Content uploaded by Ali Seifi
Author content
All content in this area was uploaded by Ali Seifi on Aug 17, 2016
Content may be subject to copyright.
The Scrub Revolution: From
Hospital Uniform to Public Attire
Bahinah C. Callahan, BS, and Ali Seifi, MD, FACP
Wander into a coffee shop in the heart of a medical center
around 3 PM and you will find many people wearing
‘‘scrub’’ uniforms as they order their afternoon pick-me-up.
These people may be physicians, nurses, or surgical assistants,
but they also could be technicians, receptionists, veterinarians, or
even individuals whohave no connection to healthcare at all. The
growing trend of people wearing scrubs outside the clinical
setting has sparked a debate about the propriety of this conduct,
particularly when the individual wearing scrubs is a physician.
Although the uniforms of many other professions go un-
noticed in public spaces, scrubs have the tendency to stand out.
Scrubs are easily identified and often associated with the risk of
biological hazards. Some claim that such attire is unprofessional
when worn outside the clinical setting and doing so erodes the
trust that patients have in their healthcare providers. Even though
there is no conclusive evidence that scrubs aid in the spread of
infection, those who wear them in public continue to raise eye-
brows and draw criticism. In the wake of this controversy, we are
left asking the question: Should healthcare professionals be
allowed to wear scrubs outside a clinical setting?
In the late 1800s, Joseph Lister established the foundational
principles of antiseptic surgery by applying Louis Pasteur’s
advances in germ theory and pasteurization. By 1970, sterile
technique was transforming health care, and surgical attire had
changed from a simple apron worn over the surgeon’s clothes into
a uniform consisting of a simple short-sleeve V-neck shirt and
drawstring pants. This uniform would become a symbol of
cleanliness in health care and eventually be called scrubs, as a
result of being worn in a disinfected or ‘‘scrubbed’’ environment.
Patients’ perceptions of scrubs are complex; they vary
greatly based on the hospital setting, physician specialty, pa-
tient age, and location.
1
Healthcare workers’ attire has been
shown to affect patient satisfaction, trust, and confidence.
Older patients tend to favor physicians dressed in formal attire,
whereas younger patients are more accepting of casual attire
and scrubs. In the United States, patients are less concerned
about formal dress compared with patients elsewhere in the
world.
1
Patients in Asia, Europe, and Canada prefer to see
formal attire in private healthcare settings and favor scrubs for
surgeons, emergency department personnel, and intensive care
physicians. Regardless of nationality, patients consistently fa-
vor formal attire for primary care physicians because of the
long-term nature of the relationships they form with those
physicians. Understanding the impact of the visual presentation
of healthcare workers under different circumstances can help us
determine whether scrub uniforms enhance or diminish the
relationship between the physician and patient.
Scrubs have numerous benefits aside from their function in
the operating room. The most notable is that they enable phy-
sicians to be more efficient in their time management. At the end
of a shift, clinicians can change quickly into casual attire and
dispose of their soiled scrubs. Wearing scrubs to work also sig-
nificantly reduces the time that healthcare professionals must
spend on wardrobe selection, preparation, and alteration. Some
people, however, become apprehensive when they see scrubs
worn in public by clinicians.
2
They object to this uniform being
worn in public spaces because they are concerned about the risk
of contamination and the possible spread of infection. Although
there are no conclusive data to suggest that wearing scrubs in
public spaces contributes to the dissemination of infection, cli-
nicians should still examine their daily habits for any problematic
practices that may increase their risk for contamination.
Home laundering is another factor that complicates the issue
of wearing scrubs outside a hospital setting. Home laundering
has been shown to be significantly inferior in terms of efficacy
when compared with commercial processing
3
; it also can lead to
cross-contamination if hospital scrubs are washed with other
garments. Evidence shows that 44% of scrubs washed at home
tested positive for coliform bacteria, which increases the risk of
these harmful bacteria reaching household members and com-
munities, and even returning to hospitals.
3
These inconsistent standards and frightening statistics
suggest that the present dress code policies are inadequate.
Proposing new strategies can reshape hospital policies to be
specific and address attire guidelines for settings outside the
operating room and for hospital laundering services. Adminis-
trators should actively educate staff regarding the professional-
ism of their attire and encourage them not to leave the hospital
wearing scrubs. Hospitals can educate and monitor healthcare
personnel by offering mandatory training modules and arranging
quality improvement projects. Providing locker rooms to all staff
will permit them to change into their personal attire before
leaving the hospital and will encourage the use of hospital
laundering services for scrubs. By establishing stricter regula-
tions that prevent scrubs from being worn outside a healthcare
setting, we strengthen their associated healthbenefits for patients,
physicians, and all members of the community.
Perspective
326 *2016 Southern Medical Association
From the Boston University School of Medicine, Boston, Massachusetts, and
the University of Texas Health Science Center at San Antonio.
Correspondence to Ali Seifi, MD, FACP, Departments of Neurosurgery, Neurology,
University of Texas Health Science Center at San Antonio, Mail Code 7843,
7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail: seifi@uthscsa.edu. To
purchase a single copy of this article, visit sma.org/southern-medical-journal. To
purchase larger reprint quantities, please contact reprints@wolterskluwer.com.
B.C.C. has no financial relationships to disclose and no conflicts of interest to
report. A.S. has provided expert testimony and reviewed medicolegal cases;
received funding from ITPR, the Department of Defense, and SAGE
Therapeutics; and received compensation for lectures, including service on
the speaker’s bureau of The Medicines Company.
Accepted January 20, 2016.
Copyright *2016 by The Southern Medical Association
0038-4348/0Y2000/109-326
DOI: 10.14423/SMJ.0000000000000455
Copyright © 2016 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.
Global awareness of hospital-acquired infections has
sparked speculation within the healthcare industry. Canada,
like the United States, allows hospitals to create and implement
their own individual policies regarding dress code.
4
Some
Canadian hospitals have announced that they would put poli-
cies in place requiring scrubs and white coats to be worn only
within a hospital setting. Similarly, in Belgium, healthcare
workers are forbidden to take their work clothes home to be
washed; they instead must be laundered by the hospital.
5
Although there is not enough evidence for us to under-
stand the potential harm of wearing scrubs in public, the United
States can take preventive measures to minimize risk. Clini-
cians also need to acknowledge that their presentation outside
the hospital affects the integrity of the healthcare system. We
need to facilitate adherence to stricter regulations by increasing
access to receptacles for the daily disposal of soiled scrubs and
designating areas to acquire hospital-laundered scrubs atthe start
of every workday. In addition, hospitals can provide changing
rooms for all specialties and enforce policies that will ensure that
physicians change after shifts. Progress can be made without
damaging the public’s perception of health care.
References
1. Petrilli CM, Mack M, Petrilli JJ, et al. Understanding the role of physician
attire on patient perceptions: a systematic reviewof the literatureVtargeting
attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open
2015;5:e006578.
2. Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-
operating-room settings. Infect Control Hosp Epidemiol 2014;35:107Y121.
3. Nordstrom JM, Reynolds KA, Gerba CP. Comparison of bacteria on new,
disposable, laundered, and unlaundered hospital scrubs. Am J Infect Control
2012;40:5 39Y543.
4. Madwar S. No scrubs. No shoes. No serving. CMAJ 2011;183:E703YE704.
5. LovedayH, Wilson J, Hoffman P, et al. Public perception and the social and
microbiological significance of uniforms in the prevention and control of
healthcare-associated infections: an evidence review. Br J Infect Control
2007;8:10Y21.
Perspective
Southern Medical Journal &Volume 109, Number 5, May 2016 327
Copyright © 2016 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.
