Results of a Survey Among Adult Patients on the Appearance of Nurses in Italy

1. INTRODUCTION

A symbol is an element of communication representing a concept or quantity (e.g., an idea, an object, a quality). It is a sign that can be i) conventional, under a social convention, or ii) analogical, i.e., capable of evoking an association between a concrete object and a mental image [1]. For example, spoken language consists of distinct auditory elements representing symbolic concepts (words) arranged in an order that further specifies their meaning. Symbols have an intersubjective solid character, as they are shared by a social group. In particular, symbols differ from signals since the latter have a purely informative and non-evocative significance. Symbols also differ from brands, which have only a subjective matter.

The word symbol derives from the Latin symbolum and, in turn, from the Greek σύμβολον “sùmbolon” having the meaning “together”, the connection of two distinct parts. In ancient Greece, the term symbol had the purpose of an identification card. Usually, the relationship between symbols and what they represent is conventional and not solely an imitation. Furthermore, it plays a key role in nonverbal communication [2]. Accordingly, the “uniform” identifies the wearer, indicating belonging to a specific category. Its goal is to recognize groups of people (doctors, soldiers, priests, etc.) who perform the same function within a particular setting. The type, color, and cut should be the same for all category members [3]. Therefore, the uniform of nurses immediately identifies the professional figure and related prerogatives [4].

Nursing uniforms have changed over time, following scientific and industrial revolutions, leading to modifications in the hospital organization [5]. Nursing became an acknowledged profession in the 1800s [6].

Primarily considered a women's role, the original nurse uniform consisted of a high-collared shirt, a floor-length tabard dress, and a bonnet. They were worn to hold hair back, while aprons were used to protect garments from medical solutions, biological secretions, and infected fluids [7]. The first known example of a nursing uniform was introduced by Florence Nightingale, who was a nurse manager and trainer during the Crimean War in 1855 [8]. It consisted of a full-length dress with long sleeves and an apron. Moreover, nurses wore a white sash with embroidered “Scutari Hospital” in red and a white cap resembling a nun's clothing. Nurses did not wear gloves or masks at that time to protect them. In addition to acting as a barrier from infection, the uniform was an important visual symbol to ensure nurse recognition by patients and doctors. In 1860, Nightingale founded the first nurses' school, and accordingly, a teaching method based on education hierarchy, discipline, dedication and high standards of behavior. According to the modern practice of nursing established by her, the first private school was founded in Italy between 1800 and 1900 [9, 10]. She also inspired Red Cross founder Henry Dunant, who advocated the formation of national voluntary relief organizations to care for wounded soldiers during wartime [11]. The undisputed symbol of the Red Cross was the red Helvetic cross sewn on the chest or the armband.

Through the 19th and 20th centuries, the uniform changed into a more practical outfit able to distinguish nurse hierarchy [12]. White color was the primary choice for nurses' uniforms (1915-1945). The overtime changes in nurse uniforms reflected social evolution in the healthcare system [10, 13]. Nowadays, practicality has become a priority; however, views on the nursing uniform are conflicting [14]; traditional clothing symbolizes history, and the meaning ascribed to the white uniform is purity and cleanliness. According to Smith [15], the uniform represents a sort of legitimation; it suppresses individuality and creates a totem. It also establishes distance between nurse and patient, revealing the wearer's authority and a sharper professional identity, as demonstrated in Italian nursing students [16]. On the other hand, especially in the United States, this kind of distance between healthcare professionals and patients is abolished by using various solid-colored uniforms, not considered authentic uniforms [17].

The fundamental issue revolves around activities or jobs that involve close contact with a specific group of people, in particular patients, implying the possibility of being identified immediately by the patient, regardless of words (explanations), avoiding confusion with other professional figures [18].

Given the symbolism attributed to a uniform, people expect that the person wearing a particular uniform can act in a specific way [19]. Although attire might not affect healthcare activities, the instinctual patient's perception of a nurse figure can influence his/her compliance to share confidential information, health education, therapeutic interventions, and so on [20]. In a review by LaSala et al., it was highlighted that appearance, behavior, dress, and communication skills made an essential contribution to the image of professionalism projected by nurses. For all these reasons, dresses, make-up, hairstyles, jewelry, piercings, and body art may strongly impact the patient-nurse interaction [21].

Several authors have evaluated the role of standardized clothing of the nurse figure with contrasting results [22-24]. However, patients prefer nurses with a professional appearance because it is thought to improve nurse-patient interactions [25, 26].

In particular, the use of casual clothes by nurses has been advocated with the aim of improving nurse-adult-patient relationships [27]. Casual clothes may be considered more practical by nurses; however, patients—through questionnaires— expressed the belief that the abolition of the uniform could make it challenging to identify these figures, especially during emergency situations [27]

In Italy, no studies are currently available regarding patients' preferences for nurses' clothing; for this reason, we conducted a survey on a large convenience sample using a previously validated questionnaire.

2. METHODS

2.5. Ethical Considerations

The study was approved by the local institutional review board (the General Management of the Azienda Ospedaliero Universitaria of Sassari and the Medical School and Nursing School, University of Sassari, Sassari, Italy). According to Italian law [30], the survey did not require ethics approval. Participation in the study was on a voluntary basis, and the questionnaire was anonymous.

Table 1.

Male Attire	I like it	I do not like it	Indifferent
Name tag
Formal, classic clothing
Casual clothing (jeans and T-shirt, jeans and more)
Uniform
Perfume
Classic shoes
Sport shoes
Clogs
Sandals
Without socks
Long hair
Short hair
Beardless
Neat beard
Long beard
Overweight/obesity
Clean teeth
Long nails
Short nails
Earrings (piercing), necklaces
Tattoos

3. RESULTS

4. DISCUSSION

Nurse attire can be a fundamental key in patient-nurse interaction. It has been reported that “competence”, “confidence”, and “credibility” are judged by others in the first 12 seconds of an interaction, which includes attire [31].

Our survey showed that Italian adult patients prefer professional attire over casual, traditional, trendy, or more nonchalant clothing. These results agree with a previous study conducted in the Cleveland Clinic (Cleveland, OH, USA) on adult and pediatric patients and hospital visitors [32]. Adult patients preferred solid colors and white uniforms because they considered this type of clothing to be

associated with nurse professionalism traits (e.g., confidence, competence, attentiveness, efficiency, approachability, and care, among others) [32]. Porr et al. conducted a similar study in Canada [25]. The authors showed photographs of the same nurse in eight different uniforms of adult patients. In line with our findings, the white pantsuit scored higher for professionalism than other kinds of uniforms [25]. Several years earlier, a literature review about patient perceptions of nurses' attire, conducted by Lehna et al., had reached the same conclusions: patients still preferred traditional white dress. However, other forms of clothing were acceptable [33]. In a multicenter study conducted in acute care hospitals across Utah, 2,430 respondents, including patients, nurses, and administrators, were surveyed regarding their first impression of the professional image of nurses' uniforms, which showed that white pant uniforms with stethoscopes rated significantly higher than other uniforms. In comparison, colored designer scrubs and white pants with a colored top obtained the lowest score [34].

Unfortunately, Italian studies on the same topic conducted in adult patients are not available to compare with our results. Instead, a similar survey was conducted on children admitted to a pediatric hospital [35]. In contrast to our findings, the impact of a multi-colored, non-conventional attire was shown to be preferred by the pediatric population and their parents. The authors concluded that child preferences can improve the child–nurse relationship and have the potential to reduce the discomfort given by hospitalization. A more recent Italian study also extended to nurses, as well as children, confirmed previous findings, with the color uniforms being the most chosen [36]. These results are reasonable for children. For example, in a study reporting the rationale for their choice of a specific attire, mothers explained that they did not like white uniforms because their children were afraid of nurses wearing white uniforms [37]. However, in the same study, military veterans preferred white uniforms because they were associated with professionalism and cleanliness [37]. More importantly, adult patients perceived nurses with white uniforms as associated with greater competence, followed closely by the lab coat over street clothes [37].

In addition to the type of clothing, the attire may be completed by details, such as hairstyle, jewelry, make-up, and so on, which can impact the patient-nurse relationship and, in turn, patients' adherence [20, 21].

Our study revealed that some details, such as long nails, overweight or obesity, long beards, tattoos, piercings, and long hair in male nurses, and heavy make-up, overweight/obesity, long nails with polish, jewelry (aside from ring and watch) and body art in female nurses scored very low. More importantly, significant differences between age-decade groups about perceptions regarding piercings and tattoos were not detected. A study by Newman et al. conducted among patients in the emergency department showed that visible nontraditional body art negatively impacts first impressions [38]. Similar to our findings, the authors found that for a sizable proportion of respondents, facial piercings were inappropriate for physicians [38]. Thomas et al. observed that visible tattoos and piercings are associated with poor caring skills among nurses, students, and faculty personnel [26]. Although there is a growing trend of individualism and, therefore, the right to express oneself anyway, and everywhere, including the workplace, especially from “Generation Next”, visible body art and unconventional piercing are also growing among nurses. However, according to Thomas, “the nurse is there to help patients heal, not to subject them to their right of self-expression” [26].

Data about the preferences of patients for overweight/obese nurses are limited. However, previous studies across different countries [39], including Italy, reported weight stigma (stereotypes, rejection, prejudice, criticisms, and so on) in more than 50% of the obese individuals interviewed [40]. It is, therefore, not surprising that nurses can also evoke body weight stigmatization by patients.

Overall, our findings highlight how external appearance is not a negligible component in the nursing profession. Even details, such as visible underwear, rumpled uniforms, and pants that are too long or too short negatively affect patient and visitor perception [32]. Attire is part of non-verbal communication, representing the first means of interaction; thus, a scruffy appearance, not appreciated by the patient, might compromise the professional relationship [32]. Nonetheless, the uniform is a visual and instantaneous symbol that enables patients to identify nurses immediately [34]. Nowadays, casual, unconventional clothing is gaining popularity even among doctors. Another survey on patients' preferences about physician attire, conducted in the same hospital [anonymized for review], similar to the findings obtained for the nurse attire, showed that the majority of patients preferred conventional outfits (surgical uniform or formal dress under a white coat with a name tag) [29]. Trendy attire was preferred by a minority (1.1%). Moreover, long hair, visible tattoos, piercings, wearing trousers, and excessive make-up for women were considered unsuitable [29].

Misidentifying the professional roles may confuse the patients, wasting time and resources in explanations [32]. In addition, the casual clothing of the nurse may result in less hygiene [18]. In these circumstances, casual clothes are laundered at home or in a private offsite laundry by inadequate laundering processes. This may pose a severe problem for microorganism contaminations in an era where nosocomial bacterial resistance has increased, leading to significant morbidity and healthcare costs.

This study has several limitations. Based on its cross-sectional design, it did not allow evaluation of differences over time. Moreover, it was based on a probably culturally specific instrument, at least for some elements, which do not necessarily reflect current social expectations. Some items may be missing (e.g., mobile phone, with or without earphones, pins or other ornaments hanging from the uniform, etc.). Using convenience sampling and participants of the same ethnicity and demographic characteristics may reduce the generalizability of our results to the populations of other countries.

CONCLUSION

In conclusion, our findings confirm preferences for the traditional attire of nurses among a large cohort of patients across different generations. If confirmed, the results of this study might guide healthcare facilities to set up dress codes compliant with the wishes of patients, aiming to increase their adherence to diagnostic tests, treatment, and follow-up.

Furthermore, considering that the “school,” and in particular, the school of nursing, not only educates but especially trains professionals, the results of our study could contribute to the process of “knowing how to be” as well as “knowing how to do.”

REFERENCES