When the topic is a dress code for nurses, everyone has an opinion, but almost no one has any evidence. At our hospital, the question of how nurses should dress was brought to our Professional Nurse Practice Council. The primary concern was that patients couldn’t identify 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 wanted all nurses in white. Others were firmly against wearing the whites. Some raised concerns about infection-control standards when nurses wore artificial nails, several rings, or bracelets. We heard a range of views, but all the discussions and debates went nowhere. Personal opinions created gridlock.
In search of facts
Our goal was to establish a dress code that provided physical and emotional safety for patients while allowing nurses as much personal freedom and comfort as possible. Our review of the literature revealed many opinions but only five research studies on dress codes for nurses. Only one of the five focused 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 research to answer these questions:
• How well can patients identify the nurses responsible for their care?
• What are patients’ perceptions of the nurses’ professionalism?
• How do patients prefer to identify nurses?
• What manner of dress for nurses do patients prefer?
Our study design and tools
The sample for our prospective descriptive study consisted of 430 randomly selected, adult inpatients. Patients on the gastrointestinal, pulmonary, medical telemetry, surgical telemetry, women’s surgical, oncology, neurology, and orthopedic units participated. We excluded patients who were either in isolation, too ill, or physically unable to complete the questionnaire.
Our survey tool had four parts. The first 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. Two questions focused on the patients’ ability to identify their nurse. Four questions addressed the professional image of the nurse caring for the patient. Seven questions were designed to determine how patients prefer to see a nurse dressed and how they prefer to identify a nurse. The fourth part of the survey asked patients to look at a poster with 12 pictures of nurses in various manners of dress and identify the picture they preferred.
A panel of experts, including 15 members of the Professional Nurse Practice Council and five community members, tested the face validity of the tool. A pilot study using 20 randomly selected patients from the surgical telemetry unit was performed to test the internal reliability of the tools. The results: The subscales of image and ability to identify the nurse had good internal reliability with Cronbach’s Alpha of 0.84 and 0.87, respectively.
Patient protection and data collection
Institutional Review Board approval with a waiver of consent was obtained by an expedited review. The patients’ actions of filling out and returning the survey tools anonymously were considered patient consent.
Four nurses collected the data, but because the patients completed the questionnaire, interrater reliability 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 professional clothing, not nursing uniforms. They did wear their identification badges.
We explained to patients that they would remain anonymous and that participation was voluntary. If they didn’t want to participate, they could put the survey back in the envelope and seal it. We didn’t collect identifying information, so no one would know who participated, and the patients completed the survey in private. Of 466 surveys given to patients, 430 were returned completed.
What the patients wanted
We interpreted the responses to questions in parts 2 and 3 as follows: 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 identifying their RN was easy.
• 55% thought that identifying their RN was not easy.
• 94% thought nurses appeared to be professional.
• 64% thought nurses should be allowed to wear any color uniform.
• 73% thought nurses should keep their hair back and off their shoulders.
• 91% thought nurses should not wear long fingernails.
• 80% said they would like to identify their RN by a large print “RN” on a name badge.
• 39% said they would like to identify their RN by uniform color.
• 28% said nurses should wear all white.
When asked to select the photo that best represented the way they would like to see a nurse dress, patients 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 reinforcing the evidence that our patients don’t care what color the uniform is.
Study limitations and strengths
Although we made efforts to make sure the survey was anonymous and voluntary, responses may have been biased by concerns that the nurse collecting data would learn the patients’ answers. Also, we can’t know whose professionalism the patients were evaluating because many didn’t find it easy to identify their own nurse. The question on excess jewelry didn’t clearly define “excess.” And despite randomization procedures, the sample had a significantly higher number of men and African Americans than our total patient population.
According to probability estimates, our sample size was large enough to represent the population. The patients had real-life, current experience with the nurses in the hospital, and thus were in the best position to know how a nurse’s appearance affected a patient. To avoid bias, data collectors used the same script for every patient, and the collectors were not caregivers on the unit. We maintained anonymity. And the responses to the questions were confirmed by the most common choices of the photos.
New dress code
Guided by the evidence of patients’ preferences, the Professional Nurse Practice Council has written a new dress code. After a period of feedback from 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 jewelry. We respect a nurse’s right to self-expression, but we also recognize how that self-expression affects our patients—and we enforce our new code.
We plan to learn what effects the new dress code and the new large print name badges have on our nurses’ professional image and our patients’ ability to identify their nurses. We’ll also determine if our nurses are satisfied with the dress code. Of course, we’ll find out by doing research, not by endless debate.
Cohen, S. The image of nursing. Am Nurse Today. 2007;2(5):24-26.
DeKeyser FG, Wruble AW, Margalith I. Patients voice issues of dress and address. Holis Nurs Pract. 2003;17(6):290-294.
Dungan JM. Dungan model of dynamic integration. Nurs Diagnosis. 1997;8(1):1-17.
Page JG, Lawrence PA. Attitudes toward dress codes. Nurs Manage. 1992;23(12):48-52.
For a complete list of selected references, visit www.AmericanNurseToday.com.
Laura Windle, RN, is a Clinical Nurse III Staff Nurse in the Surgical Telemetry Unit, Kelly Halbert, RN, is a Clinical Nurse III Staff Nurse in the Float Pool, Cheryl Dumont, PhD, RN, is the Director of Nursing Research, Kathyrn Tagnesi, BSN, RN, MA, CNAA-BC, is the Vice-President of Nursing, and Kathleen Johnson, BSN, RN, is the Director of Surgical Services. All work was done at Winchester (Virginia) Medical Center.
Thank you for taking the time to research this important issue! As the nurse manager of a wellness center for disadvantaged youth, I have been trying to develop and enforce a dress code my staff can live with. In order to implement a dress code I also need upper management to respect that it is important enough to adopt as policy. You have given me the evidence I need to push forward with this. Evidence also strongly supports NO artificial nails in direct patient care areas! Thank you!