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approach to creating a new"'
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nursing dress co:de,
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Z2gA survey of patients reveals what nurses;,;:;:: . , '
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should-and shouldn't-wear.
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WHEN THE TOPIC is a dress code
for nurses, everyone has an opin-
ion, but almost no one has any evi-
dence. At our hospital, the question
of how nurses should dress was
brought to our Professional N~I-se
Practice Council. The primary con-
cern was that patients couldn't
identlfy their nurses, but we on the
Council also faced the larger issue
of defining appropriate dress and
personal appearance for nurses.
So we listened, discussed. and
debated. Some wantecl all nurses in
white. Others
were funlly
against wear-
ing the whites.
Some raised concerns about
infection-control standards
when nurses wore altificki
nails, several rings, or
bracelets. We heard a
range of views, but
all the discus-
By Laura Windle, RN,
Kelly Halbert, RN, Cheryl
Dumont, PhD, RN, Kathyrn
Tagnesi, BSN, RN, MA, CNAA-BC
and Kathleen Johnson, BSN, RN
sions and debates went nowhere.
Personal opinions created gl-idlock.
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In search of facts
i . bll
Our goal was to establish 'a dress
code that provided physical and
emotional safety for patients while
allowing nul-ses as much personal
freedom and comfort as possible.
Our review of the literatul-e re-
vealed many opinions but only five
research studies on dress codes for
nurses. Only one of the five fo-
cused on adult inpatient settings
and was less than 10 years old. And
that study was done in Israel. In
short, our search yielded no results
we could use for our inpatient
adult population on the east coast
of the United States.
We decided to conduct reseal-ch
to answer these
How well can patients idenufy the
nurses responsible for their care?
What are patients' perceptions of
the nurses' professionalism?
How do patients prefer to identi-
f y nurses?
What mannev of dress for nurses
do patients prefer? ;; .! . , t b
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Our study design and tools
The sample for our prospective de-
scriptive study consisted of 430 ran-
donlly selected, adult inpatients. Pa-
tients on the gastrointestinal,
nl~lmonary, ~nedical telemetry, sur-
gical telemetry, women's surgical,
----ology, neurology, and 01.-
~opedic units palticipated.
,
<:..,it:i.>,j~i!jw-,*., -
We excluded patients &I% wel-6 ei-
ther in isolation, too ill, or physically
unable to complete the questio~maise.
Our sunrey tool had four pasts.
Tile fmt asked for the patient's age,
sex, and race. The second and third
parts were questions with response
choices on a numerical rating scale
of 1 to 10. (See 13 Quatiom onpro-
fessional image andpatientpr&r-
ences.) Two questions focused on
the patients' ability to identdy their
nul-se. Four questions addressed the
professional image of the nurse car-
ing for the patient. Seven questions
were designed to determine how pa-
tients prefer to see a nurse d~-essed
and how they prefer to identlfy a
nurse. The foultl~ part of the survey
asked patients to look at a poster
with 12 pictures of nurses in various
manners of dress and identlfy the
picture they preferred.
A panel of experts, i~lcluding 15
members of the Professional Nurse
Practice Council and five communi-
ty members, tested the face validity
of the tool. A pilot study using 20
randomly selected patients from
the surgical telemetry unit was per-
formed to test the internal reliability
of the tools. The resulis: The sub-
scales of image and ability to iden-
tify the nurse had good internal re-
liability with Cronbach's Alpha of
0.84 and.0.87, respectively. I, I
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Patient protection and data il
collection
Institutional Review Boarci approval
January 2008 American Nurse Today 17
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.11,3 Qw~ti.ons on professionalimageand patient
preferhces v
private. Of 466 surveys given to pa- , '
-Our survey asked patients to answer these questions.
tients, 430 were returned completed.
Nurse image: Circle the number that best describes how you feel.
1. I was able to identify the registered nurse (RN) responsible for my care during \at the patients wanted
~,.:
this hospital stay.
we interpreted the responses to
Strongly disagree 1-2-3-4-5-6-7-8-9- 10 strongly agret
questions in parts 2 and 3 as fol-
2. My RN was dressed in a manner that helped me feel confident in hisfher ability
to care for me.
Stronglydisagree 1-2-3-4-5-6-7-8-9-10 stronglyagree
3. In this hospital, it is easy to identify the RN.
Strongly disagree 1 - 2 - 3 -4- 5 -6-7- 8-9- 1 0 strongly agree
lows: A rating of 7 or more on a
. ,
10-point scale indicated agreement,
and a rating of 3 or less on the 10-
point scale indicated disagreement.
Here's what we found:
31% of the patients thought that
idenbfying ;heir RN was &asy.
4. In this hospital, the RNappears professional.
Strongly disagree 1-2-3-4-5-6-7-8-9-1 0 strongly agre
55% thought that identifying their
RN was not easy. I
5. In this hospital, the RN appears to be skilled.
94% thought nurses appeared to )
~ ~
Strongly disagree 1 - 2 -3 - 4- 5 -6- 7-8- 9- 1 0 strongly agree be professional.
6. In this hospital, the RNappears to be warm and caring.
Strongly disagree 1 -2-3 -4-5 - 6- 7 -8-9- 1 0 strongly agree
64% thought nurses should be al- l
lowed to wear any color unifm.1
73% thought nurses should keew '
Patient preference: Circle the answer that best describes your preference.
1. All nurses should wear white uniforms.
Stronglydisagree 1-2-3-4-5-6-7-8-9-10 stronglyagre~
-,
their hair'back and off thein~in~ti
shoulders.
~
>lIlN>. . , . . .
91% thought nurses should not , , .
wear long fingernails. I
2. Nurses should be allowed to wear any color uniform.
Stronglydisagree 1-2-3-4-5-6-7-8-9-10 stronglyagree
3. All nurses should have their hair off their shoulders when taking care of patients.
Strongly disagree 1-2-3-4-5-6-7-8-9- 1 0 strongly agree
4. All nurses should have clean, short finger nails.
Stronglydisagree 1-2-3-4-5-6-7-8-9-10 stronglyagree
5. All nurses should not wear bracelets, multiple rings, and dangling earrings.
Strongly disagree 1-2-3 -4-5-6-7-8-9- 10 strongly agree
6. 1 could best identify my RN by the color of the uniform.
Strongly disagree 1 - 2 - 3 -4-5 -6-7-8 -9- 1 0 strongly agree
7. 1 could best identify my RN by having a large-print name tag stating "RN."
Strongly disagree 1-2-3-4-5-6-7-8-9-1 0 strongly agree
with a,waiver of consent was ob-
rained by an expedited review. The
patients' actions of f h out and re-
Nming the survey tools anonymous-
ly were consi ded patient consent.
Four n m s collected the data,
but because the patients completed
the questionnaire, interrater relkdbity
wasn't tested. To ensure consistency
and help limit bias, data collectors
used a script to explain the study.
The four data collectors didn't collect
data on their own units. They were
dressed in casual prafessional cloth-
ing, not nursing uniforms. They did
wear their identification badges.
We explained to patients that
they would remain anonymo!ts and
that participation was voluntary. If
they didn't want to participate, they
could put the survey back in the en-
velope and seal it. We didn't collect
80% said t hey would like to
identify their RN by a large print. ,
"RiV on a name badge. .. .
3Yh said they would like to iden-'
bfy their RN by uniform color.
286 said nurses should wear all o
white. (See Rafinuing tbe mean : ,
responses.) ';
When asked to select the photo ,
that best represented the way they : . . . '
would like to see a nurse dress, pa- i
.
tients chose photos of nurses with
their hair back and a large print
"RN" name badge. The patients' top
three choices represented all of the
uniform color combinations, thus
inforcing the evidence that our
tients don't care what color the
form is. (See Who's the best dressed
Study limitations and strengths
Although we made efforts to make .. . .
sure the survey was anonymous
and volytary, responses may have ?
been biased by concerns that the 4 '
nurse collecting data would learn
the patients' answers. Also; we can't
know whose professionalism the
18 American Nurse Today Volume3, Issue 1
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Reviewing the mean responses
These two graphs show the mean responsec Qur 13 4
disagree; a rating of 10 means str a
ong-
patients were evaluating bemuse
many didn't find it easy to idenuly
.their own nurse. The question on
excess jewelry didn't dearly defme
"excess." And despite randomiza-
tion procedures, the sample hadl a
significantly higher number of men
and Amcan Americans than our to-
tal pahent population.
According to probability esu-
mates, our sample size was large
enough to represent the population.
The patients had real-Me, current
experience w~th the nurses in the
Who's the best dressed?
We showed patients 12 photos and asked them to pick the one that best represented how
they wanted nurses to dress. Here are the top three picks. Note that all three nurses have
their hair pulled backand are wearing a ~ar ge- ~r i nt "~~"name badge. Clearly, there's no con-
sensus on uniform color.
hospital, and thus were in the best
positior to know how a nurse's
appeaxnce affected a patient. To
avoid bias, data collecto~s used the
same script for every patiens and
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the collectors were not careeivers on.
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the unit. We maintained anonymity.
And the responses to the questions,
were confirmed by the most com-
mon choices of the photos.
1
New dress code
Guided by the evidence of patients
preferences, the Prqfessional Nurse
Practice Council has written a new
dress code. After a period of feed-
back fmm the nursing staff, the
dress code was put into effect. We
still have some nurses who feel
strongly about being able to wear
long artificial nails and excess jew-
elry. We I-espect a nurse's right to
self-expression; but we. also recog-
nize how that self-expression af-
fects our p8tieIits-and we enforce
our new ccde.
We plan to learn what effects the
new dress code and the new large
print name badges have on our
nurses' pmfessional, image and our
patients' ability to identify their nun
es. We'll also determine if our num
are satisfied with the drw ccde. Of
course, we'll find out by doing re-
search, not by endless debate. .I
Selected references
Cohen, S. The image of nursing. Am Nune
Taday. 2207:2(5):2426.
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Professional dress:
I Keep it simple and
&THE FnST MJZWION ing white. But they want nurses to m.ear a name tag with
of writing or revising a
dress code, my blood pressure rises. My view is that
nurses should be responsible for making appropriate
judgments about what to wear. They should not need a
written dress code. However, over the years, my observa-
tions suggest that not every nurse dresses in a manner
that conveys professionalism and confidence to patients.
In the Nightingale era, uniforms enhanced the image,
pride, and work of nurses. The uniforms differentiated
nurses from servants, cooks, laundresses, and prostitutes.
Civil War soldiers recognized the authority of nurses and
treated them with espect.
The first rraining schools for nurses snuggled to differ-
entiate educated nurses from those pressed into setvice
following arrest for drunkenness or other improper con-
duct. In those days, uniform helped create an image of
sobriety, public-health protection, and refmement. And
they helped change the image of nurses, bridging the
divide between working-class women and middle- and
upper-class women.
Later, uniforms identified nursing students and
schools, and young women wanted to project a positive
image of their schools. Through the first half of the 2Gth
century, nurses remained protective of their image. Their
uniforms were white, a color that suggested cleanliness.
But as nursing changed over the years, so did the
styles, colors, and fabrics. The white uniform became a
symbol of oppression and demcted from autonomous
professional practice. Nurses abandoned their caps as im-
practical. And dresses gave way to pants that accommo-
dated men as well as women. Today, almost universally,
nurses wear scrubs, which are relatively inexpensive,
easily laundered, fit va1bu.s body types, allow freedom of
movement, and allow for individual expression.
So what does all the change mean for nurses and their
patients? The authors of "An evidence-based approach to
creating a new nursing dress code" in this issue of Amer-
ican Nurse Today conducted a survey of patients to help
answer some related questions: How well can patients
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idennfy the nurses responsible for their care? What are
patients' perceptions of the nurses' professionalism? How
do patients prefer to identlfy nurses? What manner of
dress for nurses do patients prefer? You may be surprised
that the patients were not concerned about nurses wear-
the large letters "&," so they can idenbfy the nurses car-
ing for them. And they w-ant nurses to have neat hair and
to avoid wearing long fingernails.
In line with these findings, today's dress codes try to
address safety, infection control, and the ability to iden-
tlfy our caregivers. The Centers for Disease Control and
Prevention's "Guideline for hand hygiene in health-care
settings" advises us to keep fingernails short, citing the
harboring of high concentrations of bacteria in the sub-
ungual areas of the hand. Although study results aren't
definitive, most clinicians accept that wearing a d~c i a l
nails poses an infection risk. The use of a name tag
with the large letters "RN" is popular and well received
by patients and families. The name tag assures patients
that an RN is close by to provide care or respond to an
emergency.
When defming policies on dress and appearance, or-
ganizations now must consider body modifications
tpiercings and tattoos), jewelly with religious symbols,
and styles of cultural dress. By law, private employers
can mandate dress codes, but the larger issue is how to
allow individual expression while maintaining a profes-
sional identity
The article, "The image of nursing" in our May 2007
.issue, evoked a strong reader response on both sides of
the debate about whether nurses should wear clothing
adorned with cartoon characters. Most agreed that the
pediatric setting allowed for more light-hearted clothing.
Others, however, warned that nurses will not gain the re-
spect they need to be key decision makers and authori-
ties on care when they dress in such a casual manner.
Gone are the days of demerits for wrinkled uniforms
and scuffed white shoes. But like it or not, people judge
others based on appearance and some degree of con-
formity. I suggest a back-to-the-basics approach when it
comes to dress. Simple and functional designs, plain
colors, and a prominent display of "RN" can ensul-e that
our dress doesn't diminish our mles as professional nurses.
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pamela E Cipriano, PhD, RN, FAAN
Editor-in-Chief
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6 American Nurse Today Volume 3, Issue 1