| | Balancing between being a person and being a patient—A qualitative study of wearing patient clothingReceived 18 December 2007; received in revised form 7 August 2008; accepted 8 August 2008. Abstract BackgroundThe nursing literature is replete with articles on the function of clothing in preventing and controlling infections. However, although contemporary literature demonstrates intimate connections between clothing and identity, there is a lack of studies which illuminate the meanings associated with wearing patient clothing. ObjectivesThis study aimed to illuminate the meanings of wearing patient clothing as narrated by patients and nurses in Swedish care settings. SettingsData was collected between 2001 and 2003 at a hospice, an in-patient geriatric unit, an acute medical unit, and an in-patient oncology unit in Sweden. ResultsThe phenomenon of ‘wearing patient clothing’ was found to consist of four themes: (1) being comfortable and cared for; (2) being depersonalised; (3) being stigmatised; and (4) being devitalised. Interpreted in the light of philosophical literature on identity and symbols, the comprehensive understanding of wearing patient clothing is that it is a balancing between being a person and being a patient. Patient clothes were experienced as being comfortable and practical, but also as being stigmatising symbols of illness, confinement, and depersonalisation. ConclusionsThe tension between patient clothing as being practical and comfortable and at the same time enabling feelings of being depersonalised and stigmatised suggests that nursing staff need to balance the practical benefits of these garments with the social and existential meanings they might have. What is already known about the topic? •Different types of clothing are used to prevent and control infections in nursing. •Practical objects and routines can also have symbolic meanings. •Clothing has powerful expressive functions of identity and place in society. What this paper adds •Patient clothing is a powerful symbol of illness. •Patient clothes are practical and comfortable but can also be depersonalising and stigmatising. •Patient clothing may reduce individuals’ opportunities for presentation of self, and facilitate feelings of becoming less of a person and more of a patient. 1. Introduction  It is common procedure in a number of acute hospitals in Sweden to provide patients with special clothing during their stay in the hospital. Unlike the various gowns worn for specific medical or surgical procedures, these particular garments serve as a replacement for the patients’ ordinary clothes; they typically resemble pyjamas and consist of drawstring cotton pants, T-shirts, and button-up jackets in uniform colours. Clinical experience and anecdotal evidence suggest that nursing staff in acute hospital wards often encourage patients to use this type of hospital clothing on the basis of its practicality, since these garments generally have a loose fit and thus are easily removed for examinations and other purposes, and if stained they are conveniently and efficiently taken care of by the hospital laundry system. During the course of a larger study on the impact of environment on patient well-being, interviews revealed vivid experiences and conflicting views of this type of clothing, and it was decided to further explore the meanings attached to this seemingly overlooked aspect of hospital care. This article reports the findings from a phenomenological hermeneutical analysis of the meanings of wearing patient clothing as narrated by people receiving and providing care in Swedish hospital settings. From a sociological perspective, it has been argued that appearance and clothing are so familiar and visible in everyday life that their meanings are mostly taken for granted, even though clothing functions to substantiate a person's sense of self and place in society (Kaiser, 1997). The communicative functions of clothing are said to reflect, express, or enhance personality—whether the bearer is conscious of this or not. The expressive function of clothing includes communication of social status, occupation, role, self-confidence, intelligence, conformity, individuality, and other identity characteristics (Horn and Gurel, 1981, Crane, 2000, Klein, 2000). Historians, anthropologists, sociologists, psychologists, and nurses have investigated how clothes define individuals and groups by time and place, and the massive amount of contemporary literature on clothing ranges from the protective functions of clothing to the cultural meanings of specific garments and the identity reinforcement carried out through popular images, brands, and symbols found on clothing in contemporary society. In short, the sociological literature indicates that in the eyes of others, you basically are what you wear. Database searches of PubMed and Cinahl on the use, meaning, and function of clothing in nursing reveal surprisingly few studies of the meanings of hospital clothing. Most of the literature relates to prevention and control of infection (cf. Jenkinson et al., 2006); for example, factors influencing nurses’ use of plastic aprons during direct patient care (Candlin and Stark, 2005), appropriate glove use in preventing infections (Flores, 2007), inappropriate use of gloves by nurses (Hampton, 2003), correlations between protective gloves and prevalence of occupational dermatitis (Sasaki and Kanda, 2006), the protective barrier properties of various gloves (Zinner, 1994), the cost effectiveness of surgical gloves (Fay and Dooher, 1992), and perspectives on and effects of various foot support devices for diabetic foot care (Johnson et al., 2006). However, no studies were found that focused on the meanings of wearing patient clothing. There is a clear clinical and theoretical rationale for illuminating the meanings of wearing patient clothing; the common use of patient clothing in hospital contexts, and the dearth of literature illuminating the meanings attached to wearing and seeing others wear patient clothing. There is, in addition, an empirical rationale; this area repeatedly emerged in interviews conducted as part of a larger study of environmental influences on patient well-being, and thus demanded further analysis. 2. Aim This study aimed to illuminate the meanings of wearing patient clothing as narrated by patients and nurses in Swedish care settings. 3. Method 3.1. Participants and data collection The data for this analysis was derived from a larger study exploring caring environments as experienced by patients, significant others, and health care staff. The larger study employed a grounded theory explorative design involving fieldwork observations and conversational research interviews (Kvale, 1996) with patients (n =41), significant others (n=20), and staff (n=51). Data was collected between 2001 and 2003 at a hospice, an in-patient geriatric unit, an acute medical unit, and an in-patient oncology setting. The results of the larger study have been reported elsewhere (Edvardsson et al., 2005, Edvardsson et al., 2006, Edvardsson and Street, 2007, Rasmussen and Edvardsson, 2007). In line with the principles of grounded theory methodology (Glaser, 1976), the path of discovery was followed when the phenomenon of ‘wearing patient clothing’ repeatedly surfaced in interviews, and data collection was focused on this emerging area of interest. Participants were recruited according to the principles of maximum variation from the above-mentioned settings, to narrate their experiences of wearing patient clothing. This meant that interviews were performed with patients (both wearing and not wearing patient clothing) and staff (seeing patients wearing those garments) in all the settings about their experiences of wearing themselves or seeing others in patient clothing. Participants were specifically asked to narrate their experiences of patient clothing and their perceptions of its functions, and to further elaborate on their feelings connected to these clothes. The interviews lasted between 15 and 45min, and were tape recorded and transcribed verbatim. Additional interviews were conducted until a sense of saturation emerged; that is, until further participant narrations ceased to reveal any new experiences and meanings which had not already been covered in previous interviews. In total, nine interviews with patients and five interviews with staff were performed. Although data collection was performed according to the principles of grounded theory methodology, the analysis was influenced by phenomenological hermeneutics. The decision to use a phenomenological hermeneutical analysis was based both on the research question and on the character of the empirical data. Phenomenological hermeneutical analysis enables the researcher to illuminate meanings, and the empirical data generated in this study was rich in metaphors and had existential and symbolic qualities that called for this type of analysis. Thus, the process of data collection was influenced by the principles of maximum variation as described in grounded theory literature (Glaser, 1976), whereas the data analysis was performed according to the principles of phenomenological hermeneutics (Lindseth and Norberg, 2004). The study was approved by the ethical committee of the medical faculty at Umeå University (§01–071). All persons eligible for interviews were given a letter stating the aim and methods of the study, and were asked personally to participate in the study. Informed consent was established verbally. 3.2. Data analysis The interviews were analysed using a phenomenological hermeneutical method influenced by the work of Ricoeur (1976). This is an approach which is appropriate for interpreting and understanding the meanings of phenomena in people's life worlds (Van Manen, 1997). In this research tradition, the analysis and interpretation of texts moves dialectally between understandings of the whole and parts of a text. The interpretative analysis involves three methodological steps. 3.2.1. Naive understanding First, all interviews are aggregated to form one single text, which is read through in its entirety before an initial tentative interpretation of the meanings of the text, a naïve understanding, is formulated. The naive understanding is a preliminary interpretation of the whole and is not static or linear, but rather dynamic and circular. This means that the interpretation is not formulated once and for all, but is revised and developed during the course of the structural analyses as interpretations evolve or are discarded. After repeated readings of the interviews constituting the whole text, a tentative interpretation of the meanings of wearing patient clothing was formulated. The naive understanding of the phenomenon was that patient clothing had positive meanings of being comfortable, at ease, and cared for. Participants felt comfortable in these loose fitting clothes, and they also felt at ease because they did not have to worry if the clothes became stained with bodily fluids. Feelings of being cared for arose from the provision of clothing free of charge and without having to arrange for washing and drying. However, wearing patient clothing also had more negative meanings, with existential and social implications. Wearing these clothes brought feelings of being depersonalised; of being less of a unique person and more of a patient. Another meaning which surfaced was that of being ‘marked’ by such clothes—as being identified as a patient at all times. Finally, wearing patient clothing was also described as conveying a meaning of the wearer's being ill and devitalised, and thus as a strong symbol of illness which seemed to foster a ‘sick’ role and passive behaviour in patients. 3.2.2. Thematic structural analyses As a second analytical step, structural analyses are employed to discard or validate these first tentative interpretations of the text's meanings. The structural analyses are directed towards the structure of the text, and aim to find evidence for or against the tentative interpretation formulated in the previous phase. The concept of a meaning unit, which means a section of text of any length conveying a specific piece of information, is used in these analyses. Four structural analyses were performed on the interview texts of this study. The first was concerned with the meaning units containing narrations of wearing patient clothing as being practical and convenient; the second with the meaning units involving the existential meanings of these clothes; the third with the metaphors used by the participants to describe the symbolic meanings of patient clothing; and the fourth with the meaning units concerning the social meanings of wearing patient clothing. These structural analyses validated the naïve understanding and provided a structured sorting of the texts that enriched the interpretation and opened up for developing the thematic structure of the phenomenon and the comprehensive understanding. 3.2.3. Comprehensive understanding The final step of the analysis involves the formulation of the comprehensive understanding that has emerged through the previous two phases. This comprehensive understanding is a more sophisticated mode of understanding in that it is supported by the structure of the text and is elaborated upon in relation to the theoretical literature (Lindseth and Norberg, 2004). In the formulation of the comprehensive understanding, the meanings in the text have evolved in a critical dialectic between the reader's pre-understanding and parts and the whole of the text, and relevant theoretical literature is used to deepen and widen the understanding of the text (cf. Ricoeur, 1976, Lindseth and Norberg, 2004). The comprehensive understanding of wearing patient clothing is that it means a balancing between being a person and being a patient. This interpretation will be explicated, developed, and illuminated further in the following section. 4. Findings The phenomenon of ‘wearing patient clothing’ was found to consist of four themes: being comfortable and cared for, being depersonalised, being stigmatised, and being devitalised. 4.1. Being comfortable and cared for The participants described how wearing patient clothing created feelings of being comfortable and at ease, since these clothes were very practical, convenient, comfortable, and easily disposable. Being ill meant being at risk of leakage of various bodily fluids associated with illness and bodily malfunction. Wearing patient clothing meant being physically protected from the stress of staining, changing, and washing private clothing; the clothes were appreciated by those wearing them as they eased the burden of suffering the embarrassment and labour associated with staining their clothes. The following account from Lucy, a woman admitted to the medical ward, illuminates how the lightness and ease of wear of the hospital clothing fostered feelings of being comfortable and at ease. It also provides a glimpse of the comfort associated with being able to simply replace a stained garment with a fresh one. I noticed that you are wearing hospital clothing…? Well the first thing that happens is that you get these clothes, which are very practical. They’re light and easy to wear, and it's easy to take them on and off. Another thing is that they’re easily replaced if they get stained; you just put them in the bag for dirty linen. Several of the participants described how they almost took for granted that being a patient in the hospital meant that you would be given patient clothing, and this service was widely appreciated. The texts support the interpretation that being given these clothes free of charge can be understood as a manifestation of caring. The generosity exhibited in not only providing these clothes, but also allowing patients to replace them as often as they wished, contributed to feelings of being cared for. Beth, a woman at the geriatric clinic, described the patient clothes as being comfortable, and like Lucy she also appreciated the convenience of replacing them on demand; the meaning of generosity is illustrated in the excerpt below in the expression ‘as often as you like’. It's very comfortable to wear such loose fitting clothes. And another thing is that it's very convenient in terms of washing, you don’t have to wash them yourself, you just throw them in the right bags. And you can replace them as often you like. 4.2. Being depersonalised The participants’ descriptions of wearing patient clothing also contained more existential meanings connected with the communicative functions of clothing in relation to personhood and identity. The idea of clothing as a significant part of personhood emerged throughout the interviews. Private clothing was described as a powerful part of the self which one wishes to communicate to the world, as it was seen as having expressive functions related to social identity and presentation of self. Eva, a member of staff at the hospice, used the metaphor of the prisoner to describe the relationship between clothing and self. I believe that it is a significant part of one's integrity and one's self to keep wearing one's own personal clothing, instead of walking around looking like a prisoner in those patient clothes. You can’t have your own identity if everyone else is walking around wearing the same yellow or blue outfit as you are. Meanings of being depersonalised emerged through descriptions of becoming more anonymous as a result of wearing the patient clothing. The data supports the interpretation that, for these participants, wearing this type of clothing meant having one's personal identity camouflaged, as the person was transformed into a patient with associated feelings of being less unique and more anonymous. John, a man at the medical ward, explained how the clothes made him feel more anonymous, and like a nameless part of a crowd. So how does it feel to wear the yellow patient gown supplied by the hospital? Well, I haven’t thought about it very much, it seems almost mandatory when you’re in the hospital. But of course, it makes you become more anonymous, like one of the crowd. Another meaning which emerged in the interviews was that wearing these patient clothes meant feeling less like a person and more like a patient. The participants often used metaphors to describe the impact of patient-specific clothing on the personalities of themselves or others. Metaphors such as ‘looking like a clown’ and ‘feeling like a patient’ surfaced frequently. Sam, a man at a medical ward, described how he wore hospital clothing only reluctantly, due to feelings of becoming less of a person and more of a patient. It's rather reluctantly that I wear these clothes, I would certainly prefer my own, but I guess this is the way it is when you’re in the hospital. These clothes make you feel less like a person and more like a patient. 4.3. Being socially stigmatised The most dramatic meanings of wearing patient clothing surfaced in interviews with participants who had refused to wear the clothes due to the symbolic meanings they perceived them as conveying. Bill, a man at the medical ward, used a vivid contemporary symbol of confinement and social stigma, the attire of Guantanamo Bay prisoners, to convey his feelings about the patient clothes provided by the hospital. So, I noticed that you’re not wearing the hospital clothing…? No, I feel more at home in my own clothes. Those yellow patient gowns make you look like the American prisoners in Cuba, the only thing missing is the bag over your head. For me it's a relief to have something which doesn’t remind you of illness and disease, which those patient gowns very much do. Another metaphor associated with social stigma and confinement came from Roger, being cared for in the medical ward. The patient clothes reminded him of the look of Nazi camp prisoners during World War II—stigmatising and immediately recognisable. Perhaps not surprisingly in light of what the patient clothing meant to him, Roger wore his own clothes. In addition to illuminating meanings of confinement and stigma, his narrative also illuminates the context dependence of symbols and meaning. The region in which Roger lived had had a large traditional mental institution in which patients could be seen wearing institutional clothing which at the time was often perceived as very stigmatising and shameful. Thus, for him, wearing similar clothing within the hospital would resemble the recognition, shamefulness, and stigmatisation of ‘the crazy people’. I don’t want to wear those gowns as they remind me of the pictures from the Nazi concentration camps—everyone wearing exactly the same horrible clothes. And it's no fun being recognised as a patient wherever you go – it's somewhat depersonalising, like – there goes a patient. All this together with the history of the mental hospital in this region, where all the patients wore the same clothes so that everyone recognised and avoided those “crazy people”. I won’t wear them. 4.4. Being revitalised The staff members described the wearing of patient clothing as containing similar meanings to those described in the patient interviews; bringing increased anonymity, stigmatising its wearers, and symbolising patients and illness. Staff members described how by wearing patient clothing, people seemed more ill and less responsible for their own care, as if the illness symbolism of the patient clothes reinforced the ‘sick’ role. Conversely, patients dressed in their own personal clothes seemed more well and more confident, and seemed to take greater responsible for their own care. Staff members also described how they used clothing as a form of nursing intervention to revitalise their patients. The following quotation from Sarah, a nursing aide at a geriatric rehabilitation unit, illuminates how dressing patients in their own clothes was used as a revitalising nursing intervention: I most often encourage the patients to start wearing their own clothes as soon as possible. And why is that? Well I believe that it makes them feel a bit safer. And I also believe that much of our personality is attached to the clothes we wear. It's my experience that patient clothing functions in the same the way as our staff clothing; they take on a ‘sick’ role just as we take on a ‘staff’ role when we’re wearing staff clothes. In some peculiar way… Mandy, another nursing aide at the geriatric clinic, described how her view of (and perhaps also the way she encountered and interacted with) the person in front of her could change depending on what clothes they wore. She narrated how patients in their own clothing seemed not to embody the patient role as much, but appeared less ill and seemed to take more responsibility: Well I actually think that I look upon patients differently depending upon if they wear personal or institutional clothing. Patients in their own clothing appear less ill, and seem to take more responsibility for their care. They seem not to embody the patient role as much, being less passive and more of a unique person. 5. Comprehensive understanding and discussion The comprehensive understanding of wearing patient clothing is that it means balancing between being a person and being a patient. Wearing patient clothes can mean feeling comfortable and feeling cared for, as the clothes are practical and comfortable, and the generosity exhibited in providing them free of charge could be experienced as caring. However, wearing these clothes can also mean the risk of becoming depersonalised and stigmatised, through being literally and metaphorically stripped of parts of one's history and identity, and becoming less of a person and more of a patient—being objectified by being assigned collective patient clothing for medical purposes. Thus, the powerful symbolism of patient clothing can influence the balance between being a person and being a patient. The understanding of identity is subject to debate, as there seems to be no consensus over whether it is biological and fixed, or socially constructed and fluid. Ricoeur (1992) distinguishes two major meanings of identity depending on which of the Latin equivalents for ‘identical’, idem or ipse, is used. Idem refers to identity as having a sameness and permanence in time, thus implying its unchanging nature. Ipse, on the other hand, carries no implications of an unchanging nature, but rather is used to describe identity as being fluid and socially constructed. Thus, the understanding of the concept of identity depends on whether the essentialist (idem) or the non-essentialist (ipse) view of identity is used. There is ample support for viewing identity as being transactional, dialogue dependent, formed and reformed in relation to others, and influenced by contemporary symbols such as clothing (Bruner, 1990, Crane, 2000). Goffman (1959) used dramaturgy and concepts from theatrical performance as analytical tools to describe the use of clothing as a central part of people's presentation of self in everyday life. He argued that since clothes are powerfully expressive equipment by which others identify and make inferences about the wearer, the curtailment of self-connected to being in total institutions can be explained by being stripped of the ‘identity kit’ of one's own clothing. Institutional clothes can constitute a stigma—a visual mark that exposes something unusual and negative about the moral status of the bearer (Goffman, 1968a, Goffman, 1968b). As described by Goffman (1968b), the stigma functions to separate the normal from the abnormal, and thus to reduce the humanity of the (abnormal) person bearing the stigma. Interpreting the interviews in light of these texts means that patient clothing reduces the possibilities for presentation of self, and hence can foster a loss of self by taking away the ‘identity kit’ from the individual. Ultimately, these institutional garments can be understood as a form of stigma. By being a well-known and easily distinguishable social marker of illness, confinement, and patienthood, patient clothing can convey meanings concerning the person's moral status: that this individual is not a person but is first and foremost a patient (a concept which in itself is a stigmatising term, and one used to impute imperfections or undesired differentness from ‘normal’ people—cf. Goffman, 1968b). As the narrations of staff members also showed, patient clothing was experienced as a symbol which influenced how people in hospitals were interpreted and perceived, and how they were experienced to behave. Since patients in private clothing were seen as embodying the patient role to a rather lesser extent, as appearing less ill, and as taking more responsibility, some staff members took the decision to use clothing as a nursing intervention: dressing patients in their own clothes as a revitalising action. However, as these clothing interventions were based on the nurses’ experiences of clothing, the causal connection remains to be studied. The relationships between words that were revealed by this study do not reflect the external relationship among the things signified by the words, but merely indicate a need for more experimentally oriented studies of the possible effects on patient outcomes of different kinds of clothing. For example, it would be of interest to examine whether wearing patient clothing versus personal clothing can affect outcome measures such as length of stay, consumption of medication, and quality of life and nurse–patient interactions for patients in hospitals. Further studies would be valuable. In illuminating the symbolism inherent in patient clothing, the results of this study provide support for previous findings that even if the various forms of clothing, dressing, and physical environments in nursing have technical, hygienic, and architectural rationales, these rationales can coexist with more symbolic messages of shame and stigma, caring or uncaring, and inclusion or exclusion (Edvardsson et al., 2006). As health care professionals, we need to take a critical and analytical approach to the aspects of nursing care that we take for granted. For example, what does our clothing and that of our patients symbolise? How does it influence interactions and feelings? And how do patients experience hospital environments with all their specific symbols? The symbolic aspects might need greater consideration, in addition to the technical and hygienic aspects, in future designs for care (and caring) environments, clothes, and other aspects of nursing care. 6. Methodological discussion and limitations The findings of this study might be seen as limited, as they are based on a subset of data from a larger study. However, emerging data called for more focused data collection to address the emerging issue of meanings of wearing patient clothing. The large amount of intriguing data on wearing patient clothing which had emerged by the end of the main study, in combination with limited space in the original publication, provided the rationale for conducting an analysis of a subset of the data. Another limitation of the study is that the results are based on a small and diverse sample, and this should be kept in mind when reading the results and conclusions. There could for example be a deferens in the meaning of wearing patient clothing between different participants and settings, which are two important issues worthy of additional study. It is acknowledged that these findings would have benefited from further exploration in additional interviews with participants in other settings, and it is to be hoped that future research can explore the findings further. However, the narrative character and social construction of meaning implies that interpretations can change between contexts, cultures, and interpreters, and that larger samples do not automatically equal greater applicability. Nevertheless, the findings of this study are grounded in the lived experiences of the participating nurses and patients, and the findings call for an expanded consciousness of the possible meanings of wearing patient clothing. Even though debate is ongoing regarding which concepts to use for assessing and describing rigour in qualitative research in general and for interpretive phenomenology in particular, qualities such as auditability, persuasiveness, credibility, and applicability are generally viewed as important (see De Witt and Ploeg, 2006 for an up-to-date discussion of qualitative rigor). Auditability refers to providing information about the research process so that the reader can assess the rationale for and quality of the decisions made. Persuasiveness refers to the extent to which a given work convinces the reader; the extent to which it ‘rings true’ and matches the reader's experiences of his or her own life world. Credibility refers to the extent to which the findings of qualitative research can be confirmed by other work or by the participants. Finally, applicability is concerned with whether the findings can be applied in settings other than those in which they were uncovered (Sandelowski, 1993, Schneider et al., 2003). The information provided about the research process and the way in which the findings are portrayed and presented in this article form the basis for assessing the auditability and persuasiveness of the study, and you as the reader will be the ultimate judge of this. Furthermore, since credibility and applicability have a temporal aspect, this article and its findings may achieve credibility and applicability if and when other researchers and clinicians find them credible and applicable enough to use them in their own work. Thus, the rigour (or lack thereof) of this study can be only partly established here and now. 7. Conclusions and implications for nursing The tension between patient clothing as being practical and comfortable on the one hand, and as bearing meanings of being depersonalised and stigmatised on the other, calls for some clinical reflection before routinely providing such attire to people dependent on care. The findings suggest that nursing staff can consider balancing the practical benefits of patient clothing with the social and existential meanings of depersonalisation, shame, and stigma. They also suggest that allowing patients to choose between patient clothing and their own personal clothing reflects the ethical and professional demand to provide individualised and person-centred care. Acknowledgements This study received funding from Swedish Brain Power, Umeå University, La Trobe University, the Swedish Council for Working Life and Social Research, and King Gustaf V and Queen Victoria's Foundation. Conflict of interest: None declared. 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