Healthcare Personnel Attire in Non-operating-room Settings

Gonzalo Bearman, MD, MPH; Kristina Bryant, MD; Surbhi Leekha, MBBS, MPH; Jeanmarie Mayer, MD; L. Silvia Munoz-Price, MD; Rekha Murthy, MD; Tara Palmore, MD; Mark E. Rupp, MD; Joshua White, MD

Disclosures

Infect Control Hosp Epidemiol. 2014;35(2):107-121.

Discussion

Overall, patients express preferences for certain types of attire, with most surveys indicating a preference for formal attire, including a preference for a white coat. However, patient comfort, satisfaction, trust, and confidence in their physicians is unlikely to be affected by the practitioner's attire choice. The ability to identify a HCP was consistently reported as one of the most important attributes of HCP attire in studies. This was particularly true in studies that evaluated the effect of attire of actual physicians on patient satisfaction in a real-world setting rather than those assessing the influence of physician attire on patient satisfaction in the abstract. Patients generally did not perceive white coats, formal attire, or ties as posing infection risks; however, when informed of potential risks associated with certain types of attire, patients were willing to change their preferences for physician attire.^[11,18]

Data from convenience-sample surveys and prospective studies confirm that contamination occurs for all types of HCP apparel, including scrubs, neckties, and white coats, with pathogens such as S. aureus, MRSA, VRE, and gram-negative bacilli. HCP apparel can hypothetically serve as a vector for pathogen cross-transmission in healthcare settings; however, no clinical data yet exist to define the impact of HCP apparel on transmission. The benefit of institutional laundering of HCP scrubs versus home laundering for non-OR use remains unproven. A BBE approach is in effect in the United Kingdom for inpatient care; this strategy may enhance hand hygiene to the level of the wrist, but its impact on HAI rates remains unknown.

Hospital policies regarding HCP attire were generally consistent in their approach to surgical attire; however, general dress code policies varied from guidance regarding formal attire to use of job-specific uniforms. Laundering and change of clothing was also not consistently addressed other than for surgical attire. Finally, accountability for compliance with the attire policies by HCP and supervisors was not routinely included in the policies.

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Table 1. Studies of Patient and Healthcare Worker Perception of Healthcare Worker Attire (1990–2012)
Lead author, year (country)	Methodology	Findings
Ardolino, 2009 (UK)¹	Survey (n = 100): Pts Re: Preference for MD attire before/after awareness of BBE policy	Before BBE policy: prefer suit more than WC but WC preferred for junior MD, scrubs not preferred as unprofessional and difficult to distinguish MDs After BBE policy: prefer short-sleeve shirt without tie (older Pts); prefer scrubs (younger Pts)
Baevsky, 1998 (US)²	Survey (n = 596): Urgent care Pts seen by MD in WC and on alternating days, scrubs vs formal attire Re: Satisfaction for courtesy, concern, skill, and likelihood Pt would return/recommend ED	No difference in satisfaction elements for scrubs vs formal attire WC ranked higher when MD broke protocol and did not wear, although when stratified by scrubs vs formal, higher mean ranks for WC noted only when MDs wore scrubs Attitude, mannerism, and professionalism likely more important than attire
Bond, 2010 (UK)³	Survey (n = 160): ENT InPts, OutPts Re: Attitudes toward MD attire with photos of male MD in scrubs, formal, and BBE	Most professional: formal 72%, scrubs 23%, BBE 5% Most hygienic: formal 10%, scrubs 87%, BBE 3% Ease to identify as MD: formal 59%, scrubs 35%, BBE 6% Overall preference: formal 48%, scrubs 41%, BBE 11%
Cha, 2004 (US)⁴	Survey (n = 184): OutPts in predominantly resident-run OB/GYN clinic Re: Preference for MD attire and confidence and comfort with photos of MD in various attire	Attire preference: no preference 60%, WC 38% Pt comfort level: attire does not affect 63% vs does affect 28% Confidence level in MD: attire does not affect 62% vs does affect 24% Mean scores for comfort and confidence levels decreased as attire moved from clinical/formal (scrubs/WC) to casual
Ditchburne, 2006 (UK)⁵	Survey (n = 100): Public in hospital concourse Re: Attitudes to MD not wearing ties	93% did not object to tieless MD, but for staff more likely considered as professionalism factor Most important: wearing shirt and dress trousers (vs denim), being clean, tidy, formal, wearing clear identifications
Fischer, 2007 (US)⁶	Survey (n = 1,136): Pts and OB/GYN MD before/after randomization of MD attire type Re: Pt satisfaction with MD attire; MDs asked for their preference	Pt satisfaction overall was high and did not change with different MD attire No difference for perceived MD competency and professionalism MD preference: 8 casual, 7 business, 5 scrubs
Gallagher, 2008 (Ireland)⁷	Survey (n = 124): OutPts Re: Preference and ranking of MD attire with photos (formal, casual, WC, scrubs)	Prefer WC, formal, and semiformal vs scrubs and casual WC most preferred; scrubs and casual least preferred
Gherardi, 2009 (UK)⁸	Survey (n = 511): InPts Re: Rated photos of MD in various attire to inspire confidence	WC ranked highest and most confidence inspiring All dress styles rated above neutral except casual (rated lower) Older Pts found scrubs less appealing
Gonzalez del Rey, 1995 (US)⁹	Survey (n = 360): Parents of pediatric ED Pts shown pictures of MD dressed in various types of attire Re: Which doctor would they prefer for their child, does attire matter, do clothes affect trust in MD?	Most preferred attire: formal 44% (P < .001) selected for all shifts but less likely selected for Pt seen by night shift Least preferred attire: casual without WC 64% (P < .001) Overall, 69% of "most-liked" pictures had WC, and 89% of "least-liked" pictures did not have WC Pictures with scrubs favored by parents with children seen for surgical emergencies Majority did not consider most formally attired as most capable, did not matter how MD dressed and did not influence trust
Hennessy, 1993 (UK)¹⁰	Survey (n = 110): 2 groups of pre-op Pts, seen by same anesthetist, dressed formal vs casual Re: Select adjectives to describe anesthetist/visit, graded 15 dress items as desirable, neutral, or undesirable	No difference between adjective choices (professionalism, approachability) of anesthetist in formal vs casual dress Desirability: name tag (90%), WC (66%), polished shoes (62%), short hair (57%), suit (36%) (suit and tie selected more likely desirable if viewed) Undesirability: clogs (84%), jeans (70%), trainers (67%), earrings (64%), long hair (62%), open-necked shirt (36%)
Hueston, 2011 (US)¹¹	Survey (n = 423): OutPts Re: Preference for MD attire before/after being informed of possible microbial contamination	Before education: no clear attire preference but did not favor scrubs (6%), poor agreement with Pt preference and what their MD wears After education: decrease preference for WC/tie/formal attire Conclusion: attire preferences may change with awareness for contamination
Ikusaka, 1999 (Japan)¹²	Survey: OutPts seen by groups of MD in WC or private clothes Re: Pt tension/satisfaction, preference for MD attire	Tension: WC group 42%, private clothes group 33% Satisfaction: no significant difference between attire groups WC preference: WC group (older Pts more likely to prefer WC) 71%, private clothes group 39% (P < .001)
Li, 2005 (US)¹³	Before/after trial (n = 111) of Pt opinion in ED Re: ED MDs wore WC/formal vs scrubs	No significant difference in scores between 2 dress styles in appearance, satisfaction, or professionalism
Major, 2005 (US)¹⁴	Survey (n = 410): InPts, surgeons, and public Re: Surgeons' attire	WC necessary: surgeons 72%, InPts 69%, public 42% Scrubs appropriate: surgeons 73%, InPts 41%, public 33% (P < .05) Clogs appropriate: surgeons 63%, InPts 27%, public 18% (P < .05) Denim appropriate: surgeons 10%, InPts 22%, public 31%
Matsui, 1998 (Canada)¹⁵	Survey (n = 220): OutPt pediatric children/parents Re: Asked who they would like as their MD from photos of MD with and without WC; parents also rated attire appropriateness	Selected MD in WC: children 69%, parents 66% Most appropriate and favored: name tag, WC, well groomed Neutral: scrubs, formal dress Not favored: open-toed sandals, clogs, shorts
McKinstry, 1991 (UK)¹⁶	Survey (n = 475): OutPts in 5 practices Re: Pt acceptability for different styles of attire (photos of male and female MDs) for different attire and whether attire influenced their respect for MD	Formal dress favored (suit/tie or WC) 28% would be unhappy seeing one of MDs shown, more likely those dressed informally 64% thought how their MD dressed was important Practice to which a Pt belonged was an independent factor in Pt choice of dress
Mistry, 2009 (UK)¹⁷	Survey (n = 200): Pediatric dental parents/children Re: Attitudes on MD attire using photos	WC and mask most popular overall but children favor casual attire Formal WC preferred over pediatric coat by parents and children Mask preferred over visor (eye contact potentially important)
Monkhouse, 2008 (UK)¹⁸	Survey (n = 50): Surgical Pts random survey (ER and elective admits) Re: Attitudes toward dress (formal vs scrubs) before/after educational intervention on transmission of microorganisms on ties	Before education: prefer formal for professionalism and approachability; prefer scrubs for hygiene, equal for identifiability; prefer formal dress overall After education: prefer scrubs (24% before to 62% after); formal preference decreased (52% before to 22% after) Authors' conclusions: if rationale behind modes of surgical dress are explained, Pts are more likely to prefer scrubs to formal clothes
Nair, 2002 (Australia)¹⁹	Survey (n = 1,680): InPts after discharge with crossover trial of MDs in varying attire Re: Pt confidence/trust in MD in informal vs "respectable" attire	Pt confidence highest with "respectable" dress Loss of WC or tie did not deteriorate confidence significantly Informal dress protocol "affront to sensitivities" and presence of nose ring most deleterious
Niederhauser, 2009 (US)²⁰	Survey (n = 328): Pts at naval OB/GYN clinic Re: Preference for MD attire and effect on comfort or confidence using pictures	86% neutral whether MD wore a WC 88% said attire did not impact confidence in MD ability Active-duty women were more likely than dependent wives to say MD attire influenced their comfort discussing general/sexual/psychological/personal topics Authors conclude active-duty women may withhold pertinent medical information (eg, personal, sexual history) due to intimidation from military uniform of officer MD Aspect of military uniform unique to this study
Palazzo, 2010 (UK)²¹	Survey (n = 75): InPts Re: Attitudes of MD attire Randomly chosen medical/surgical InPts rated 6 statements (modal responses provided) and provided reasons for importance of MD dress code; opinions solicited after education of new dress code policy	"MD dress important"—strongly agree (reason: dress code instills confidence) "Your MD this admission dressed professionally"—strongly agree "Scrubs are acceptable form of dress"—strongly agree (reason: appears clean) "MD should wear WC"—strongly disagree (reason: sleeves might encourage infection spread, might induce fear and anxiety in Pts) "MD should wear ties"—strongly disagree (reason: unnecessary, uncomfortable) "Is it easy to distinguish between different grades of doctor based on their dress?"—strongly disagree (hard to differentiate MD vs the public) No Pts noticed dress code change prior to being informed of the change All Pts favored dress code change when the suggested impact on infection was explained Conclusions: MD attire important but necktie and WC not expected
Rehman, 2005 (US)²²	Survey (n = 400): Pts/visitors in OutPt clinic Re: Preference, trust, willing to discuss sensitive issues with photos of MDs in various attire	Preferences: professional attire with WC 76%, scrubs 10%, business dress 9%, casual 5% Trust and willing to share sensitive information significantly associated with professional attire (P < .001) Female MD dress significantly more important than male MD
Shelton, 2010 (UK)²³	Survey (n = 100): InPts Re: Rate MD attire with photos of male and female MDs before/after being informed of microbial contamination	Before information: no significant difference between most attire except casual dress and short sleeves (considered less appropriate) After information: scrubs and short sleeves considered most appropriate, scrubs preferred for females
Baxter, 2010 (UK)²⁴	Survey (n = 480): InPts Re: Attitudes toward MD attire using photos of male MDs in long sleeves/tie, scrubs, short sleeves	Most professional: long sleeves/tie 77%, scrubs 22%, BBE 1% Greatest transmission risk: long sleeves/tie 30%, scrubs 33%, BBE 37% Preference for MD attire: long sleeves/tie 63%, scrubs 33%, BBE 4%
Toquero, 2011 (UK)²⁵	Survey (n = NA): orthopedic InPts Re: Awareness/preference for recent BBE policy	Unaware of policy: 86% Attire preference: shirt/tie 63%, suits 22%, short sleeve shirt 6%, Pt trust high despite change to less preferred attire
Garvin, 2012 (US)²⁶	Survey (n = 1,494): InPts, MDs, RNs Re: Attitudes toward MD attire	MD appearance important for Pt care: MDs/RNs 93%, InPts 83% (P < .001) Concerned with appearance of other provider but did not engage them: MDs 39%, RNs 43%, Pts 16% (P < .001) Concerned with appearance of other provider but did not engage them: MDs 39%, RNs 43%, Pts 16% (P < .001)

Note BBE, bare below elbows; ED, emergency department; ENT, ear, nose, and throat; InPt, inpatient; MD, physician; NA, not provided; OB/GYN, obstetrics/gynecology; OutPt, outpatient; Pt, patient; RN, nurse; WC, white coat.

Table 2. Apparel and Microbial Burden: Review of Studies in Laboratory and Clinical Settings
Lead author, year	Methodology	Findings
Bearman, 2012³⁶	Prospective crossover trial of HCWs in ICU (n = 30) Randomized to antimicrobial vs control scrubs Samples obtained from scrub abdominal area, pocket, and hands weekly	HCW scrubs colonized during course of Pt care with MRSA Antimicrobial scrubs associated with a 4–7 mean log reduction in MRSA but not VRE or GNR No differences in bacterial hand burden or in HCWs with unique positive scrub cultures No data reported on cross-transmission to Pts
Burden, 2011²⁸	Randomized trial comparing contamination on regular (dirty) WC vs short-sleeved UK-style MD uniform laundered daily	No significant difference in bacterial burden between dirty WCs and recently washed uniforms; clean uniforms contaminated within few hours of donning No information on frequency WCs were washed or hand hygiene rates Suggests no microbiological advantage of BBE
Burger, 2011⁴⁰	Prospective observational study (n = 66) MDs from multiple specialties (38 BBE, 28 were not) volunteered without notice during normal work day Agar imprints of fingers, palms, wrists, and forearms, repeated after hand hygiene; imprints of cuffs of those not BBE	No significant difference in bacterial counts (many skin commensals, no MRSA) between groups Some MDs had higher counts after HH Large variation in number of colonies cultured Authors conclude "no difference in density or type of baseline flora on hands and forearms irrespective of dress code" HH reduced colony counts from fingertips, palms, and wrists in all groups
Ditchburne, 2006⁵	MD ties cultured (n = 40)	MD ties capable of carrying bacteria, including MRSA: 40% of ties grew MSSA (1 with MRSA) 70% had never laundered tie 93% had no objection to not wearing ties Authors suggest substitute other attire for ties to preserve professional image No data reported on cross-transmission to Pts
Farrington, 2009⁴²	BBE vs non-BBE randomized trial of MD (n = 58) and medical students (n = 61) at a 900-bed teaching hospital Participants cleaned hands using alcohol, with areas fluorescing by UV light considered "missed" and recorded on a standard hand diagram	No significant difference found between 2 groups in percentage area of hands missed The non-BBE group missed more wrist vs BBE group (P < .002) Mean percent area missed on wrists significantly higher than hands in both groups (P < .001) Strengths: high participation rate without dropouts, single investigator created hand diagrams Weaknesses: Hawthorne effect Author conclusions: BBE did not affect quality of HH, and although BBE improved wrist washing, the clinical significance is uncertain
Gaspard, 2008²⁹	Descriptive study of staff clothing in 3 LTCFs Uniforms (n = 256) from 90 RNs, 166 care partners sampled from waist zone pocket and between pockets	HCW apparel frequently contaminated with MRSA 27%–80% MRSA recovery from "waist zone"; 18%–60% MRSA recovery from "pocket zone" Authors stressed HH to limit cross-transmission from apparel to Pts via HCW hands No data reported on cross-transmission to Pts
Jacob, 2007⁴³	Department of Health Working Group on Uniforms and Laundry: evidence-based document on wearing and laundering uniforms from 2 literature reviews (Thames Valley University and University College London Hospital NHS Trust) Examined role of uniforms in infection transfer, efficacy of laundry practices in removing contamination, how uniforms affect image of individual and organizations	No conclusive evidence that uniforms pose a significant hazard to spread infection Public does not like seeing hospital staff in uniform outside workplace All components of properly designed and operated laundering help to remove/kill microorganisms on fabric Ten-minute wash at 60°C sufficient to remove most microorganisms Detergents can remove many microorganisms from fabrics at lower temperature (eg, MRSA removed at 30°C) No conclusive evidence for difference between commercial or domestic laundering to remove microorganisms Authors provide list of good (and poor) practice examples with reasons: • Good practice example: "Dress in a manner which is likely to inspire public confidence" • Poor practice example: "Wear false nails for Pt care"
Loh, 2000³⁰	Random sample (n = 100) Cultured medical students' WCs	MSSA recovered from back, pocket, and sleeves Students report occasional or infrequent WC laundering Authors suggest hospitals provide laundered WCs for students No data reported on cross-transmission to Pts
Lopez, 2009³¹	Sampled shirts/ties from internists/surgeons (n = 25/25) for paired bacterial counts	16 participants had never cleaned their tie; 20 participants could not remember when tie last cleaned Bacterial counts from ties significantly higher than those paired from shirts Significant fraction of physicians (16) had Staphylococcus aureus isolated from clothes Apparel infrequently laundered (ties) associated with higher bacterial burden No data reported on cross-transmission to Pts
Morgan, 2012³²	Cohort study of sequential HCW interaction with Pts with culture of gowns/hands linked to environmental cultures	Study with PFGE linking environmental isolates, gowns/gloves, and Pts in >80% of cases (Acinetobacter, MDR Pseudomonas, MRSA) Contamination of gowns/gloves during care of MDRO Pts most frequent with A. baumannii Environmental contamination major determinant of transmission to HCW gloves/gowns Environmental cultures related to gowns/gloves more than clothing
Perry, 2001³³	Cross-sectional sample (n = 57) Bacterial contamination across 5 services Sampled belt area–hem at start vs end of shift	MRSA, VRE, and Clostridium difficile recovered Bacterial contamination of hospital-supplied apparel present at start of shift and increased by end of shift: • Start shift: 39% of uniforms positive with ≥1 microorganism • End shift: 54% of uniforms positive with ≥1 microorganism All uniforms laundered at home No data reported on cross-transmission to Pts
Scott, 1990⁵⁸	In vitro experiment: bacterial transfer from laminate surfaces and cloths to hands	Contaminated inanimate surfaces (eg, laminates, textiles) associated with bacterial transfer to fingers: Escherichia coli, Salmonella species, MSSA
Steinlechner, 2002³⁷	Cohort of orthopedic surgeons (n = 26) Sampled ties for bacterial growth	Ties of orthopedic surgeons heavily colonized with pathogens 295 bacterial isolates: 45% were Bacillus cereus, CNS, GNRs, S. aureus No data reported on cross-transmission to Pts
Treakle, 2009³⁴	Cross-sectional study Attendees (n = 149) of medical and surgical grand rounds at a large teaching hospital Sampled WCs for growth	34 (23%) WCs grew S. aureus; 6 (18%) were MRSA No VRE recovered Large fraction of HCP WCs contaminated with S. aureus, including MRSA WCs may be vectors of S. aureus transmission No data reported on cross-transmission to Pts
Wiener-Well, 2011³⁸	Cross-sectional convenience sample of MDs/RNs (n = 135) with survey and cultures of uniforms/WC	Nearly all HCW clothing heavily contaminated with skin flora, 63% with potential pathogens (Acinetobacter species, S. aureus, Enterobacteriaceae) No data reported on cross-transmission to Pts
Willis-Owen, 2010⁴¹	Prospective, cross-sectional, observational study (n = 92) Agar imprints of MD hands from multiple specialties during normal work day (49 BBE, 43 not) No. of CFU graded light (<10), moderate (10–20), or heavy (>20) with presence of pathogens recorded	No significant difference in either CFU or pathogens in BBE vs no BBE No MDRO cultured from MD hands Participants not given an opportunity for hand hygiene prior to enrollment Study does not identify group for the 50% of MDs who wore uniforms with antibacterial properties Authors concluded that BBE per se does not have impact on degree of contamination on MD hands and BBE initiative should not divert from other important measures, such as hand hygiene, appropriate Pt:RN ratios
Wilson, 2007⁵⁹	Systematic review of published literature	HCW uniforms and WCs can become progressively contaminated with bacteria of low pathogenicity (from HCWs) and mixed pathogenicity (from environment) Data do not support role of apparel as vehicles for cross-transmission
Wong, 1991³⁵	Cross-sectional survey Bacterial contamination of WCs in a British hospital	25% MSSA contamination of WCs for both physicians and surgeons (cuffs, pockets) Degree of contamination associated with increased frequency of WC usage No data reported on cross-transmission to Pts
Wright, 2012⁵⁴	Outbreak report Cluster of 3 Pts with deep sternal wound infections due to Gordonia species	Same species in RN anesthetist, her clothing, her roommate, and her roommate's clothing; home laundering of scrubs implicated (but not confirmed) as origin of staff clothing colonization Reminder that home laundering scrubs can be problematic

Note BBE, bare below elbows; CNS, coagulase-negative staphylococci; GNR, gram-negative rod; HAI, healthcare-associated infection; HCP, healthcare personnel; HCW, healthcare worker; HH, hand hygiene; ICU, intensive care unit; InPt, inpatient; LTCF, long-term care facility; MD, physician; MDR, multidrug resistant; MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible S. aureus; NHS, National Health Service; OutPt, outpatient; PFGE, pulsed-field gel electrophoresis; Pt, patient; RN, nurse; VRE, vancomycin-resistant enterococci; WC, white coat.

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