Changing how the world thinks about nursing

Join our Facebook group

THE WHITE DRESS
WHAT SHOULD NURSES WEAR?
BY JOHN SEABROOK

This article was originally published in the New Yorker on March 18, 2002, pp.122-127. Reprinted with John Seabrook's permission. See his work at www.johnseabrook.com

One morning last fall, the designer Yeohlee Teng was standing outside her office building, on Seventh Avenue at Thirty-ninth Street, waiting for a ride to the hospital. Yeohlee designs and owns the line of pricey but practical women's sportswear and evening clothes that bears her name, and she has a small, loyal following that includes Susan Sontag, Oprah Winfrey, Patti Smith, and, now, Valley Hospital, a four-hundred-and-fifty-one-bed facility in Ridgewood, New Jersey. About eight months earlier, Yeohlee had signed a contract with Valley to redesign the garments worn by both the patients and the staff, beginning with Valley's more than a thousand registered nurses. Today, she was going to present the Valley management with muslin prototypes of those uniforms.

As anyone who has been in a hospital in recent years knows, the white dress, which was for decades the emblem of a registered nurse, has all but disappeared. These days, the R.N.s wear "scrubs," those loosely fitting cotton pants and V-neck tunics, and sometimes a short jacket with big pockets. Because scrubs, which are made in a rainbow of colors and a variety of prints, have become the standard hospital attire for nurses, orderlies, technicians, and maintenance personnel alike, patients have no easy way of knowing whether the person putting in the I.V. is a nurse, a nurse's assistant, or a groundskeeper. Reintroducing uniforms would help to reëstablish a sartorial hierarchy in the hospital.

"Nurses are one of the most important aspects of health care, but in most hospitals you can't tell who they are," Yeohlee explained, speaking precisely, as she sat with perfect posture in the back of a town car heading for Jersey. Yeohlee, who was born in Malaysia, came to New York in the early nineteen-seventies to study at Parsons School of Design, and has lived here ever since. She represents herself as an anti-fashion designer, a clothing architect who is more concerned with comfort and maintenance than with glamour and display; she describes her clothes as "shelters." Today, she was sheltering in a short black raincoat, black pants, a black knit top, black leather boots with thick work soles, and the kind of black rectangular glasses favored by people who are serious about design. "Uniforms make people feel proud of their work," she continued, "and if you're a highly trained professional, like a nurse, you want people to know it." She thought for a moment, bowing her head so that her dense black hair concealed most of her face. "There's a terrible nursing shortage going on right now," she said, "and I have this romantic notion that if the uniforms looked more attractive more people would want to go into the profession."

The elderly woman behind the reception desk at Valley Hospital was wearing a pink jacket. Yeohlee, who asked to see the hospital's C.E.O. and president, Audrey Meyers, knew from her research that pink meant the woman was one of Valley's three thousand volunteers.

"Is she a patient?" the receptionist asked.

"She's the president of the hospital," Yeohlee said. "Please tell her Yeohlee is here."

"Yo-lee?"

"Y-E-O-H-L-E-E."

"Is that your first name or your last name?"

Yeohlee gave a slightly ominous-sounding sigh.

"Just say Yeohlee. She'll know."

The designer took a seat on a floral-patterned chair and looked around the lobby, a large two-story space with expensive lighting and, in one corner, a grand piano. In recent years, hospitals have begun to look more and more like hotels (at a time when fashionable hotels are looking more and more like hospitals, with gleaming expanses of glass and plastic). Where there was once li-noleum there is now carpeting; white walls are now burgundy or beige. These changes are made partly in order to promote "a healing environment," but they're also expected to improve the institution's image. Valley, which was founded fifty-one years ago, and has long served as Ridgewood's community hospital, nowadays has to compete with other hospitals in Bergen and Passaic Counties for prospective patients, especially those seeking elective surgery, maternity care, and fertility treatment. At Hackensack University Medical Center, about eight miles south of Valley, uniformed doormen welcome people to the hospital, patients receive complimentary toilet kits and bedside facials, and are invited to use the hospital's newly completed day spa. Fashion borrows from uniforms, and uniforms borrow from fashion, but designers of fashion apparel rarely design uniforms. The uniform industry, a ten-billion-dollar-a-year business, which makes clothes worn by approximately twenty-seven million Americans, has almost no overlap with the fashion industry, and designers who do venture across this sociological divide tend to limit themselves to the high end of the service industry. (Ralph Lauren designed flight-attendant uniforms for T.W.A. in the seventies, and the staff at the W hotels wear uniforms by Kenneth Cole.) The constraints of economy and practicality in uniform design often confine fashion designers to a range of parameters so narrow they can't do much aesthetic maneuvering. And then there's the problem of sizing. Stan Herman, the president of the Council of Fashion Designers of America, who began his career in evening-wear and sportswear design and now is known for his FedEx, McDonald's, and Amtrak uniforms, told me recently, "In uniform design, it's the sizing alone that puts a lot of fashion designers off. You know, not too many designers can bring themselves to do an elastic waist."

For Yeohlee, who had never designed a uniform before, the hospital clothes were a test of her functionalist philosophy. Whatever she came up with for Valley Hospital would have to be low cost, low maintenance, hot-water washable, crease and stain resistant (blood is a tough stain, but bile is worse), and sized to fit a much greater variety of shapes than those of the women who buy Yeohlee. The hospital had also stipulated that the uniforms not cost any more than scrubs cost-about thirty-six dollars for a top-quality set, although it's possible to find scrubs that cost about half that much. Most hospital workers buy their own clothes, and while Valley was budgeting money to buy staff members one new uniform each, after that the employees would be paying themselves.

"I am trying to make some sense of all this," Yeohlee said, pointing out the different outfits worn by staff, while she waited for Meyers. At Valley, as in most hospitals, the physicians wear white lab coats over business clothes. Some of the other clinicians wear white lab coats, too, but usually over scrubs, and only the doctors are allowed to have their names embroidered on the coat, over the breast pocket. About half the staff nurses wear white outfits. The others wear a variety of colors and prints. Although the original scrubs were all green (possibly because blood and gore, or the "expunge," as it's sometimes called in hospitals, lose their red tint against a green background and look just damp), venders now sell a huge array of colors. At Valley, the clinicians in the Breast Center wear honey-colored scrubs, the imaging technicians are in navy blue, the EKG and telemetry staff wear raspberry, transport aides are in beige, diet aides wear pink, service associates sport royal-blue scrubs, female volunteers wear pink jackets, males wear burgundy, and the patient-care associates, or P.C.A.s, which is what Valley's nurses' assistants are called, wear dark-purple scrubs.

One of the P.C.A.s, a sad-eyed Latino of about thirty, was slouched in wrinkled purple scrubs in a chair near Yeohlee. On several of Yeohlee's earlier research visits, some of the staff told her they liked wearing scrubs, especially the larger people ("They hide in them, poor dears," Stan Herman says), but others said they would welcome a change. Of all the workers, the P.C.A.s were the most unhappy in their attire.

"They feel they look like Barney," Yeohlee said quietly, with a sympathetic wince in the man's direction. "It's difficult to feel good about your job when you're dressed like a purple dinosaur." Her gaze drifted down to the man's athletic shoes and socks, and her expression hardened a little. "Employees get to wear their own shoes," she said. "I would like some input into this decision."

Meyers was eventually located, and Yeohlee was escorted into the boardroom. Meyers, a slim, energetic woman who was wearing a skirt-and-jacket ensemble, was surrounded by her executive staff. Most were wearing business clothes. (At Valley, as at most institutions, people who wear uniforms work for people who don't.) Also present was a staff doctor, Earl Wheaton, in a white lab coat with his name embroidered on it, as well as the chief nurse, Linda Cuoco, in a slightly shorter lab coat, and three nurse-models. While the doctors at Valley are in favor of redesigning the rest of the uniforms, they do not want their own attire to change. "They're proud of their lab coats," Meyers said.

Yeohlee's staff helped the first nurse get dressed, standing behind a screen which had been set up at one end of the long room. As we waited, Everett Ferri, vice-president of facilities management, told me the story of how the hospital happened to find Yeohlee. "Since we were investing all this time and money in how the rest of the place looked, it seemed like we should think about the clothes. You can use all the earth tones you like, but if you walk down the hall and see some guy's butt hanging out of the back of his gown it kind of defeats the purpose. So we thought about it and we decided we needed to hire a designer." The problem was they didn't know any designers. They called some names-the New York offices of Ralph Lauren, Calvin Klein, and Liz Claiborne, among others-"but they never called us back," Ferri said. "I don't think we got past the receptionist."

One day, Ferri was discussing the problem with a local developer, and the developer said he knew a New York-based fashion photographer named Trudy Schlachter. A delegation from Valley went to see Schlachter, and for a consulting fee she arranged interviews with four designers, including Stan Herman and Yeohlee. The hospital chose Yeohlee mainly on the strength of her presentation, in which she glued digital pictures of the staff onto blownup architectural drawings of the hospital's facilities, and talked about coördinating the uniforms with the interior design of each wing. "We were really impressed by her intellectual approach," Ferri said.

The first model, Melissa Meaney, a blond nurse in her twenties, emerged wearing a white wraparound skirt, which came down just below the knee, a white top, and a stylishly cut lab coat. She walked back and forth in front of the group, giggling self-consciously.

"Could you work in that?" Meyers asked.

"Well, I'm not a skirt person," the nurse said, adding "I like the T-shirt."

"Knit shirt," Yeohlee said. "You're going to call it knit." She was kidding, but only sort of.

The coat was about the same length as the lab coats the doctors wear. Of all the garments, it looked the most like one that Yeohlee, who has a particular talent for coats, would show on the runway. It might not make the nurses any more noticeable on the hospital floor, but at least now they'd be mistaken for doctors, not for P.C.A.s.

"What about the pockets?" Cuoco, the chief nurse, asked. Yeohlee had done horizontal pockets, which were crucial to the line of the coat. All the nurses in the room wanted big patch pockets, such as scrubs have, so that they could carry their stuff around.

With a stoic air, Yeohlee asked one of the other nurses to take everything out of her scrub-jacket pockets. Out came pen, notepad, tissues, scissors, adhesive tape, beeper, phone, and stethoscope.

The nurses in the room were also concerned that the coat was too long. The line was nice, but would you knock over a bedpan when you were working in a tight space?

The pants, which Meaney modelled next, flat front with side pockets, would, like the skirt, also come with an elastic waist. Valley's staff of R.N.s includes fifty-eight men; the pants and knit shirt and jacket would be their uniform, too. Everyone liked the pants, which were higher waisted and wider in the leg than scrubs pants.

Meaney retired behind the screen, and reappeared in the dress, a simple wraparound with short sleeves and side pockets. The underlap was attached to a drawstring that went around the back and tied to the overlap in front, forming a V neck.

"I could wear that out in the evening!" Meyers exclaimed.

Cuoco was immediately skeptical of the wraparound construction. "What would happen to someone with a bigger bust, if she was bending over a patient?"

"I definitely think it could flap open," Meaney said. "If you're bending down to lift a patient out of a bed, it's going to do this." She made a spreading gesture in front of her chest.

Yeohlee was nodding-she saw the problem. She stepped in with her notepad. She would adjust the closing of the dress.

"No one wants to get into a less than professional situation with patients," Cuoco said. "Or doctors. It makes people uncomfortable, when you're having very intimate conversations with people, if you're not dressed appropriately."

The presentation lasted a little more than an hour, and when it was over the Valley management appeared delighted. Yeohlee reviewed the changes, and the administrators arranged to come to her New York showroom in about a month, to select fabrics.

"We are going to have the best-looking nurses!" Meyers said.

Imagine a starched white cotton dress, long enough to cover the knee, worn with white stockings, white shoes, and a white cap. Although this uniform, which was for more than half a century the uniform of registered nurses in the United States, is hard to find on hospital floors these days, it remains fixed in the popular imagination. Few outfits conjure up such a potent and unstable mixture of associations. Perhaps because nursing was the first job that employed professionally educated women in uniform, a profession that is still, at 2.7 million, one of the largest employers of women in the country, the white nurse's dress is an intensely ideological garment.

The first United States nurses' uniforms were actually gray or blue, and they looked like hybrids of nuns' habits and the uniforms Florence Nightingale's nurses wore during the Crimean War. (Nightingale wanted her "Angels of Mercy" to wear uniforms in order to distinguish them from the "camp followers" who tagged along after armies.) The color white did not become popular until the early twentieth century, following the new findings about germs and their role in spreading infection. Prominent nursing schools hired designers to make genteel-looking dresses for their graduates, so they wouldn't be mistaken for domestic servants. Caps were an important way of showing rank among nurses. A black stripe on the cap meant the wearer was a registered nurse; a cap with no stripe meant the wearer was still a student.

Why did nurses stop wearing the white dress? During the nineteen-sixties, an era that was hard on uniforms in general, feminists began to read its whiteness as a sign not of power but of diminishment. Elizabeth Norman, a professor of nursing at N.Y.U. and the author of two books on the history of wartime nursing, told me, "In the constant struggle for independence from doctors, some nurses started to see the white uniform as a symbol of the angelic, demure, dependent woman, not of the tough, resourceful professional she really is." Around the same time, as hemlines went above the knee and nurses' dresses got sexier, the naughty nurse-that authoritative yet submissive female-began to appear in Playboy cartoons, among other places. As the actual uniform has vanished from hospitals, this fantasy nurse seems to have grown in the collective id; she is a fixture of countless randy-postcard displays in magazine stores everywhere. Naughty nurses rarely dress in scrubs.

In the nineteen-seventies, hospital nurses began wearing white pants suits, and the eighties saw the explosion of scrubs. Scrubs were originally worn only by nurses in the operating room and other specialized units such as burn centers-they were the clothes you wore before you scrubbed. From there they spread to intensive-care units, and then, driven in part by the popularity of the television series "M*A*S*H," the style spread throughout the hospital. Scrubs are cheaper than uniforms, and the heavy lifting and tight maneuvering required in nursing is much easier in scrubs than in dresses or skirts. Scrubs are unisex, which helps eliminate the gender problem in nursing. And they are easier to keep clean, especially if they aren't white. So popular was the scrub that it hopped over into fashion in the late eighties, and remains a grunge fixture on college campuses.

Just as the white nurse's uniform was representative of certain attitudes about health care around the end of the last century, so colored scrubs tell you something about the nature of hospitals and health care today. Under managed care, many of the functions formerly performed by a hospital's own staff are provided by outside health-care companies. In many cases, hospitals need to operate within spending limits imposed by these service providers, so they cut their own staff, and replace R.N.s with P.C.A.s, or with technicians who provide limited diagnostic procedures and support but lack the training of professional nurses. At Valley, administrators have tried to designate each type of hospital worker with a scrub color, but many other hospitals simply let employees wear any color they want. "Putting everyone in scrubs makes it possible for hospitals to hide the fact that there aren't many nurses on the floor," Linda Aiken, a professor of nursing at the University of Pennsylvania, said.

At the same time that hospitals have been reducing the number of nurses, people in hospital beds have been getting sicker. Hospitals often admit patients on the same day as their surgery, and discharge them before they're fully recovered; most of what used to be considered nursing is now done outside the hospital. Nurses who remain in hospitals are a disgruntled group. A May, 2001, study of more than forty-three thousand nurses found that forty per cent of those working in hospitals were dissatisfied with their job and almost twenty-three per cent were planning to quit within the next year. The average age of a nurse in an American hospital is forty-three, and many are expected to retire within the next eight years. A recent study published in the Journal of the American Medical Association estimates that by 2020, around the time the baby boomers are really going to need some nursing, there will be four hundred thousand fewer R.N.s.

Yeohlee's notion-that designing more stylish clothes for nurses might help draw young people to the profession-did not fare well among the women I spoke to. Linda Aiken said, "I applaud the attempt to make nurses more visible again, but the major problem in hospitals is that there aren't enough nurses, and they can't do their work as they're trained to do. The idea that changing the uniforms will make any difference in the quality of their work, or in attracting more nurses to hospitals, strains belief."

A nursing student in North Carolina, Rachel Lowder, said, "If I was applying for several jobs, one thing I would be looking for would be a flexible attitude toward workwear. Nursing is hard work. Swollen feet are a real issue, fashion is not."

The strongest endorsement for the return of the white uniform came not from a working nurse but from Laural Wood, who is a "nurse practitioner" at Medicaltoys.com, one of the largest dealers of medical-fetish paraphernalia on the Web. "Kudos to that N.J. hospital!" she wrote to me. "We feel that fetishists and non-fetishists alike would like to see the return of the crisp white uniform and cap. It represents a level of respect and recognition achieved through years of training and schooling."

In December, the Valley administrators came to Manhattan to choose fabrics. Yeohlee arranged to meet them at the museum at the Fashion Institute of Technology, where a retrospective of her work from the nineties, entitled "Yeohlee: Supermodern Style," and sponsored in part by DuPont, was taking place. In recent years, Yeohlee's reputation in the art world has grown. There was an exhibition of her clothing at the Victoria and Albert Museum, in London, two years ago, and a book of her designs, "Yeohlee: Work," will be published in April.

Yeohlee, again dressed in black, showed the group her capes, coats, ponchos, sarongs, and chaps, explaining her concept of clothing as shelter. Patricia Clark, one of the Valley group, said she was pleased to see Yeohlee's clothes at last. "I looked in the Lord & Taylor on Route 17," she said, "but they didn't carry Yeohlee." After they had seen the exhibit, Yeohlee escorted the group to her showroom, a minimalist space with stylishly distressed concrete floors. Rows of fabric swatches had been laid out, and the group went through them, fingering each piece. They seemed a little lost before all the choices. Audrey Meyers caressed a swatch of silky polyester microfibre. "Would a guy wear this?" she asked Everett Ferri.

Ferri felt it and shook his head. "Not masculine enough."

Yeohlee pointed out a swatch of stiff fabric called Healthguard, which is apparently impervious to blood. "Why don't we pick a poly base and a cotton base, and then two cotton fibres for the tops, and I'll get prices on them," she said. "Do you want white white or off white?"

"White white, but not Nurse Ratched white," Meyers said.

When all the choices were made, everyone sat down for a moment. "So how do you think the project is going?" Yeohlee asked.

Ferri looked at the floor a little nervously and said that at the most recent meeting of the hospital's budget committee, the nurses' uniforms had come up, and some board members had wondered why Valley couldn't defer the uniforms until next year.

Yeohlee said, "But there's a moral need for this."

"I know," Ferri said, "but some people are saying we shouldn't spend money on uniforms when we don't have enough nurses in intensive care."

In early March, the finished nurses' uniforms-pants, skirt, knit top, jacket, three-quarter-length coat, and dress-went out to New Jersey in the back of another town car, for a final review at Valley. This time, the audience for Yeohlee's presentation consisted of practically the entire nursing leadership of all the health-care units in the hospital, along with the management group. Twenty senior nurses were clustered at the far end of the room. They looked like a tough audience.

Bettyann Kempin, one of the two nurses modelling today, who manages the nurses in critical care, was shocked at the prospect of wearing a dress, and refused to put it on. "I never, ever wear dresses," she said. "Maybe at the Christmas party, but that's it."

The lab coat was the most successful of the pieces. A center back seam with two princess seams on either side gave the coat both its shape and its one decorative flourish. Like most of the garments, it was made in two types of fabric, a polyester and a cotton, both incorporating DuPont Type 400 elastic fibers, which are supposed to stand up better than Lycra in hot water.

"I'm in love with this jacket," Kempin said as she walked around the room modelling it. "I could do CPR in this jacket."

When the dress came out on the second nurse, Karen Adounian, management started to applaud, but the nurses were silent, and the clapping quickly died away.

"Now how practical is this?" asked Meyers, as Adounian walked around the room.

Complete silence from the nurses. "No, no, no," Kempin was saying under her breath.

"I'm not hearing any interest for the dress." Meyers looked around at the council of nurses. The nurses looked grave. "Thumbs down on the dress?" Meyers asked. It seemed so, but the dress's final fate was postponed for further review.

After all the pieces had been modelled, Meyers asked the nurses for a general critique of what they had seen. They liked the pants, but thought that the legs were too wide, and that there should be elastic in the back. They also thought the knit top was too fitted around the bust, and that it was too short--you couldn't cover your butt with it.

"So for the bigger people," Meyers said, "you want a sort of tunic, like the one Bettyann was wearing?"

"A scrub top," said Kempin.

"Right," Meyers said, "a scrub top."

Yeohlee bowed her head and said nothing for most of this, smiling occasionally, a smile that became more ironic as the critique proceeded.

Even the coat came under attack. For some of the nurses, it was still too long and bulky to work in. "It looks great, but you have to be comfortable," said one.

This statement seemed to rouse Yeohlee. "I strongly disagree that it's not comfortable," she said. "It's taste, not comfort, that we're talking about here."

"I think we all agree that we're talking about taste," Meyers said brightly, looking over at the nurses, who didn't look as if they agreed at all.

"Well, would you be able to sell these uniforms to your units?" Meyers asked.

Another silence. Finally, one of the nurses said that what her unit wanted was choice. The nice thing about the scrub system was that it offered choice, not uniformity. Also, as things stand the nurses can buy their scrubs from a number of suppliers, and the fierce competition keeps the price down. Under the Valley-Yeohlee proposal, they would be buying their uniforms from one supplier, at whatever price the hospital and its supplier set.

The meeting ended with the management and the nurses agreeing that they should put off making any final decision about the uniforms until they had talked to their staffs.

On the way back to Manhattan, Yeohlee said she was "dispassionate" about the poor reception her designs had received in the hospital. "Ultimately, someone has to say, This is what we're going to do," she said. "One cannot design by committee. One person has to decide."

She was sitting cross-legged on the car seat, and the soles of her Manolo Blahnik boots bore the white chalk marks of the cobbler who had stretched them, Jim's, on Fifty-ninth Street. "I really believe I have a proposal that looks better than what they have," she said, "and I believe they will come around and agree. And I still feel that when you are wearing something that looks better, you feel better about yourself. You know, there's nothing more awkward than people who are uncomfortable in their clothes."