Searches of Medline (January 1948-March 2012), CINAHL (January 1981-March 2012), PubMed (January 1946-March 2012), and PyscINFO (January 1960-March 2012) online databases were performed to identify peer-refereed publications from the disciplines of medicine, nursing, and psychology. Keywords and medical subject headings (MESH) used included nurse, nursing, uniform, and dress code. Database searches used the explode function for the following key terms: uniform and dress code. English-language and full-text article limitations were imposed from the university subscription sources. The literature review recognized 201 articles. Title and abstract review of articles focusing on the clinical or professional role of nurses (n = 79), duplicate manuscripts (n = 58), comments or opinions (n = 11), full-text unavailable (n = 4), editorials (n = 1) and English-language restriction (n = 1) were excluded from full-text analysis. Full-text analysis discarded studies that focused on a specific discipline (n = 19), journal articles without original data (n = 11), studies older than 10 years (n = 6), and unpublished dissertations (n = 5). The remaining studies (n = 7) were critically evaluated for inclusion in this integrative review (see Figure, Supplemental Digital Content 1, which presents the process for review of literature exploring nursing uniform and dress code, http://links.lww.com/JONA/A177). An evidence table was constructed to provide specific details on each of these studies and strength of evidence (see Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A178).
The quality of evidence (level of evidence) was appraised using the Oxford Centre for Evidence-Based Medicine (CEBP) evidence hierarchy and criteria.9 This evidence rating system was selected after a critical comparison of the CEBM to the evidence-based medicine pyramid10 and the Commonwealth of Australia National Health and Research Council levels of evidence table.11 The CEBM hierarchy was favored as a structure reflecting clinical decision making; explicitly refraining from making definitive recommendations; offering potential advantages in simplicity, clarity, and discriminatory ability; and having utility when there is a lack of meta-analyses, systematic reviews, and randomized controlled trials.12,13 Levels of evidence range from 1 (highest level of evidence) to 5 (lowest level of evidence) and are assigned based on study design and methodological quality (see Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A178). All studies included for analysis were rated independently by the 1st and last authors and compared for consistency. When evidence ratings differed, the 1st and last authors met and used the CEBM hierarchy to reevaluate the individual studies. Consensus was reached to assign a final score to the study.
Variations in the Methodology of Reviewed Studies
All studies included in the analysis used convenience sampling methods.1-4,14-16 Windel et al,16 however, did randomly select participants from an available inpatient population. Sample characteristics are reported for each study (see Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A178). Two studies conducted outside the United States recruited participants from Ghana and Israel.3,14
Outcome measures of nursing uniform studies are linked to nursing identification, caring behavior, or professionalism. Kaser et al4 used the Nursing Image Scale (NIS) developed by Mangum et al.17 The NIS ranks 10 conceptual domains for the professional nurse (confident, competent, attentive, efficient, approachable, caring, professional, reliable, cooperative, and empathetic) on a 5-point Likert scale with reported validity and reliability. Albert et al2 and Skorupski and Rea1 used author-modified versions of the NIS to assess nursing professionalism with nursing attire. DeKeyser et al3 and Hussein et al14 administered instruments to determine how easy it was to identify the nurse but not the degree of professionalism associated with nursing attire. The remaining 2 studies15,16 described nurse or patient uniform preference or perceived professionalism but did not explicitly measure components of nurse professionalism.
Variations in Patient Perceptions
Findings suggest that patient perceptions of a nurse’s professionalism and competence are linked to nursing attire. Using a survey methodology, Skorupski and Rea1 explored patient perceptions of nursing professionalism by showing patients the same nurse in 3 different solid-color scrub uniforms: white, blue, and lavender. The investigators found that seniors, defined in this study as 58 years or older, consistently chose the white uniform as representative of professionalism and approachability, whereas generations Y (ages 18-24 years) and X (ages 25-38 years) and Baby Boomers (ages 39-57 years) chose uniforms with a print as being approachable. Thomas et al15 developed and administered the perception of nurse caring, skill, and knowledge questionnaire to measure individuals’ perceptions of nurse caring, skill, and knowledge in relationship to appearance and specific features of nurses’ workplace attire. Findings suggest that nurses were viewed as more skilled and knowledgeable when wearing solid-color uniforms compared with a print shirt or T-shirt. Visible body art such as piercing and tattoos evoked the least favorable impressions of nurses being caring, skilled, and knowledgeable. Windel et al16 randomly distributed surveys to 430 inpatients, eliciting their thoughts about professionalism and nursing attire. Ninety-four percent of patients perceived nurses’ appearance as professional. Notably, only 31% were able to identify the RN caring for them and 55% found that it was difficult to do so. Patients preferred large-print RN name badges (80%) and a designated uniform color (39%) to distinguish nurses as their care providers. The patients did not have a preference for the nurse’s uniform color.
Kaser and colleagues4 surveyed 100 patients using the NIS to elicit their perceptions of nurse professionalism. Patients associated the highest level of professionalism with solid white scrubs (53%). However, patients chose blue (26%) over white (25%) as the most preferred color for nursing attire. Similarly, data collected from 390 adult and 109 pediatric inpatients with a modified NIS and NIS for children to characterize professional nursing based on uniform also corroborated higher NIS scores for white uniforms as compared with small print, bold print, or solid colors.2 The NIS scores for the white uniform were positively correlated with increasing age of respondents. DeKeyser and coinvestigators3 distributed an 18-item Likert questionnaire (patient sensitivity questionnaire) to 76 Israeli inpatients to examine patient-provider forms of address and professional appearance. Results showed that Israeli patients preferred formal attire for professional nurses and felt that the white dress made it easier to identify nurses and to understand their role work and favored a more formal way to address their professional nurse. Hussein et al14 interviewed 354 postpartum women in Ghana to determine how they identified their main birth attendant. Through surveys, interviews, and focus groups, the most common means that women identified their main birth attendant was by their role (42.2%) or their birth attendants already known to them (39.7%). The attendant’s uniform ranked 3rd (23%) as a means of identification.
This integrative review presents a state-of-the-science summary of the research on nurses’ work attire. The professional image of nursing creates a framework by which the public perceives nurses and the nursing profession. Nursing professional image is an emotional connection with a patient that integrates that patient’s values, expectations, and responsibilities with the RN and the organization in which the nurse works.15,18 The lack of consensus regarding a universally agreed upon style and color of standardized uniforms has hindered many organizations in establishing and enforcing dress code policies. It is likely that decisions will remain in the purview of organizations in the future, guided by personal preferences, organizational culture, and patient populations.
In the few studies involving nurses, students, and faculty as participants, nurses rated the T-shirt attire more caring than faculty did, students rated the solid-color uniform higher for skill and knowledge, whereas faculty believed that nurses were more professional in solid-color scrubs.15,19 Recently, Akhtar-Danesh et al20 conducted a qualitative study with nursing faculty and students to elucidate components of nursing professionalism. Four distinct viewpoints emerged from the analysis of respondent data. One of the viewpoints, identified as portrayers, consisted of individuals who believed that nursing professionalism is evidenced by one’s image, attire, and expression.
Several studies document the preference for the color white by both patients and nurses as being more professional,1,2,4 but solid colors were also among favored choices. Uniform type, predominantly scrubs, with solid colors was rated more skilled and knowledgeable.2,4,15 The more colorful clothing worn by pediatric nurses is aligned with the developmental stages of the child. Data demonstrate that the colorful uniforms reduce children’s anxiety and provide a more child-friendly environment to promote quality of nursing care.21,22
Regardless of differing study findings, most experts call for some standardization with uniforms or guidelines for workplace attire to delineate professional boundaries and promote role identity.19,23 While evidence underscores the significance of a unified appearance for professional nursing in cultivating therapeutic relationships,24-26 there is a paucity of research to guide nurses towards a standard style and color representing the universal beliefs and values of the profession. Nurses’ professional image should be promulgated given the numerous opportunities to improve the public’s perception of professional nursing in light of the stereotypes of nurses in the media.6 Evidence illustrates that uniforms can positively influence patients’ perception of nurses.
Appraisal for Strength of Evidence
A number of limitations exist in the current state-of-the-evidence regarding the impact of standardized nursing uniforms, including study design, weak or untested reliability and validity of outcome measures and instruments, and small sample sizes. The overall strength of the evidence with respect to standardized uniform style and color for RNs in this review is low. This assignment is derived from the Oxford CEBP evidence hierarchy and criteria that identified the published peer-refereed studies in this review as level 3 evidence. Most studies reviewed for this article were not randomized, some lacked comparison groups, and others failed to control for extraneous variables that could potentially influence outcomes. Several studies used pictorial images of nurses in uniforms, and none conducted prospective designs with episodes of care exposures to nurses dressed in a particular attire. Although a systematic review is an aggregation of evidence, a systematic review of low levels of evidence is not persuasive enough to guide nurse executives to change practices and policies.
Recommendations for Nurse Executives
Most hospital nursing mission and vision statements promise quality nursing care; however, the inability of patients to identify the RN as the individual directly responsible for providing patient education and quality clinical care poses a significant patient safety concern. The evidence demonstrates that patients attempt to identify their nurse by name badge, but more than half find it difficult. Because patients believe that an identifiable uniform assists in the identification of their nurse, it is recommended that organizations consider adoption of a standard uniform style and color for RNs. In the absence of an evidence-based national standard for uniform style and color, the peer-refereed studies suggest a solid-color scrub for adult inpatient units.
Nursing leaders should introduce greater scientific rigor into research studies investigating the impact of standardized uniforms and dress codes for nurses. If a transition to standardized uniforms is considered, project plans should consider pretest and posttest designs to measure preferences for current and new styles and colors of uniforms within the context of culture and patient populations. In addition, outcomes measurement for evaluating the impact of work attire changes should be expanded to include indicators measuring the impact on nurse and patient satisfaction.
Current research examining the effect of a standardized uniform style and color for RNs is not substantiated with rigorous, well-designed studies. Further research in this area is important to support changes and trends in attire and culture differing from what was accepted traditionally in previous generations and supporting quality care and the image of nursing in the future.
The authors acknowledge and thank the members of the Professional Image Council, Department of Nursing, Pennsylvania Hospital, Penn Medicine Philadelphia, Pennsylvania, for their assistance in retrieving and critiquing articles considered for this review.
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