Page and Lawrence (1992) that showed a negative perception
to t-shirts, skirts and running shoes in adult hospitalised
patients. However, this study was performed on adult
patients who have different perceptions of hospitalisation.
The study performed by Livingstone (1995) showed that
most patients preferred traditional clothing, so that expecta-
tions of hospitalised children regarding good care, was met
through wearing of white uniforms by the nurses. The
authors believed that this was related to a media-enhanced
picture of the nurses wearing white uniforms. Rumfelt (1980)
suggested that ‘children viewed the nurse as a person who
could be identiﬁed by apparel, namely, a white uniform,
white shoes, a cap and a pin’
4 (p. 22).The studies that support
white nursing uniform are older studies related to a time
period that this clothing signiﬁed the nurses’ presentation of
conﬁdence, identiﬁcation and accessibility to patients. How-
ever, this view has changed in developed countries in recent
years. Similarly, our study which has been performed in a
developing country is based on an evidence-based view to
nursing clothing and shows that public view has also changed
and that nursing skills and identity is no more symbolised in a
white uniform. Few studies have been performed in Iran
about the quality of nursing care and patient-nurse relation-
ship (Salimi et al. 2003). However, there has always been a
traditional emphasis on the role of the nurse in alleviating
patient’s distress and suffer through setting an effective
communication. This role can be better performed through
wearing coloured clothing by nurses who provide care to
children as it can enhance a close and friendly atmosphere
(Salimi et al. 2003).
Other predictors of anxiety in our study were sex and child’s
educational level and number of siblings. Studying the
relationship between sex and anxiety level, Tiedeman and
Clatworthy (1990) found that boys experience more anxiety
during hospitalisation. The authors believed that it was due to a
difference between boys and girls in coping styles. Boys usually
use physical methods for expressing their anxiety and aggres-
sion while girls usually use verbal methods. As physical activity
is limited during hospitalisation, boys express more anxiety
during hospitalisation. These results support our ﬁndings.
Higher educational level, as an accompaniment of higher
age is associated with less anxiety in the child. Margolis et al.
(1998) showed that younger children are more prone to
higher stress level. Piaget’s theory of cognitive development
may help explain the increase in anxiety level in this age
group. A review article in 2006 showed that children with
lower number of siblings are more prone to anxiety and are
more sensitive for social failure and separation anxiety
gels & Brechman-Toussai 2006), that our ﬁndings
support it, too.
A limitation of our study was failing to get a deeper
knowledge of the family characteristics, such as family
function, parent psychopathology and family stressors. The
study ﬁndings were strengthened by studying family param-
eters as it could help better detection of anxiety in hospita-
lised children. In spite of similarity of two groups, lack of
control on some confounding variables, such as medical
diagnosis, type of surgery, surgical and medical care was
inevitable. Children were not screened for colour blindness.
Also, the geographic setting of the study may limit general-
isation of its ﬁndings.
Conclusion and implications for clinical practice
Emphasis on nurses white uniform is based on the view that it
conveys authority, power and professionalism while wearing
coloured clothing is of great importance in promoting a child-
friendly environment that decreases anxiety level (Lehna et al.
1999). Promoting a child-friendly atmosphere should include
good communication in addition to appropriate appearance.
If nurses can satisfy children’s expectations by using mature
communication styles (Pelander & Leino-Kilpi 2004), they
can establish a warm connection with children, that helps to
create a sense of security and trust for them and declines their
anxiety (Pelander et al. 2007). Such styles are appropriate
ways for helping children cope with stressful experience of
hospitalisation and alleviate the need for meeting ideals of
nursing care through wearing a white uniform, provided that
standards of nursing care are favoured.
The authors would like to thank all nurses, surgeons and
pediatricians who helped them in performing this study.
Study design: HR, AP, MS; data collection and analysis: HR,
AP, MA, NT, MT and manuscript preparation: HR, NT,
gels SM & Brechman-Toussai ML (2006) Family issues in child
anxiety: attachment, family functioning, parental rearing and be-
liefs. Clinical Psychology Review 26, 834–856.
Brewer S, Gleditsch SL, Syblik D, Tietjens ME & Vacik HW (2006)
Pediatric anxiety: child life intervention in day surgery. Journal of
Pediatric Nursing 21, 13–22.
Campbell S, O’malley C, Watson D, Charlwood J, Susan M &
Lowson SM (2000) The image of the children’s nurse: a study of
H Roohafza et al.
6 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing