What should we wear to care? A person-centred exploratory study of care staff clothing in care homes for people living with dementia

Some care homes swear by staff uniforms, others have done away with them altogether to make themselves more “homely”. Faith Frost and colleagues conducted research among staff, visitors, residents and relatives, finding that they liked a spectrum of workplace clothing depending on context

The role of staff uniforms in care homes has been an ongoing debate for many years. Many staff feel their uniform gives them a sense of professionalism and that residents find it more reassuring to have personal care from someone in uniform. Others see uniform as a barrier to creating a homely environment or a symbol of an “us and them” power imbalance which can trigger adverse reactions for residents.

There are corresponding differences between residents’ families. Some families like the non-uniform style, whereas others find it confusing not to be able to immediately identify a member of staff. There are also costs and tax implications and the necessity for “appropriate dress” associated with wearing one’s own clothes to work.

While most care home staff wear uniforms when at work, an ambition to make care homes more homely has led some organisations to remove uniforms from their care homes. In 2018, Sally Knocker made “a passionate call to action” encouraging care homes to move away from uniforms. While acknowledging the reasons for keeping uniforms, she argued that by their very nature they make staff look the same which may “result in a person with dementia finding it harder to distinguish between different paid carers as individuals.”

Even so, there is very little research evidence about the wearing (or not) of uniforms and the small number of studies that exist are inconclusive as to the best approach. Where care homes have tried moving to non-uniform, responses have been positive, but findings tend to be anecdotal rather than evidence-based (Short 2018, Haseltine & Dirksen 2020). Indeed, a lack of formal evidence may discourage some care homes from considering making a change. In order to address this, health and social care provider Care UK was keen to explore the attitudes of residents, relatives and staff to the wearing of uniforms so as to inform the development of its dementia strategy.

Literature review

An initial discussion paper one of us produced noted that “the missing link appears to be actually involving people living with dementia and those who care for them both family, friends and professionally” (Mumford 2019). Information about the benefits of uniforms is often found on websites for companies promoting or selling uniforms and workwear (Interweave Healthcare 2019, Heath 2018, Hatfield 2016), which raises questions of potential bias.

Indeed, some begin from the premise of a uniform being the assumed default and focus more on the different styles or colours available rather than alternatives to uniforms (Hatfield 2016, Verity 2008). When one company did raise the issue of uniforms, it referred to a survey which found that 62% of people thought care home workers should wear uniforms (Interweave Healthcare 2019). However, another organisation found that when they made the wearing of uniforms optional “seventy per cent of staff immediately took up this opportunity”, indicating that what staff feel should happen does not always match what they would like to do when given the chance (Jones & Miesen 2004).

Where changes to uniforms have been made, polo shirts or tunics in different colours appear to be preferred rather than own clothes (Gardner 2012, Stonehaven 2013), although as acknowledged by Sanderson (2016), “having a smart dress code, but wearing our own clothes was important. We explored the poloshirt with logo idea – but this is simply a different kind of uniform”.

When some care homes have considered changing uniforms, the focus has been more on the need to use colour to differentiate between job roles, rather than whether uniforms should be used at all (Kelly 2016). Such changes have also included new name badges (Kelly 2016, Ford 2018) with “the name of the staff member in bigger and bolder print, so it is easier for our residents and their families to read” (Kelly 2016).

Where consultations regarding uniforms have taken place, it has tended to be with the workforce and stakeholders (Ford 2018) and not with residents. A case study by Mitchell (2018) reported that it was “agreed that the people living with dementia should remain at the centre of discussions.” But their views were not included, and instead some of the objections to not wearing uniforms related to infection control and how it may be perceived by agency care staff and visitors. Concern was also expressed that changes may cause confusion for people with dementia, without considering the potential longer-term benefits that may result.

Uniforms can be an emotive subject with people having their own personal views. These views often seem very convincing even when they promote opposite sides of the conversation, which means that no solution will ever please everyone. Perhaps the questions that need to be considered instead are “whose opinions should take precedence?” and “should we allow potential difficulties to prevent us from taking a risk and trying something different?”

Aims

The pros and cons of wearing uniforms tend to be based on care home provider or practice educator views and opinions, rather than taking the wider group of stakeholders such as residents and family carers into account. Our exploratory, small-scale study was conducted to provide an insight into the views of care home staff, regular visitors, residents, and relatives so that their voices were represented in the debate.

As name badges are an integral part of the staff uniform, the study also aimed to obtain feedback on preferred badge design. The findings from the study will inform the development of Care UK’s organisational strategy for a staff dress code and potentially lead to a larger-scale project to explore this topic in greater detail.

Method

Our study used two main means of data collection, a survey and a table-top activity, both of which revolved around a set of six photographs designed to elicit responses about people’s preferences in different situations. The photographs were taken to illustrate three uniform options:

  • a traditional or more formal uniform representing what care staff are most likely to wear currently
  • a polo shirt, representing a less formal version of a uniform
  • an “own clothes” option which was the least formal.

To ensure that these options, particularly “own clothes”, would be acceptable for care staff to wear at work, they were agreed with the management teams from two Care UK homes based on guidance around style, sleeve length and neckline.

To minimise colour becoming an influencing factor, the three options were of a similar colour where possible, with purple being chosen to match existing Care UK branding. Each uniform option was photographed with the member of staff in two contrasting poses, one being “approachable” and friendly, and the other being “unapproachable”.

Three surveys were co-designed with the contribution of the management teams, focusing on three key groups: care staff; the wider staff team and visiting professionals; and family members of residents. The photographs were presented in the surveys in a mixed-up order, so that the two poses for the same uniform option were not adjacent. For consistency, the same order was used in all three surveys.

Images of three badges were also included, one representing the existing Care UK staff badge, and two variations which put different emphases on the staff name and Care UK logo. Each survey was tailored for each group to capture their personal opinions on which uniform options and badges they liked most and what they felt the residents’ views would be.

To get valuable feedback directly from residents living with dementia, a “table-top activity” was designed using the same set of photographs alongside images that cued conversations about different activities. The activity was facilitated by a member of staff, providing residents with the opportunity to pair up photographs showing their preferred uniform choice for each activity.

For example, when shown an image of a garden and asked a question such as “which person from the photographs would you like to go out for a walk in the garden with?” the resident was able to select the staff photograph of their preferred choice to match that scenario. The scenarios included a mix of formal care activities such as personal care, as well as social activities.

Two care homes were selected to take part in this small-scale study. However, the first Covid-19 lockdown in March 2020 occurred just after the surveys and table-top activity kits had been distributed to the care homes, so data collection was delayed until the homes were able to proceed. One of these homes was eventually forced to withdraw, but a replacement care home was identified and brought up to speed.

Despite the best efforts of all involved, data collection was still affected by the pandemic: survey responses were lower than anticipated and only one care home was able to complete the table-top activity with residents.

Results

In all, 27 members of care staff, eight visitors or wider staff team members and 14 relatives completed surveys as part of the study. Additionally, six residents participated in the table-top activity to provide feedback on staff uniforms and badges.

Formal option, approachable pose

Overall, the more formal uniform option with the “approachable” pose was the preferred choice for staff to wear when formal care activities were taking place. Indeed, it was the option that residents associated most with staff providing personal care and physical assistance.

In numerical terms, we found that 65% of care staff thought residents would prefer staff to be wearing the formal uniform when helping them to get washed and dressed, rising to 79% of relatives and 88% of the wider staff team and visitors.

Our findings indicated that 86% of relatives and 88% of the wider staff team and visitors would feel confident approaching a member of staff wearing this uniform option to discuss a resident’s physical health needs, with 78% of care staff and 57% of relatives also feeling that residents would prefer to ask someone for help if they were wearing the formal uniform.

Overall, the formal uniform was thought to make staff members look trustworthy by 59% of care staff, 50% of relatives and 88% of the wider staff team and visitors. The same percentage of the wider staff team and visitors thought it was the most appropriate option for care staff, while 70% of care staff themselves considered it to be the most practical option.

It should be noted that the formal option is closest to the existing Care UK uniform. This may have introduced unintentional bias as it would look the most familiar to people, which could have influenced some responses.

Own clothes option, approachable pose

The “own clothes” option with the “approachable” pose was the preferred choice when thinking about residents participating in more social activities, including activities that take place outside of the care home environment. In total, 41% of care staff, and 75% of the wider staff team and visitors felt that residents would most like to go on an activity outside of the care home with someone wearing this type of clothing. Indeed, 100% of residents reported that they would want to go on trip with a member of staff wearing the own clothes option, with 67% preferring the “approachable” pose.

This option was also the style chosen by 50% of the wider staff team and visitors in terms of who they felt residents would most like to talk to, again reflecting the link with social activities. It was also rated as looking the most comfortable of the three options presented by 44% of the care staff.

Polo shirt option, approachable pose

The polo shirt option was generally a strong second choice for most activities, both in terms of those providing care and those with a social focus. It was rated by 63% of the wider staff team and visitors as representing the person they would be most comfortable approaching if they were concerned about a resident’s emotional health. The same percentage also thought that residents would be most likely to ask this member of staff for help.

This option could therefore be an alternative to a formal uniform, as it was an acceptable choice for most scenarios. While this would still be a form of uniform, it could be used as a stepping stone to explore the potential impact and disruption caused by a change of uniform, before moving to a full “own clothes” option in the future if desired.

Impact of ‘pose’

Regardless of the uniform option, the study findings clearly indicated that the approachability of a member of staff is an incredibly important factor. When the residents were asked if there was anybody in the pictures that they would not want to care for them, only photographs showing the model in an “unapproachable” stance were selected. The three photographs featuring this pose were very rarely chosen throughout the surveys by any group of respondents, but, when they were chosen, they reflected the overall pattern of the formal uniform for formal activities and the own clothes option for more social activities.

Badges

There was a clear and consistent view from both the surveys and table-top activity that the badge which focused on the staff name, rather than the corporate logo or job title, was the easiest to read. It was the preferred choice for 74% of care staff, 77% of relatives, 100% of the wider staff team and visitors, and 100% of residents.

This is particularly pertinent when PPE such as aprons and masks is in use. Since staff faces and uniforms are obscured, as has often happened during the pandemic, badges have an even more significant role to play in helping residents to identify members of staff.

The study used a set of six photographs designed to elicit responses about people’s preferences in different situations

Discussion

There has been a paucity of research into the wearing of uniforms in care homes, especially research that includes the views of staff, relatives and residents. Most literature relating to uniforms appears to be anecdotal rather than adding to the limited evidence base.

Despite its relatively small scale, this exploratory study has therefore provided an important insight into the views of a range of stakeholders in the uniform debate, which have been captured through a combination of surveys and a table-top activity. It has also reiterated that with suitable adaptations in place, residents with dementia are able to share their views on issues that directly affect them, and that they should not automatically be excluded from research because it is assumed that they cannot participate or it would be “too difficult”.

While views differed between groups of respondents, there was an overall feeling that there is no one size fits all approach when it comes to uniforms. The choice of uniform needs to match the type of activity being undertaken. For more formal and practical activities such as providing health care, a more formal uniform was generally preferred with a polo shirt being an acceptable second choice. For informal activities or activities that provide support with emotional wellbeing, including those involving leaving the care home, a more casual choice of “own clothes” was preferred, with a polo shirt again being the second choice. To what extent these views are influenced by what staff currently wear in the participating care homes is unclear.

The study findings indicated that posture of the person in the photographs affected which version of the uniform options was chosen, with the “approachable” photographs being preferred across the board. Indeed, residents themselves stated that they would not like to be cared for by a person in an unapproachable pose. This demonstrates that the stance and posture that staff “wear” as part of their uniform is just as important as the style of the outfit itself.

While name badges may not immediately appear to be a key part of a uniform, they have a very important role to play in care homes. They can help to identify people and provide useful information to both residents and relatives. As the description suggests, though, a person’s name is the key element of the badge, and to this end it needs to be easy for people to read.

Our study clearly shows that a badge in which the focus is on the member of staff’s first name rather than job title or corporate logo is the easiest option for people to read. This suggests that a “quick win” could be to change the style of name badges to reflect this clearer layout, particularly pertinent when PPE is being worn.

Conclusion

Different styles of uniform were preferred for different types of activity, with a link between the choice of clothing and the context in which staff are working. While different uniforms for different situations would be impractical, our findings suggest that, if care homes were looking to move away from existing formal uniforms, a polo shirt could be an acceptable alternative for everyone.

As indicated by the literature review, a polo shirt would still be a form of uniform, but could be used as a less disruptive stepping stone to a full “own clothes” option in the future. Care UK has made a simple change to badges with first name only as a direct result of this research.

The approachability of staff was clearly identified in this study as being just as important, or possibly even more so, than the clothes being worn. This might suggest that the interpersonal skills staff are the key factor: what is worn can help amplify the message of approachability or trust, but it will not change a negative reaction into a positive one.

The prospect of making any form of change in a care home can be daunting, especially when there is a risk of causing disruption for residents as well as staff. However, the potential longer-term benefits of a change, particularly for residents, should be taken into consideration when planning a change rather than focusing on any short-term disruption.

If care homes can successfully be refurbished or redecorated because the new design is more enabling and dementia-friendly for residents, then a phased alteration to uniforms should be possible, especially when residents have indicated that a less formal uniform option would be preferable in some circumstances.

Managing any change is just as important as the change itself. Clear communication with everyone involved should help to reduce anxieties and give people a sense of ownership of what is happening. Additionally, any change to uniforms should be accompanied by suitable training and support to help staff understand the reasons for the change and the anticipated benefits for all.

Such training and support should also reinforce to staff the importance of their body language and attitude as an integral part of their uniform, rather than solely focusing on the style of the clothes worn.

References

Ford S (2018) Care home group responds to staff call for new uniforms. Nursing Times, www.nursingtimes.net (28 March).

Gardner G (2012) Bath dementia homes see the rainbows end. Blog at www.grahamegardner.co.uk (17 December)

Haseltine W, Dirksen A (2020) Voices in Dementia Care: Reimagining the Culture of Care (second edition). Austin, Texas: Greenleaf Book Group.

Ηatfield M (2016) Bright and Colourful Care Home Uniforms – The Right Stimulus for Your Patients. Blog at www.uniforms4healthcare.com (7 March).

Heath J (2018) Uniform essentials for working in a care home. Blog at www.simonjersey.com (22 February).

Interweave Healthcare (2019) What do UK care workers wear? Blog at www.interweavetextiles.com (20 September).

Jones G, Miesen B (2004) Care-giving in Dementia: Research and Applications (Volume 3). Abingdon: Routledge.

Kelly R (2016) Erskine Care Home revamp their uniforms. Blog at www.renfrewshire24.co.uk (13 December 2016).

Knocker S (2018) Uniforms: the first and final frontier in dementia care. Journal of Dementia Care 24(6) 16-17.

Mitchell G (2018) Uniforms in dementia care: A barrier or a necessity? Nursing Ethics 25(3) 410-412.

Mumford S (2019) Fulfilling Lives our Approach to Care: Discussion document – Uniform or no uniform. London: Care UK.

Sanderson H (2016) Uniforms and home care. Blog at helensanderson.net (14 October).

Short J (2018) Undressing the Uniform Debate. Blog at www.fromenursinghome.com

Stonehaven (2013). A New Look for our Care Team. Blog at stone-haven.co.uk (19 November).

Verity J (2008) Why rainbow uniforms? Blog at dementiacareinternational.com (24 July).

Faith Frost is research associate, Jennifer Bray is research assistant, and Professor Dawn Brooker is director, all at the Association for Dementia Studies. Suzanne Mumford is head of nursing, care and dementia services at Care UK.

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