Commentary on Roohafza H, Pirnia A, Sadeghi M, Toghianifar N, Talaei M & Ashrafi M (2009) Impact of nurses clothing on anxiety of hospitalised children. Journal of Clinical Nursing 18, 1953–1959


  • Linda Shields

    1. Author:Linda Shields, PhD, FRCNA, FRSM, Professor of Paediatric and Child Health Nursing, Child and Adolescent Health Service, School of Nursing and Midwifery, Curtin University of Technology, Perth, WA, Australia
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Linda Shields, Professor of Paediatric and Child Health Nursing, Child and Adolescent Health Service, School of Nursing and Midwifery, Curtin University of Technology, Perth, WA, Australia.

This paper about the impact of nurse clothing on anxiety levels in hospitalised children (Roohafza et al. 2008) is important from two aspects. First, there is some research about this topic, but not enough; so this is a very welcome addition. Second, it is very important that research like this by nurses comes from countries outside the Western developed block nations. This paper from Iran is particularly interesting. The study itself has been established in a hospital where, traditionally, all nurses wear white uniforms. It has been carefully designed and implemented, and examines the anxiety levels of children using a validated tool (although one of the problems with the study is that they have not described the translation process from English, and how this was validated).

Using two groups of children who were, in the main, old enough to complete the questionnaire themselves, the investigators found that the children were less anxious during hospital admission if the nurse caring for them wore coloured uniforms rather than the traditional white. This effect was found to be larger in girls than boys, in those with in higher grades at school compared with their younger counterparts and those with a higher number of people in the household. In such studies, it is difficult to determine the effects of different aspects of culture on such measures, but because it used a standardised questionnaire that has been used internationally in many settings, it might, perhaps, have missed factors that are culturally driven; however, these factors would perhaps best be determined by qualitative investigation. One important aspect of this study is the fact that it is the children’s opinions that are used; the younger ones supported by their parents, but their voices nonetheless.

Much of the research in this area is now fairly old, much of it has been done in adults, with little input from children. We could, however, assume that children would be those most affected by anxiety derived in this way. Adults are quite able to reconcile that nurses’ uniforms are seen by some as a necessary part of the way a hospital works. Duffield’s (2009) recent editorial in JCN discussed the importance of uniforms in hospital wards so that people can readily identify the different professions and the status and role of different staff. While I would never agree with her tongue-in-cheek title ‘Bring back the veil’, she may perhaps have a point that in these days of corporate uniforms, colours, patterned fabrics, etc., identification of staff in hospital wards can be difficult. A major problem with nursing in some countries is that nurses’ uniforms are often no different to those of the domestic staff. I assert though, that an efficient system of name badges containing ID photos, full name, and position in the organisation should be in place to enable patients and relatives to identify staff on the ward. While once doctors wore white coats (in the same era as sisters wore veils), for a long time now, doctors have worn ordinary clothes to the wards and I know of no research where patients have not been able to identify those doctors. In children, research such as Roohafza et al.’s (2008) shows that non-traditional uniforms may be acceptable to children and may help to decrease their anxiety about hospital admission.

Importantly, this research gives insight into the hospital care of children in a country often not accessible to those reading English language journals. This is beneficial to everyone, nurses, doctors, hospital staff of all kind, academics and children and parents. To much of the audience of a publication such as JCN, Iran is a somewhat mysterious and inaccessible country. It has a very ancient history and sophisticated culture and was one of the most important countries in the development of medicine, as the home, for instance, of medical pioneers such as Abu Ali Sina Balkhi (known as Avicenna in the West), in the 10th–11th Centuries (Porter 2003). Also, the influence of Islam in Iran is very strong, though many other religions exist there. As with nursing in any country, factors such as a predominant religion influence nursing practice, education and research. Nonetheless, it is self-evident that the care of children in health services must be similar in all countries, regardless of any cultural construct, and good nursing care, similarly, is universal. Research such as this demonstrates a lively and productive nursing research culture in paediatric nursing. This research project was led by Roofzaha, a behavioural scientist, and is in collaboration with the head nurse, Pirnia, from the Department of Paediatric Surgery at the Isfahan University of Medical Sciences, and others; thus demonstrating a healthy collaborative research environment.

The researchers are to be congratulated for this small but interesting research project, its interdisciplinarity and the interest it will stir amongst other nurses in non-Western countries (and Western countries as well) to become involved in research. As evidence generated by nurses in their own country, this study will provide impetus to bring about changes in practice in paediatric services. One of its most important aspects, though, is that by publishing in Iran in a mainstream English language nursing journals, the authors demonstrate to the nursing world that nursing research is alive and well in Iran.