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A uniform approach

January 7, 2013

TwitterI committed to writing this blog following a Twitter conversation on the wearing of uniforms and nursing staff.  Although the conversation started with a focus on district general hospitals it moved on to discuss mental health hospitals and touched on community working. It was part of a larger conversation on nursing, some of which can be read on Storify here.

Firstly a quick google and dictionary search:

  • A uniform is a type of clothing worn by members of an organization while participating in that organization’s activity.
  • The use of uniforms by these organizations is often an effort in branding and developing a standard corporate image but also has important effects on the employees required to wear the uniform.
  • The distinctive clothing worn by members of the same organization or body or by children attending certain schools: Oxfords


Here’s a few tweet-bites from midway through the conversation

@anniecoops: @UHCW_ChiefNurse I agree. I know this is an age old argument too but my husband goes off on one about uniforms – he cant tell who is who.

A perspective that came up regularly during the public and staff national uniform consultation across Scotland.

@UHCW_ChiefNurse: Wales and Scotland now have national uniform – does that help?

National uniform

National Uniform NHS Scotland

National uniform Wales

National Uniform NHS Wales

@UHCW_ChiefNurse: of course – uniform symbolises many things

@AgencyNurse: I like the idea of a national uniform – great sense of pride and identity

@anniecoops: I think so, am a fan, but its probably unaffordable? Scale etc

@NorthwayRuth: Wales has a national uniform. However not appropriate for all nurses to wear uniform. Not all nurses work in hospital

@BPotter38: Agree not suitable for all nurses.1 example would be CPN’s #stigma #mentalillness

Although I had planned to include comment on this topic in the blog, it was already fairly long so I’ve not covered community.  Suffice to say I think there are differences and this needs actively considered

@Sammij40: But less confusing than MH services where no-one wears a uniform.

@TildaMc: Is not wearing a uniform adding to stigma of MH?  If professionals can’t be open how can public?BPotter38: Agree not suitable for all nurses.1 example would be CPN’s #stigma #mentalillness

@dtbarron: I think that MH nurses should wear a uniform in the ward

@UHCW_ChiefNurse: is that to protect them emotionally or something else?

@dtbarron: Multifacitated – worthy of further discussion I think

@dtbarron: We have a national uniform policy – why would MH be excluded?

Inverse stigma

If we start from the position, which we do in Scotland, of having a national uniform the question I would ask is why would MH nurses be excluded?  I don’t buy the stigma angle – ‘wearing a uniform stigmatises those with whom we share care’; .. hmm, in what way?

Let’s be honest – there is a power differential in the ward setting, are we seriously expected to believe that the lack of a uniform rebalances this or that the existence of a uniform increases the power and stigma?

How many staff ask the service users on the ward ‘can I go for my break now?’, yet we set general mealtimes for those on the ward.  Access to your smartphone – read this blog by @victoriabetton and @chaosandcontrol then tell me the uniform is making the difference, it’s why ‘confiscation’ happened.  How many nurses have been physical restrained from leaving the ward at the end of their shift, by service users saying “no, your not well enough to go out?”  How many nurses have been told by services users ‘I’m detaining you for up to two hours or until the doctor assesses you, as I think you are unwell and need to stay in hospital’? (nurses holding powers under the Scottish MH Act).

Setting apart

Now, let’s return to the stigma of wearing a uniform?  “Stigma is the extreme disapproval of, or discontent with, a person on the grounds of characteristics that distinguish them from other members of a society. Stigma may attach to a person, who differs from social or cultural norms” (Wikipedia).

Wearing a uniform somehow sets one person apart from another within the ward setting?  No, the role we play as nurses sets us aside, not because we have a uniform on.  The fact we can access all the areas of the ward, the fact that we have certain duties, responsibilities and account abilities, that’s what sets us aside – the how we choose to carry out those duties determines the impact we have on those with whom we share care as partners.

So, again let’s ask the question, if we have a national uniform policy why would mental health nurses working in a ward setting be excluded?  Isn’t the greater risk that we invoke an inverse stigma by wanting to stand out as different, somehow mental illness isn’t a real illness so we should dress differently?

@dtbarron: I think nurses tend to hide behind the therapeutic relationship

@dtbarron: I’m so against ppl using it as an excuse about engagement

@dtbarron: I think it’s a false argument about breaking down barriers

I’ve unfortunately heard this one rolled out when people don’t want to wear a uniform.  So, the underlying assumption here is that what I wear can determine how therapeutic I am, or perhaps how approachable I am. By wearing cut jeans and a tee-shirt I’m the greatest therapist in the world, I can make better connections to the service user on the ward – I don’t think so!

A uniform is not a barrier to engagement, you, the nurse are who the person wants/needs to engage with, not the uniform.  How you approach the interaction, what happens during the discussion, how you listen, how you respond – that’s what makes the difference, not the presence or absence of a uniform.

Identifying the nurse

When I worked in the wards it was very clear I was a nurse, service users, families and carers approached me to talk to me BECAUSE I was a nurse, not because I was wearing something they approved or disapproved of.  What I am wearing has never impacted on my ability to engage with service users, to share with them deeply personal events, fears, hopes and aspirations they have brought to discuss, or that we have discovered, that are impacting on their wellbeing.

As a mental health nurse the uniform isn’t the symbol of your ability to support someone in their recovery; you are!  The person you are, your knowledge, your skills, your compassion that’s what matters.

20 Comments leave one →
  1. January 7, 2013 9:29 am

    Hi, just wanted to share an aspect of mental health working that I think is important.

    When we work on wards, part of our role includes going out into the community. We might take someone home to get clothes, or we might be going out for a therapeutic visit or walk. We might also be going out to persuade someone to return to hospital after an absence. Whilst I agree with a lot of your thoughts above, stigma for people who have been resident on mental health wards is very real. Do people want to turn up at home with ‘uniformed’ nurses? How does this add to or detract from social stigma experienced by people who have spent time as in-patients?

    Community nurses will practice in the community, and may meet people in cafes, libraries, community centres as well as their homes. Does wearing a uniform assist with social integration of people with mental health histories, or detract from it?

    Additionally, one of the important aspects of wearing uniform is infection control, but mental health workplaces don’t often have staff changing areas, so people would travel to work in uniform. At every physical health setting I have worked there have been clear guidelines to change once arriving at work to avoid the risk of cross-contamination via clothing. How would this work in practice?

    I do, however, recognise that on wards it can be confusing for people to identify staff, and that uniforms can help with this. Like you, I don’t believe the therapeutic relationship is adversely affected by uniform wearing.

    What do you think?

    • January 7, 2013 8:23 pm

      Claire, thanks for your comments and valid points. In some regards the argument is a point of principle rather than one that is always practical at this point in time. There are some hospitals (MH and DGH) that have no onsite staff changing facilities, a poor reflection on our approach to staff care and physical wellbeing given that we are creating difficult for staff who may wish to walk, jog or cycle to work but then cannot get changed for duty – however I digress.
      I am not convinced that community MH nurses (or for that matter O/Ts) should be wearing a uniform when undertaking community tasks – you are correct in that this community aspect is part of the normalisation process, as such our role is to be there as guide, support and on occasion as assessor of the individual undertaking or being involved in day to day activities, probably best done when we are not ‘standing out’ as healthcare workers. Why do I think that? Probably, being pragmatic, because I recognise that stigma still exists in society – would anyone think twice if an O/T or stroke nurse was assisting someone mobilising? I think not, so my response is tinged with sadness that stigma is still a daily reality for some. I think being on the ward is different – its hardly what I would term the normalisation process. Hospital is not a ‘normal’ place to be, whether that is a MH hospital or a DGH, if I had my choice I wouldn’t be in either.
      Infection control – spot on with this observation about the need for MH staff to engage fully with infection control processes, to protect those on wards and themselves/their families. In the recent outbreak in Novovirus our MH wards were not immune. In the new MH hospital we are in the process of designing there will be staff changing areas built in from day one – it is 2013 after all! Thanks for taking the time to comment on the blog, much appreciated. Derek

  2. @maidenturret permalink
    January 7, 2013 10:14 am

    Thanks Derek. I always find the ‘uniform’ debate polarises opinion. I usually sit on the fence, but I disagree with your argument.
    What is the purpose of uniforms? Yes there’s a corporate/professional image/identity argument, but the main focus in hospitals is practical considerations – moving and handling, body fluids, infection control etc.
    I find it interesting that medical staff don’t usually wear a uniform, while all other professionals do. While I agree that a uniform is no measure of ability to engage/ communicate with people, I would happily get rid of uniforms if practically possible. I would argue that uniforms are a ‘barrier’, which demonstrate that we still cling on to our institutional identidities. Surely we should be ‘normalising’ interactions if we are serious about therapeutic relationships. I have no real experience of mental health wards, but have always felt they should be as ‘homely’ as possible and de-clinicalised. Non- verbal communication so important.
    I’m not familiar with the evidence base in mental health, but I know that on the adult in-patient side, patients still wish to see nurses and others in uniform (belts, hats, American tan tights etc – that just the men lol!). We do have to listen to the public, but my personal view remains – get rid where ever possible!

    • January 7, 2013 9:29 pm

      Andrew, thanks for your response and not sitting on the fence I appreciate you voicing your disagreement with me, however I’m not entirely clear on which aspect you are disagreeing, so I’ll try to answer what I think you are disagreeing with and you can correct me.
      We seem to agree on uniforms re corporate identity, professional image and infection control and we agree that uniforms are not a measure of ability to communicate with people. We don’t seem to agree on the ‘barrier’ aspect, however you stated that uniforms don’t measure ability re engagement with people – I’m unclear therefore which aspect is the barrier. Medics in MH used to wear a uniform, it was a white coat!! fortunately we have moved well away from that these days.
      I disagree that MH wards should be ‘homely’ and ‘de-clinicalised’ – on the basis? People admitted to wards are there for treatment, what makes their treatment any less deserving of high quality clinical care? Inherent in this approach is the non illness aspect of MH – if you are admitted to a surgical ward you get the uniform, environment and a situation focussed on getting you out of hospital at the earliest opportunity that is safe to achieve (after all hospitals are NOT a normalised environment for anyone). However your suggestion is that in MH we admit you to a homely environment, because after all you are not really ill? If someone is ill, then why do they deserve anything less?
      The basis for the blog was a question around equality of approach – is it stigmatising to exclude MH from the national uniform policy? I still maintain it is, we are there as clinicians, we have a clinical/therapeutic role to undertake in caring for and working with those admitted to our wards – I think the underlying ‘not requiring a uniform’ is an unnecessary approach in not recognising someone’s illness and treating it as such i.e. an illness. I however respect your view and that it is different from mine, its only by sharing and exploring views and opinions that we continue to learn and develop. Derek

  3. tiltic permalink
    January 7, 2013 9:12 pm

    Thanks for your blog on this topic.I wear the Scottish national uniform in a ward setting. Despite constant moaning, wishing to win the lottery to jack it in and
    subject to almost constant media negativity I am proud of being a nurse and grateful to be able to wear the corporate logo of NHS Scotland ,god forbid we ever have to wear Virgin care or any other “providers” logo. As I tweeted last night I feel the Mental Health approach of protecting patients from social stigma may be reinforcing that stigma. Separate casenotes is another bug bear. If I have a patient who has had any contact with other acute services I have access to their medical history. I can review previous care and this background information can assist in their current admission. yet a whole chunk can be missing if they have had Mental health problems a special request has to be made for those notes.

    • January 7, 2013 9:50 pm

      Tiltic, thanks for your comments here and on Twitter. It was your original observation/question on Saturday that spurred me to writing this blog, so thanks for that as well.
      I’m delighted that you are proud to wear the national uniform that says you are a nurse in NHS Scotland – to be honest most of our nurses are fabulous, caring and compassionate individuals.
      I understand your frustration re MH clinical records and general health clinical records – however I’m not sure I completely agree with you for a few reasons. Firstly, in the Board you work all the notes are not all amalgamated across the ‘acute’ services. When I worked in that particular Board (where I’m still a patient) my notes could be in four or five different sets of paper records depending on which hospital I had been admitted to during my life. The MH records are similarly dispersed across numerous areas of the city – psychology notes are separate from nursing notes which are separate from medical notes and on occasions AHP notes are again separate. So which set of notes should be amalgamated?
      I recently carried out an inspection visit (outwith MH) in my own Board, on the DGH ward there were medical case notes, nursing notes and careplans and separate AHP notes for physio and occupational therapy – this was on one ward! Lets not even start down to A&E that most likely have a different set of notes.
      The only way this will ever be resolved is when we have full electronic records – but that brings a different set of issues related to confidentiality and appropriate access to deeply personal information that may be recorded therein. In NHS Ayrshire & Arran all nursing records are electronic, the medics record in the electronic system and all clinical letters are uploaded to the system – this is available 24/7 by MH staff, who are also available 24/7 in community, in A&E or in any of our hospitals.
      No-one said it was going to be simple. Thanks for your comments – if you do win the lottery, spare a thought for us, your ex-colleagues 🙂 . Derek

      • tiltic permalink
        January 7, 2013 10:24 pm

        Thanks ,agree about the complex nature of casenotes. Sure you didn’t visit my ward . Co-morbidities certainly present lots of challenges. Hope technology spreads northward quickly . I will add you to my “who gets what ” list

      • January 7, 2013 10:47 pm

        Thanks for adding me to the ‘who gets what list’ – every little helps. I don’ think it was your ward I was visiting or at least not since I left there in 2007.

  4. Ailsa Rayner permalink
    January 7, 2013 9:44 pm

    In the mental health unit here only the security guards and wards staff (orderlies/cleaners) wear uniforms. The nurses look like one of us and could be. They wear ID tags on lanyards with two break points or clips to their belts. This is a practise, wearing civvies, that reduces the power differential. The student nurses do however wear uniforms and this serves the purpose of distancing.

    • January 7, 2013 9:58 pm

      Thanks for the comments Ailsa – it always welcome to hear the views of others. I’m still not of the opinion that the uniform is what creates the power differential, but that’s the joy of sharing, each has a equally valid perspective and while we always listen, we don’t always need to agree. Thanks Derek

  5. June brown permalink
    January 10, 2013 9:54 pm

    LD nurses historically and I’m generalising don’t wear uniform as it symbolises ‘power’ over the person they are supporting. This opinion held from long stay institution days. Recent MLDN co-production group interestingly had a view there were benefits of nurses wearing uniform. Identify nursing staff, feel safer, feel confident in nurse etc. think we should ask the people we provide care to their views!

  6. January 14, 2013 12:49 pm

    Interesting blog, David. I’m an ex nurse (not practiced for years) and one that didn’t practice in MH. I trained in a very traditional hospital (one of the last generation of hospital based training) and it was drummed into us that if we were seen out of the hospital in our uniform, it would be regarded as a disciplinary offence. They did have changing areas. So today when I see nurses / carers out in the uniform when not on a caring duty (ie out shopping) – I have a little shiver of *eww* with regards to cleanliness / infection control thinking.

    When we did the psychiatric part of our training, we all wore mufti. If I was a patient in that setting, I don’t think I’d like to be supervised by someone in surgical scrubs but would like to be treated by someone who was distinctively (ie visually) part of the ‘staff’. But that’s me – I tend to get confused by faces especially when stressed and so – plus I’d appreciate the barrier that the uniform would create.

    • January 14, 2013 7:33 pm

      Thanks for the comments and thoughts on uniforms – like you I personally would prefer to have staff who are working with me to be in uniform, I’ve never seen. It as a barrier within an inpatient setting. The only thing I’d say re uniforms is that our nurses don’t wear scrubs, we have a national uniform which they must wear, which in a way is how this blog started. Thanks for taking the time to read and comments. Derek

  7. February 10, 2013 10:20 am

    I’m late to this Derek but here’s something slightly tangential.

    I recently heard the proposition that what we wear is part of a ritualisation process.
    If we have learnt to do something whilst dressed in a certain manner it is part of the recognition patterns that get formed in out brains which are associated with performing that role.
    When we need to perform that role again, the process of pulling on ‘the uniform’, brings those patterns of memory closer to the surface and you are able to perform the role easier.
    That’s the idea behind it.
    I’m not a nurse (though I have spent 25 years living with one) but it does seem to work for me.
    Apologies if this seems a trivial example but when I’m buying bricks and timber at the builders merchant I am always much more effective at getting a decent price if I turn up in my yellow high viz coat and work boots than a suit on my way home from work.
    Site work was a significant part of my younger life and putting on the ‘uniform’ from that time enables me to function more effectively in that environment.
    That’s almost as long as one of my posts.

    • February 11, 2013 1:00 am

      Good point Chris – I agree that putting on the uniform, can and does help us play the part the uniform signifies. I’ve never seen it as a barrier, indeed you example shows us the impact a uniform can have, on both the person wearing it and those around them – in a positive sense of belonging. Power in that setting isn’t always a negative proposition. Thanks for the comments. Derek

  8. March 30, 2013 5:25 am

    Good blog & I agree your Healthcare Uniforms relate post.


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