The image of the children’s nurse: a study of the qualities required by families of children’s nurses’ uniform

The image of the children's nurse: a study of the qualities

required by families of children's nurses' uniform

STEVESTEVE CAMPBELLCAMPBELL BNurs, PhD, RGN, RSCN, NDN Cert , RHV, FRSH

Principal Lecturer and Head of Division of Children's Nursing and Learning Disabilities Nursing,

Faculty of Health, Social Work and Education, University of Northumbria at Newcastle,

NE7 7X41

CHRISTINECHRISTINE O'O'MALLEYMALLEY Dip HE, BSc, Adv Dip Health Sciences ,

RN(Chi ld)

Staff Nurse, PICU, The Newcastle Upon Tyne Hospitals NHS Trust, Newcastle General

Hospital, Westgate Road, Newcastle Upon Tyne, NE4 6BE

DONDON WATSONWATSON BA, MPhil , PhD, C Psychol , AFBPsS

Emeritus Professor in Applied Psychology, Faculty of Health, Social Work and Education,

University of Northumbria at Newcastle NE7 7XA

JANJAN CHARLWOODCHARLWOOD BA, RGN

Staff Development Manager, The Brendon Care Foundation, The Old Malthouse, Victoria Road,

Winchester S023 7DU

SUSANSUSAN MM. LOWSONLOWSON DMS, MA (Qual Mgt) , RGN, RSCN

Quality Development Manager, Southampton University Hospitals NHS Trust Tremona Road,

Southampton, S019 4XY

Accepted for publication 7 May 1999

Summary

· Traditional views of the nurse see `her' in a nurse's uniform, whether she be a

`sex symbol', àngel of mercy' or `battle axe'. Children's nursing has, over recent

years, moved away from the idea of the uniform into more child friendly clothes,

though the traditional uniform is still presented to the public by the media.

· The staff members of a Children's Outpatients Department (COPD) of a large

acute hospital requested knowledge of the qualities families required from the

uniform of nurses caring for them, prior to any change in uniform. This study

aimed to develop an understanding of these qualities via the use of a survey

presented to those attending the COPD.

· The ®ndings indicate that there is a complex relationship between the qualities

that families wish the uniform to present. A balance is needed between

presenting a professional authority ®gure, providing security for families and

suggesting an approachable ®gure, to allow effective communication between

staff and families.

Journal of Clinical Nursing 2000; 9: 71±82

Ó 2000 Blackwell Science Ltd 71

Keywords: atmosphere, children's nurse, communication, identi®cation, patient

con®dence, uniform.

Introduction

In the UK there has been a recent trend for children's

nurses to dispense with traditional uniforms. Glasper &

Miller (1992) have suggested that this re¯ects a desire to

make hospital environments more child friendly and

family centred. However, there has been little research

about the impact this has on families and about their views

on traditional uniform. Consequently, when a change in

uniform was proposed in the Children's Outpatients

Department (COPD) of an acute NHS trust, a study was

conducted to investigate the families' perspective on this

issue.

The nature of uniform in society

In order to set this study in context it is important to

consider some historical and fundamental issues about the

nature and role of uniform.

PURPOSE OF UNIFORMPURPOSE OF UNIFORM

Both uniformed organizations and the public view

the uniform as ideology, the former to proffer a

desired image to outsiders, the latter to retain

cherished emotive symbols. (Joseph, 1986; p. 116)

The essence of this statement is the belief that uniform

projects information about the identity of its wearers. It

informs about what they do and the qualities and attitudes

that can be expected of them. Thus uniform is used

explicitly as a form of communication and is interpreted

implicitly by individuals. Such communication takes place

among three participants: the wearer, the organization and

members of the public, individually and en masse.

Besides its role in transmitting information, uniform

also has an obvious, though perhaps secondary function, of

practical expediency. Smith (1990) suggests that uniform

can be viewed from these two perspectives, the intellectual

and the practical. Coombes & Heilman (1993) refer to

uniform in general as a non-verbal method of communi-

cation that denotes status, occupation, authority and

power, while Joseph (1986) also ®nds that uniform is a

method of communicating relationships both within and

without an organization. This involves the communication

of control implied by the `cluster of values and norms

which support these relationships' (Joseph, 1986; p.2) and

which affect the manner of communication between the

uniform wearer and the public. Uniform has a powerful

effect on the public, often bestowing on the wearer status

and a `certi®cate of legitimacy' (Joseph & Alex, 1972) to

invade physical and personal space. Nurses in particular

are endowed with this licence of safety, and children and

their families still tend to recognize a nurse by identi®-

cation with a uniform (Livingstone, 1995).

Brennan et al. (19952 ) recognizes the practical role of

uniform in nursing, in terms of maintaining cleanliness,

promoting freedom of movement and identifying the

wearer as a member of the nursing profession. However,

the role of the uniform in hygiene and infection control is

dubious, and nurses have been found to pay more

attention to infection control whilst wearing their own

clothes (Sparrow, 1991). Moreover, the promotion of free

movement has been limited by traditional uniforms

(Castledine, 1987). Its role in identifying nurses may be

questioned in the light of the ease of access to nurses'

uniforms and possibility of abuse of this status.

THE HISTORICAL DEVELOPMENT OF NURSES'THE HISTORICAL DEVELOPMENT OF NURSES'

UNIFORMSUNIFORMS

Three different vocations had a strong in¯uence on the

evolution of the role of the nurse: the church, the military

and the servant (Tiffany & Sparrow, 1987; Davies, 1995).

Each of these affected the way traditional nurses' uniforms

developed. Religious orders throughout history have cared

for the sick and dying, and nurses adopted the discreet

attire of the nun including a headdress similar to a wimple.

The military history of nursing dates from the period of

Nightingale during the Crimean war. She presented

nurses with a militaristic uniform of buckles, badges and

stripes, because they were working with soldiers who were

socialized into respecting the emblems of rank and

uniform. The servant-like uniform of nurses in cap and

apron also developed during the mid 19th century to

distinguish between trained nurses from religious and

military training institutions and the morally questionable

untrained nurses who offended the Victorian propriety of

the day (Tiffany & Sparrow, 1987; Davies, 1995).

PERCEPTIONS OF UNIFORMSPERCEPTIONS OF UNIFORMS

There are con¯icting views about perceptions of nurses'

uniforms. The symbolic role of representing care, com-

passion and authority can be seen as advantageous, and

many nurses claim to wear it with pride. At the same time

72 S. Campbell et al.

Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 71±82

it carries with it the confused stereotyping of nurses as sex

symbols, battle axes or angels of mercy (Nightingale,

1983), images which tend to be exploited and exaggerated

by the media.

An alternative view refers to the intellectual perception

of uniform as an outdated mode of dress for independent

professionals. It relates to a history of subservience no

longer appropriate for contemporary nursing, which has

already been abandoned in some ®elds such as mental

health and learning disabilities. MacFarlane (1990) adds to

the debate by questioning the legitimacy of formally

prescribing uniform for a set of professionals. This view

also regards uniform as counterproductive to the devel-

opment of a therapeutic relationship in which nurse,

patient and family are partners in care (Casey, 1988).

Uniform: a conceptual framework

An analysis of the meaning of uniform in general and of

nurses' uniform in particular identi®es the recurrent

themes of communication and stereotyping. A framework

may be constructed around these issues to allow some

theoretical consideration of the importance of nurses'

uniform, and to indicate what implications there may be

for nurses.

The literature indicates that uniform is seen as the

embodiment of social expectations of the nurse: it

visualizes the stereotype, and in so doing provides the

public with an obvious source of communication about the

healthcare system (Livingstone, 1995). It helps in com-

munication between the public and healthcare profession-

als by acting as a passport in initiating personal and

physically intimate relationships. Such communication is

generated by public expectations of what the uniform

symbolizes, irrespective of the quali®cation of the wearer

(Sparrow, 1991).

Stewart et al. (1979) point out that stereotyping ®rst

became a prevalent issue in psychology in the 1920s, but

since that time corruption of the concept has made it an

almost derogatory term. They analysed the work of

Cauthen et al. (19713 ) examining the traditional view of

stereotyping and concluded that as a method of grouping

behaviour it is a concept

¼ in which a single characteristic or label serves to

elicit a set of expectations or attributions which are:

1 too simple to describe accurately the class of

person (or any of its members) and, at the same time,

are

2 too broadly generalized to individuals to have

more than occasional validity. Additionally, it is

sometimes assumed that stereotypes are

3 particularly rigid and resistant to change.

(Stewart et al., 1979, p. 2)

They viewed previous de®nitions of a stereotype as too

simple and suggested that a contemporary conceptualiza-

tion of the process of stereotyping could be found within

the psychology of cognition, development of a stereotype

being equivalent to development of a schema. A schema is

characterized, within the cognition process, as a mental

operation, cultivated through experience, that is used to

understand new factors in the environment of the subject

by comparison with previous knowledge. Stereotypes arise

because information about new factors in the environment

is too complex, incomplete or ambiguous to rationalize

into individual perceptions. Because of this, stereotypes

are used as a means of categorizing such information.

Stewart et al. (1979) also refuted the notion that stereo-

types present rigid parameters for the perceptions that

could be contained within them, arguing that, like

schemata, stereotypes alter with experience.

The principal stereotype of the nurse and its visual

presentation by uniform has developed as the culmination

of three branches of the profession's origins, the servant,

religious and military backgrounds (Davies, 1995). The

notion of the nurse as a kindly handmaiden following

doctors' orders is wrapped up, quite literally, in nurses'

uniforms. This schema is maintained and supported by the

media, which usually portray nurses in traditional uniforms,

thus maintaining the stereotypical perception. This view of

the nurse seems to be one with which society is comfortable,

as most research indicates a preference for traditional

uniforms. Research ®ndings also indicate that traditional

uniforms present the expected image of the nurse and

increase the con®dence of those experiencing physical

treatment (Hawkey & Clark, 1990; Meyer, 1992; Marr &

Matthews, 1993; Rowland, 1994; Livingstone, 1995).

However, according to Stewart et al. (1979), stereotypes

can be altered and updated. Consequently, the outdated

view of the modern professional nurse as `handmaiden'

may be changed by the development of a schema

incorporating directly observed information about nurses

and their uniforms, thus producing an updated stereotype.

Such an acceptance has direct implications for the

representation and practice of nurses. It suggests that

acceptance of the public's perceptions and preferences

merely prolong the traditional stereotype and do nothing

to alter it.

The study

Children attending outpatients departments bring with

them a variety of experiences. They may be acutely or


Users' experiences of care Children's nurses and uniform 73

chronically ill, they may have already experienced hospi-

talization, and they will have almost certainly been

exposed to representations of hospital by the media.

In the Child Health Directorate of a busy, acute NHS

trust, nurses on the wards wore an alternative uniform

(polo shirts, colour coded to the practice area, with the

choice of trousers, skirts or shorts in navy blue). However,

nurses in COPD still wore traditional uniforms. Although

they were considering change, they were reluctant to do so

without good reason, and they felt suspicious that the

decision had already been made for them to adopt the

alternative style. The aim of the research was to establish

the perceptions of families, nurses and other healthcare

professionals in relation to nurses' uniforms. The results

of the research were to be the basis on which nursing staff

made a collective decision on whether to change uniform.

Methods

A method was designed using interview and questionnaire

techniques to explore families', nurses' and other health

care professionals' perceptions of nurses' uniform in

COPD. Ethical consent was gained prior to the com-

mencement of the interviews.

Stage one: the interviews

An inductive approach was taken initially, to develop a

tool that would identify factors which families considered

important about uniforms. This took the form of open-

ended, in-depth interviews with a group of families and

with a group of staff from a variety of professions

including nursing. Using a grounded theory approach

(Glaser & Strauss, 1967), the interviews were expected to

identify key categories that could be used for further

quantitative analysis of the views of families in the COPD.

In order to reassure the COPD nurses that their

involvement was valued, all were interviewed (n� 12). A

sample of paediatricians (n� 3) and a single representative

from the other professions (i.e. physiotherapist, dietician,

administrative assistants) were also involved (n� 5). In all

20 families were interviewed, two from each half-day

session in COPD. These COPD sessions are mainly

organized according to paediatric speciality, with general

paediatric problems included on most days. Families were

largely represented by mothers, and also by some older

children. Interviews of the professional and family groups

went on in parallel; it was concluded data had reached

saturation when constant comparison ceased to highlight

new areas of interest (Glaser & Strauss, 1967).

Interview ®ndings

The ®rst and clearest category to emerge from the constant

comparison of data was that of identi®cation by uniform.

Families expressed a need to know whom to approach

about issues that they wanted resolved in the COPD. This

was also an issue for other health care professionals, who

wanted to be able to identify nurses correctly.

Both groups, families and healthcare professionals, felt

that nurses' clothing should distinguish them from parents,

although the latter group was less concerned about this.

Family members felt embarrassed about approaching the

wrong person, and also did not want to confuse other

parents by being mistaken for nurses themselves.

Besides anxieties about distinguishing nurses from parents,

concern was expressed about identifying quali®ed staff.

Families wanted to differentiate between nurses and care

assistants, and care assistants did not like being mistaken

for quali®ed nurses. This issue was also raised by health

care professionals who were new to the COPD (a

physiotherapist and a paediatric registrar).

It was also seen as important to be able to identify the

sister-in-charge; this was an issue for a large number of

family members and for health care professionals. Families

wanted to know who was in authority to deal with their

concerns and problems. Healthcare professionals expres-

sed a need to identify the person in charge as a matter of

recognition of seniority.

The second major category found in interviews con-

cerned the type of àtmosphere' uniform was expected to

generate, and the personal attributes that the nurse

wearing it was expected to hold. There was debate

relating to the type of atmosphere the uniform was

expected to foster: a relaxed approachable environment or

a clinical, authoritative, con®dent one.

Communication was the third category and related to

issues such as perceptions of the formality and friendliness

of the nurse in uniform.

It was accepted that the categories were inextricably

linked but that they were de®nitive issues for further

investigation. The categories identi®ed in the interviews

were referred back to the nurses involved, to con®rm their

validity. The nature of these categories was discussed, and

there was acceptance that they represented areas that were

important to both families and nurses. (One category that

had been identi®ed by nurses, the ease of laundering

uniform, was recognized as of little interest to families.) It

was also useful to involve nurses in validating categories

because it helped them to perceive the research process as

`transparent' and not hidden from them. They were



therefore less likely to misconstrue the process as a

conspiracy to force them to change uniform.

A similar process of validation was undertaken with six

individual families, again to identify whether their views

about uniform could be encompassed within these cate-

gories. Families found this process dif®cult, because they

needed to develop some understanding of the concept of

content validity. Nine statements were developed for use

in the questionnaire and there were no issues discussed

during interviews that could not be accommodated within

these statements. The ®ndings were therefore accepted as

valid by both the nurses and the families (other profes-

sional groups were not included in this process).

Second phase of the study

The nine statements were used as the framework for the

subsequent questionnaire (see Fig. 1). Because of the

Figure 1 The children's outpatient department questionnaire.



diversity of children and families using COPD it was

decided to use as large a sample size as possible. A self-

report tool was required because of the large sample size

required. This also needed to assess the importance of

each of the statements to the families, and so it was

decided to use a tool based on a Likert-type scale.

Copies of the questionnaire were handed out to families

on registration at COPD by administrative staff and they

had the option to refuse to participate in the study. They

were then asked to return the form to the same place when

they came back to make their next appointment. Alto-

gether 500 copies of the questionnaire were distributed

and 430 (86%) were returned. No family refused to

participate.

Findings

Findings are presented in three groups derived from the

themes identi®ed in the interviews: identi®cation, atmo-

sphere and communication (Fig. 2).

IDENTIFICATIONIDENTIFICATION

Statement 1: Ìt should be easy to identify nurses as nurses'

The results of Statement 1 illustrate that families

wanted nurses' clothing to allow them to be easily

identi®able as nurses (95% of the sample felt or

strongly felt that nurses should be clearly identi®able).

The inference is that people wish nurses to look like

nurses. However the statement does not ask in what

way nurses should be identi®able (there was a prefer-

ence for polo shirts rather than traditional uniform in

response to the ®nal question of the questionnaire). The

implication is that the role of the nurse is still associated

with a uniform that has been prevalent in the profession

throughout history and that the public wants nurses to

conform to their stereotypical schema. The preference

for polo shirts suggests, however, that this stereotype

may be changing.

Parents and children identify nurses by their uni-

forms. This identi®cation is based on historical stereo-

types and acceptance of the message given by uniform

and may provide the family with a false sense of

security. Livingstone (1995) found that children pre-

ferred the traditional style of uniform, perhaps because

it made them feel safer and reduced their confusion due

to their stereotypical, media-in¯uenced expectations of

nurses. Changing the way nurses present themselves

may have an impact on children's sense of security,

although it has been noted that children's preferences

can change when they experience more nurses dressed

less formally (Glasper et al., 1991). This seems to

indicate that there is potential for changing children's

stereotypes.

Statement 2: Ìt does not matter if nurses wear the same

kind of clothing as other staff or parents'

The purpose of Statement 2 was to identify whether

families were concerned about whether nurses wore

everyday clothing. In response to this, 67% disagreed or

strongly disagreed with the statement that Ìt does not

matter if nurses wear the same clothing as other staff or

parents'. The implication is that families want nurses to

appear physically different from other professionals and

the public.

The security provided by uniform may not only be

inappropriate but potentially hazardous. The assumption

that a person in uniform is a genuine nurse may have

serious child safety implications, and yet research shows

that people do make such assumptions. Franzoi (1988)

found that respondents identi®ed a nurse in traditional

uniform because such presentation met with expecta-

tions and yet failed to identify nurses in other clothing

such as `scrubs'. The implied security issue is that

uniform acts as a passport to patients and environments

without the need for validated identi®cation (Sparrow,

1991). The use of an informal uniform may, however,

stimulate patients, children and their families to ques-

tion the status of healthcare professionals, and to

recognize differences within the generic term `nurse',

thus developing different and more appropriate rela-

tionships with nursing staff. Consequently, there is an

implied need for education of patients and families on

appropriate identi®cation of staff.

Parents seem to want to be able to identify nurses easily

by their similar and distinctive clothes. It is important that

this need is met, whilst also taking into consideration

issues of security and other requirements of nurses'

uniform as put forward by families. The study did not ask

why families wanted to be able to identify nurses easily. It

would be interesting to pursue this question to give a

better insight into families' feelings about nurses and their

perceptions of the role.

Statement 3: `Nurses should wear the same kind of clothing'

The purpose of Statement 3 was to assess whether

different grades of nurses should wear the same kind of

clothing. The overall judgement on the statement at face

value was that they should (74%). However, re¯ection on



Statement 3 produced ambiguity of interpretation. This

ambiguity rests on whom the sample used as comparison

in deciding whether nurses should wear the same type of

clothing, i.e. does it matter, or should nurses wear the

same type of clothing as other nurses, other grades of

nurses, other health care professionals or the public? If one

assumes that the sample interpreted the statement as

intended then the results indicate that nurses should wear

the same type of clothing, irrespective of grade. It would

have been interesting to see whether the results would

have been consistent if Statement 3 had been presented

prior to Statement 2. It is possible that the group has

interpreted the statement accurately as they have already

indicated a preference relating to nurses' clothing in

respect to other professionals and the public.

Statement 4: Ìt is not important to be able to recognize

the Sister in Charge by the clothes that she wears'

Over 60% of the sample disagreed with this statement. The

need to identify the sister indicates that families still see the

sister as having responsibility for the care of the patient and

the nurse as carrying out sister's instructions. The

implication is that families are operating on a hierarchical

responsibility structure, in which the sister has responsi-

bility for the care of their child rather than a named nurse

under the auspices of the `Patient's Charter: Services for

Children and Young People' (Department of Health,

1996). Uniform may serve to perpetuate this outdated

mode of nursing, but parents want to be able to make this

distinction. It may be possible that those still seeking to be

able to identify the sister have not understood the concept

of the named nurse in family-centred care. The concept

may not have been conveyed clearly to parents, or they may

not have con®dence in the named nurse concept because of

the history of stereotyping of the nurse/sister relationship.

The implication therefore is that the public has a limited

understanding of the professional role, autonomy and

responsibility of the individual nurse: the stereotype of

handmaiden continues.

ATMOSPHEREATMOSPHERE

Statement 5: `The clothing that nurses wear should

promote a relaxed, clinical atmosphere'

The results of Statement 5 indicate that families wish

nurses to promote a relaxed atmosphere by the clothing

that they wear. Altogether, 90% of respondents agreed or

strongly agreed with the statement that clothing should

promote a relaxed clinical atmosphere.

The context of the term àtmosphere' relates to an

environment in which therapeutic relationships can be

promoted. In the past, the stereotypical hospital has been a

clinical, hierarchical, authoritarian institution run by

doctors and administered by servile ranks of nurses

(Davies, 1995). Such a culture may have contributed to

the fear of hospitals that appears commonplace in society.

The nursing profession has been attempting to alter this

perception, particularly where children are cared for, by

promoting models of care involving partnerships with

children and families (Casey, 1988). The aim is to create a

relaxed atmosphere in which families feel able to play an

equal role with nursing staff in caring for children in

hospital. This can only be achieved by developing

complementary relationships between staff and families,

which will be in¯uenced by the presentation of health care

professionals.

Rowland (1994) also supports the view that uniform can

affect the atmosphere of a relationship, and found that

traditional uniform was favoured for clinical tasks but that

the development of a therapeutic relationship was en-

hanced by a more casual uniform. Similar studies with

children have produced a variety of results. Meyer (1992)

found that children preferred to be cared for by nurses

wearing smock tops, and that they were frightened by

traditional uniform. Barrett & Booth (19444 ) assessed

children's preferences for doctors' uniforms, and found

that formal dress represented competence and was reas-

suring, whilst casual dress was seen as denoting friend-

liness and gentleness.

It can be seen from the literature that different styles

of dress meet different needs. Healthcare professionals

are perceived as more friendly when wearing casual

clothes, and this seems to contribute to the development

of a relaxed environment. However, more formal dress

carries with it an aura of competence and can instil

con®dence.

The results from Statement 5 raise the issue of whether

nurses aiming to produce a relaxed atmosphere can also be

assessed by their patients as being ef®cient. This has been

considered in previous papers; Kucera & Nieswiadomy

(1991) found that patients preferred traditional uniform

when a nurse was performing nursing care, but that when

ful®lling a counselling role a less clinical uniform was

considered appropriate. Rowland (1994) concurred with

these ®ndings in a general practice environment. It

appears therefore that traditional uniform is expected

during clinical procedures yet may act as a barrier in

developing nurse±patient relationships. Marr & Matthews

(1993) found that uniform was preferred because it created

an atmosphere that was military, organized, respected and





Figure 2 Questionnaire ®ndings.10



promoted con®dence in the wearer. Franzoi (1988)

showed that uniforms were expected to promote an

atmosphere of competency, order and organization rather

than to enhance personal relationships. The sample

population was not children orientated, but similar views

were found within such an environment. Livingstone

(1995) found that children and parents preferred tradi-

tional nurses' uniforms; they may allow children to feel

more comfortable because they recognize the stereotypical

presentation of the nurse. Glasper & Miller (1992) found

that parents may have greater con®dence in uniformed

nurses, because of historical socialization, despite uniform

creating barriers in the development of the family±nurse

relationship.


re¯ect that of an authority ®gure'

This statement deals with the issue of presenting a

clinically ef®cient nurse as opposed to an approachable

nurse with whom the families can develop a therapeutic

relationship. A signi®cant minority wished for an author-

ity ®gure (39% of the sample agreed or strongly agreed

with the statement that clothing should re¯ect an author-

ity ®gure). Extending the statement to which type of

atmosphere was required for clinical procedures as

opposed to discussion may have produced further data

that developed the ®ndings of Rowland's (1994) study.

A large minority (39%) did look to the nurse to present

an authority ®gure, which again may re¯ect stereotyping

of the nurse to instil con®dence. The development of

family participation in care seeks to promote the nurse as

an approachable ®gure, and expansion in understanding of

participation for consumers of health care will hopefully

see a greater acceptance of the nurse as a partner in care

rather than provider of care to passive recipients.

Another characteristic of uniform is the authority and

power it gives regardless of the actual role of the wearer.

Bamford & Sparrow (1990) found that uniforms did not

immediately create an awareness of grade of staff but

rather produced in patients a sometimes inappropriate

level of con®dence and competence in the wearer. Glasper

et al. (1991) reiterated this from the viewpoint of the

nurse, stating that uniform is used to gain authority and

increase the con®dence of nurses and particularly stu-

dents. Bischof (1995) suggests that uniform can aid

compliance by conferring legitimacy. Thus children may

permit activities which are uncomfortable or normally

taboo if performed by a doctor wearing a white coat, since

this is the uniform they expect to see. This argument may

be extended to justify the use of nurses' uniforms.

Con®dence in the professional, assessed by uniform,

may be inappropriate. Leventon (1989), reporting anec-

dotally from the view of the lay carer, found that uniform

produced a false sense of nurses' abilities, because

although nurses were differentiated by the colour of their

dress their rank was not. It was only by experience,

through long-term support by `nurses' in the generic

sense, that the carer was able to distinguish the compe-

tencies associated with the various coloured uniforms.

Dring (1987) states that nurses should be aware that it is

unacceptable to assume authority through wearing a

uniform in an environment in which nurse and patient

should be working in partnership. However, it is certainly

possible that uniform is used as a tacit method of control;

removal of traditional uniform may reduce this acceptance

of misplaced authority and enhance the therapeutic

relationship (Rowland, 1994). In conclusion, it could be

proposed that lay people see uniforms as enabling

differentiation of rank and profession; however, there is

inappropriate understanding about roles and this may lead

to conferring legitimacy that may not be justi®ed.

COMMUNICATIONCOMMUNICATION

Statement 7: `The choice of nurses' clothing should

create an informal situation'

The sample wanted an informal situation: 71% agreed/

strongly agreed with the statement.

Statement 8: À casual style of uniform makes people

feel insecure'

A total of 59% disagreed/strongly disagreed with the

comment that uniform makes people insecure.


help them to seem friendly'

Of these respondents, 93% agreed/strongly agreed with

clothing helping the nurse to seem friendly.

Comparing the results from Statements 7±9 with those

of Statements 5 and 6 suggests that although patients

require an atmosphere that instils con®dence in the

effectiveness of the practitioner, parents and children are

also looking for an informal, friendly environment in

which they feel secure and con®dent. Families require an

environment in which barriers to communication are

reduced and a successful partnership can be developed for

the bene®t of the child and family.

An atmosphere of equality and approachability is

espoused by children's nurses, with the aim of providing



an appropriate environment in which to develop a

therapeutic relationship with families. This therapeutic

relationship is common to all areas of nursing and has been

shown to be enhanced by removal of traditional nurses'

uniform in favour of ordinary clothes or more casual

uniform (Glasper & Miller, 1992). The abandoning of

nurses' uniforms removes a barrier to communication,

thus nurturing the development of a bene®cial relationship

(Coombes & Heilman, 1993). This phenomenon was ®rst

highlighted in psychiatric nursing and continues to be

used in the mental health ®eld, although questions have

been raised about the validity of the research techniques

used to study this (Smith, 1990). There seems to be a

degree of agreement among healthcare professionals that

communication is improved by the absence of uniform,

and that uniform acts as a barrier to effective communi-

cation (Castledine, 1987; Tiffany & Sparrow, 1987;

Davies, 1995). The effect of uniform on communication

is also recognized by clients of healthcare; Leventon (1989)

regards it as a barrier to effective communication, which

fosters dependency on a uniform per se rather than

establishing con®dence through a relationship with the

professional beneath the uniform.

A separate question was included on the questionnaire

about speci®c uniform preferences. The majority of the total

sample preferred polo shirts (57%). However a signi®cant

minority (32%) preferred the old style of uniform.

Implications for nursing

Following analysis of the results, nursing staff in COPD

changed their uniform to polo shirts, with different

colours of shirt denoting different grades of staff. This

decision was considered consistent with the ®ndings of the

study.

The need for families to identify nurses could be

perceived as simply related to stereotypical images.

However, as previously discussed, the interviews revealed

that this seemed more related to issues of communication.

This supported the ®ndings of a number of key workers

(Castledine, 1987; Tiffany & Sparrow, 1987; Coombes &

Heilman, 1993; Davies, 1995). There was a strong

consensus that all nurses should wear the same kind of

clothing. If children's nurses decide to wear polo shirts

this means that there is potential for the stereotype to

change (Stewart et al., 1979) and for this to become the

new uniform in the eyes of the public. The stereotype of

the nurse consists of an authority ®gure ®rst and

foremost, and an approachable ®gure second (Sparrow,

1991). Our ®ndings indicate that families reverse this

view, and prefer nurses to be approachable ®rst and

authority ®gures second. Again this may imply that there

is a potential for the image of the nurse, as represented by

uniform, to be changed, thus in¯uencing the stereotype

(Stewart et al., 1979). This is echoed in our results by the

need for nurses to create an informal situation through

what they wear.

It has been suggested by some of the nurses in this

study, and elsewhere, that a casual style of uniform leads

parents to feel insecure. Our results seem to refute this

notion and may even suggest the opposite view, that a

more casual style of uniform can actually instil con®dence

in families. These conclusions would support Leventon's

(19895 ) view that uniform hinders the development of a

con®dent relationship. Participants in this study were

concerned that the image of children's nurses should be a

friendly one and this would seem to be closely linked with

issues of approachability.

There has been a general change in the uniform of

children's nurses in recent years, based on the rationale that

it is important to produce a more child friendly environ-

ment. Many children's wards have adopted a casual style of

uniform including polo shirts, use of child-orientated

materials in uniform or wearing ordinary clothes. This

mood of change, however, has not been captured by the

media, which is generally recognized as a major factor in

forming stereotypes. The media still present the nurse in

traditional uniform in advertising, the press and popular

television programmes. Until the media recognize the

changing uniforms and roles of nurses, other forms of direct

education are needed in order to help the public update their

schemata in relation to nurses' uniforms, nurses and the

environment of care in which they work (Kucera &

Nieswiadomy, 1991). It is the responsibility of every nurse

to present to the public a professional, therapeutic and

supportive image that is projected by behaviour rather than

relying on the nature of the uniform that is worn.

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Documents

The image of the children’s nurse: a study of the qualities required by families of children’s nurses’ uniform