To inform and support our work, we turned to a number of medical and academic sources for evidence relating to hospital gowns, self esteem and enclothed cognition, and trauma response.
A variety of studies show that the hospital gown is detrimental to patients wellbeing. Morton et al. (2020) found that patients associated the hospital gown with the sick role, with loss of control to medical professionals, and emotional and physical vulnerability. These findings were exacerbated in women and those battling long-term health conditions.
In a survey of 928 participants, Morton found that 72% of gown wearers felt exposed, 60% felt self-conscious, and 58% felt vulnerable. Moreover, 64% struggled to put it on themselves and 58% felt it had, or may have, limited their activity. Wellbery and Chan (2014) summarized the findings of Topo and Iltanen-Tähkävuori (2010) by stating, "... hospital clothing is not only a metaphor for illness, but a way of designating the lowly status of patients because of emphasis on caregiver convenience over attention to fit, coverage and aesthetics." Each study of the hospital gown came to the conclusion that patient clothing should be redesigned to reflect a patient centred approach.
The importance of self-esteem in the healing process is often overlooked. Kogler et al. (2017) found that self esteem is a factor in stress resilience, concluding that "high levels of self esteem are protective against adverse mental health outcomes and are important resilience factors." Cast et al, (2002) concluded that without esteem through self-verification, individuals are more likely to develop depression, anxiety, and hostile behaviours.
In support of the opportunity for clothing to be used as a tool, Adam and Galinsky introduce the term enclothed cognition "to describe the systematic influence that clothes have on the wearer's psychological processes" (2012). Their study found that research participants performed differently on tasks depending on the garments they wore and the associations attached to them. Their work demonstrates the depth of impact clothing has on the wearer, to not only improve self esteem, but also impact performance and processes. Self esteem and enclothed cognition research supports the promising benefits of positive clothing associations in a healing environment.
In the process of necessary medical interventions, there are often unavoidable stressful and traumatic experiences. However, there are opportunities to address and respond to these experiences in order to limit their impact on the patient. Van der Kolk (2014) emphasized that often the most challenging part of trauma treatment is not dealing with the past, but in "enhancing the quality of day-to-day experiences.”
Morton et al. (2020) contend that, "feeling as safe as possible, feeling empowered, and feeling in control are important neuropsychological protective factors in the face of threat against trauma-related disorders. Conversely, feeling objectified, powerless, and passive acceptance can contribute to their development." Based on the results of this research, we can conclude that introducing feelings of safety, empowerment, and control through clothing may offer a powerful opportunity for a patient's mental healing. Additionally, Caraballo et al. (2019) point to reducing patient stress and improving the healing environment as strategies to reduce post hospital syndrome - a studied period of generalized risk for a range of adverse health events in the six weeks after release from hospital.
"Our patients' control has been taken away... things that medical professionals might deem less important, actually are sometimes all our patients have left."
To further inform our work, we turned to healthcare workers and patients to share their lived experiences. We specifically focused on addressing two gaps in the existing research: the logistics of hospital clothing innovations, and the experiences of patients facing mental health challenges.
Our research with healthcare workers included phone interviews to better understand their roles, perspectives, and needs. These conversations provided a valuable hands-on perspective of clothing in healthcare settings and highlighted logistical considerations of patient clothing.
Patient research included phone interviews with individuals between the ages of 18-35 who had spent more than two cumulative weeks as an inpatient. This age range was chosen due to being an especially vulnerable time for individuals’ self esteem and sense of identity. These dialogues allowed for a more personal understanding of the challenges faced by patients, and illuminated the experiences of those in mental health facilities.
"We need to raise awareness. And healthcare providers are going to have to stop and think at some point and recognize that we have to ask patients, what do you need?"
Adam, H., & Galinsky, A. (2012). Enclothed cognition. Journal of Experimental Social Psychology, 48(4), 918-925.
Baillie, L. (2009). Patient dignity in an acute hospital setting: A case study. International Journal of Nursing Studies, 46(1), 23-36.
Bone, K. (2017). Trapped behind the glass: Crip theory and disability identity. Disability & Society, 32(9),1297-1314.
Caraballo, C., Dharmarajan, K., & Krumholz, H. M. (2019). Post hospital syndrome: Is the stress of hospitalization causing harm? Revista Española De Cardiología (English Ed.), 72(11), 896-898.
Cast, A. D., & Burke, P. J. (2002). A theory of self esteem. Social Forces, 80(3), 1041-1068.
Cho, K., (2006). Redesigning hospital gowns to enhance end users satisfaction. Family and Consumer Sciences, 34(4), 332-349.
Detsky, A. S., & Krumholz, H. M. (2014). Reducing the trauma of hospitalization. JAMA : The Journal of the American Medical Association, 311(21), 2169-2170.
Edvardsson, D. (2009). Balancing between being a person and being a patient: A qualitative study of wearing patient clothing. International Journal of Nursing Studies, 46(1), 4-11.
Gordon, L., & Guttmann, S. (2013). A user-centered approach to the redesign of the patient hospital gown. Fashion Practice, 5(1), 137-151.
Kogler, L., Seidel, E. M., Metzler, H., et al. (2017). Impact of self-esteem and sex on stress reactions. Scientific Reports, 7, 17210.
Krumholz, H. M. (2013). Post-hospital syndrome — an acquired, transient condition of generalized risk. The New England Journal of Medicine, 368(2), 100-102.
López-Pérez, B., Ambrona, T., Wilson, E. L., & Khalil, M. (2016). The effect of enclothed cognition on empathic responses and helping behavior. Social Psychology, 47(4), 223–231.
McDonald, E. G., Dounaevskaia, V., & Lee, T. C. (2014). Inpatient attire: An opportunity to improve the patient experience. JAMA Internal Medicine, 174(11), 1865-1867.
Morton, L., Cogan, N., Kornfält, S., Porter, Z., & Georgiadis, E. (2020). Baring all: The impact of the hospital gown on patient well-being. British Journal of Health Psychology, 25(3), 452-473.
Przezkziecki, A., Sherman, K. A., Baillie A., Taylor, A., Foley, E., & Stalgis-Bilinski, K. (2013). My changed body: Breast cancer, body image, distress and self compassion. Psycho-Oncology, 22(8), 1872-1879.
Slater, J. (2012). Youth for sale: Using critical disability perspectives to examine the embodiment of ‘youth’. Societies, 2(3), 195-209.
Topo. P., & Iltanen-Tähkävuori, S. (2010). Scripting patienthood with patient clothing. Social Science and Medicine, 70(11), 1682-1689.
van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.
Wellbery, C., & Chan, M. (2014). White coat, patient gown. Medical Humanities, 40(2), 90-96.