Comprehensive design considerations for a new hospital gown: a patient-oriented qualitative study
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* Saif Syed
* Peter Stilwell
* Jonah Chevrier
* Connie Adair
* Gary Markle
* Kenneth Rockwood

## Abstract

**Background:** The standard hospital gown has remained relatively unchanged despite reports that it is uncomfortable, embarrassing to wear and compromises patients’ dignity. The objective of this qualitative study was to explore the experiences and perspectives of stakeholders involved in the gown life cycle.

**Methods:** We conducted a constructivist, qualitative interview study with a patient-oriented lens. A patient partner was fully integrated into our research team and directly involved in interview guide development, recruitment, data collection, analysis and writing. We audio-recorded telephone interviews with adult (i.e., aged 18 yr or older) patients and family members, interdisciplinary clinicians and key system stakeholders (e.g., designers, manufacturers, textile experts) in North America. We used a hybrid deductive–inductive approach to coding and theme development. This study took place from May 2018 to March 2020.

**Results:** Analysis of 40 stakeholder interviews (8 patients and family members, 12 clinicians, 20 system stakeholders) generated 4 themes: utility, economics, comfort and dignity, and aesthetics. Patients and clinicians emphasized that current gowns have many functional limitations. By contrast, system stakeholders emphasized that gowns need to be cost-effective and aligned with established health care processes and procedures. Across the stakeholder groups, hospital gowns were reported to not fulfill patients’ needs and to negatively affect patients’ and families’ health care experiences.

**Interpretation:** Our findings suggest that the standard hospital gown fails to meet the needs of those involved in providing and receiving high-quality health care. Redesigning the gown would be a step toward increased person-centred care and requires partnership across the stakeholder groups involved in the gown life cycle to minimize implementation barriers while placing patients’ needs at the forefront.

**Plain language summary:** Patients have complained about hospital gowns for years, but little has been done to design a gown that makes people feel less exposed and more comfortable. New designs have been developed, but they have high costs and do not fit within current health care processes and procedures. Our interview-based study gathered the experiences and points of view of a wide range of people involved in the gown’s life cycle, from creation to disposal. We interviewed 40 people from 3 main groups: patients and family members; health care workers; and others such as designers, buyers and launderers. All groups felt that gowns are not user friendly. This affects how patients and families feel about their health care experiences. Patients want a gown that is better designed to meet their needs. However, not everyone may benefit from redesigns. For example, different fabrics could result in higher shipping and laundry costs. Everyone involved in the gown’s life cycle must work together to create a comfortable and useful gown that does not cost much more to make or look after.

The design of the standard hospital gown is not patient centred. Hospital gowns can convey a sense of exposure, discomfort, disempowerment, embarrassment, reduced self-esteem and compromised dignity. 1–3 As a result, governments, researchers, celebrity designers and private health care systems have made efforts to redesign the standard gown to improve patients’ experiences. 4–7 However, design innovations have not been met with substantial market uptake; new designs are still being developed and tested.8–10 Gown studies and redesigns have focused on the needs of patients and clinicians,1,3,7 resulting in costly products7 that limit use.1 Little work has explored the perspectives of other gown stakeholders, such as manufacturers and launderers.11

In its life cycle, the standard gown goes through 4 discrete stages: manufacturing, transport, patient utilization, and sterilization or disposal.10 An effective patient gown design must meet the unique stakeholders’ and functional challenges at each stage while considering impacts on patient experiences and outcomes. For example, fabric type can increase the risk of pressure injuries.12 The objective of this qualitative study was to explore the experiences and perspectives of stakeholders involved in the life cycle of hospital gowns, while maintaining a patient-centred focus.

## Methods

### Study design and setting

We conducted a constructivist, qualitative interview study through a patient-oriented lens. A constructivist paradigm13 appreciates each individual’s unique experiences and perspectives. Findings are co-constructed between researchers and participants. Within our constructivist approach, we had a patient-oriented focus, as outlined by Canada’s Strategy for Patient-Oriented Research,14 which advocates for patients as partners in the research process to ensure studies focus on patient-identified priorities. This study took place from May 2018 to March 2020 and is reported following the Consolidated Criteria for Reporting Qualitative Research15 and the Guidance for Reporting Involvement of Patients and the Public — GRIPP2 Short Form.16

Our research team consisted of S.S., a medical student (Dalhousie) with graduate (MBA) experience and training in quality improvement and innovation; P.S., a PhD candidate (Dalhousie) with qualitative research training and experience and a physical rehabilitation background; J.C., a surgical quality analyst (Michael Garron Hospital, Toronto) with graduate-level (MSc) research training and experience and involvement in hospital quality improvement; C.A., a patient partner with extensive volunteering experience at Michael Garron Hospital, including participation in patient experience panels and steering committees, and involvement in the Research and Innovation Council; G.M., an associate professor of craft — fashion design (Nova Scotia College of Art and Design [NSCAD] University, Halifax) with collaborative design experience in research; and K.R., a clinician-scientist (Dalhousie and Nova Scotia Health). All team members came in with the assumption that the current gown design was suboptimal.

### Participants and recruitment

We used a maximum variation17 approach to purposeful sampling to explore a diverse number of stakeholders’ experiences and perspectives. We sampled to exhaustion; recruitment and analysis continued until the data yielded little or no new information.18 We identified stakeholders through the research team’s volunteer and professional networks at Michael Garron Hospital, Nova Scotia Health and NSCAD University. We identified additional system stakeholders through Web searches. We also used a snowball sampling strategy with all stakeholder groups, asking participants to recommend others based on our recruitment gaps at that point in time. To be eligible, participants had to be 18 years or older and located in North America.

We recruited participants by email from July 2018 to February 2019. We provided potential participants with details about the study and our goal of informing the redesign of the hospital gown. Those interested were emailed a consent form and invited to schedule an interview.

### Data source and collection

We developed a semistructured interview guide to explore stakeholders’ experiences and perspectives. The guide was based on our team’s collective expertise, knowledge gaps regarding gown-related experiences and perspectives, and literature on qualitative interviewing.13 Before recruitment, P.S. led a qualitative-interviewing training session with C.A., S.S. and J.C. The interview guide was pilot-tested with mock interviews among C.A., S.S., J.C. and P.S. We subsequently revised the guide (Appendix 1, available at [www.cmajopen.ca/content/10/4/E1079/suppl/DC1](http://www.cmajopen.ca/content/10/4/E1079/suppl/DC1)), incorporating feedback and specific wording provided by our patient partner (C.A.).

Interviewers (C.A., S.S. and J.C.) obtained each participant’s verbal consent directly before conducting one-on-one, semistructured telephone interviews. Participants were asked to report their sex, age and geographic location. Interviews were audio-recorded and transcribed verbatim. Interviewers took field notes during the interviews and directly afterward. Transcripts were not returned; however, to enhance the credibility and confirmability of our findings,19 we emailed participants a summary of findings and gave them the opportunity to provide feedback.

### Patient engagement

Our patient partner (C.A.) was trained in research ethics and fully integrated into our research team, with the goal of ensuring the patient perspective was considered through every stage of the study. C.A. was directly involved in interview guide development, recruitment, data collection, analysis and writing. C.A. guided our team to integrate additional interview prompts that mattered from the patient perspective (e.g., added prompts about potential benefits and disadvantages of gown features such as pockets).

### Data analysis

Analysis of transcribed recordings was ongoing throughout sampling and data collection, using NVivo 12 software for Mac (QSR International). Owing to sporadic technical errors (audio recordings cut short), in some cases, we imported the interviewer’s field notes into NVivo in lieu of transcribed data. We used a hybrid deductive–inductive approach to coding and theme development as it is an established qualitative method to analyze and report experiences and perspectives.20 P.S. developed an initial codebook in NVivo in the form of deductive a priori “nodes” representing the basic concepts covered in the interview guide, such as “colour,” “fasteners,” “safety” and “costs.” P.S. then coded the interview transcripts, assigning segments of text to corresponding nodes. During this process, new nodes were inductively created, such as “double gowning,” “durability” and “pattern or print.” During regular teleconference calls, we discussed patterns and preliminary themes and triangulated them with field notes generated by C.A., S.S. and J.C. This facilitated the credibility and confirmability of our findings.19 Thematic consensus was reached between P.S., C.A., S.S. and J.C., and then reviewed by G.M. and K.R. Toward the end of the analysis, we determined that we had obtained adequate information18 for each stakeholder group.

### Ethics approval

This study received ethics approval from Nova Scotia Health’s Research Ethics Board and the Research Ethics Board at Michael Garron Hospital.

## Results

Across the 3 stakeholder groups, we interviewed 40 individuals (Table 1). Interviews typically lasted from 20 to 40 minutes. No participants retracted their data or requested alterations after receiving an email with a summary of the findings and a request for feedback. Four main themes were generated: gown utility, gown economics, gown comfort and patient dignity, and gown aesthetics.

View this table:
[Table 1:](http://www.cmajopen.ca/content/10/4/E1079/T1)

Table 1: 
Demographic profile of participating stakeholders

### Gown utility

Participants described the standard hospital gown as primarily a utility garment to facilitate health care processes. Though all stakeholder groups discussed this topic, clinicians focused on gown utility and its impact on patient outcomes. Functional benefits noted by clinicians included easy stain identification (e.g., bleeding), easy donning owing to large arm openings and open back, easy access for certain procedures (e.g., back opening for epidurals), and observation (e.g., easy to monitor for bruises or tissue injury on legs).

Many functional limitations of gowns were also outlined. Participants discussed how gowns complicate aspects of clinical examinations (e.g., cardiorespiratory examination) and interfere with equipment (e.g., intravenous lines). The standard back opening was frustrating to several clinicians as it did not have utility. Participants emphasized how gown-related factors can have a negative impact on recovery. Gowns were reported to restrict mobility and contribute to increased bed rest, owing to factors such as inability to fasten or close the gown and fear of exposure. The standard gown has 2 ties at the back of the garment that can accommodate a variety of patient shapes and sizes. However, participants reported challenges for patients with limited range of motion in their shoulders or issues with dexterity and fine motor skills. Participants also commented on issues when patients rolled over in bed; ties and loose gown material were reported to be uncomfortable and tended to get stuck under a patient’s body. Gown donning was also reported to be confusing, with patients not knowing if the opening should be in the front or back and how the ties worked.

From a laundering and gown-processing perspective, participants noted that ties are the primary reason gowns are discarded, as they are torn off or knotted such that they cannot be untied. Participants suggested fastening alternatives such as buttons, snaps, zippers, magnets and Velcro. Others opposed these options, citing issues with snaps (difficult to replace, short lifespan, choking hazard), zippers or magnets (technical difficulty with hospital imaging; e.g., radiography), and Velcro (poor lifespan, skin irritation and infection control issues).

Overall, particpants reported that the current hospital gown has both benefits and limitations regarding utility. Suggestions for improvements were conflicting, reflecting the different needs and perspectives of the stakeholders interviewed. Supporting quotes for this theme are provided in Table 2.

View this table:
[Table 2:](http://www.cmajopen.ca/content/10/4/E1079/T2)

Table 2: 
Quotes supporting the theme “gown utility,” reflecting the functionality of the gown and impacts on health care processes and procedures and patient outcomes

### Gown economics

All stakeholder groups, especially system stakeholders, discussed the economic challenges that shape the life cycle of the hospital gown. Participants discussed the challenge of balancing health care expenses, industry profits and the needs of clinicians and patients. Although manufacturers and launderers appreciated the needs of clinicians and patients, design changes to the current gown can disrupt well-established gown processes (e.g., washing, ironing, folding and storage). Therefore, it was reported that any gown alterations or innovations would need buy-in from those involved in gown processing before being implemented at scale.

Some participants discussed gown innovations that might enhance patients’ experiences while also providing cost savings. For example, changing to a more economical fabric (e.g., from cotton to polyester) or implementing design changes that would mitigate “double gowning,” the practice of wearing 2 gowns (one backward and one forward) to increase coverage or provide warmth or both. System stakeholders commented that designs that provide coverage yet have fewer gown parts (i.e., fewer seams) can result in decreased costs and increased durability. They also noted that heavier fabric should be considered carefully, as cost is often a function of weight. Heavier materials can also negatively affect laundering processes (e.g., fewer gowns per load).

Overall, participants emphasized that gown redesigns must benefit as many stakeholders as possible and that implementation would be easier when compromise among the various stakeholder groups is maximized. Many noted that cost is unfortunately a substantial barrier to patient-centred gown implementation and that gown redesign is not a health care priority. Supporting quotes for this theme are provided in Table 3.

View this table:
[Table 3:](http://www.cmajopen.ca/content/10/4/E1079/T3)

Table 3: 
Quotes supporting the theme “gown economics,” reflecting the tensions between gown costs and design versus gown users’ needs

### Gown comfort and patient dignity

Participants across all stakeholder groups indicated that the current gown design is humiliating, invades privacy and is culturally insensitive. This was of particular concern when patients are walking, have decreased levels of consciousness or are unable to fasten the standard gown with a back opening and ties. Family members and clinicians discussed the inherent vulnerability of patients while in hospital and the need to remove gown-related barriers to comfort and dignity. In terms of alternatives to the standard open-back gown, all stakeholder groups suggested a front- or side-opening robe-like gown, with fabric overlap.

Participants across all stakeholder groups discussed the lack of control patients have over the current hospital gown design and the need to give patients options and control, specifically appropriate sizes, comfortable materials and easy fastening. There was discussion on the choice of sleeve length, material thickness, colour and size, and options related to skin coverage to align with patients’ gender identities and religious beliefs (e.g., Muslim women who might feel as if they are not covered enough, and some men who feel that the gown is like a “dress” and are hesitant to wear it — or when they do, they may interact differently with family). One patient mentioned the possibility of gown vending machines that would allow patients to select their own gown, similar to scrub-dispensing machines for clinicians. The suggestion of pants was made multiple times, as well as garments that are “more like clothes,” as described by a researcher and patient.

System stakeholders highlighted the challenges associated with enhancing gown options for patients. The primary tradeoff is that increasing gown options reduces bulk orders of “one size fits all,” resulting in increased costs because of changes in order volumes. It was reported that having multiple types of gowns, to facilitate comfort and dignity, can create issues from a laundering perspective, as established processes are in place to accommodate the current gown and to minimize labour (i.e., reduced number of manual folds before using a folding machine).

Overall, tensions across stakeholder groups were apparent; introducing new gowns may be met with process-related behaviour change or implementation problems despite the potential to increase patient comfort and dignity. The current gown was reported to not fulfill patients’ needs and negatively affected patients’ and families’ health care experiences. Supporting quotes for this theme are provided in Table 4.

View this table:
[Table 4:](http://www.cmajopen.ca/content/10/4/E1079/T4)

Table 4: 
Quotes supporting the theme “gown comfort and patient dignity”

### Gown aesthetics

Participants frequently commented on the look and feel of the current gown and how it could be improved. Regarding colour, some participants indicated their preference for the light colours of the current gown, as these have calming effects, are gender neutral and promote the perception of a clean or sterile environment. However, most participants suggested the colour could be improved upon or that patients should be given options. Participants also commented on the psychosocial impact of wearing the gown in public, noting that one does not normally wear pyjama-like clothes around strangers and that it may be embarrassing. Participants commented that the current gown is “ugly” and like a “prison jumpsuit.” Gown colour suggestions are found in Box 1 and supporting quotes for this theme are provided in Table 5.

View this table:
[Table 5:](http://www.cmajopen.ca/content/10/4/E1079/T5)

Table 5: 
Quotes supporting the theme “gown aesthetics”

Box 1: 
### **Gown colour suggestions and rationale discussed by participants across stakeholder groups**

*   Brighter, “cheery” or fun colours to improve psychosocial impact.

*   Hospital colours (i.e., colour of hospital logo or branding); others suggested something “less hospital like.”

*   Darker grey or blue, white or cream to get away from institutionalized colours and to facilitate a cozy, clean and comfortable experience.

*   No busy colours or patterns, and no shades of black (considered too depressing) or reds (hides blood).

*   Gender-neutral colours, such as yellow, green or grey.

*   Ties to be a darker colour than the gown so they are easier to see.

## Interpretation

Our thematic analysis of 40 interviews across 3 stakeholder categories generated 4 main themes: gown utility, gown economics, gown comfort and patient dignity, and gown aesthetics. Although different stakeholder groups addressed different priorities for gown redesign, all stakeholder groups emphasized that there is much room for improvement. This is in line with a 2009 survey of 1200 interprofessional caregivers, of whom 63% felt that it was important to change the design of the current patient gown.21 More recently, a 2020 qualitative study of 10 patients, 10 physicians and 10 nurses at an academic medical centre echoed this finding: a common theme across the groups was the negative impression of the gown and the need for improvements.1

Our findings about patients’ priorities reinforce results from a 2020 multimethod study consisting of semistructured interviews and an online survey that focused specifically on patients’ perspectives on gown wearing.3 Regarding function, most patients reported that they struggled to put the gown on by themselves (64%) and that it did not fit (70%). With respect to dignity and comfort, most patients reported feeling exposed (72%), self-conscious (60%) and uncomfortable (57%). The 2020 qualitative study also reported that both patients and providers used the words “uncomfortable” and “exposed” as negative connotations related to the “patient gown.”1 This theme was reiterated in a 2020 opinion perspective in the *BMJ* by a consultant in geriatric and acute general medicine,22 who suggested that gowns be used only when they serve a function, in order to preserve patients’ dignity.

Consistent with this theme, patients in our study strongly emphasized that the current gown design is confusing, lacks comfort and compromises their dignity. Clinicians also commented that the gown can affect patient outcomes and impede care. System stakeholders emphasized economic considerations associated with gown redesign, specifically laundering and processing. Although overlapping considerations are put forth by both patients and clinicians, successful gown innovations must also compete with or improve on the operating costs for the current gowns. Consistent with our findings, others have suggested that there is potential for redesigns not only to be more dignified, but also cost-effective, given the common practice of “double gowning,” whereby a second gown is offered in an effort to maintain patient dignity.3

Our participants’ experiences and perspectives may inform future research and gown designs that can be assessed with key stakeholders in mind. Further research is required to develop fabrics, fasteners and wearable technologies that can improve patient outcomes, user experiences and the overall economics of the garment’s life cycle. To date, we lack high-quality research that uses both subjective and objective outcomes to compare gown redesigns; there are opportunities for new gown developments and mixed-methods research to evaluate redesigns.

### Limitations

Although we employed a maximum variation approach to purposeful sampling to explore diverse experiences and perspectives, most of our participants were in Canada; therefore, our results may not generalize to other countries and cultures with different patient populations and clinical settings. In addition, our design, and qualitative interviews in general, come with important factors to consider, including both self-report and recall biases.

### Lessons learned from patient engagement

Our patient partner (C.A.) was involved in every step of this study. Her involvement helped us better explore and represent patients’ experiences and perspectives. In particular, her surgical waiting and recovery room volunteer experience gave her first-hand insight into the problems associated with the gown, which informed aspects of the interview guide. Further, her involvement and experiences also helped us better identify and describe competing priorities across stakeholder groups.

C.A. reported that the team was “great and made me feel welcome and valued throughout the project.” She did not come from a health care or research background; therefore, she “found the learning curve steep, but the team was always willing to answer questions and offer guidance.” She offered that the “need for hand-holding may be a consideration for other teams to keep in mind.” Further, she identified that, at times, she was not certain of her role and what was expected. Therefore, there were instances where she felt concerned that she was “overstepping.” The team felt that C.A. was proactive and eager to participate in all aspects of the study; this was welcomed and valued as she was considered a fully integrated member of our research team. However, in retrospect, a clear written summary of the patient partner role and expectations may have mitigated her concerns about overstepping or breaching her role, while also facilitating and validating her important contributions. We note too that other team members reflected on how their experience as patients informed their critiques of gowns.

## Conclusion

The current patient gown design fails to meet the needs of those involved in providing and receiving high-quality care. A patient-centred redesign of the hospital gown will require alignment between user and system interests and can be informed by elements elucidated in this study. This will require partnership across the stakeholder groups involved in the gown life cycle to minimize implementation barriers, while placing patients’ needs at the forefront.

## Acknowledgements

The authors thank Dr. Rizwaan Farid and Dr. Jeff Powis for their contributions to this research.

## Footnotes

*   **Competing interests:** Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University’s Industry, Liaison, and Innovation Office, and, with Olga Theou, copyright of the Pictorial Fit-Frail Scale. Dr. Rockwood reports receiving funding from the Social Sciences and Humanities Research Council (SSHRC) as co-investigator on the SSHRC Individual Partnership Engage Grant paid to co-author Gary Markle, in support of the present manuscript. Dr. Rockwood also reports receiving honoraria from McMaster University to present on frailty, and consulting fees from Nutricia, the Singapore National Research Foundation and the Wake Forest Medical School Innovation Advisory Board. Dr. Rockwood chaired the data safety monitoring board for the National Institutes of Health–sponsored Apathy in Dementia Methylphenidate Trial 2 (no honorarium). He is associate director of the Canadian Consortium on Neurodegeneration in Aging (unpaid position), which is funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada and several other charities. Dr. Rockwood is co-founder of Ardea Outcomes, which (as DGI Clinical) in the last 3 years has had contracts with Danone, Hollister, INmune, Novartis and Takeda on individualized outcome measurement. Finally, Dr. Rockwood receives salary support from Nova Scotia Health, Dalhousie University and Dalhousie Medical Research Foundation. No other competing interests were reported.

*   This article has been peer reviewed.

*   **Contributors:** All of the authors contributed to the conception and design of the work, and the acquisition, analysis and interpretation of data. Saif Syed, Peter Stilwell, Jonah Chevrier and Connie Adair drafted the manuscript. Gary Markle and Kenneth Rockwood revised it critically for important intellectual content. All of the authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

*   **Funding:** Canadian Institutes of Health Research, Social Sciences and Humanities Research Council.

*   **Data sharing:** No additional data are available.

*   **Supplemental information:** For reviewer comments and the original submission of this manuscript, please see [www.cmajopen.ca/content/10/4/E1079/suppl/DC1](http://www.cmajopen.ca/content/10/4/E1079/suppl/DC1).

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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