"I don't feel like me anymore": The impact of the hospital gown on wellbeing


The impact of clothing
Despite the known impact of clothing on social identity and self-expression, the impact of hospital clothing on patient wellbeing has been widely overlooked. In the UK a 'one size fits all', backless gown, held together with ties at the back, is commonly used to provide access to medical professionals for examination and medical investigations.  We were interested in exploring the impact of wearing this gown on patient wellbeing during a time of medical vulnerability.  We led this work in collaboration with Dr Georgiadis, Sports and Exercise Psychologist, University of Suffolk.
Using a multi-method approach, consisting of two studies, we considered the impact of the hospital gown on wellbeing among adults with and without chronic health conditions. The first study consisted of conducting in-depth, semi-structured interviews (n = 10) with adults living with a lifelong chronic health condition (Congenital Heart Disease). The second study was a cross-sectional, online survey exploring adults' views (n = 928) and experiences of wearing the hospital gown.  


Key themes
Preliminary analysis of our findings revealed the following master themes associated with wearing the hospital gown.
(1) A loss of healthy identity: Wearing the gown represented a shift in participants’ psychological state; a transition from ‘healthy’ to ‘sick’ identity which had implications for how participants felt within themselves:
‘As soon as they like “take it off” just like, you dehumanise me I don’t feel like me anymore’ (Jenny)

(2) Symbolic embodiment of the ‘sick’ role:  The hospital gown, in itself, contained customary obligations and expectations based on the social and cultural norms associated with wearing it and ‘being sick’.
‘Psychologically, suddenly when you put it on you’re now ‘ill’, you know so for a scan, you know I’m fine going in, nothing's wrong with me they’re just doing this to ensure everything’s flowing the way it should, for the pacemaker change, and then when you put that gown on you suddenly feel a bit more vulnerable (Kevin)

(3) Relinquishing control to medical professionals: Participants described how they often relinquished control to medical professionals; this was reflected in their passive acceptance of having to wear the hospital gown:
‘You’re being asked to wear something that you’re not necessarily feeling that comfortable wearing, but, you know, you have to (laughs). So it’s all part of that whole process of, you know, not being in control, not being able to wear your own clothes, and not being able to do, you know, what you want to do, and then you have to let the medical team sort of take control of everything’ (Camilla)

(4) Vulnerability, disempowerment and embarrassment: The lack of 'patient orientated' functionality of the gown resulted in participants feeling insecure and unsafe which further heightened their sense of being emotionally and physically vulnerable whilst wearing the gown.
‘When you walking around or so, it can be opened at the back so you’re quite often trying to turn your back on something, trying to cover yourself up or sit down or whatever. But also with these gowns, there's basically nothing underneath so if you’re sat down it can ride up your leg and people can walk past and see other things’ (Callum)

Online survey
Findings from the online survey data found that 59% of adults reported wearing the hospital gown despite being uncertain that it was medical necessity, with its design generally being considered to be not fit for purpose and lacking in dignity. The majority of participants reported feeling exposed (72%), self-conscious (59%), vulnerable (58%) and uncomfortable (57%). Almost two thirds of participants (64%) struggled to put the gown on by themselves with 70% reporting that it was either too big or too small for their size; 41% experienced ‘double gowning’, that is being offered a second gown to wear the other way around to protect their dignity; 58% reported it had or maybe had limited their activity; 75% felt it either did or maybe did influence how others saw them, and 70% felt it either did or maybe did influence how they saw themselves. Females and people who identified as living with a long term condition were more likely to report negative emotions associated with wearing the gown. 

Recommendations
Our findings suggest several areas for improved design of the gown including a tie at the side without open back, a design which is easier for people to put on by themselves, less revealing, more comfortable, a better fit, warmer and able to accommodate medical equipment.   The use of the gown should be limited to medical necessity with patients changing back into normal clothing as soon  as possible, whilst avoiding having to wear it in public areas.

Challenging cultural norms
These findings emphasise the importance of challenging cultural norms in healthcare since de-humanising aspects of care, as symbolically represented by the hospital gown, may adversely impact on patient wellbeing consistent with a call for better Psychologically Informed MedicineInterestingly this work has attracted a lot of public interest, with over 27,000 reads of our conversation article, stimulating lively debate on social media, perhaps demonstrating the importance of addressing this issue.   We were delighted to be awarded Strathclyde University’s Images of Research Impact Award 2019 for this work and you can find out more about the story behind this research which emerged from the lead author’s lived experience, or watch our presentation from the #endpjparalysis global online summit 2019.  We look forward to presenting this work at the forthcoming Lancet Public Health conference in London, November 2019. 

Nicola Cogan is a Lecturer at University of Strathclyde having previously worked as a consultant clinical psychologist and clinical lead in mental health services in the NHS. Her research interests are in the areas of mental health, wellbeing, resilience, recovery and citizenship in applied health and social contexts. 


Liza Morton is a Counselling Psychologist working part time as a teaching fellow on the Clinical Health Psychology MSc at Strathclyde University and in Private Practice in Stirling.  Her current research interests are promoting psychologically informed medicine including the impact of hospital clothing on wellbeing and the psychological impact of living with a heart condition from birth.  Her experience in this area bridges academia, lifelong personal experience and engagement with key stakeholders and policy makers.   You can follow Liza on twitter @drlizamorton 


References:
Morton, L.,  Cogan, N., Kornfalt, S., Porter, Z. Georgiadis, E. Baring all: the impact of the hospital gown on recovery and wellbeing for adults living with a heart condition from birth, (submitted) British Journal of Health Psychology.

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