Journal of Hospital & Medical Management

Keywords

Patient clothing; Role; Body; Object; Patient anonymity; Environment

Introduction

This article describes and problematizes the use of patient clothing as a part of the health care environment and its potential significance for patients, care delivery, the nursing staff and the healing process. Within Scandinavia, hospital clothing is either offered as an option or required for inpatient care. In certain units, such as in psychiatric care, patients usually wear their own clothes, whereas surgical units usually require patients to wear hospital clothing. In many other European countries, access to hospital clothing is provided, but patients may choose to wear their own clothing during hospitalization. The most common reasons that hospitals began to provide, require or offer clothing to patients included improved hygiene and reduced risk of infection, as well as ensuring that all patients were given access to acceptable clothing [1]. A more recently cited reason is that clothing can be stained or ruined by leakage of bodily fluids that may occur during various examinations, treatments and medical procedures during hospitalization. In certain healthcare settings, life-saving measures that require access to the naked body may need to be rapidly initiated to allow technical equipment to be connected to the patient. Under such circumstances, the time required for removal of private clothing may delay critical treatment. However, such arguments are not backed up by scientific evidence.

The word patient is often associated with a passive or dependent role – the role of the patient. The word “patient”, by definition refers to “a person who suffers patiently”. This state of human suffering can therefore be present without any disease or contact with the health care system. The word patient was also, during the seventeenth and eighteenth centuries, used as a designation for prisoners who were tortured and later executed [2].

Patients are not homogeneous and they thereby use a variety of clothes privately. As a consequence, the unified patient clothes will have different effects and be of more or less importance. Since hospital or patient (used synonymously) clothing is identical for all patients and also indicates an affiliation with an institution, an important question becomes what significance such clothing may have for the relationship between patients and personnel and for patient identity. Does this entail a transition from being a patient in the classic sense to assuming a “patient role” in a system with secondary consequences?

The significance of clothing for humans can be discussed from a historical perspective, including the relationship to human nudity and how clothing can be interpreted based on different types of “institutionalization.” Some of these concepts and phenomena are issues that concern various approaches to and knowledge about the body, nudity and baring the body, identity, and the role of the patient and disease in relation to objectification, as well as the significance and implications of clothing. The purpose of the historical background is to lead us to the question: Does wearing patient clothing/hospital clothing depersonalize and anonymize patients as unique individuals, forcing them to assume a patient role?

The overarching purpose of this article is to discuss the relationships and role allocation created between patients and hospital staff when patients wear hospital clothing and by extension, the type of care provided and whether the potential for recovery of health is affected.

Clothing from a Historical Perspective

The answer to the question of why we use or need clothing is to protect the body from sexual exposure, weather and wind and to be able to regulate heat and cold. Other potential responses may be that clothing hides the body to avoid judgment from others, and protects the body as something private that should only be revealed in situations when the individual so chooses. Clothing may also have complex implications, for example, as a symbol of control and power. In this way, the body and clothing, as well as social position, are all associated with each other.

According to Duerr's [3] viewpoint of how nudity and bodies were perceived, as well as the so-called athletic and military nudity of ancient Greece, the naked body should not be displayed to others. It was considered especially important to protect the genitalia with a loincloth and in the case of women, to also cover the breasts. Showing or allowing someone, especially of the opposite sex, to see the intimate parts of the body entails shame. Despite this attitude, there are paintings on bowls, vases and other utilitarian objects, as well as statues, showing naked men and women. There appears to be a difference between what was socially and culturally accepted in “reality” and in art. Duerr [3] holds that nudity during antiquity also signifies that the person in question is not wearing their usual clothing. This attitude also appears to persist into the Middle Ages.

During the Middle Ages, the sick and less fortunate were primarily cared for by nuns and monks in cloisters [3]. In the cloisters, people were forbidden to reveal their naked or half-naked bodies to their fellow monks or nuns. Some of these rules were carried over to medieval hospitals and university dormitories during the fifteenth century. Depictions of fourteenth century hospital wards show that all patients wore night shirts under which they also wore some type of underclothing. According to Duerr [3], this image can be recognized from both the Byzantine Empire and Western Europe. The body was to remain covered even in the hospital baths, which were also separated by gender. Both the hospitals and the sick rooms at cloisters were to be genderfree zones, which was important to highlight both the distinction between male and female wards, but also to neutralize men and women as sexual beings. In this context, clothing can be a means of achieving a desexualized “space." In the middle of 1800 nightdresses, for both men and women, became more common in several social groups [4]. In the end of 1800 and in the beginning of 1900, the pyjamas for men became more common even at hospitals. Nightingale’s experiences from the Krim war and the observations made by Lister and Semmelweiss resulted in that hospitals should offer washed and clean patient clothes, bedclothes and towels [4]. In prisons and in conjunction with torture and execution, prisoners were not naked either, even if so indicated; rather, they were often clothed in a shift made of sack cloth. Prior to execution, they often wore “torture clothing.” The victims were forced to remove their regular clothing and don their torture clothing under the watchful gaze of the executioner, which in itself was both degrading and humiliating. During the seventeenth and eighteenth centuries, prisoners who were tortured and later executed were called patients [2].

Clothing – Significance and Social Implications

Twigg [5] holds that clothing is integral to the embodiment of the self. Clothing shapes the immediate physical environment of the wearer, as part of the social interaction and ultimately as a dimension of control and normality. Usually, clothing is theorized in terms of agents/intermediaries and choice. This concept is usually presented within a cultural framework of consumption and as part of a material culture, which defines an economic and social space and self-development. In contrast, there is also an aspect of structure, ranking (order) and conformity [6], including a desire to express an individual difference at the same time that there is a desire for social convergence. According to Twigg [6], clothing represents both personal expression and social meaning, including continual interaction between these elements of structure and mediation. From the late eighteenth century until around 1950, clothing had some significance for maintaining social boundaries. One example is the headwear and hairstyles worn by women in rural society, which indicated their marital and social status [7]. Thus people use their clothing to signal and communicate their personality, values, social status, occupation, roles, self-esteem and identity [8].

Clothes and clothing must also be understood in terms of bodies that take refuge in the clothing, which gives them life, for which reason clothing cannot be separated from the human body. Clothes are an extension of the body, directly linked to the physical core, where individuals take ownership of their clothing. Clothing also affects how we move, how we sit and what we do.

According to Kontos [9], the self is incorporated into the body and expressed through the body. Identity can be expressed in gestures and actions, but the self is not individual, but rather social. Inspired by Bourdieu, Kontos [9] holds that the selfmanifests in socio-cultural specific ways of being in the world. Humans can demonstrate their social class through their choice of clothing and dressing. The clothes we wear do not just embody how we present ourselves, but are part of how we express our being. Clothes are the key intermediaries between the body and the social world [10]. In addition to conveying the identity and personality of the wearer, clothing must also communicate or portray a person experience and adorn the body [11]. The aesthetic expression of clothing is important for how individuals view themselves and how others view them. In this way, clothes play a role in preserving continuity of the self. Ugly clothing is associated with the risk that the wearer will be poorly viewed and treated [12], but it may also mean that the bearer might feel being unworthy. Forced use of institutional clothing is likely to affect the self. Since clothing can be viewed as an intermediary of different values and personalities, clothes can also contribute to the individual being seen as an object or as playing a particular “role.” Examples of patient clothing (Photo 1 and 2).

Photo 1: Underwear for women.

Photo 2: Shirt for both men and women.

Institutions, Control and Patient Clothing

Various approaches will be presented to gain insight into the reasons and purpose of providing patients with hospital clothing during their stays. An institution is described as an environment where the normal trinity of life – work, spare time and sleep – disappears [13]. The classic example is the Panopticon prison (Jeremy Benthams 1748 – 1832), where prisoners were nonindividuals providing information by being observed from a distance without having a relationship with the supervisors; they were thereby freely interchangeable. The advantages of institutional organization have also been frequently expressed within health care. “In order to be able to offer a treatment perfectly adapted to the illness, we try to obtain a complete, objective idea of his case: We “observe” him in the same way that we observe the stars or a laboratory experiment” [14] (p 19). “In order to know the truth of the pathological fact, the doctor must abstract the patient to distinguish the symptoms from the temperament and age of the patient” [15].

Because hospital personnel control the "normal trinity of life" an inherent antagonism exists between those who control and those who are to be controlled; in other words, there is a similarity to other institutions, including prisons. One of the distinguishing features of disciplinary power is its supervisory function [7]. Many words express the commonality with these seemingly different organizations, such as “admission, discharge, department, and visiting hours.” Goffman [13] described a number of characteristics typical of “total institutions.” These institutions were divided into five groups: institutions intended to care for people who are unable to care for themselves but are otherwise harmless (e.g., hospitals); institutions intended for people incapable of caring for themselves who pose a threat to themselves (e.g., mental hospitals); institutions for people who pose a threat to society (e.g., prisons); institutions that convey knowledge (e.g., military facilities) and those that represent a retreat from the outside world (e.g., monasteries and convents).

Admission to an institution entails a humiliating and mortifying process that deprives us of our role. According to Stevenson [16], institutional care symbolizes longing and horror, dependence and a need for solidarity, as well as power since patients must depend on the staff. Goffman [13] refers to such role deprivation and humiliation as the mortification process. In the hospital world, this consists of taking a history, assigning a bed (room and bed number), and possibly a shower/bath. The admitted patient must also give up their private clothing and instead wear the symbols of the institution. Hospital/patient clothing was and still usually is a uniform, thereby easily distinguishing patients from personnel. Institutional care also requires that patients be prepared to expose their body and undergo various physical examinations. Social contacts may also be forced upon patients, for example, by sharing a hospital room with strangers. These practices usually are not deliberately intended to humiliate or to deprive people of their dignity, but are pragmatically motivated. Meanwhile, however, such practices are a symbol that may affect the allocation of roles, since they violate the private space or sphere of the individual and may entail subordination and objectification. Those who control and those who are controlled are clearly defined. This is amplified by the fact that patients must assume a subordinate role of dependence on staff since they suffer from disease/ill health and require help, care or treatment. The above viewpoints, which are based on Goffman's ideas and studies, have and can be criticized. In particular, Goffman [13] neglects the penetrability or transparency of the system and the system is portrayed as static [17]. An organization should preferably be viewed as undergoing constant change to meet or strive toward certain goals [18].

Clothing, the Environment and Personal Identity

Patient clothing is considered to be part of the care environment and plays a significant role in the interaction between individuals and their world [19]. According to Topo and Iltanen-Tähkävuori [1], clothing represents an example of body-based technology and such embodiment refers to the integration of being in the world and its connection to body and soul. Topo and Iltanen- Tähkävuori [1] refer to hospital clothing as a materialized ideology, a script to be interpreted or decoded; in other words, how “patientship” is construed in relation to clothing, but also how clothing design represents a technology that allows the healthcare system to manage and govern care. To wear hospital clothing is to be a patient and assume a role. The needs of the system take priority over the needs of the patient. Patients must sacrifice their identity and therefore cannot present themselves as morally and culturally competent participants. Hospital clothes reinforce an impersonal view of patients, transforming them into an anonymous mass that consolidates the system and role allocation. Patient clothing becomes a materialized ideology where standardized uniform clothing, in addition to control, also induces passivity, separation and degradation [5]. One of the distinguishing features of disciplinary power is its supervisory function [7].

The relationship between personnel and patients may be strengthened by the task-oriented nature of today’s healthcare system. As a result, organizations may tend to influence the duties of caregivers in a direction toward greater control and oversight with less care and treatment. Observations concerning the patient, entered into a computer, may become more important to contemplate and discuss than the actual physical patient encounter. In such a system, which resembles Panopticon, the individual caregiver can easily be replaced, which may be of significance for system efficiency. Although it is beyond the scope of this article to address hospital staff clothing, in the name of system efficiency, caregivers become more interchangeable if also anonymized in relation to patients. Clothing may promote the depersonalization of various participants within the healthcare system and prioritize role interactions over interpersonal coexistence.

The question becomes whether the allocation of roles denoted by the system and clothing affects relationships between hospital staff and patients?

How Do Patients Feel About Hospital Clothing?

Few published studies are available that focus on perceptions, experiences and viewpoints of patients and caregivers regarding hospital clothing. Four themes could be identified from an interview study [20] in which some patients wore hospital clothing while others did not: (1) being comfortable and cared for, (2) being depersonalized, (3) being socially stigmatized and finally (4) being revitalized. Patients felt comfortable wearing hospital clothing since they did not have to concern themselves about access to clean clothing or having their clothes washed. In addition, they did not want to have their private clothes soiled by various bodily fluids, which they felt was a risk of their disease. Wearing hospital clothing could also entail being objectified as well as being viewed and feeling more like a patient than a person. Hospital clothing also allows greater anonymity. Edvardsson [20] discusses the risk of being stigmatized, marked or labeled as something abnormal, negative or unusual that sets the person apart from the normal through the wearing of hospital clothing. However, it is also conceivable that there may be an underlying purpose to being a patient that allows others to recognize their suffering - that people has the right to be patients and that this state is not necessarily associated with weakness and dependence. Caregivers felt that the revitalization process entailed less embodiment of the patient role among patients who wore private clothing than those who wore patient clothing.

They felt that patients wearing their own clothes were more secure and appeared to assume greater responsibility for their own care and also seemed to be less ill. Yet another question is whether the staff's attitude toward and relationship with patients would change if patients were to wear private clothing.

In a study based on content analysis by Topo and Iltanen- Tähkävuoris [1], patients expressed the idea that wearing defined pajamas would entail a rite of passage into the patient role. The manner in which this was undertaken was also of significance; i.e., whether a discussion occurred in front of others regarding the size and body shape of the patient and what would fit. Such an approach was perceived as a violation of integrity. Patients also felt that these pajamas revealed too much of their body, which caused embarrassment, that entailed a feeling of moral incompetence. The material was perceived as alien and harmful, but was preferred by the staff, especially in acute care hospitals where standardized clothing was viewed as a way of putting patients on an equal footing and treating them equitably. Cost effectiveness was also a factor since color coding enabled laundry personnel to handle the clothing quickly. Patients questioned whether special patient clothing was actually necessary. Wearing personal clothing was important for self-esteem and self-confidence, and facilitated expression of personality, while hospital clothing led to infantilization of the person in question. Topo and Iltanen-Tähkävuori [1] based their discussion on the fact that patients sharply criticized the wearing of hospital clothing and noted how such clothes reflect the limited opportunity people have to maintain an intact lifestyle and identity while hospitalized. They feel this indicates that health problems/illnesses or functional problems lead to dependence, vulnerability and the need for care. In this way the care environment becomes an unpleasant experience, thereby increasing patient suffering.

Objectification – Disease and Recovery

According to one theory, hospital clothing improves the potential for good treatment and recovery. The practice of medicine can be viewed as an endeavor to find the right treatment for each patient [21]. This endeavor can be facilitated when patients are viewed abstractly and objectified. Patient clothing may help to anonymize the individual and eliminate plurality, causing all patients to resemble one another in accordance with the principle of equality [22]. One point of view is that providing hospital clothing underscores that every person, regardless of who they are, is entitled to care and concern – especially since private clothing may also be viewed as a symbol of status, thereby entailing a risk of unequal treatment. For example, in the Japanese baths, such as the Yasuragi spa, all guests are asked to dress in bathing suits, bathrobe and slippers that are identical in appearance. The idea is to disregard the person’s role within the system and instead reveal the underlying humanity.

The above logic supports objectification and anonymization as a basis to see the illness more clearly, thereby increasing the potential for optimal care. Nevertheless, patient clothing signifies illness [20] and the illness becomes more apparent at the expense of the patient and the person. This type of situation does not necessarily promote health. As noted earlier, clothing represents a signal for the self. Self-perception is usually rooted in a healthy existence. Since patients are required to change into hospital clothing, they have no choice in how they show themselves and therefore there can be no reconciliation between the self and the clothing [5]. A healthy perception of self can thereby be effected. In theory, wearing private clothing when ill could signal the primary self-perception of health and well-being externally toward care providers and internally toward the person and the patient.

As previously discussed, hospital clothing can be perceived as a symbol of disease that promotes passive behavior [20]. Passivity and objectification are negatively charged concepts according to the P4 approach to medicine and the pathway it outlines to health. P4 medicine promotes Participatory, Personalized, Predictive and Preventive actions and attitudes [23].

Participation includes being part of a unified environment in which healthcare units become a place for encounters among equals. Such an approach challenges healthcare personnel to share in suffering, rather than just looking for symptoms and furnishing diagnoses. A unified view concerning clothing would be necessary (private clothing vs uniform dress).

The given or induced mental status of the patient has an influence on recovery. There seems to be an interrelationship between certain mental processes with regard to patient clothing and depression. One is dissociation, a mental process in which the person becomes detached from the environment. Several forms of dissociation have been identified, one of which is depersonalization. As discussed above depersonalization is associated with use of patient clothing, as is objectification. Self-objectification is associated with a concomitant increase in depression, suggesting a causal relationship.

Some examples would be: Depression decreases the ability to affect repair. It may lead to infections and cause or worsen cancers [24]. Depression in patients with femoral neck fractures who are younger than age 60 are at increased risk of postoperative femoral head avascular necrosis [25]. Intraoperative time for coronary artery bypass surgery is longer in depressed patients and such patients have a higher maximum postoperative Troponin T, indicating greater injury to the heart muscle [26].

The question is: Does patient clothing have a positive or negative effect on recovery?

Conclusion

Whether or not hospital clothing is provided to patients admitted to the hospital has many implications. On the one hand, hospital clothing can be viewed as supporting the equal value of all patients and increasing the focus on the disease with greater opportunity to find the best treatment, while meeting hygienic requirements and addressing other practical issues such as rapid access to the naked body for certain treatments. Such clothing contributes to cost-effective systems ranging from the need for labeling systems in the laundry to defining the division of roles between patients and personnel.

On the other hand, hospital clothing can precipitate depersonalization and objectification of the patient, which may lead to an emphasis on the disease that is amplified by the loss of self and the usual positive self-image of the individual. A defined division of roles arises between those who control and those who are controlled. Passivity is automatically induced and mental processes may occur that are related to depression, both of which may pose an obstacle to recovery.

Whether the staff's attitude toward and relationship with patients would change if patients were to wear private clothing remains unclear. It is likely that this relationship would be affected if both parties wore private or identical clothing. An effect on patient recovery would be likely to occur, although in which direction remains uncertain. The importance of the choice of clothing for patients and personnel appears to be significant and requires further study.

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