White Coat Underground

Medicine has traditionally been full of hierarchies. Employees’ uniforms make their role easy to identify: one color for radiology techs, another for secretaries, etc. When I was a resident, medical students wore short white coats, residents long blue coats, and attendings long grey coats.

Medicine is also a traditionally male-dominated field, and despite the fact that a small majority of medical students are female, the higher academic and administrative positions are still male-dominated.

Nursing, on the other hand, is traditionally female. Nurses, despite their indispensable role in health care, are traditionally subordinate to doctors, a role made explicit by doctors giving “orders” and nurses following them.

Nurses have taken on a much more complex and diverse set of roles over the last several years. Critical care nurses and nurse anesthetists are some of the most highly trained and highly skilled of medical professionals.

So how come nursing students wear white, see-through scrubs?

Not all nursing schools and hospitals follow this standard, but many do. The uniform I see most often is white scrubs which are usually thin enough to be see-through. These young professionals are required to wear a demeaning uniform under which they often wear another set of clothes (warm and uncomfortable) or specially chosen underclothing that isn’t immediately visible as such. Or they may “choose” to simply allow their underclothing to show through their scrubs.

These uniforms serve no medical or professional purpose. They help reinforce a subservient role rather than emphasizing a nurse’s role as a partner in the health care team.

This isn’t to say all hierarchies are bad. If a nurse doesn’t follow the orders I write in a patient’s chart, that’s a problem. But if a nurse blindly follows my orders instead of feeling comfortable enough to call me if my order looks questionable, the patient will suffer. Nursing student uniforms that demean the wearer set up a situation that is not only bad for the student, but also bad for patients.

So why do we still do this?

Comments

#1 Pascale
February 4, 2010

They did get rid of those damn hats and white stockings…
Seriously, the student nurses I see have colored scrubs with a patch identifying their school on it. Our regular nurses wear some sort of scrub, depending on their unit and hospital. Cartoon characters are popular, even on non-pediatric wards. I have never seen the “see-through” variety you describe.
Many of the nurses do wear something underneath their scrubs, but then so do our residents on call.
I believe we still have the clothing hierarchy for a number of reasons. First, to readily tell who is who (so those nasty docs scream at real nurses instead of student nurses). Second, wearing that lab coat or scrub set is a right of passage; you are now “authorized personnel” in the medical center. I still remember wearing scrub tops in public, because that marked you as a “cool” medical person, not one of the usual public (OMG, I can’t believe we really did that, but I’m afraid there are photos somewhere). Finally, most nurses like wearing scrubs because they have messy jobs and this preserves their real-life clothes. Our nurse specialists do not wear them; instead they wear professional street clothing.
Personally, I have not worn a lab coat since residency when it was last required of me. Oh, I have one for the lab, but I like to wear suits and other “professional” outfits. Lab coats scare some kiddos, and over the years I have learned to avoid pee/puke/stool pretty well. Our students and residents are still required to wear them, but there are centers that do not do this (WFMC comes to mind).
#2 Katherine
February 4, 2010

Because the people designing the uniforms (anywhere) are not the people who will have to wear them, and they do not care to consult with the people who will.
#3 PalMD
February 4, 2010

@Pascale
I do not disagree with having color coded scrubs etc, and I actually think docs should change into and out of scrubs at the hospital.

Some of our student nurses come from institutions where they where dark green or what have you, but one particular institution requires the white ones.
#4 nsib
February 4, 2010

WTF? I’ve never seen scrubs like that, and I can hardly imagine a hospital in this day and age requiring something like that (disclaimer: My experience is limited to one city). How could they possibly rationalize that decision?
I agree with what Pascale says about scrubs, and that’s been my experience as well.
#5 SJordanRN
February 4, 2010

As an RN and a dedicated reader of your blog as well as many other evidence-based medicine blogs, I suffered through wearing a white uniform and stockings in nursing school. I’ll never forget one of the professors telling us on that day in the 1980′s that one should always wear undergarments that matches one’s skin tone, not the uniform…. Words of wisdom from dear Dr. Cornett that I never, ever forgot. I was just happy not to have to purchase a cap.

Nursing is a profession that continues to suffer from an identity problem, as nurses may have as little as a hospital-based old-fashioned “diploma” or 2-3 year community college degree as an entry level education, or a Bachelor’s degree. There is division even without the nursing community about what the license-entry requirement should be, so arguments about uniforms are not widely discussed in the nursing education community.

As a MS-prepared Licensed Advanced Practice Nurse, I’m more concerned that because I have RN after my name, my first name only is printed on my nametag. PA’s (most of whom have a similar level of education, but less scope for independent practice in my state) and MD’s get their last names printed with their title. I am still in the backseat from a professional recognition point of view.

There is a great deal of debate regarding uniforms and different facilities’ requirements as well as different professionals’ attitudes towards uniforms. When I worked in neuro ICU as a staff nurse at a major tertiary referral hospital in Northern California, I personally never understood how my co-workers felt that wearing scrubs covered with cartoon characters allowed them to feel like the educated professionals they were. Color coordination is a plus, but not all facilities require this due in part to union contracts. If the facility requires a uniform, the facility has to provide it, such as in the OR still at most places.

I think every medical professional should wear an identifying “uniform” for clarity to patients and customer service. Mine “uniform” is a nice white lab coat with my name and title tastefully embroidered–no bunnies or hearts or other decor–over professional street clothes. I believe physicians, physical therapists, nurses, and housekeepers should be easily differentiated to the layperson. As my late grandmother once told me after a hospitalization: “I wish the nurses still wore caps because I can’t tell them from the floor sweepers in those pajamas.”

As far as nursing school attire, the decisions and policies are up to the nursing school and not the facility. Here on the west coast, I have found that the various schools require a particular color of scrubs (usually not white) with a school patch on the shoulder. It is the nursing school and not the hospital which requires the particular uniform. It is the budget of the student that allows how much to spend on clothing and uniforms. More opaque scrubs are thicker and often 100% cotton, which are hard to find and much more expensive than the polyester or cotton/poly blends that dominate the catalogs and “scrubs stores” that fill strip malls near medical centers.
#6 PalMD
February 4, 2010

I understood the no-last-name thing to be at the request of nurses to avoid stalking. the first time I saw it was in the EC where nurses would put tape over all but their first name and last initial. They eventually found a way to get admin to allow non-printing of last name.
#7 WcT
February 4, 2010

@5 and 6

I was also under the impression that the last name thing was in regards to stalking. The nurse who gave us lectures regarding nurse-doctor interactions commented that it’s more of an issue since nurses spend a much larger fraction of their time with any individual patient. At my institution the nurses still have last names on the tags, which they then put black tape over.

The white uniform thing isn’t exactly standard, here the nursing students where scrubs that are the primary color of the school colors, very dark, very opaque.
#8 Comrade PhysioProf
February 4, 2010

I haven’t seen this kind of thing at our medical center. The nursing students all seem to wear dark scrubs, distinct from the greenish ones worn by docs.

In relation to uniforms, I love watching the ceremony where our first-year medical students get their little white coats and name badges, and then pose for a group photo. It brings a little tear to my eye every time I see it.
#9 PalMD
February 4, 2010

The white coat ceremony serves an important purpose, i think, in helping to emphasize the gravity of the new role.
#10 Daniel J. Andrews
February 4, 2010

Is this just a localized thing? I’ve not seen this type of scrub in any hospital I’ve visited, nor did I ever see these scrubs on the student nurses at the universities I’ve attended (two in Ontario and one in BC, all three of which had a nursing program–also a college where I once taught had the nursing program going on just down the hall, and they didn’t have these scrubs either).
#11 antipodean
February 4, 2010

The white coat is gone round here. Only the crustiest old physicians use them. And I’ve never seen anybody wear white scrubs.

One of the reasons for visable marks of hierarchy is that the patients like them. If you don’t have these marks you then have to explain who and what you are each time. When you don’t remember the patient sits and wonders what you are, where you fit into things and doesn’t listen to what you are saying.
#12 Comrade PhysioProf
February 5, 2010

Oh, and BTW, *everyfuckingbody* is wearing motherfucking Danskos! I even saw a nurse the other day with leopard-print Danskos!
#13 ginger
February 5, 2010

When I was in nursing school, it was white pants with the short white jacket, and every school had a different patch on the jacket. The pants were supposed to be an opaque fabric but not one of us managed to find pants that were thick enough. (My Mormon colleagues were particularly irritated that their Garment was visible.)

On the other hand, the short coats were the bomb – they had plenty of pockets and didn’t look nearly as stupid as the fanny-packs and utility belts you have to wear with scrubs. Plus, it annoyed the med students that even with colored pants they might be mistaken for us, so that was a bonus.

I think the historic reason for white nurses’ uniforms is to prove you’re wearing something fresh spanking clean. (The cap was to prevent transmission of lice. Ugh.) I don’t know why physicians aren’t held to this standard – sure, the coats are white, but I have seen a zillion filthy coats and when do docs in training have time to do laundry anyway?
#14 eNeMeE
February 5, 2010

I’ve never seen the type of scrubs you describe, and I’ve spent a lot of time in hospitals (in Canada, mind you).

White uniforms, sure, but certainly not transparent.
#15 stripey_cat
February 5, 2010

I suspect white is a hangover of the days when they’d be boiled up in a copper to get them clean – even modern dyes would start to look faded and shabby very quickly under that sort of abuse. These days, especially with cheap, semi-sheer fabrics, darker colours make more sense; and most people wash their laundry at 30C regardless of colour and cleanliness.
#16 Kim
February 5, 2010

I toured a local nursing school that had those flimsy white scrubs as the student uniform. I was pretty taken aback by that, too.
#17 momkat
February 5, 2010

The nursing programs around here (2-year ADN and 4-year BSN) all have white uniforms but the fabric is not flimsy, They are bought from specific companies that cater to school markets to insure uniformity (no pun intended) and are not cheap. Each program then has a school patch on the shoulder. Sounds like your students have budget scrubs as a money-saving measure.
The white is a student status indicator. No licensed nurses in my hospital (600+ bed) wear white. I’ve noticed lately that some of the university student nurses are wearing crimson or white (school colors), but I imagine the ones in red are confused with ACCU nurses. We have four nursing schools which send students for their clinical programs and I haven’t seen any inappropriate uniforms among them. Maybe it’s because this is the deep south and we are more traditional.
Now the hospital staff, that is another story. Freakin’ cartoon pajamas is right. And the absurd shoes some people wear are just ridiculous.
#18 BB
February 5, 2010

They wear colored scrubs where I am, both student and graduate nurses.
#19 OleanderTea
February 5, 2010

Back when the earth was cooling and I was a medical assistant (and in a kind of pre-nursing-program training course), we had to wear the white uniform, white stockings, and horrible shoes. The uniform wasn’t see-through to start off with, but once a patient slopped a basin of water on you it sure was.

I always thought scrubs a more logical option for nurses and others involved in direct patient care.

As to your hospital’s use of see-thru scrubs for nursing students, could it be that whomever chose them really is that clueless? Someone should show them the scrubs, in bright light, preferably with a very dark-skinned person wearing the scrubs to make the point even more obvious.
#20 Tsu Dho Nimh
February 6, 2010

If the scrubs are provided by the hospital, it’s because they were too cheap to pay for heavier weight set.
#21 Silver
February 6, 2010

Our BSN program required the all-in-white for students until only one or two years ago. As all the local hospitals have their own color code systems for scrubs, the college of nursing said for a long time that white was the only color not taken. Most of us had the impression (not backed up by evidence) that it was all about the tradition, though…

There are no school-issued scrubs – what the heck? these are grownups, who buy their own clothes, in compliance with an appropriate dress code – so most students found some fairly sturdy twill scrubs. For women, there are various skin toned undergarment options that don’t show through, by the way – I assume the same exist for men.

Recently, the college went to white scrub tops with college patch, a white lab coat with college patch, and dark… blue? I think blue… scrub pants for the BSN students, and a different dark color pant for the associate degree students.

One nice thing about the whites: marking a student as such meant that faculty and protective staff would come to the rescue, quickly, and would snag a student for anything interesting.
#22 DLC
February 7, 2010

nursing has come a long way indeed.
Prior to the Crimean war it was largely the responsibility of whomever the surgeons could dragoon into service who handled the changing of bandages and managing patient’s bodily needs.
Modern historians give Florence Nightingale the credit for making a real profession out of the job, and of course there are other milestones. Members of the nursing profession do so much more now than in the 1850s. I never did understand the whole business of color-coded scrubs. could be worse — you could have your job pasted on the back of your shirt, like the guys on Navy Aircraft Carriers.
#23 arrzey
February 12, 2010

As a PhD scientist in a med school, the white coat thing cracks me up. The scientists who might actually need to wear a coat to protect themselves, where t-shirts & jeans, or chinos if they are in a classy mood. The doctors, who wear pristine, white, ironed & starched coats would faint, or change coats if they got dirty.
#24 PalMD
February 12, 2010

Really? Are you sure they’re real doctors? Cuz it’s not unusual to get all kinds of horrible stuff on our lab coats…which is why we have them cleaned or toss them out pretty often.
#25 peggy
February 14, 2010

When I worked in labor and delivery, we wore scrubs, which we changed into and out of at work, but covered them with lab coats if we left the unit. It was to prevent bringing pathogens into the unit, and changing before going home was to prevent taking any nasties with us.

Seeing scrubs all over town makes no sense. If one is to be exposed to fluids and germs, then change at work.

Also, my pet peeve: Why do office personnel wear scrubs? They look like they’re having a pajama party!