Exploring how nursing uniforms influence self image and professional identity | nursing times

Nurses often have strong feelings about their uniforms. This study examined student nurses’ views and how to balance modernity with nursing’s heritage AUTHORS KATE SHAW, MNURSSCI, RN, is

staff nurse, Nottingham University Hospitals, City Campus; STEPHEN TIMMONS, PHD, MSC, MA, MA, PGCAP, BA, is associate professor, School of Nursing, Midwifery and Physiotherapy, University of

Nottingham. ABSTRACT SHAW K, TIMMONS S (2010) Exploring how nursing uniforms influence self image and professional identity. _Nursing Times_; 106: 10, early online publication. BACKGROUND

Uniforms are thought to hold personal significance for those who wear them and act as powerful symbols representing the profession’s identity and image. AIM To gain an insight into the

influence of uniform on self image and professional identity among student nurses. METHOD Fourteen qualitative, semi structured interviews were carried out with pre registration nurses on

diploma and degree programmes at a university in England. RESULTS AND DISCUSSIONUniform raised issues in a number of areas including gender, equality, power and identity. Pride, combined

with a strong self image and professional identity, lead to enhanced confidence and, therefore, better performance in clinical practice. CONCLUSION Since this study shows the importance of

uniform to students, uniforms need to balance a professional and modern image while retaining an appreciation for nursing’s heritage. This will project a realistic image to the public and

help nurses to form a positive professional identity. KEYWORDS Students, Uniform, Professional identity, Self image * This article has been double-blind peer reviewed PRACTICE POINTS * A

return to a more structured system of uniform including clearer distinctions between healthcare professions could be beneficial for the nursing profession. * Nurses need to be consulted more

on what they want from their uniform. * A promotional campaign should be launched based on the model used to recruit teachers, to eradicate persisting stereotypes of nurses and to promote

the more modern face of the profession. * Further research on uniforms and their relationship with professional identity and image is needed. BACKGROUND Nurses’ uniform has long been a

source of controversy. As McNally (1990) said: “Forget staff shortages, clinical grading and the poll tax; nothing gets nurses more worked up than their uniforms.” The uniform is familiar

and over the decades its style has changed significantly to adapt to the requirements of the profession. The traditional uniform of Florence Nightingale’s era was designed to project an

image of neatness and servitude (Page and Lawrence, 1992). Items such as the belt, cap and buckle are often looked on with fondness by many as they symbolise status and a group identity.

Tradition has a strong influence on nursing and symbolic items remind us of the “inextricable link” between uniform and the profession’s history (Houweling, 2004). This deep rooted history

has a profound effect on nurses, as they seek to formulate an identity which is modern but does not forget the profession’s heritage. LITERATURE REVIEW Professional identity has become an

increasingly important concept in nursing (Page and Lawrence, 1992). Fagermoen (1997) strongly associated it with nurses’ self-esteem, defining professional identity as “the values and

beliefs held by the nurse that guide her/his thinking, actions and interactions with the patient”. However, whether nursing is a profession in its own right has been a contested issue

(Etzioni, 1969). Its professional image has been defined as the perceptions, impressions, beliefs and ideas that people have about nurses and nursing (Ginzel et al, 1992). Over the last

century the image of the nurse has changed substantially, and the media have played a significant role in creating often derogatory images. Nursing uniforms are a “nonverbal, conscious

statement that nurses have the skills and knowledge to care for others” (Spragley and Francis, 2006). However, wearing uniform does not automatically mean that a nurse acts as a professional

and is a good nurse (Newton and Chaney, 1996). A common concept is that uniforms give nurses a certain level of confidence to carry out their role and prepare the individual psychologically

for work. This implies that nurses play a role when they put on their uniform and removing it is a symbolic sign that they are able to take up their other life roles (Pearson et al, 2001).

It appears that this is an important process to help them leave the issues and responsibilities of their nursing role at work. On the other hand, Sparrow (1991) found that when nurses did

not wear uniform their assertiveness with doctors increased and they felt doctors were more willing to involve and talk to them. Not only can a uniform contribute to nurses’ self confidence

but it is suggested it instils reassurance and confidence in patients (Sparrow, 1991). However, uniforms can be frightening to some patients and can sometimes form a barrier to communication

(Richardson, 1999). Although extensive literature on nursing uniforms confirms their importance both to nurses and others, only a limited number of empirical studies examine this

phenomenon. The nurses in Sparrow’s (1991) study, who did not wear uniforms, said how important they were to them, especially in terms of their identity, with one saying: “I don’t feel like

a nurse without one.” Rafaeli and Pratt (1997) undertook action research in Israel to investigate whether nurses should wear informal clothes or uniforms in a rehabilitation service. They

found that uniforms were strongly symbolic for these nurses, though the symbolism was complex. No studies have looked specifically at students and the role that uniforms have in developing

professional identity. AIMS This study aimed to: * Formulate a picture of current student nurses’ views on nurses’ uniform; * Investigate the impact of nurses’ uniforms on their performance,

confidence, view of self, feelings of pride and overall professional identity. METHOD The study used an opportunistic sample of 14 pre registration students on diploma, BSc or (pre

registration) Master’s courses at a university in England. Participants were of varying ages, years of training, branch of nursing and included both men and women. Semi structured interviews

allowed the interviewer to probe for more information and gain clarification (Parahoo, 2006). Interviews are flexible and allow interviewees to follow their train of thought while the

researcher maintains an element of control (Green and Thorogood, 2004). The interview schedule was derived mainly from the literature, with some questions added based on our experience. An

initial pilot study was carried out to establish whether the schedule and themes discussed were appropriate. The study was explained to participants and any questions answered. Kate Shaw

conducted the interviews, which lasted 30-45 minutes, during autumn 2008 in the school of nursing, and these were digitally recorded and then transcribed verbatim. The findings were formally

analysed using thematic content analysis. The data was organised into codes and then these were categorised into common themes (Green and Thorogood, 2004). Theschool of nursing internal

ethics review panel granted ethical approval before the study started and the head of school gave permission to approach students. All participants signed a consent form to ensure they were

aware of the nature of the project; this made clear what was involved, whom to contact, the study’s purpose, any risks involved and ensured they knew they could withdraw at any time.

Participants were anonymised at transcription. RESULTS AND DISCUSSION Four main themes were derived from the transcripts and within these, sub-themes were formulated. The findings are

presented and discussed at the same time. DIFFERENTIATING PROFESSIONS AND LEVEL OF EXPERIENCE Many participants highlighted that it was important to be able to distinguish between

professions and level of experience. _“I feel a little bit annoyed that someone would mistake me for someone who works in a nursing home”_ (participant 13). Confusion was evident both in

terms of profession/role and grade or level of experience. Participants felt that professions needed to be clearly delineated by their uniform not only to reduce confusion but also to

maintain strong professional affiliation and pride. In addition to a clearer system for identifying professions, participants wanted students to be clearly identified visually by their year

of study, to prevent confusion over their level of experience. Some also suggested having a national uniform, as has been agreed for Wales and Scotland. Some participants felt the more

modern uniforms still encouraged nurses’ subordination to doctors. Although the relationship between the two professions has changed significantly over the last century, issues of gender and

power remain and the nursing uniform can sometimes emphasise this. Many participants thought uniform played a key role in creating unity within the profession and equality between other

professions. They suggested that introducing a uniform for all healthcare professionals would be beneficial to team dynamics and promote a more equal and productive working environment.

UNIFORM STYLE AND HISTORIC CHANGES A large proportion of participants said they would prefer to wear scrubs rather than tunics. Those who preferred dresses and tunics thought these were

smarter. It has been suggested that scrubs portray a competent and trustworthy image and command a certain level of respect as they are often associated with “prestigious” areas such as

intensive care or A&E (Rafaeli and Pratt, 1997; Newton and Chaney, 1996). Some discussed the perception that in the past nurses took a lot more pride and care in their appearance and had

a stronger identity. They commented that nurses used to look smarter and therefore appeared more professional. Other participants felt nurses’ uniform was not as special as it used to be

and were even in favour of the traditional form being re-introduced: _“I’d have it all, the white dress with the white hat and the cross. I want the badge and the cape”_ (participant 13).

Two participants discussed the importance of their fob watch. They and others described it as symbolic of the profession and many female participants were disappointed it was gradually being

removed. However, Wright (2008) questioned whether the older symbols should still be necessary to formulate nurses’ identity, adding that key symbols of nursing have not been lost but have

changed to things such as “facial expressions or tone of voice”. THE IMPACT OF UNIFORM ON INDIVIDUALS A number ofparticipants claimed they were proud to wear the nursing uniform because of

what it represents. They discussed the idea that the way nurses present themselves in their uniform sends out a message to patients and staff about their attitude to their job: _“To me your

uniform reflects the pride you have in your job … you don’t have pride in yourself, you don’t have pride in your job, therefore you are not going to be as willing to provide good care”_

(participant 10). One participant had worked previously as a healthcare assistant for 20 years and used to wear a hat and belt in that role. She commented: _“I was proud to wear it …. It was

really special and I felt really privileged to wear it … I used to feel great, I loved it”_ (participant 5)_._ Conversely, one male participant said he did not feel proud wearing his

uniform, which was largely influenced by his current peers. It appeared that due to friends’ stereotyped associations, he felt embarrassed rather than proud. Another male participant

described how he did not want to be seen in his uniform as he would easily be associated with the nursing profession. If an organisation’s external image is negative, then the individual is

likely to reduce their affiliation as much as possible (Kahn, 1990). The interviews showed that female participants were more likely to speak fondly of the traditional uniform, which is not

usually associated with male nurses. Participants acknowledged that feeling like a professional was important to self image and uniform played a large part in this. One highlighted that the

current uniform did not make her feel very professional due to being poorly fitted and generic: _“I don’t feel very professional, I feel more like a cleaner”_ (participant 5). Some mentioned

that “feeling good” about themselves in their uniform was important and that they would prefer uniforms to be measured to size and of better quality. Several participants explained that if

they had a good self image, felt comfortable in their uniform and had pride in their role, then they would perform better as nurses: _“It’s about self esteem - if you feel awkward because

something doesn’t fit properly then you’re less likely to be assertive”_ (participant 8). Several also found it difficult to define the concept of professional identity. Forming professional

identity can be a complex and difficult task as nurses have to juggle between personal and public perspectives (Hallam, 2000). It could be argued that there are two groups of nurses:

modernisers and traditionalists. _“Nursing is caught between wanting to still be that [stereotyped image] so that it has all the positive stereotypes that are associated with it and wanting

to push for more rights”_ (participant 4). Students may be more likely to subscribe to the “traditionalist” identity as society currently influences them more than nursing culture (Milward,

1995). However, they may be more accepting and open to a “modernising” identity and it is possible that nurses who have been working for a long time are more likely to prefer “traditional”

images of nursing. Students’ position and identity develop as they settle into areas of work and become exposed to the politics and ethos of colleagues around them. STEREOTYPES AND THE

PROFESSION’S IMAGE The majority of participants acknowledged that stereotypes of nursing still existed and were prevalent in the media: _“The associations that the media or the public have

with nurses haven’t really changed much since … Barbara Windsor”_ (participant 6). More recently modern medical dramas have obviously influenced opinions on uniform: _“I think the media also

helps … in terms of ‘ER’ because … scrubs are cool”_ (participant 2). Stanley (2008) suggested that recent feature films are beginning to represent nurses more accurately and present a more

“modern” image which many students admire. All participants thought uniform was an extremely important issue and that it directly affected practice and therefore needed attention. In order

to retain staff and enhance nurses’ job performance, it is vital to improve their self image and the public’s perception of nurses (Takase et al, 2006). This has been recognised by the Prime

Minister’s Commission (Department of Health, 2010). Participants recognised  that a new image or identity for nurses would help to further remove old fashioned stereotypes and promote a

more autonomous and professional image. However, they made clear that remembering nursing heritage and traditions is also important and a fundamental part of identity. CONCLUSION We

acknowledge that the conclusions drawn are limited to the participants interviewed. Due to time constraints and the study’s length, only 14 people could be interviewed, and from only one

university. This study suggests that uniform is a complex issue that influences many areas in nursing and healthcare. It is clear it plays a key role in forming student nurses’ professional

identity and maintaining pride in the profession. Most participants were “modernisers” and their training had developed certain values in them about nursing as an independent profession.

However, they also recognised the value of nursing’s heritage and tradition. How nurses feel about themselves in a uniform is extremely important and it was clear that participants wanted a

uniform that made them feel confident in their appearance. Uniform and the image of nursing need, therefore, to be considered carefully, balancing modernity with an appreciation for

nursing’s heritage. This will help to portray a more realistic image to the public and to form positive professional identities. DEPARTMENT OFHEALTH (2010) Prime Minister’s Commission on the

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