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The Professional Image of Nursing

PAH SON 1940

Since 1999, nurses have topped the annual Gallop poll that rates 11 professions on honesty and ethical standards, with the exception of 2001, when firefighters were recognized for their tremendous contributions during and after the 9/11 terrorist attacks.

That’s higher than medical doctors, police officers and clergy.

Nurses in front of Pennsylvania Hospital's historic Pine Building, in 1940.

Yet, for a profession viewed in such high regard, its corresponding uniform doesn’t always evoke the same kind of immediate recognition and respect of say…a physician’s white coat.

“When you’re in an airport, can you tell who the pilots are? Absolutely you can. You see them with epaulets on their shoulders, or stripes on the cuffs of their jackets, and the hats. You know immediately – they’re pilots,” said Linda A. Hatfield PhD, NNP-BC, director of Research and Evidence-based Practice at Pennsylvania Hospital (PAH), and an assistant professor of Evidence-Based Practice at the University of Pennsylvania’s School of Nursing. “It used to be the same for nurses.”

Starting in 1836 and for about 130-plus years, nurses were immediately identifiable by their standardized uniforms. While the stark white outfits were perhaps not the most practical when it came to dealing with patients, they were impressive and they were completely unambiguous about the role of the wearer.

By the 1970’s however, nursing uniforms underwent a major change during a time of many cultural changes like the sexual revolution and women’s liberation. Things got more casual and more colorful. Out were the starched caps and the head-to-toe white attire. In came the scrubs of all colors and patterns depicting all kinds of cartoon characters. While scrubs are a logical and practical evolutionary advance of the nursing uniform, the wild variations found in the workplace were not. Ultimately, Hatfield says, they only added to patient confusion.

“This made us want to know whether the professional image of nursing at Pennsylvania Hospital truly portrayed the level of expertise, knowledge and compassion of our nurses,” said Mary Del Guidice, MSN, BSN, RN, CENP, chief nursing officer. “We also wanted to ensure that our image elevated our nurses sense of professionalism and emphasized their care and commitment to our patients.”

Linda Hatfield with Poster

At the poster session of a nursing conference last week at the Hospital of the University of Pennsylvania, Hatfield presented findings from PAH.  The poster titled, “Does a Standardized Uniform Style and Color Influence the Professional Status of Registered Nurses?,” featured a study in which Hatfield and her colleagues – CNO Del Guidice, and clinical nurses Courtney C. Maloney MSN, RN,Anne Kinzey BSN, RN, Gina Knight BSN, RN, and Margaret Pearce, MSN, FNP-BC –sought to identify a standardized uniform style and color that reflected the professional status of registered nurses as perceived by patients and RNs themselves.

First, they conducted an integrative review of other peer-reviewed studies, “The Professional Appearance of Registered Nurses,” published in February 2013 in the Journal of Nursing Administration. They found that there simply wasn’t much out there to assess the impact of standardized uniform style and color for registered nurses. Out of seven other studies with inconsistent findings, one common finding did emerge: a standardized uniform style and color clearly increased the perception of professionalism and recognition of RNs among patients.

“This is crucial, as it proves this is essentially a patient safety issue, because a patient could potentially receive inaccurate information from unlicensed assistive personnel,” said Hatfield, first author of the JONA article. “Patients need to know who their nurse is. It is all too easy to mistake someone else, such as the patient care technician who takes your blood pressure, for example – for your nurse. What if you’re with a family member in the hospital and that family member is in trouble. You don’t want to be standing in the hall thinking, ‘Who can help me?’  You want to be able to look down the hall and know immediately, ‘That’s a nurse. That is who can help me.’”

“The lines have become blurred and we need to make the necessary distinctions,” Hatfield added.

As if to underscore the need for proper staff distinctions in patient care, Nurse Title Protection legislation is now in effect in 38 states, including Pennsylvania since March 2015, to ensure the safety and quality of patient care and avoid misrepresentation of those who are not licensed or educated to practice nursing. The legislation prevents anyone other than a licensed nurse (LPN or RN) from using the title nurse. PAH has changed its “nursing assistant” title to “patient care technician” in response to the legislation.

“Reserving the title ‘nurse’ for individuals who have actually met the educational and licensing standards of a nurse, allows the public to distinguish licensed nurses from other health care providers and standardizing uniform style supports this positive trend,” Hatfield said. “It’s just a really good idea all around.”

Research by the PAH Professional Image Council (PIC), which included direct patient interviews and nursing staff focus groups, helped to clarify things further. While both groups acknowledged that hospital staff awareness and identity, along with interdisciplinary collaboration, are central to the delivery of safe, effective, quality health care and positive patient outcomes, 55 percent of patients interviewed admitted that brightly colored and patterned scrubs made it difficult for them to distinguish RNs from other staff members. Forty three percent simply could not identify the RN caring for them.

“A nurse’s attire and color of that attire sends a vital message about the skills and quality of care a patient receives. We discovered it’s more effective than an ID badge in helping to identify an RN,” Hatfield said. “Half of the people interviewed found the badges difficult to read, plus you have to be very close to read an ID badge.”

After 12 focus groups and an online survey of nearly 1,000 nurses, it was determined that nurses preferred solid dark blue color scrubs with matching top and bottom. Patients, however, did not have a preference. While they were sympathetic to nurses’ needs, the majority agreed that the uniform style should be “something comfortable and easy for nurses to do their jobs” (scrubs being the obvious choice), when questioned further, they did have a color preference:  solid blue.  

PAH RNs 2012

As a result of the studies and the PIC’s recommendations to the CNO Del Guidice, a new standardized professional image policy was implemented at PAH during Nurses Week (see photo). The transformation was not without critics.

“Our biggest challenge was engaging our nurses in the understanding they wouldn’t lose their individuality,” Hatfield said. “Our nurses are the representation of the profession itself and this policy elevates the profession and moves away from the ‘it’s about us’ way of thinking to our patient centered care model.” 

As it so happens, Hatfield and colleagues’ work with the nursing professional image was chosen for submission as the research part of PAH’s Magnet document. The PAH’s Magnet Site visit will take place October 19-21, during which time appraisers will see the new Professional Image Policy – which is standardized throughout Penn Medicine – in action.

“A standardized professional image provides nurses a sense of pride in their profession and makes them feel as if they are recognized for their knowledge and education. And patients reported how easy it was to identify nurses in the hospital,” Hatfield said. “In turn, the success of this initiative inspired other hospital departments – escort, radiology, laboratory and respiratory services – to also utilize a standard uniform color as a way to identify their service line.”

“After we launched the new Professional Image Policy a patient told one of our nurse managers that it made him feel safe,” Del Guidice said. “The patient said, ‘When I see someone walking down the hall in dark blue, I know that’s a nurse, right there, watching out for me.’ This validates all we believe, all we found in the literature, and all we found in our own research regarding how important the professional image of nursing is to us and our patients.” 

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