Who is the RN? Can You Tell?

Looking Back, Looking Ahead

Laura A. Stokowski, RN, MS   April 06, 2017

Before entering the locker room, a nurse approaches a large vending machine. After swiping his badge, he presses several buttons on a digital screen. He then removes a pair of correctly sized scrubs from a chamber below, ready to be donned for his upcoming shift. Before he is able to access the scrubs dispenser again, however, he will be obliged to return his worn scrubs to the cabinet, thereby maintaining tight control over the hospital’s scrubs inventory.

Scrubs dispensing cabinets, the latest technology in nursing apparel, are eons away from what the earliest professional nurses had to endure. Those nurses were also their own seamstresses and laundresses, making and laundering their uniforms by hand—a feat almost unimaginable today.

For as long as nursing has been a profession, it has had a dress code. In 1854, Florence Nightingale required nurses headed for the Crimea to wear identical outfits that comprised a grey tweed dress, grey worsted jacket, plain white cap, and short woolen cloak. Over their shoulders the nurses wore a sash embroidered with the words, “Scutari Hospital.”

Were these nurses overcome with pride to wear these new uniforms? Hardly. The Crimea nurses characterized their ill-fitting garments as “ugly” and “frightful.” Miss Nightingale hoped that the hideous uniforms would protect the nurses from the disorderly conduct of the wounded soldiers they would care for. Later, when she founded the Training School for Nurses at St Thomas’s Hospital, Nightingale’s probationers wore a simple brown uniform with white apron and cap.

The ploy of dressing women unattractively to fend off unwanted advances by male patients targeted a real problem. In her book, A Cultural History of the Nurse’s Uniform, Christina Bates portrays the nurse’s uniform as a necessity at a time when women were entering a male-dominated workforce. Few jobs were available to women, and none that required such intimate contact as touching, cleansing, and manipulating the human body, especially the male body. The early uniform, with its long sleeves; high neck; wide, floor-length skirt; and stiff bib, apron, and cuffs, was like armor—an impenetrable barrier between the nurse and the patient. Many nurse dresses of this era even had a longer train on the rear hem, so that it would cover the nurse’s ankles when she leaned over a patient’s bed. Like Nightingale’s Crimea nurses’ uniforms, the typical nurse attire of the late 19th and early 20th century did not invite, or even permit, improprieties.

Other than this, however, what was the point of dressing alike? After all, physicians of the time wore ordinary clothing, and still do. A few theories have been offered about the origin of nurse uniforms. One is that uniforms grew from the association between nursing and the military, with its heavy emphasis on uniforms to establish order, camaraderie, and rank. Another is that uniforms were a modification of the habits worn by the nuns who were the first women to assume the role of nurses. The truth might have been a little of both. In line with the military, a streak of discipline ran through the first nurse training programs, and like the religious orders, many early nurses looked upon their work as “a calling.”

But nursing was changing: It was becoming a profession with standards of education, practice, behavior, and dress all its own. It is possible that as nurses began to see themselves as trained professionals to be admired and respected, they wanted to set themselves apart from the untrained nurse class—the “fallen women” who were a little too fond of drink, and as likely as not to end up in the arms of a patient. In the mid- to late 19th century, the typical domestic servant’s attire was very similar to what nurses were wearing, down to the muslin cap perched on top of their heads.

The Museum of Nursing History at LaSalle University has one such uniform on display. It belonged to Alice Fisher, a disciple of Miss Nightingale’s, who emigrated to the United States in 1884 to start a training school in Philadelphia.

The similarities to what household servants wore slowed the widespread acceptance of uniforms for nurses. Initially, many of the women enrolled in the new nurse training schools were ambivalent about wearing uniforms, still associating them with the lower classes rather than the upward mobility they sought.  They warmed to the idea of uniforms when they saw a respected classmate wearing an attractive new uniform, and found that the public reacted positively to their neat professional attire.

During the late Victorian period, and well into the 20th century, nursing uniforms followed the fashions of the time, albeit some years behind. For example, typical female fashions, such as leg-of-mutton sleeves and laced corsets, shaped some nursing uniforms just as they did the dresses of fashionable ladies.

Inevitably, though, fashion took a back seat to practicality. Nursing uniforms had to support heavy physical, and often dirty, work, so they were compelled to incorporate elements of servant attire: plain, serviceable fabrics, and a lack of adornments.  The basic dress might be made of wool, linen, silk, or cotton, in a range of colors from drab greys and browns, to lighter shades of blue, green, and pink. Hospital training schools often went to great lengths to find a distinctive fabric for uniforms that would identify the wearer as being associated with their institution.

Concessions were also made to the realities of daily life at the time. Wash and wear was still in the future. Uniforms made of wool could not be laundered as easily as today’s cotton garments; hence, nurses wore aprons, bibs, collars, and cuffs that could be removed for more frequent washing. These items protected the dresses underneath from soiling.

Uniforms were initially designed primarily for nursing students. The reason? Students were educated under the apprenticeship model, and they provided the bulk of care for hospitalized patients while wearing their training school uniforms. Few full-fledged nurses worked in hospitals—most were private duty nurses who worked in patient’s homes. Others joined the Red Cross or the military, organizations that outfitted their nurses for work in the field. But things were changing. The 1928 Burgess Report (originally titled Nurses, Patients, and Pocketbooks) and the 1932 Weir Report exposed hospitals’ exploitation of nursing students and urged hospitals to break the chain of dependency between hospital labor and nursing education.

After these reports, hospitals were increasingly staffed with graduate nurses. This new cadre of staff nurses wore either their white graduate uniforms or uniforms supplied by the hospital, which were either simplifications of the student uniform or newly designed white dresses.

Requiring nurses to wear a uniform was at least in part a way of enforcing strict standards of dress and behavior. In a concept borrowed from the military, the uniform was symbolic, molding the behavior of the new nurse by disciplining the body as well as the mind.  The nursing uniform, as a concrete expression of occupational identity, became cemented in the minds of nurses, patients, physicians, and the public.

The move to all-white uniforms for nurses—what many consider the traditional look—did not happen overnight. Historical photographs reveal that many nurses were wearing entirely white uniforms in the early 20th century, and by the 1930s, white was standard for graduate nurses, both in the hospital and in private duty work, and white hose and shoes were also de rigueur for staff nurses.  Before World War II, “all white” meant a long-sleeved white dress and removable white apron and bib. The first entirely one-piece uniforms were introduced in the 1940s and, following the fashion of the day, had short, cuffed sleeves. White had become a status color, representing cleanliness, purity, and high-minded scientific pursuit.  By the 1960s, it was a symbol of the entire nursing profession.

In the evolution of the white nurse uniform, the most obvious change was in the hemline, which gradually rose with each decade, according to the style prevalent for all women at the time.

Students, being the youngest nurses, tended to push the fashion envelope the furthest.  At a time when short skirts were becoming more acceptable for nurses, student skirts were the shortest.

Matrons, supervisors, and directors of nursing were forced to surrender control over what their nurses wore with the end of proprietary uniforms.  The decision to no longer provide and launder nurses’ uniforms was a cost-cutting measure that shifted the long-standing power dynamic between nurses and hospitals.

Nurses began to take charge of what they would wear. Uniform manufacturers, which began to appear in the 1920s, exploded in number, and began to advertise and sell uniforms directly to nurses. As a result, newer styles and the latest synthetic fabrics (such as nylon, Vycron, and Dacron®) became popular and available for the first time.

These sheer fabrics raised eyebrows, however. Nurse Lilla C. Chiaville wrote to the American Journal of Nursing in 1954 to complain. “Why do nurses persist in buying ridiculously sheer uniforms? A nurse’s uniform should be professional looking, and worn in a manner to warrant respect. How can a person attribute a Florence Nightingale attitude to a person who looks like a lingerie model?”

Hold on to your rage, Lilla. As popular as it had become, the pert, professional white dress—even a transparent one—was about to be upstaged by the next style wave in nurse uniforms: the pantsuit.

Sheer dresses and short skirts may have been scandalous, but they were still a variation on the established theme of white dresses. Wearing pants was more daring, as well as significant. This was not a fad—it was a sign that nurses intended to change with the times.

By the late 1960s, wearing pants was commonplace for women outside, but not yet inside, the hospital, except among nurses in the armed forces. But social and gender mores were changing rapidly. More men were entering the profession of nursing. Federal antidiscrimination laws of the 1960s forced hospitals to treat women and men equally, and dresses for female nurses could no longer be mandated. So, did nurses have men to thank for the option of wearing pants to work? Possibly. Switching to pants may also have been an act of defiance. But hospital administrators may have had another reason for abandoning their resistance to pantsuits. As one director of nursing put it in 1970, “Pantsuits are infinitely preferable to the mini”.

Pants became so popular, so fast, that uniform shops had trouble keeping up with the demand.  If hospital administrators (and the public) were scandalized by short skirts and pants, imagine their shock if famous designers’ visions of modern nursewear had been adopted.

Fortunately, nurses were happy enough just to wear pants, which offered comfort as well as style, with elasticized waistbands or flared legs. Less common, but no less fashionable, was the white jumpsuit.

At first, these easy-care pantsuits and jumpsuits, made of cotton or a polyester knit, kept the white theme going, but it wasn’t long before colored tops crept in. Usually in pastels, these tunic-style tops were typically paired with white slacks and white shoes. Throughout the 1970s and well into the 1980s, most, although by no means all, nurses wore pants. Tradition was not easily discarded, however, and many nurses held fast to the white dress, cap, hose, and shoes. This iconic look was respected by the public and was still a source of pride for many nurses.

White was on its way out. One nurse quipped that uniforms and shoes came in “only two colors: white and dirty white.” But looking back, it wasn’t only the color white that was in jeopardy. Another sea change was about to take place in nurse uniforms.

Walk into almost any healthcare setting today, and you will see employees from the desk clerk to the person cleaning the bathroom wearing surgical scrubs.

Throughout the 1970s and 1980s, while most nurses were still wearing pants and pastel-colored tunics, nurses in intensive care units, emergency departments, and maternity wards had already switched to scrubs, the newest trend in nurse attire. Scrubs got their name from the fact that they were originally worn only when the wearer was “scrubbing in” to enter the operating room. Initially provided and laundered by the hospital, scrubs were thought to be cleaner because they were donned in the locker room right before starting work. They were easy to change when soiled, and the nurses no longer ruined their own uniforms with bloodstains.

Uniform companies caught on quickly and began offering “scrubs” in a wide range of prints and colors, allowing a high degree of self-expression in the selection of one’s personal work attire. They were comfortable, and nurses loved them. Before long, the scrub trend had spread widely, replacing uniforms throughout the hospital. But this created a new problem. With everyone wearing scrubs—therapists, laboratory and radiology technicians, clerks, and housekeepers—no one could identify the nurses.

Still, there was no going back to conventional, all-white nurse uniforms, no matter how loudly certain factions (patients and some physicians) complained. The best solution, it seemed, was “color coding.” With this system, each role or department within the hospital wears a specific color of scrubs. For example, all nurses might wear navy blue scrubs regardless of the unit in which they worked. All respiratory therapists might wear grey, and all unit secretaries might wear pink. Patients are provided with a key telling them what each color represented.

But this system has flaws. Hospitals have so many departments, they easily run out of colors. Patients become confused trying to sort out this rainbow of colors. Some nurses resent the lack of individual choice in what can wear. Only the pediatric nurses are permitted some personal expression because research shows that children and their parents prefer to see their nurses in brightly colored prints.

From the 1930s onward, any nurse would tell you that there was much more to a professional nurse’s complete look than clothing. Beauticians, waitresses, and maids wore white dresses, too, but without the accessories that “made” the nurse.

Even today, decades after nurses stopped wearing them, nothing says “nurse” like a traditional nurse’s cap. Although this fact dismays many nurses, who viewed their caps as annoying and useless, others remember their caps with affection.

Caps may have started out being utilitarian (containing or protecting the hair), but they rapidly became symbolic. Affiliated with a specific training school, a nurse’s cap conveyed not only where she trained, but whether she was a student or a graduate nurse and her status within the hospital. Some caps were downright famous.

Caps were bestowed either early in training or at graduation in a rite-of-passage ceremony known as “capping,” reflecting the importance of the cap during its heyday.

Like the military, stripes on a nurse’s cap reflected her rank.  A black velvet band encircling the cap typically signified graduate nurse status, although some hospitals awarded blue, yellow, or even pink stripes, either during or after training.

By the 1960s, the cap had become a focus of rebellion.  The attractiveness of a stiff white cap perched on a nurse’s head belied its reputation among many nurses as a nuisance. Maintaining a “clean” white, starched, neatly pressed, pleated, or folded cap was not easy, and as nursing itself became more complex, the cap was an occupational hazard. Caps were dirty, unwieldy, and impractical—even dangerous. They became tangled in privacy curtains, croup tents, monitoring wires, intravenous tubing, and children’s fingers. They dropped onto sterile fields during procedures. They were uncomfortably hot and caused traction alopecia.

Disposable caps solved some of these problems, but by being deeply unpopular among nurses who valued their hard-earned caps, they served only to speed the cap’s demise.  Much like the contentious issue of wearing pants, women resented wearing caps when they were not required for men. Conquering an early wave of resistance and discipline from hospital administrators, nurses increasingly went capless. By the 1970s, nurses’ caps were optional in most institutions.

Why did caps, with no apparent function other than to identify the nurse, last as long as they did? As early as the 1920s, when short hairdos were already in vogue, this question was being asked. Despite many other concessions to fashion and convenience, nurses didn’t abandon the cap for more than 100 years.

Next to the cap, one of the most admired items in the nurse’s wardrobe was the cape—the only item that wasn’t white. Made of navy, blue, black, or grey wool, and lined with red, the cape presented a distinguished and dramatic contrast to the white dress. Capes had button closures and varied from waist or hip length to full length, covering the entire uniform. The collar was embroidered with the nurse’s initials and/or the name of her training school

Unlike their successors—the scrub jacket or lab coat—capes were worn only outside, typically with one side flung over the shoulder to expose the bright red interior.  The cape completed the iconic look so well that even contemporary nurse fashion dolls had smart navy-blue capes.

Almost as important as the cap was the nursing school pin. In the 19th century, pins were a tradition of the Nightingale School of Nursing at St Thomas’s Hospital in London, where students were awarded the Maltese cross at graduation. The first pins (designed by Tiffany and Co.) in the United States were presented to nurses in the graduating class of Bellevue Hospital in New York City in 1880.  Pinning ceremonies are still traditional at many US schools.

Each school or college designs its own pin. Today’s nursing pins are constructed of enameled gold, silver, alloys, or other metals, and incorporate the name of the nursing school and various symbols (eg, crosses, lamps, books, birds or animals, people.)

Pins were proudly worn on the nurse’s lapel until nurses began wearing scrubs. Now, pins can be found attached to lab coats, identification badges, or lanyards. Pins have permanence, which may be why they have endured as a symbol of accomplishment in nursing education. In many schools, pins and pinning have replaced caps and capping as the chief way of celebrating the passage from student to graduate nurse.

The only item of jewelry other than pins routinely worn by nurses was a watch. Early uniforms even had a “fob pocket” for the nurse’s pocket watch, and later, the nurse’s wristwatch was an ubiquitous, and necessary, feature of the nurse’s uniform.

In his book, Men in Nursing: History, Challenges, and Opportunities, Chad O’Lynn tells a funny anecdote about his first day as a student in a mostly female profession, and how his overwhelming gender isolation began with the difference in uniforms for male and female students:

My classmates wore blue-and-white striped jumpers with starched white blouses and white hose. I wore some sort of polyester tunic that gave me the appearance of a crazed orderly from an old B-movie.

Much has been written about nursing uniforms over the years, but men are rarely mentioned in this context. A few surviving photographs give us the best idea of the nursing uniforms worn by men.

When nurses began wearing uniforms, the few men still in the profession were left out. Instead of designing a unique uniform for them, hospitals tended to use medical or dental wear as a model for the men in their training programs. Because men didn’t wear caps, other elements of the military crept into the men’s uniforms to signal rank—black bands on shirt pockets, or chevrons on the epaulettes of their shirt sleeves.

Some schools of nursing provided men with a tunic or shirt made of the same fabric and color used to construct the women’s uniforms.  When women discarded their caps and both sexes switched to scrubs, gender equality was finally achieved in nursing uniforms.

Every Thursday, the nurses at a Mississippi hospital honor their nursing legacy by dressing in traditional all-white uniforms, some complete with cap.  It’s a nice homage, but when white becomes mandatory, the sentiments behind it aren’t widely shared. The enforced adoption of white uniforms to help patients and others identify the nursing staff is viewed by some as archaic.

The feelings of most nurses who remember the traditional white nurse’s uniform fall somewhere in the middle. At one time, they wore their uniforms proudly, and speak of them with fondness today. Medscape reader Patti Mitchell describes the day she first got to wear her new graduate nurse uniform:

I was so proud to wear this white uniform. I continued to wear it (along with my cap) for several years after most nurses quit wearing them. I am now a nurse practitioner, but even with all I’ve accomplished in my career, I don’t think I’ve ever been prouder than at the moment this picture was taken.

More than 150 years ago, nursing leaders struggled with the question of whether nurses should wear uniforms. They wanted to seal the identity of their fledgling profession, and they succeeded beyond their wildest dreams. The decision of those leaders to put nurses into uniforms was reinforced, many times over, by what uniforms came to symbolize, not just to the nurses who wore them but also to patients, colleagues, and the public. Real or imaginary, the uniform promised a certain degree of knowledge, skill, experience, and dedication on the part of the wearer. Regardless of the changes that took place in its appearance over the decades, the uniform remained a steadfast external representation of the nurse.

But the nursing uniform hasn’t survived without controversy. When nurses faced strict new dress codes aimed at quelling rising hemlines, colored uniforms, or slacks, or when new policies were instituted to satisfy patient requests for nurses to “look more like nurses,” many spoke up.

The professional status of nursing does not depend on what we wear; a uniform is only a convenient means. In the long run, we are judged by the effectiveness of care given to patients by the individual nurse.

Although that was written almost six decades ago, in 1958, similar opinions are voiced when hospitals try to crack down on rumpled scrubs, tattoos, piercings, or bare midriffs. “It’s not what I wear that defines me; it’s what I do,” is still heard today.

For most of the 20th century, nurses held fast to the link between their uniforms and their professional identity. But the need to gain respect through the vehicle of a crisp white uniform began to erode in the 1970s. Feminism may have played a big part, as wearing all-whites shifted from being a symbol of power to one of oppression.  To those just entering the profession, any uniform was emblematic of subservience in the still male-dominated world of medicine. Their attachment to caps and white dresses was weak, and these were easily discarded as the women’s rights movement escalated. Throughout the 1970s and 1980s, the nurse uniform looked increasingly like a relic.

In fact, it is possible that in the decades that followed, scrubs actually saved the nurse uniform from extinction. Given that scrubs are comfortable, androgynous, relatively inexpensive, and easy to care for, few nurses have found anything to object to in them. Scrubs have endured for the past 25 years or so, far longer than any other trend in nurse uniforms.

So what’s next? It’s hard to imagine that attire for nurses will ever become a free-for-all. Even nurses don’t see themselves providing acute care in street clothes and lab coats.  Patients largely continue to associate professional attire with honesty, knowledge, and high-quality care, and even now, they prefer to see their nurses in white.

The “who is the nurse?” refrain hasn’t abated, and identification badges haven’t proved sufficient. One hospital addressed the nurse identity problem by embroidering their nurses’ scrub tops and jackets with the words “registered nurse.”

We have other unsolved uniform-related problems as well. Anything worn in the course of care becomes a vector of infection,  and solving this problem might well be the next frontier in nurse attire.

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Carol Duff, MSN, BA, RN

Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.

She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – one daughter-in-law; Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with her husband Gordon Duff, many cats, and two rescues.

• Carol’s Archives 2009-2013