The Pharmaceutical Journal
Vol 279 No 7465 p181-183
18 August 2007

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What should pharmacists wear?

Should pharmacists “dress for success” or should they focus on how care is delivered rather than worry about whether or not their shirts or blouses are ironed? Lin-Nam Wang (on the staff of The Journal) investigates

ARTICLE CONTENTS Dress codes Infection control Religion and belief Substance over style? Future looks

The issue of what people wear to work regularly makes headlines. In June 2007, for example, a Home Office review of removals of families from the UK recommended that immigration officers should wear softer colours in order to be less intimidating to children.

Then there was the debate over whether or not a British Airways worker should be allowed to wear a Christian cross. Even Jeremy Paxman has been at it, calling ties “an utterly useless part of the male wardrobe” and questioning whether it is time for Newsnight men to stop wearing them.

Clothing protects, decorates, identifies, unites and displays status. According to Desmond Morris, author of ‘Manwatching: a field guide to human behaviour’ (Triad Books, 1978), it is impossible to wear clothes without transmitting social signals.

Other authors suggest that people make judgements on credibility, likeability, education level and trustworthiness — important attributes for pharmacists — based on clothing and, over several decades, researchers in social psychology and communication have built an evidence base to support such theories.

Studies that look at the influence of apparel typically involve showing people photographs of a model dressed in different styles and asking them to appraise each one using adjectives, such as “knowledgeable” and “friendly” or to score each for descriptors, such as “confidence in ability”. Targets for these types of study have included students (judging what teachers wear) and patients (judging doctors’ attire).

What a person wears can also affect the behaviour of others. For example, one study showed that pedestrians are more likely to ignore a “red man” at a crossing if they see a person dressed in high status clothing ignoring the signal. Another found that people are more likely to comply with a request made by someone dressed in a uniform than with a request from someone not in uniform.

It has also been shown that levels of political support and charitable donations are affected by what the recipient wears. It makes sense, therefore, to assume that style of dress might influence patient-pharmacist relationships as well as how relationships with other health care professionals are formed, and this leads to the question: what should pharmacists wear in order to be positively perceived?

Comments in The Journal have blamed “the medium of the T-shirted pharmacist” (PJ, 28 October 2006, p516) and pharmacists arriving for work in jeans (PJ, 4 November 2006, p545), among other things, for tarnishing the professional image of pharmacy. At the other end of the spectrum is the white-coated pharmacist. Surgeons started wearing white coats in the late 19th century as a new aseptic method — dirt is clear on white — and, by the 1950s, many pharmacists were wearing them. Advocates of the white coat claim it makes it easy for patients to identify the health care professional and may lend an air of authority.

Although the sight of a community pharmacist in a white coat is less common these days, for some, the coat is a symbol of the profession. Many US schools of pharmacy, for example, hold “white coat ceremonies” in which incoming students are presented with a white coat and take an oath. “The ceremony and coat signify the movement into a professional programme. … Students typically wear the coats throughout their programme, during their early clinical experiences and in professional practice related laboratory sessions,” Holly Mason, associate dean of academic programmes at the Purdue University School of Pharmacy, Indiana, says.

Anthony Smith, principal and dean of the School of Pharmacy, University of London, told The Journal that white coat ceremonies are something the school is thinking about. Should professionalism, in terms of clothes, be instilled from university? The school’s dress code is currently under review (a previous version included that it “takes a dim view of baseball caps in class”) but Professor Smith says: “We would not want to be too prescriptive while [students] are at the school, but if they are on a work placement, they should observe professional norms — that’s a collar and tie for boys.”

A white coat may spell professionalism but some believe that it intimidates patients — staff on psychiatric or paediatric wards shun the white coat for this reason — and contributes to the anxiety of a consultation, hence the term “white coat hypertension”, where blood pressure is elevated in clinical settings. Approachability was a factor considered by Superdrug in its dress code for pharmacists.

Martin Crisp, head of pharmacy for Superdrug Stores Plc, says the company’s pharmacists are issued with a white shirt with the Superdrug logo attached, which is worn with black trousers or skirt. “We do allow our pharmacists to wear their own clothes if they prefer but they should be businesslike (ie, shirt or blouse). The whole pharmacy team is issued with the same white shirt or blouse, which helps identify them from the other members of the store. By wearing the same we hope that the pharmacist appears approachable and feels part of the team.”

Sagar Patel, pharmacist at Herbert & Herbert Chemist, Hounslow, comments: “Ideally, I’d like to wear jeans and a smart top because people would feel able to talk to me. Why should I wear a white coat? I don’t work in a laboratory.”

People want a community pharmacist who looks approachable and looks part of the community, especially in small pharmacies, says David Sprakes, manager of bespoke design at Simon Jersey, a company that supplies uniforms to the NHS. However, “[Pharmacists] also need that edge — that they are professionals. So while a casual element is a good idea, to make [clothes] too informal breaks down respect.” Mr Sprakes thinks male community pharmacists should wear shirts. A tie is not necessary but a polo shirt would be too casual. And they should also avoid too many colours.

“If you saw a pharmacist in a riot of colour, would you take him seriously? Personally, I like white — it is crisp and clean — maybe with an accent of another colour. White can register authority and is recognisable. That doesn’t necessarily mean a white coat; it could mean a tunic. There is such an ingrained history [of white in health care], you need to bring white into the equation. You can tweak the style and modernise, for example, choosing a jacket with a mandarin collar instead of a traditional one,” he says.

Dress codes

Many organisations use dress codes and uniforms to support health and safety and to promote a professional image and, last month, the Department of Health published an evidence-based document to guide the development of local policies on uniforms and workwear. The Welsh Assembly says uniform codes are at the discretion of each NHS trust.

Most trusts do not require their pharmacists to wear a uniform, but to comply with a general dress code that applies to all staff. Common to many codes is the prohibition of shorts, flip-flops and jeans. Excessive jewellery, heavy make up and strong smelling perfumes or aftershaves are also not permitted and shoes should be “low noise” so as not to disturb patients.

According to the Norfolk and Norwich University Hospital (NNUH) NHS Trust dress code and uniform policy, ties should reflect a professional image. “Homer Simpson saying ‘doh’ may not be appropriate,” Andrew Stronach, head of communications at the trust, comments. However, the policy also notes “in an emergency situation, especially out of hours, medical staff may prioritise a timely response over keeping up appearances”.

At Essex Rivers Healthcare NHS Trust, the dress code for pharmacists is to be “presentably turned out”, says chief pharmacist Richard Needle. If pharmacists wish, they can wear the same uniform as technicians (tunic tops and trousers). Identification badges, therefore, are the chief means of identification. When pharmacists go into a room where a patient is in isolation, they wear an apron and gloves and, in infection outbreaks, they wear “theatre blues”.

Infection control

Although there is no conclusive evidence that work clothes pose a hazard in terms of spreading infection, the rationale behind many dress code requirements is infection control.

White coats have been branded as a possible source of infections because they tended not to be washed frequently and, for the same reason, the British Medical Association has objected to tie wearing. Dr Needle says that he has not worn a white coat for over five years — although he still has one hanging up in his office — because it is an infection risk.

However, the disappearance of the white coat is not just about cleanliness, but about a change in culture: “[White coats] had an air of formality. There is a much more open and relaxed culture [now] and it is far less hierarchical. It reflects the move to a more collaborative approach,” he says.

At South Tees Hospital NHS Trust, the uniform policy is being reviewed, but the most recent version stated that the dress code for pharmacists and senior technicians is “smart clothes with white coat as necessary”. An example of necessity is when making an extemporaneous preparation, but this reflects older practice, says Alan Hall, chief pharmacist at the trust.

When asked if he thought the white coat looked professional, he answered: “I don’t now. If you’d asked me 10 years ago, I probably would’ve said ‘yes’.” Mr Hall stresses that on wards, pharmacists have to follow infection control policies. This means short or rolled-up sleeves, no watches or jewellery and no ties. Pharmacists off wards can also opt for the open collar look. “The culture is changing. You’ve only got to look at our politicians who choose to go open neck,” he explains.

Many trusts have evidence-based guidelines for laundering uniforms within their policies. Those that permit uniforms to be washed at home, generally stipulate that, for uniforms that have not been exposed to potentially infectious micro-organisms or body fluids, a 10-minute 60C wash is sufficient to remove most micro-organisms. Some also recommend tumble drying or ironing, or both, to destroy any remaining bacteria. Uniforms are expected to be washed daily and items that might not be washed daily, such as cardigans and fleeces, are not allowed in clinical areas.

At South Tees Hospitals Trust, white coats are classed as uniform, according to Mr Hall, and this implies that they should be laundered by the trust’s laundry service daily. He admits that he is not aware if this is audited, but points out that few of his staff wear them save for “one or two of the older ones”.

Trusts expect non-uniform staff to wear clean clothes (in accordance with the Health Act 2006 Code of Practice) but there is generally no specification in dress codes for how and when they should be washed. In addition, although there is an assumption that hospital staff will wash their clothes daily, this is difficult to enforce, Dr Needle said.

Should trusts, therefore, require their pharmacists to wear a uniform? “Staff who [are required to] wear a uniform are [those] in close physical contact with patients on a prolonged basis. Pharmacists are not in close physical contact with patients,” Mr Stronach says. “Our policy is adapted on the advice of microbiologists in terms of what is risky and what is not,” he explains.

However, the pharmacist’s role is becoming more clinical and the chief pharmacists of both South Tees and Essex Rivers NHS trusts told The Journal that their trusts have talked about pharmacists (and doctors) wearing theatre blues, as in the US.

“The way that hospitals clothe their staff is probably going to be an issue in forthcoming years in an attempt to stamp out meticillin resistant Staphylococcus aureus, although much of this is budget driven,” Mr Sprakes predicts. However, it may be difficult to change attitudes if people have been used to wearing their own clothes for a long time:

“High street [pharmacists] might expect to wear a uniform but in a hospital environment, which is more relaxed, they may be more against it. But there are lots of benefits to wearing a uniform. Least of all it saves your own clothes.”

Religion and belief

Following high profile debates, in March 2007, guidance from the Department for Education and Skills allowed schools in England to ban students from wearing face veils. Schools of pharmacy have considered this issue and in its offer pack to this year’s undergraduates the School of Pharmacy, University of London, states that it has a “no face veil” policy. Expected guidance on dress codes and religious belief for the NHS in England from NHS Employers (PJ, 9 December 2006, p682) will, however, not be published.

According to former health minister Rosie Winterton, the U-turn came because it was recognised that each trust comprises a work force that reflects their local communities and national guidance would be inappropriate. Sian Thomas, deputy director of NHS Employers, said: “Employers told us that they … will be reviewing [their policies] in light of ongoing legislation. … We believe the main consideration for staff uniforms is health and safety and the spread of microbiological infection.”

Employers who wish to adopt a dress code must give careful consideration to ensuring that the proposed code does not contravene the Employment Equality (Religion or Belief) Regulations 2003. The Advisory, Conciliation and Arbitration Service (ACAS) advises that general dress codes that conflict with religious requirements may constitute indirect discrimination unless they can be justified.

For example, in addition to a wedding ring, many Hindu women wear a necklace (mangal sutra) which is placed around their neck during the wedding ceremony. Some may find it distressing if they are not allowed to wear it in their place of work, unless the rule was for justifiable reasons, ACAS says.

North Somerset Primary Care Trust’s dress policy has an equality and diversity clause which includes the sentence: “Compromises to accommodate individual preferences based on differences covered by legislation will be made where possible, but modifications are unlikely to be made where there are legitimate health and safety issues, … or in situations where communication with patients and patient care may be adversely affected.”

A test case brought under the regulations was that of the classroom assistant in West Yorkshire suspended for wearing a face veil. Defences included that when she was veiled, the children did not engage as much with the assistant, they could not pick up visual cues and that her diction was muffled. Could this apply to pharmacists’ interactions with patients?

Although none of his pharmacists wears a face veil, Mr Hall believes it might: “My personal view is that I think it possibly could be difficult in terms of patient consultations. With some of our elderly patients there are communication barriers already and [the veil] adds another.”

David Regan, solicitor at Mundays LLP, stresses that every case will be judged on its facts, but says: “I believe that an employer would struggle with this argument, as there is much less necessity for a customer to rely on non-verbal cues and facial expressions than there is for a child to. If the customer was deaf, then I could see this being an issue, however then the employee could simply summon another member of staff.”

Shazia Akhtar is a locum pharmacist and practising Muslim. She does not wear the face veil but wears a headscarf and jilbab (long dress). She believes that the issue of the face veil has been politicised. “Professional Muslim women, whether they wear the hijab and jilbab or the face veil, want to contribute to society by being a part of the health care workforce. Any legislation or policy (even at a local level) can become an obstacle to this.”

She says that if it is believed to be necessary, a discussion should arise between an employer and the individual concerned, but adds that a Muslim woman who is working as a pharmacist will, like any other professional, be able to make the best judgement regarding her dress and whether it affects her ability to do the job.

Substance over style?

One of the few studies on the influence of clothing in pharmacy was published by the American Pharmacists’ Association in 2005. This looked at whether or not different levels of communication and different dress style affects a person’s satisfaction with a service.

A male pharmacist was dressed in three styles, formal (shirt and tie), business casual (khaki trousers and a polo shirt) and casual (jeans and T-shirt). The pharmacist was then filmed giving advice in a community pharmacy. There were two levels of advice, high performance (where the pharmacist sat down with the patient for five minutes, gave in-depth, uninterrupted counselling using open questions, verified the patient’s understanding and gave empathetic responses) and adequate performance (a one-minute interaction in which the pharmacist provided the patient with basic information, did not actively involve the patient and was distracted by a ringing telephone).

The six scenarios were repeated with the pharmacist wearing a white coat. In all scenarios, the pharmacist was clean, had short hair and was closely shaven. Almost 200 people were asked to watch the interactions and to rate his performance for benefit, effectiveness and helpfulness.

Analysis of the responses indicate that only the level of communication affected how the pharmacist was perceived. The high performance interaction resulted in higher ratings of quality and trust and made people want to use the pharmacist and recommend him to a friend. Dress style and whether or not the pharmacist wore a white coat made no significant difference to these perceptions.

The researchers concluded that dress is not likely to influence a person’s evaluation of a pharmacist when the performance of the pharmacist is also taken into consideration. However, they say that dress is an extrinsic cue, which is more likely to be used as a quality indicator when a consumer does not have adequate information about intrinsic attributes (in this case, performance). In other words, what a pharmacist wears may mar or enhance a first impression.

Furthermore, the researchers say that if a consumer has little or no experience with a service, does not have the time or interest to evaluate intrinsic attributes or is in a situation where the intrinsic attributes cannot be easily evaluated (ie, if the service is technical or complex), extrinsic attributes, such as attire, may take on greater importance.

Although not statistically significant, the study results indicate that wearing a white coat may lead to a more favourable response when a pharmacist is formally dressed and to a less favourable response when the pharmacist is casually dressed.

When choosing their work attire pharmacists might also consider the demographics of a pharmacy. In a study published in the British Journal of General Practice, patients were asked to judge photographs of a male and female doctor in different clothes. Those from social classes 1 and 2 and older patients were more likely to give high scores to the traditionally dressed doctors (a suit and tie for the man and a skirt and blouse for the woman). However, this study was conducted in the 1990s, when health care was more paternalistic and patients were more likely to pay attention to traditional symbols of authority.

It is interesting that a white coated male doctor came second to the one in a suit and tie, but a white coated female doctor scored higher than the one in a skirt and blouse.

Finally, what pharmacists wear could also influence how they behave and their service delivery, although even less research has been done in this area. Mr Sprakes agrees: “If you have an organisation that issues a uniform, depending on their feelings for the uniform, it can affect how staff perform.” If they are not happy with the uniform they are not going to perform as well, although this also depends on the individual, he adds.

Mr Crisp says: “I think the clothes a pharmacist wears is secondary to [his or her] ability to build rapport and empathy with patients.” However, although it may not be important compared with other factors, such as availability, helpfulness, friendliness, knowledge and ability, style of dress is something that can be changed more easily than personality and if dressing in a particular style enhances pharmaceutical care, then why not?