Earning recognition and respect as a nurse requires professionalism in performance and appearance. A nurse's appearance makes an important first impression on patients and dress codes in the hospital setting should take this into account.1 Nurses' uniforms are a "nonverbal conscious statement that nurses have the skills and knowledge to care for others."2 A uniform is a powerful form of nonverbal communication related to the wearer's identity, authority, status, and occupation.3

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Because people judge a person's character based on the first 12 seconds of an interaction, it's crucial that nurses demonstrate their character through their personal appearance.4 As part of an ongoing effort to enhance our patient experience, our nursing team standardized the required nursing attire at the three community hospitals comprising our healthcare system.

This initiative took considerable time and effort both to collaborate with nursing staff members and gain their full participation in the year-long process. This article describes our leadership team's experience promoting a professional appearance and dress code among nursing staff using a shared governance model.

Identifying the problem

The need for a consistent professional appearance among the hospital system's inpatient nurses was raised by both staff and patients. Team members noted many colors, prints, and styles worn by staff, including RNs, LPNs, technical partners, unlicensed assistive personnel, unit secretaries, and escorts. Furthermore, some staff members were noncompliant with the existing dress code. Although our dress code policy had no specific guidelines for standardized uniforms, it did address accessories such as jewelry and visible tattoos.

Through postdischarge surveys, patients consistently reported their inability to distinguish nurses from other care providers. This inconsistent RN identification occurred despite the use of large-print name badges. Patient comments also stressed the need for a professional, well-groomed appearance.

Based on these consistent observations and patient feedback, nursing leadership referred the issue to the shared governance professional development council. The council was charged with defining a professional image and uniform for RNs across the hospital system.

A uniform process

The council guided the process to review and establish a professional image and code of conduct for the nursing department. It determined through a literature review that the components of a professional image include professional appearance, quality of work, responsiveness and customer service, accountability, communication, listening, and reputation.

The council's first priority was to focus on professional appearance, creating a professional image (PI) committee to address this priority. The PI committee included representatives from each nursing specialty and was divided into five workgroups. Cochaired by an RN and a nurse manager, who met monthly, the committee's first task was to create a new dress code for hospital staff. The PI committee utilized this six-step process for change:

1. review of the literature

2. survey of patients

3. analysis of staff appearance

4. selection of professional attire

5. recommendation for professional attire

6. implementation of a new dress code.

Review of the literature

Members of the PI committee conducted an extensive literature review on nursing image. This evidence confirmed the importance of what a nurse wears in projecting a professional image. We also learned that patients had no specific preferences for colors or styles of uniforms. As a result of this review, the committee recommended that nurses have a vote in the selection of professional attire.

Survey of patients

While one workgroup reviewed the literature, another created, conducted, and analyzed a patient survey regarding patients' ability to identify their nurse. Workgroup members queried 91 patients at all three hospital campuses. Adapted from a tool developed by Windel et al., nine questions were asked and scored using a Likert scale.5 The majority of patients didn't have a preference for uniform color. (See Table 1.)

Table 1: Patient survey results (n = 91)

Analysis of staff appearance

Next, the PI committee charged the nurse spirit committee, part of the professional development council, with conducting a review of uniforms currently being worn. The nurse spirit committee members randomly photographed 15 consenting nursing staff members on inpatient units. In addition, 300 photos from the hospitals' Nurses Week were obtained for review. Only 17% to 20% of the photographed nurses were wearing the same color.

The PI committee concluded that the majority of nurses wore a variety of scrubs and cover-ups in a multitude of colors, patterns, and cartoon characters. There was no defined uniform for each level of staff, and one staff member couldn't be clearly differentiated from another.

Selection of professional attire

The PI committee representatives gathered staff recommendations on a style and color for uniforms. A form was developed to capture this information. Seventy percent (n = 637) of our 1,300 nurses completed the form; the data indicated that the preferred uniform colors were navy and white. (See Table 2.)

Table 2: Staff preferences for uniform color (n = 637)

Based on these results, the PI committee moved forward to adopt new staff uniforms. To help with the selection of uniform styles and colors, the PI committee partnered with the marketing department to create a fashion show for the three hospitals. The committee worked with a uniform vendor to identify options and obtain samples. The marketing department established the format for the fashion show and emceed the event, and nurses volunteered to be models. As music played, nurses showcased new looks on the runway. During the fashion show, each model was photographed. The marketing department developed these photographs into posters of the uniform options and delivered them to each nursing unit for staff review.

To measure the staff's choice among the three uniform options (all white, all navy, or a white/navy combination), the PI committee and human resources department developed a second survey, which was distributed electronically via the hospital e-mail system to 1,300 registered and practical nurses and 45 nurse managers/supervisors with direct patient contact. The survey was available for 7 days. The human resources department managed the survey, reviewed all of the responses, and provided the results to the PI committee. A total of 605 nurses (46.5%) and 34 (76%) nurse managers completed the survey. The results revealed that the majority of nurses preferred scrubs in all navy. (See Table 3.)

Table 3: Staff choices for uniform options (n = 639)

Recommendation for professional attire

The PI committee accepted the survey results and put forth a recommendation for nursing uniforms to the professional development council. The recommendation was a solid white or navy top and solid navy pants. Nurses would have a personal choice of uniform style within the color combination. The professional development council also sent the final recommendation to the nurse executive council for review and approval.

The final recommendation was announced to staff in a letter from the CNO. The letter also acknowledged that full-time, part-time, and casual staff would be eligible for a one-time financial support payment to offset personal expenses in procuring the new uniform. The stipends were funded through a grant issued by the system's charitable foundations.

In response to this letter, the pediatric nurses sent a request to the CNO to reconsider pediatric nurse attire. In their request, the pediatric staff members anticipated that the proposed uniforms would make them seem unfriendly, stern, and unapproachable to young patients. Their attendant review of the literature supported a colorful uniform to promote a child-friendly environment and decrease anxiety in hospitalized children. The CNO referred the concern to the PI committee for review and recommendation. Based on a validating literature review, the committee found that pediatric patients preferred bold print tops and navy or white pants.6 The committee recommended that the pediatric staff choose a specified character jacket to be worn when caring for pediatric patients. This modified recommendation was agreeable to the pediatric staff and incorporated into the overall policy.

Implementation of the new dress code

The hospital system used the uniform vendor from the fashion show to supply the nursing staff members with their uniforms. The vendor created an online ordering website. Fitting sessions were conducted in the nursing office areas at each hospital and tables of different uniform sizes and styles were available for staff to try on. The fitting areas were equipped with portable dressing rooms, greeters, and refreshments. The fitting sessions were held during all three shifts. Staff members were able to place a uniform order after participating in the fitting process.

The uniform implementation was set for January 1, 2012. The nurse spirit and PI committees partnered with the marketing department to develop a slogan for the new attire kickoff: A New Look for a New Year! Celebratory top hats with the new slogan filled with chocolate candy bars were distributed by the nurse spirit committee in the cafeteria at meal times and during the night shift. All hospital employees received candy bars to help celebrate nursing's new look.

Seeing the change

Thus far, we've achieved 99% compliance with the new dress code, as measured by observational audits conducted by the nurse managers and clinical nurse coordinators for each department. Although there was some resistance, the new nursing attire was implemented with very positive results as evidenced by staff, patient, visitor, and administrative comments, such as "so much neater," "more professional appearance," "patients know who their nurse is," "everyone looks so nice and you can tell who's who."

The process of using a shared governance model was an effective way to allow staff to self-determine a professional image. This process set the stage for the hospital system's other clinical departments, which have since selected their own specific uniform styles and colors.

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