Analysis

Patients are confused by inconsistent nurses’ uniforms – and they’re not alone

Why nurses favour a UK-wide standardised uniform that makes clear who does what

Why nurses favour a UK-wide standardised uniform that makes clear who does what

  • Scotland, Wales and Northern Ireland have all introduced national or regional uniforms for nurses in NHS roles, but England has yet to
  • Four out of five nurses support the introduction of a standardised uniform across all four countries, Nursing Standard’s image of nursing survey suggests
  • Some respondents say their ‘nursing’ uniforms are worn by cleaners or carers at other trusts, or aren’t fit for purpose in modern nursing roles
he Scottish national nursing uniform uses different shades of blue to differentiate between roles
The NHS Scotland national uniform uses different shades of blue to differentiate between clinical roles

The plethora of NHS nursing uniforms is confusing for patients and staff, leading eight out of ten nurses to back a UK-wide standardised uniform, a Nursing Standard survey suggests.

2009

The year a national nursing uniform was introduced in Wales

Colour-coded national nursing uniforms are in place in the NHS in Scotland and Wales, while region-specific nursing uniforms exist in Northern Ireland.

Yet there is no standard NHS nursing uniform in England, leading to wide variation between organisations.

And Nursing Standard’s image of nursing survey has uncovered examples of nurses wearing uniforms identical to those worn by cleaning staff at nearby trusts.

One nurse admitted: ‘As a community nurse, I get mistaken for a Tesco worker a lot.’

Responses to Nursing Standard's image of nursing survey 2019
Source: Nursing Standard’s image of nursing survey 2019

 

Existing uniforms don’t make clear roles or seniority

More than a quarter (28%) of the 2,054 nurses who responded to our survey said they did not believe their uniform made it clear they were a nurse.

Many nurses who responded said the multitude of uniforms caused confusion for patients, visitors and colleagues alike.

‘I worked in one trust where a light blue uniform was worn by cleaning staff, yet the same colour was worn by student nurses in another trust where I worked’

Survey respondent

‘I am a matron in one trust, the cleaners in a neighbouring trust wear the same uniform as me,’ said one.

Another commented: ‘My nurse uniform is the exact same as my friend who is an occupational therapy assistant.’

But others said they thought their uniform made them easily identifiable.

‘I think the uniform makes it clear that we work in care, be that as a carer or nurse,’ said one.

Another said: ‘I think people know I am a nurse, but which specialty, grade or experience won't mean a thing to them.’

In Wales, different coloured uniforms are used to identify different nursing roles
Wales’ different-coloured nursing uniforms identify different roles Picture: ​​​Jay Williams

Most nurses support UK-wide standardised uniforms

Some 82% of nurses who responded to our survey are in favour of a UK-wide standardised uniform, while 18% are against.

37°C

The peak UK temperature when Gloucestershire Hospitals NHS Foundation Trust relaxed its uniform policy for staff during the 2018 heatwave

In 2009, Wales introduced a national nursing uniform, using different colours to identify healthcare support workers, nursing students, staff nurses, ward sisters and nurse consultants.

Regional uniforms for nursing staff within the Health and Social Care service in Northern Ireland were rolled out in 2011.

Since 2012, NHS Scotland staff have worn a national uniform, with different levels of clinical staff wearing different shades of blue. A burgundy uniform for clinical nurse managers has now also been introduced.

Our survey findings echo concerns raised in an RCN congress debate in 2019, in which a number of nurses said patients, their families, staff and students were confused at the number of different uniforms across health settings in England.

Causes confusion among patients and visitors

One survey respondent says standardised uniforms across organisations could ‘save much confusion among patients and visitors’, who often have trouble distinguishing between healthcare professionals.

‘I worked in one trust where a light blue uniform was worn by cleaning staff, yet the same colour was worn by student nurses in another trust where I worked,’ they said.

Another said: ‘It is really annoying that care agencies adopt the same uniforms as nurses. My uniform has my name and title embroidered on it so it is easy for people to identify my role.

‘It is frustrating seeing carers walking around in the traditional navy blue with white stripe uniform commonly identifying a band 6 nurse.’

Outdated stereoptypes and #WhatNursesWear

Barts Health NHS Trust senior sister Jessica Anderson wanted to attempt to be the quickest woman to run a marathon dressed as a nurse
Jessica Anderson’s London marathon
run prompted a U-turn from Guiness
World Records on what nurses wear
Picture: Instagram

Nurses’ uniforms hit the headlines in 2019 when an NHS nurse was told her London Marathon world record attempt would not count unless she was wearing a skirt.

Barts Health NHS Trust senior sister Jessica Anderson wanted to attempt to be the quickest woman to run a marathon dressed as a nurse when she ran the 26.2-mile course last April wearing scrubs with trousers.

She crossed the finish line in a record 3.08:22, but had been told by Guinness World Records that her record would only count if she was wearing a skirt.

‘Must include a nurse’s pinafore and cap’

Guinness World Records said scrubs were too close to its fancy dress requirements for a doctor’s uniform. Its rules meant a ‘nurse’s uniform’ must include a blue or white dress, a pinafore apron and a traditional nurse’s cap.

Amid a wave of support from the profession and the birth of the hashtag #WhatNursesWear, Ms Anderson was later awarded the record, in a Guinness World Records U-turn.

In a statement at the time, the organisation's senior vice-president Samantha Fay admitted its guidelines were ‘outdated, incorrect and reflected a stereotype [it did not] wish to perpetuate’.

 

Queen’s Nursing Institute chief executive Crystal Oldman says a national NHS uniform may not always work in community settings
Queen’s Nursing Institute chief
executive Crystal Oldman

Difficult to distinguish nurses from care workers in the community

Queen’s Nursing Institute (QNI) chief executive Crystal Oldman says the issue is wider than hospital trusts and presents a real challenge for nurses working in the community in England. 

‘The challenges of identification are heightened by care services having very similar uniforms to the district nurses and staff nurses who provide nursing care in the home,' she says.

‘This makes it very hard for people receiving health and social care to distinguish the nurses from care workers.’

Some survey respondents pointed out that members of the police, fire and ambulance services are easily identifiable irrespective of location.

‘We have standardised police, fire service and paramedic uniforms,’ said one respondent, ‘so why not for other allied health professionals as well?’

‘We have standardised police, fire service and paramedic uniforms – so why not for other allied health professionals?’

Survey respondent

A district nurse on her rounds in Rotherham in 1965
A district nurse in uniform on her
rounds in Rotherham in 1965
Picture: Rotherham Adviser

Harder to implement in community nursing

Dr Oldman says a standardised uniform might add something by helping patients better understand who is delivering their care, and the seniority of the registered nurse, sister, charge nurse or matron. ‘Plus, of course, professional pride for the nurses themselves,’ she adds.

However, she points out this would be harder to implement in community nursing, where there is a far higher proportion of non-NHS nurses.

3.08:22

Scrub-wearing senior sister Jessica Anderson’s Guinness World Record-making time in the 2019 London Marathon

‘A standardised NHS uniform in the community could exclude organisations delivering NHS contracts, such as Virgin Care or community interest companies and social enterprises.

‘Then there are all the care homes and the GP practices.’

For others it is not just the look, but the fabric of nursing uniforms that needs to be addressed (see box below).

‘My sister, who is a fashion designer, thinks the uniforms need a major update, with modern materials instead of that stiff polyester and unflattering style,’ said one respondent.

Artist Louise Clifford's 2016 interpretation of what a modern nursing uniform should look like
Artist Louise Clifford's 2016 interpretation of what a modern nursing uniform should look like Picture: Louise Clifford

A nurse’s uniform fit for the 21st century

Nursing staff attending RCN congress in 2016 debated what a modern nursing uniform should look like. Artist Louise Clifford listened to the debate and captured the results of the discussion in water colour.

Key points included:

  • A coloured stripe around collar, cuffs and down trouser legs to show hierarchy/role
  • Epaulette to keep things smart and help with identification
  • Full, covered front-zip fastening top – so if you get something unpleasant on your uniform, you don’t have to drag it across your face to remove your top
  • Trousers with a toggle to adjust the leg length – no more damp hems after assisting with showering
  • Pockets are a must, but they need to be at chest rather than hip level to prevent staff catching themselves on pens when they bend over. 
  • Breathable fabrics that repel water
  • Comfortable, waterproof footwear – for example, Crocs

Adapted from RCN article The Future of Uniform

 

‘Uniforms perpetuate the power differential between care professions’

Others told our survey they against the idea of nursing uniforms altogether.

‘I do not see the relevance of uniform – it is only worn to highlight the subservience to the medical profession’

Survey respondent


Picture: Royston

One respondent said: ‘The uniform harks back to an 18th century serving maids’ uniform and perpetuates the power differential between care professions.

‘Uniform should be locally set up to serve needs such as infection control. 

‘A national uniform would push advanced nurse practitioners and senior nurses into uniform and perpetuate the treatment of nurses as being inferior to medically trained staff, even where they are doing the same job.’

Another respondent commented: ‘I do not see the relevance of uniform – it is only worn to highlight the subservience to the medical profession.

‘Break the shackles, if no uniform is okay for doctors, then it is okay for us.’

What did early nurse’s uniforms represent?

University of Manchester senior lecturer Jane Brooks, writing in the Women’s History Review (2007), explains that, well into the 20th century, many of the rules for a nurse’s uniform conformed to Victorian ideals.

‘In the 19th and early 20th century, nurses were encased in corsets and, depending on the codes of the day, broad skirts with many petticoats or long, slimline skirts,’ she writes.

‘Along with high collars, long sleeves and cuffs, the uniform codes provided an absolute boundary between the body of the nurse and that of her patients and male doctors, whilst at the same time exemplifying her womanliness.’

‘Dresses must be made quite plain, bodices with a little fullness at the side... skirts 10 inches from the ground’

Nurses’ uniform dressmaking instructions, Guy’s Hospital, London, 1932

A Nurses' Supply Association advert for the latest in nursing uniforms in 1913
A Nurses’ Supply Association advert ​​​​​​for
the latest in nursing uniforms in 1913

A 1913 memorandum issued by a matron from St Thomas’s Hospital in London, Alicia Lloyd Still, offers an insight into the significance placed on the nurses' uniform. It tells ward sisters that their nurses ‘shall be taught to realise, when on duty in the hospital, that they are representing a public institution, and treat with respect the uniform of the profession they represent’.

When nurses were expected to have their own dresses made

Speaking to Nursing Standard, Dr Brooks, a member of the RCN history of nursing forum, says England has never had its own national nursing uniform, and hospitals have always decided their own.

Despite this, certain conventions have become established and widely understood, such as that nurses wearing navy blue tended to be sisters. 

‘Up until the second world war, nurses would have been given the fabric and expected to get their own dresses made up themselves,’ she adds.

To this end, uniform instructions from Guy’s Hospital in London in 1932 demand that ‘dresses must be made quite plain, bodices with a little fullness at the side, sleeves an exact copy of the pattern [which was sent to all candidates], skirts 10 inches from the ground’.

Lack of protected status for ‘registered nurse’ title 

Dr Brooks adds that, in the past, it would have been clear from these uniforms whether someone was a registered nurse or ancillary staff member.

‘Back into 19th and early 20th century, cleaners [for example] would have been so obvious,’ Dr Brooks says. ‘On a ward there would be a ward sister, one staff nurse, then student nurses and a ward maid, and the maid would have been very obvious.’

She feels that the growth and proliferation of nursing support roles, and the lack of protected status for the title of registered nurse, could add to confusion for the public about nurses’ identity.

‘Especially if someone is called a “nurse” in their job title,’ she says, pointing out that many unregistered staff are given the title ‘nurse’. 

 


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