Elsevier

Applied Nursing Research

Volume 21, Issue 4, November 2008, Pages 181-190
Applied Nursing Research

Original Article
Impact of nurses' uniforms on patient and family perceptions of nurse professionalism

https://doi.org/10.1016/j.apnr.2007.04.008Get rights and content

Abstract

Background

Patients and visitors may perceive nurses as professional based on uniform color and style. Nurse image may affect patient and visitor trust and satisfaction with nursing care. Fitted white dresses have been replaced by loose-fitting or scrub white, colored, or patterned pant sets.

Objectives

This study examines nurse professionalism by assessing the nurse image traits of eight pant uniforms as perceived by pediatric patients, adult patients, and adult visitors. We also examined if uniform preference is congruent with nurse image traits.

Method

A convenience sample of 499 patients and visitors were surveyed at a large Midwestern tertiary health care center. Subjects viewed photographs of the same registered nurse identically posed in eight uniforms and rated each by image traits. Kruskal–Wallis, Steel–Dwass multiple comparison method, and Wilcoxon signed-rank sum tests were used to test for differences in the Nurse Image Scale (NIS) score by uniform style and color and subject demographics.

Results

Subjects were 390 adult patients and visitors (78%) and 109 pediatric patients (21.4%); 66% were female, and 78% were Caucasian. In adults, NIS scores for white uniforms (two styles) were higher than NIS scores for uniforms with small print, bold print, or solid color (all p < .001). White uniform NIS score increased with subject age (all ≤ .007). In pediatric patients (7–17 years) and young adults (18–44 years), the highest uniform NIS scores did not differ significantly from the others. Uniform preference was different from NIS score in pediatric and adult subjects, reflecting noncongruence between the perception of nurse professionalism by uniform and uniform preference.

Discussion

With aging, adults create perceptions of nurse professionalism based on uniform color and style. Traits of nurse professionalism were highest in white uniforms. Future research is needed to determine if transition to white nurse uniforms improves patient and family satisfaction with nursing care.

Introduction

Nursing uniforms have changed significantly during the past 25 years. Loose-fitting white, colored, and patterned scrubs with tennis shoes or clogs have replaced the fitted white dress, white leather shoes, and nursing school cap of yesterday. Dresses and skirts have become less common, and short smock jackets have replaced long laboratory coats. Nurses' appearance may affect interactions with patients and family members and may shape patient and family perceptions of nurse professionalism and image. Additionally, nonstandardization of uniform color on a single unit or throughout a hospital may increase difficulty in differentiating nurses from other hospital personnel.

Few researchers have examined the impact of the nursing uniform on nurse professionalism and image. Mangum, Garrison, Lind, Thackeray, and Wyatt (1991) studied nurse image to determine an association with uniforms. Researchers designed a survey of 10 professional nurse image traits (confident, competent, attentive, efficient, approachable, caring, professional, reliable, cooperative, and empathic) described in the nursing literature, labeled as the Nurse Image Scale (NIS). Subjects were shown pictures of a nurse wearing different uniforms and asked to rate each uniform by nurse image traits. A NIS sum score represented a measure of nurseprofessionalism. One hundred patients, 30 nurses, and 15administrators from a single hospital participated. Overall, respondents ranked white dress and cap as the preferred uniform. However, mean ratings of uniforms based on professional image varied by respondent group: Nurses and administrators rated the white top and pants with stethoscope highest, and patients rated the white dress with cap highest. Interestingly, patient scores for the highest rated uniform were not significantly different from those for the white pant set without stethoscope or cap, white pant set with cap, street clothes with laboratory coat, designer scrub pant set in maroon color, or white pants with colored top (Mangum et al., 1991), reflecting that most uniform colors and styles had a similar professional image although preferences were different.

Two other research groups used the nurse image traits of Mangum et al. (1991) to assess professionalism by nurse uniforms. In the first study, Mangum, Garrison, Lind, and Hilton (1997) replicated their previous work in a larger multisite sample of 2,430 patients, nurses, and administrators. The white pant uniform and stethoscope set had the highest mean score for professional image and was the preferred choice of patients, nurses, and administrators. Colored scrubs and street clothes with a laboratory coat were least preferred by patients and administrators, and street clothes with a laboratory coat were least preferred by nurses. Similar to a previous report of Mangum et al. (1991), patients' (n = 1,173) mean scores for professional image were not significantly different for any of the nine uniform colors and styles (Mangum et al., 1997). The second study involved 180 hospitalized adults who rated photographs of nurses in pant uniforms with jacket, in white, royal blue, and lavender pants and jacket with print top (Skorupski & Rea, 2006). A white uniform represented the nurse image traits of confidence, reliability, competence, professionalism, and efficiency, and a print uniform represented nurse image traits such as caring, attentive, cooperative, empathetic, and approachable. Patients chose the nurse in a white uniform as being the easiest to identify; however, they selected the nurse in a print uniform as one they would like to take care of them (Skorupski & Rea, 2006).

Two studies assessed nurse uniform preferences in hospitalized children. Meyer (1992) compared children who had been previously hospitalized with those who had never been hospitalized to learn if nurse image was based on uniform style. One hundred children aged 3–5 years were asked to choose the nurse they would like to care for them and the nurse they would fear after viewing five 8 × 10-in. photographs of a nurse wearing four uniforms and street clothes. The nurse wearing a colorful smock top was most preferred; the nurse wearing a white dress uniform was most feared. This study was similar to Mangum et al. (1991, 1997); however, it used photographs of a nurse interacting with children, not a nurse in a neutral pose facing forward. The nurse's facial features and expressions varied by picture. In the picture most feared by children, the nurse's hair fell forward as she leaned down toward the child. The nurse's nose stood out, but her eyes and mouth were obscured (Meyer, 1992). In a second study on a children's hospital ward, nurses' uniforms were associated with the hospital ward atmosphere and the friendliness of the nurse. Families preferred nurses to be approachable rather than authoritative, suggesting that a more casual nursing uniform conveyed friendliness and confidence (Campbell, O'Malley, Watson, Charlwood, & Lowson, 2000).

The limitations of published literature on nurse uniforms and nurse professionalism include the following: (a) subject choice, because nurses and administrators may have had a clear uniform preference that biased their selections; (b) the presence of uniform accessories in pictures, because nurse professionalism might have been influenced by the presence of a stethoscope, laboratory coat, or nursing cap; (c) nurse pose and facial expression, because subtle but visible nuances could affect a person's view on any level; and (d)data collection methodology, because rank ordering forces one uniform option to supercede others when that might not be the case. In addition, literature examining the impact of the nurse's uniform on nurse professionalism and image was not conducted in an ambulatory setting, and visitors of pediatric and adult patients have not been studied. In nurse uniform studies conducted with pediatric patients, nurse image traits identified by Mangum et al. (1991, 1997) were not used. The present study was initiated to minimize the knowledge gap of patient and visitor perceptions of nurse image based solely on nurse uniform color and style. Ambulatory and hospitalized pediatric and adult patients and adult visitors were included.

This study was designed to determine if nurse uniform style and color affected perceptions of nurse professionalism based on 5 nurse image traits in pediatric subjects and 10nurse image traits in adult subjects. Other aims were to learn if nurse uniform was an important indicator of nurse professionalism, if nurse image by uniform color and style was affected by subject characteristics, if individual nurse image traits were associated with a specific uniform color or style, and if uniform preference correlated with the uniform having the highest score based on nurse image traits.

Section snippets

Setting and sample

This prospective comparative design used a convenience sample of adult visitors, adult ambulatory and hospital patients, and pediatric ambulatory and hospital patients in a ≥ 1,000-bed urban Midwestern tertiary care teaching center. After receiving Institutional Review Board approval, awake and alert patients aged 7–100 years and visitors aged 18–100years who understood spoken and written English were approached in waiting rooms of outpatient clinics and hospital floors and in patient rooms of

Results

Fig. 2 provides a delineation of 499 subjects, of which 390 were adults and 109 were school-age children. Table 2 provides subject characteristics (by gender, age, and ethnicity) and subject type (by patient and visitor status). In adult subjects, 70% were female, 81% were Caucasian, the mean age was 50 ± 16 years, 56% were hospitalized, 33% lived in the same county as our health care center, 52% drove < 1 hour to seek care, and 90% stated that this was not their first experience being treated

Discussion

Different pant sets were studied to determine if uniform color and style affect perceptions of nurse professionalism, based on 10 nurse image traits. White uniforms in two styles dominated when comparing median MNIS scores in adult patients and visitors at ≥ 45 years. However, in patients aged < 18 years and in young adult patients and visitors between 18 and 44 years, no one uniform color or style emerged as having the highest nurse professionalism based on nurse image traits. Our results

Conclusion

As adults age, they create a perception of nurse image based on uniform color and style. Of uniform colors and styles reviewed, white uniform pant sets—a fitted top with pressed pant, or a scrub top and pant—are most often associated with nurse professionalism traits. White uniforms rated very high in all 10 traits of confidence, competence, attentiveness, efficiency, approachability, caring, professionalism, reliability, cooperativeness, and empathy. Children and young adults do not create

Acknowledgment

Cintas provided us with an unrestricted research grant to conduct this study and the uniforms worn in Fig. 1.

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