A recently published survey by McKinsey and Company reported that 32% of nurses were likely to leave direct patient care, up 10% from a similar survey published less than a year earlier.1 Key reasons for this exodus from practice include insufficient staffing levels, finding a job with higher pay, and nurses not feeling supported in their current role.1 How can we, as nurse leaders, learn to better connect with our nursing teams to promote retention and satisfaction in our profession?

Nurses feel disrespected and not valued-financially as well as professionally.1 They want creative approaches to scheduling and new ideas to overcome the immense patient acuity and high patient load during their shifts.1 I imagine these same nurses are filled with innovative and practical ideas to make their jobs better.

I couple this reality with a recent story from an esteemed nurse leader colleague. She shared with me that she decided to wear scrubs into work shortly after the pandemic began despite being in an upper-level leadership position because she never knew what she might be called upon to do, and she wanted to be ready for anything. This incredible leader had insight into how to promote teamwork amid uncontrollable chaos. About 6 months in, her CNO asked her to stop wearing scrubs, so she did. Although she was a bit bewildered, she couldn't question it.

What we wear to work often symbolizes our professional level and the type of work we're doing. For example, hard hats and high-visibility vests worn by construction workers provide both security and a visual cue that they're engaged in dangerous work. Wall Street employees are typically clothed in suits with ties or handkerchiefs, pantyhose, and heels. This stereotype isn't meant to offend those who may not fit this mold but merely to share common themes in workplace wear. Although a simple observation, what we wear is a huge symbol, sometimes defining our values, level of power, financial stability, and more. A scientific concept known as enclothed cognition, coined by psychologists out of Northwestern, has shown clothes can influence your behavior.2

Scrubs worn by nurses and other healthcare professionals are also a powerful symbol. Walk into most healthcare organizations today, and you can tell by looking at the color of a set of scrubs matched with a tag on a name badge that someone is an RN, a nursing assistant, or a respiratory therapist. For the purposes of this train of thought, I'll be focusing on scrubs worn by nurses.

Along with those matching scrubs comes an expectation of nurses held for decades: providing expert and competent care as well as exuding a level of trust unmatched by any other profession. Nurses who wear scrubs critically think, adapt, make decisions, provide psychologically safe environments, protect privacy, operate high-tech equipment, solve complex problems, and so forth. As often depicted in imagery, these nurses are modern day superheroes.

Considering the challenges we're facing, I began to wonder why one of the first things nurses do when they climb the leadership ranks is trade their scrubs for a new style of attire? Speaking from experience, the first thing I did when I transitioned to a nurse manager role was purchase a new pair of neutral pumps to go with my array of business casual skirts, blouses, dresses, and slacks. I'd climbed the ranks, and I was going to be recognized for it by how I looked in the hallway. My organization suggested I wear a long white lab coat with my name and credentials over my street clothes when I was rounding and in meetings to symbolize this new title. I was asked to critically think, adapt, make decisions, and solve complex problems just like I was before, but this time when I looked around the room, there were very few people wearing the scrubs I'd left behind.

I took one step away from the bedside and gladly left the symbolic clothing that connected me to those responsible for the unique and skilled work I was supposed to manage. Simon Sinek, well-known author and inspirational leadership speaker, has boldly suggested that as leaders we're not "in charge" but rather leaders of those "in our charge."3 By shoving those scrubs to the bottom drawer of my dresser, I exposed a major gap between myself and those in my charge.

I recognize the need to dress professionally and appropriately as we engage in valuable work as nurse leaders. It can help us gain respect in meetings and while presenting. What I'm realizing, however, is that when we disengage with our direct care teams and represent them throughout the healthcare system by dressing in business attire, we may be directly "de-professionalizing" the scrubs that we wear to do the very core of our work. How can we remember to consider the impact our boardroom decisions have on those in our charge if we have no symbol of them at the table? Some of the best managers, directors, clinical nurse specialists, and educators I've learned from in my career never traded in their scrubs. These individuals were often hugely respected by their fellow nurses but often looked upon differently by other leaders because of their clothing choice.

I know this is a broad stereotype I'm generating, but I believe our thinking has to expand along with this nursing shortage. As a passionate nurse leader, I'm willing to exude vulnerability and good judgement as we carefully consider our future as nurses.

Value, the Harvard Business Review tells us, comes from being recognized, feeling gratitude, getting feedback, having conversations about growth opportunities, and finding ways to be flexible.4 Many other studies now point to these authentic concepts for nurses. These aren't difficult concepts, but ones about which those in suits and those in scrubs can't seem to find common ground. I once heard a hospital CEO say, "'they' (the nurses) shouldn't care about their paycheck, they should be proud of the work they're doing and that should be enough." Unfortunately, that mentality separates the suits from the scrubs. Getting a paycheck isn't always enough to feel valued.

Currently, many organizations are adding and hiring new layers of nursing leaders. These leaders most likely won't come dressed in scrubs, but they'll be asked to determine staffing matrices, review unit budget numbers, manage special projects, and deliver outcomes based on patient care data. They'll sit in boardrooms and meeting spaces and make decisions that will directly impact nurses in scrubs. I wonder, with the best of intentions, how they'll be sure to include those "in their charge" as they look for solutions?

Don't get me wrong, I loved my professional wear, and I still managed to improve patient safety scores and have highly engaged employees. But during times of crisis, it's paramount to shift our paradigms. Why weren't my scrubs professional enough? Why was a symbolic reminder of those in my charge not the professional attire to don when I had the privilege to make decisions on their behalf? The second I changed my clothes, I created a purposeful and destructive hierarchal gap between myself and my team. Nurses in scrubs are seen as approachable, caring, safe, and trustworthy. In business attire, leaders can be seen as closed off, unavailable, and intimidating. Again, I ask, why did we make this trade-off?

We're standing on a precipice. We have no choice but to think differently to keep and sustain our nursing workforce. Everyone in scrubs has the capacity to think critically and solve complex problems. Everyone in scrubs can also be a leader. We need to find a way to connect with nurses in a meaningful way. What if you walked through a hospital coffee shop and you couldn't tell the difference between the nursing leaders and those working at the bedside that day? The aura of safe, compassionate, and trustworthy people would exist all around you. What if we stopped generating a gap every time we grew as a nursing leader but instead stayed connected to our teams providing care? This might not only help nurses feel more valued and understood but also remind us that all nurses wearing scrubs should be included in decision-making.

In closing, I'll completely contradict myself. It doesn't matter whether you want to dress in business casual or align with your direct care teams in a pair of scrubs. I do hope this paradigm shift rattled you for a moment, though. I'm an optimistic person, and I believe we can get out of this mess. To do this, pause and ask yourself, besides your clothing choices, how are you physically and emotionally disconnecting yourself from the nursing role in which we all began this journey? We must close the gap between ourselves as leaders and the nurses feeling undervalued; those who are trading in their scrubs for new professions in droves. Perhaps they're picking up hard hats and safety vests or starting new careers in finance. It's not important. What's vital is that, no matter what you're wearing, you bring the underdressed leaders, the superheroes in soft cotton, to sit at the table with you and figure it out together. Then, and only then, will we elevate our profession to the level it deserves.

-Ashley Kellish, DNP, RN, CCNS

Assistant Professor

Lead Faculty, Healthcare Leadership & Administration Program

University of North Carolina School of Nursing

Chapel Hill, North Carolina

ANA Consultant, Leadership & Practice Transition

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