Running head: FINAL PROJECT

Final Project
Jennifer C. Zayd
The University of Saint Mary
Analysis and Utilization of Research
NU- 703
C. Andrew Martin

Final Project
The relationship between research, healthcare policy, quality and safety, and quality
improvement
In order to improve healthcare policy, quality, and safety it is imperative that professions
continually strive to evolve. The evolution of a profession does not happen if every member of
the profession is complacent with the way things are. In order to change and grow, research must
be done to prove that the changes we wish to instill are changes that are beneficial to not only
our patients, but to all stakeholders. Furthermore, is it not enough to complete one study and
change policies based off of the findings of that study. In order to have strong evidence that the
intervention proposed is truly beneficial, numerous research studies must be complete in order to

prove validity. That is how evidence-based practice has come to be utilized in healthcare and
particularly nursing. Evidence-based practice is conscientious integration of best research
evidence with clinical expertise and patient values and needs in the delivery of quality, costeffective health care (Grove, Burns, & Gray, 2013, p. 694). Evidence-based practice is how we
apply nursing research to improve safety, quality, healthcare policy, and quality improvement
measures.
Practice Problem
In 2010 the Affordable Care Act (ACA) was signed into law. Many changes were made in
regards to how healthcare is handled here in the United States. Because of these changes,
members of the health care team are closely scrutinizing the way that business has been done in
order to adapt to the changes that the ACA has brought with it. One provision of the ACA is that
patient satisfaction rates are now being utilized to determine hospital reimbursement (Meyer,
2012). In order to improve patient satisfaction scores hospitals are attempting to find ways to
better the service provided to patients. Physician and nurse care is being directed now more than
ever toward a customer service based care model with some hospitals going so far as to script
nurse and physician interactions with the patient. The purpose of this study is to determine what
expectations do patients have of the professional nurse?
Improving Outcomes
Wocial, Sego, & Rager (2014) state first impressions are formed in an instant, so how a
nurse appears can have a significant impact on how a patient perceives the nurse (Wocial, Sego,
& Rager, 2014, p. 298). The way we present ourselves is a form of non-verbal communication. It
is with this in mind that this writer surmised that it might be possible to improve patient
outcomes simply by conforming the way that nurses present themselves to patients. This writer

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hypothesized that some of the anxiety and stress that patients feel in the hospital could be
decreased as there would be an assurance that a capable nurse was taking care of them based on
non-verbal cues. The decrease in anxiety in stress could have a modest improvement when it
comes to patient outcomes, and this in turn would be an easy and cost effective way to increase
patient satisfaction scores.
Evidence-Based Practice, Policy, or Protocol
Currently, no evidence-based practice, policies, or protocols have been identified in
regards to the professional image of nursing. This can be attributed to a lack of research in this
particular area. Johnson, Dumont, Halbert, Windel, & Tagnesi (2008) attempted to take an
evidence-based approach when creating a new dress code at their hospital. They found the
research lacking and therefore attempted their own research. The findings of their research
showed that patients found overall presentation and cleanliness more important than what the
nurse wore.
A systematic review done by Pearson, et al., (2006) also found that patients did not have
a strong preference for the presentation of the nurse as long as they appeared to be clean. More
important was that the way a nurse provides care has a bigger impact on their perception of the
care received. Finally, Hatfield, et al., (2013) did an integrative review of peer-refereed studies
that found that children and adults preferred solid scrubs with children preferring bright colors.
While this could be an initial basis for an evidence-based policy or protocol, a review of several
studies show a lack of a general consensus regarding the image patients would like to see
projected by their nurses. Furthermore, in order to adopt an evidence-based guideline, an impact
of the change should be apparent. Research needs to be completed that shows a positive

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correlation to patient outcomes related to nurse appearance in order for any evidence-based
policy to be adopted.
Ethical Considerations
The ethical considerations in relation to the changing of nurses appearance are few but
present. Changing the appearances of nurses to fit the perception of the patient is, in a way, an
illusion with no substance behind it. It is a way of making the patient feel that their care is more
capable but having a truly capable workforce does not happen because uniforms are changed. A
truly capable workforce is bred from strong leadership, investment in employees, and ongoing
education. Furthermore, nurses themselves might feel that their efforts at improving their image
and being respected for their knowledge is being held back when hospitals try to tailor the nurse
appearance only for the benefit of increasing patient satisfaction scores.
Synthesis of Literature
A nurses appearance is a non-verbal cue to patients. It can assist in creating a therapeutic
atmosphere or it can decrease a nurses chance of connecting with his or her patients. Skorupski
& Rea (2006) found that older adults (58 years old +) have a strong preference for the traditional
white nurses uniform. Thomas, et al., (2010) had similar findings suggesting that because older
adults make up the largest part of health care consumers, their perceptions should guide hospital
dress code. Porr et al., (2012) also found that patients preferred a solid white pantsuit when it
comes to professionalism but admitted that the sample size was too small to be applicable.
Brock, Metaferia, & Sumner (n.d.) found that while an all-white uniform often conveyed
professionalism, competence, and reliability print uniforms were found to convey caring,
confidence, attentiveness, cooperativeness, empathy, efficiency, and approachability.

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A study conducted by Rush and Cook (2006) found that patients did not have any specific
preferences toward uniforms, but suggested that the way a nurse communicates and performs her
job duties is the most important factor in perceiving the nurse as a professional. Wocial, et al.,
(2014) also found that patients assessed a nurses attitude, skills, and knowledge when
determining whether a nurse was a good nurse. Cleanliness and proper hygiene was a common
finding in the literature. Johnson, et al., (2008) found that cleanliness and overall presentation are
more important to patients in regards to professionalism. Clavelle, Goodwin, & Tivis (2013) also
found that patients did not have a significant preference for a specific uniform color or style but
asserted that cleanliness, ironed uniforms, and clean shoes were important.
As children make up a large segment of the health care consumer, their perceptions of the
professional nurse were also explored. Hatfield, et al., (2013) found that children preferred solid
colored scrubs. However, children preferred the scrubs of the nurse be a bright color dependent
on developmental stage. Wankowicz, et al., (2015) found that children put the most emphasis on
the looks of the nurse as the looks of the nurse affected the way that children assessed them.
Campbell, OMalley, Watson, Charlwood, & Lowson (2000) noted pediatric patients and
families were more focused on a standard way to identify a nurse but did not specifically state
that the scrub uniform was necessary to do so. The research of Wocial, et al., (2010) suggested
that like adults, children value competence above all else when evaluating a nurse.
In the end, there has been no single study that has made a clear linkage between the
importance of appearance on the perception of the professional nurse. Pearson, et al., (2006)
found that in order for nursing to improve its professional image, we must not worry about such
trivial issues such as what scrubs patients want to see. Seeking out collaborative opportunities,
personal and professional reflection, and continuing education will have a larger impact than

FINAL PROJECT

what nurses wear. Hoeve, Jansen, and Roodbol (2013) also suggest that continuing education is
necessary in order to improve the image of nurses but that nurses use their inherent
professionalism to show the public the reality of what they do. It is the opinion of this writer that
as there is no general consensus regarding what makes a nurse appear professional, we as nurses
can use this as an opportunity to define how the image of nursing is presented and much more
importantly, how we wish to be perceived as a profession.

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7
References

Brady, M. (2009, September 1). Hospitalized childrens views of the good nurse. Nursing Ethics,
16, 543-559. http://dx.doi.org/10.1177/0969733009106648
Brock, D., Metaferia, F., & Sumner, E. (n.d.). Identification required; Public perception of
nursing uniforms. Retrieved from LaGrange Website:
http://www.lagrange.edu/resources/pdf/citations/2010/18Brock_Metaferia_Sumner_Nursi
ng.pdf
Campbell, S., OMalley, C., Watson, D., Charlwood, J., & Lowson, S. M. (2000, January). The
image of the childrens nurse: a study of the qualities required by families of childrens
nurses uniform. Journal of Clinical Nursing, 9, 71-82.
http://dx.doi.org/http://dx.doi.org.stmary.idm.oclc.org/10.1046/j.1365-2702.2000.00347.x
Clavelle, J. T., Goodwin, M., & Tivis, L. J. (2013, March). Nursing professional attire: Probing
patient preferences to inform implementation. Journal of Nursing Administration, 43,
172-177. http://dx.doi.org/10.1097/NNA.0b013e318283dc78
Grove, S. K., Burns, N., & Gray, J. R. (2013). The Practice of Nursing Research: Appraisal,
synthesis, and generation of evidence (7th ed.). St. Louis, MO: Elsevier Saunders.
Hatfield, L. A., Pearce, M., & Giudice, M. D. (2013, February). The professional appearance of
registered nurses: An integrative review of peer-refereed studies. Journal of Nursing
Administration, 43, 108-112. http://dx.doi.org/10.1097/NNA.0b013e31827f2260
Hoeve, Y. T., Jansen, G., & Roodbol, P. (2014, February). The nursing profession: Public image,
self-concept, and professional identity. A discussion paper. Journal of Advanced Nursing,
70, 295-309. http://dx.doi.org/http://dx.doi.org.stmary.idm.oclc.org/10.1111/jan.12177

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Johnson, K., Dumont, C., Halbert, K., Windel, L., & Tagnesi, K. (2008, January). An evidencebased approach to creating a new nursing dress code. American Nurse Today, 3(1).
Retrieved from http://www.americannursetoday.com/an-evidence-based-approach-tocreating-a-new-nursing-dress-code/
Meyer, Z. (2012, December 24). Medicare payments tied to patient surveys: Special measures
taken to keep patients happy during stay. USA Today. Retrieved from
http://www.usatoday.com/story/money/business/2012/12/24/hospitals-satisfactionsurveys-medicare/1788833/
Pearson, A., Porritt, K., Doran, D., Vincent, L., Craig, D., Tucker, D., & Long, L. (2006,
September). A systematic review of evidence on the professional practice of the nurse and
developing and sustaining a healthy work environment in healthcare. International
Journal of Evidence-Based Healthcare , 4, 221-261. http://dx.doi.org/10.1111/j.14796988.2006.00046.x
Porr, C., Dawe, D., Lewis, N., Meadus, R. J., Snow, N., & Didham, P. (2014, 2014). Patient
perception of contemporary nurse attire: A pilot study. International Journal of Nursing
Practice, 20, 149-155.
http://dx.doi.org/http://dx.doi.org.stmary.idm.oclc.org/10.1111/ijn.12160
Rush, B., & Cook, J. (2006, April 13). What makes a good nurse? Views of patients and carers.
British Journal of Nursing, 15, 382-385. Retrieved from
http://web.a.ebscohost.com.stmary.idm.oclc.org/ehost/detail/detail?
vid=13&sid=c33ced50-6eae-405c-b51b68050f36f122%40sessionmgr4005&hid=4109&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ
%3d%3d#AN=106305169&db=ccm

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Skorupski, V. J., & Rea, R. E. (2006, September). Patients perceptions of todays nursing attire:
Exploring dual images. The Journal of Nursing Administration, 36, 393-401. Retrieved
from http://www.nursingcenter.com/pdfjournal?AID=665789&an=00005110-20060900000005&Journal_ID=54024&Issue_ID=665776
Thomas, C. M., Ehret, A., & Ellis, B. (2010, November). Perception of nurse caring, skills, and
knowledge based on appearance. Journal of Nursing Administration, 40, 489-497.
Retrieved from
http://journals.lww.com/jonajournal/Fulltext/2010/11000/Perception_of_Nurse_Caring,_
Skills,_and_Knowledge.9.aspx
Wankowicz, A., Wankowicz, P., Golubka, P., Golubka, W., Dluski, D., Mierzynski, R., ...
Emeryk, A. (2015). Examining the image of nursing among the children hospitalized in
the oncology ward. Polish Journal of Public Health, 125(2), 90-93.
http://dx.doi.org/10.1515/pjph-2015-0031
Wocial, L., Albert, N. M., Fettes, S., Birch, S., Howey, K., Na, J., & Trochelman, K. (2010,
November-December). Impact of pediatric nurses uniforms on perceptions of nurse
professionalism. Pediatric Nursing, 36, 320-326. Retrieved from
http://web.a.ebscohost.com.stmary.idm.oclc.org/ehost/detail/detail?vid=6&sid=c33ced506eae-405c-b51b68050f36f122%40sessionmgr4005&hid=4109&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ
%3d%3d#AN=104956387&db=ccm
Wocial, L. D., Sego, K., & Rager, C. (2014, May). Image is more than a uniform: The promise of
assurance. Journal of Nursing Administration, 44, 298-302.
http://dx.doi.org/10.1097/NNA.000000000000070.x

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Name of Database
Cinahl

10
Description of the Database by the Publisher
CINAHL Complete is rich collection of full text for nursing
& allied health journals, providing full text for more
than 1,300 journals indexed in CINAHL. This
authoritative file contains full text for many of the
most used journals in the CINAHL index, with no

Academic Search Complete

embargo. Full-text coverage dates back to 1937.

This comprehensive database contains over 13,780 indexed
and abstracted journals and 9,000 full-text journals on
most academic disciplines. The database has full-text
content for more than 7,850 peer-reviewed journals

Google Scholar

and is updated daily.

Google Scholar provides a simple way to broadly search for
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Lippincott Nursing Center

Created by nurses, for nurses, NursingCenter is a nursing

community that provides peer-reviewed professional

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development resources based on the best evidence
available. A host of more than 50 nursing journals,
including over 1,400 continuing education activities,
NursingCenter provides the tools nurses need in
todays challenging healthcare environment.