Let's talk about scrubs: A reflection during COVID-19 : Nursing Management (2025)

COVID-19 introduced a whole new dimension of fear and social awareness among people, and scrubs used by healthcare workers became a hot topic of discussion. Abuse of healthcare workers for wearing scrubs in public has occurred, with the World Health Organization reporting 35 incidents in 11 countries.^1-3 Some of these occurrences may have been due to misunderstanding or a lack of information and education.³ It was also reported that nurses in Mexico stopped wearing uniforms while commuting to work; in Australia, nurses were told not to wear scrubs outside.³ While these discriminatory behaviors were occurring, some healthcare workers had no alternative but to wear work attire during their commute because they were being discouraged from using hospital-issued scrubs.⁴ Healthcare workers were caught in this conundrum while trying to navigate their own safety.

This article explores the literature for evidence of scrubs as a source of infection, optimal ways to decontaminate, and the role of leadership to support nurses by developing appropriate policies or guidelines.

The possibility of contamination

Mitchell and colleagues identified healthcare apparel as an epidemiologically significant means of pathogen transmission to patients, other healthcare workers, and the community.⁵ However, the CDC states, “the risk of actual disease transmission from soiled linen is negligible” and that “in the home, normal washing-drying cycles, including ‘hot’ and ‘cold’ cycles, are adequate to ensure patient safety.”⁶ The Association of Surgical Technologists (AST) reports that the extent of contamination indicates a possibility of infection and it proactively recommends all scrubs be hospital laundered, transported carefully, and used effectively.⁷ These differences in recommendations make it difficult for organizations to develop evidence-based policies.

The type of scrub material and duration of use can impact the level of contamination. Gupta reported that microbial adhesion is influenced by fabric type; the microbial load on polyester cotton blend fabric is 60% higher than on polyester fabric.⁸ Advances in textile technology may help invent fabric that can repel pathogens and be worn for longer periods such as an entire 12-hour shift.⁵ A study of scrubs with silver-impregnated fabric and three different materials (n = 40; 2,185 cultures) during 12-hour shifts indicated that the type of material didn't impact the contamination level.^9,10 This study didn't find any differences between scrubs made of treated fabric and regular fabric. However, fabric with a hydrophilic barrier may reduce the bioburden by repelling fluids when spills of body fluid are present.⁵ Live organisms were found on scrubs more than 48 hours after shifts ending in some studies.¹¹ Further research on materials and duration of use for specific units may be needed to establish stronger evidence.

The Society for Healthcare Epidemiology of America workgroup on healthcare worker attire assessed the policies and perceptions regarding transmission of pathogens and gave recommendations and a call for well-designed studies to establish evidence of attire contamination and healthcare-associated infections (HAIs).¹² Its guidance was based on a thorough literature review and policies at seven large teaching hospitals. It was found that hospital staff laundered scrubs every 1.7 days compared with white coats (12.4 days).¹² Nine studies reported Staphylococcus aureus contamination of scrubs in the range of 5% to 29%, and vancomycin-resistant Enterococcus, methicillin-resistant S. aureus, and Clostridium difficile contamination increased with shift work.¹²

Managers may have to educate nurses; hold staff members with scrubs and lab coats accountable; and encourage unit-based research, particularly on units with increased incidence of HAIs. Gordonia bronchialis bacteria in three patients who had postoperative sternal wound infections were linked to a nurse anesthetist's scrubs.¹³ However, Munoz-Price and colleagues couldn't find evidence of contamination of scrubs in their study.¹⁴ Although the evidence to support that HAIs can result from contaminated scrubs varies, it's essential for leaders to make sure that their staff members take care of scrubs effectively to prevent any potential for transmission.

Several barriers exist to having specific policies regarding wearing scrubs only in clinical settings. These include a lack of changing areas in the hospital or that the changing area is far from the patient care unit. When hospitals don't facilitate change of scrubs in the clinical setting, poor compliance can occur and nurses may wear scrubs during their commute to the hospital. In addition, hospital laundering may be cost prohibitive, although every hospital OR washes their scrubs in the hospital laundry. The AST recommends changing to personal clothing before leaving the surgical department.⁷

Optimal laundering practices

Although laundering practices can affect the virulence of organisms, the decontamination of scrubs and policies on laundering vary from hospital to hospital and even unit to unit. Historically, hospitals laundered uniforms for their staff, but during the 1970s hospitals ceased this practice. Commercial laundering with standardized water temperature and detergent is reported to be better than home laundering.^7,15-17 White coats washed in hot water and bleach were better decontaminated than lukewarm water.¹⁸ The National Health Service standards for washing uniforms include the water temperature, type of detergent, drying conditions, frequency of changing, and washing load if using a home washing machine; however, implementation of these policies vary.¹⁵ Even though policies are essential for effective implementation, nurse leaders may face challenges.

Commercial laundry may have standard guidelines; however, home laundering can't be standardized. The Association of periOperative Registered Nurses provides some guidelines for home washing of surgical suite attire, suggesting that domestic washing and ironing may be sufficient for decontamination, but scrubs must be laundered separately and must be ironed.¹⁷ With the emergence of no-iron textiles, ironing isn't required for appearance and people may forego ironing. Putnam further reported that some scrubs negative for bacteria became positive after home laundering, indicating that washing machines can be a source of contamination.¹⁷

Practice changes during COVID-19

COVID-19 forced US healthcare organizations to implement stricter policies regarding scrubs. Reports indicate that some hospitals mandated staff change to hospital-issued scrubs before entering the unit and leave the hospital-issued scrubs before exiting the unit to prevent transmission.⁴ Other hospitals didn't allow nurses to wear hospital-issued scrubs but did allow physicians and NPs to use them.^19,20 In the UK, policies prohibited healthcare workers from wearing uniforms outside the clinical work setting; however, the lack of changing facilities caused some healthcare workers to continue to wear uniforms on their commute.^21,22 This raises the question, should all healthcare workers be asked to wear hospital-issued scrubs or uniforms every day, even after COVID-19?

Scrubs are comfortable to wear and easily identify the nurse as a healthcare worker. The pockets are convenient to carry essential items needed for communication and documentation of care. In the US, most units other than the OR don't have a policy on wearing scrubs outside patient care areas, so healthcare workers wear scrubs during their commute, and some may wear scrubs to complete activities of daily living such as shopping.

Public opinion research on the use of scrubs in nonprofessional settings revealed an interesting finding. Bambekova and colleagues found that although healthcare workers indicated flexibility in wearing scrubs after work, nonhealthcare workers believed that scrubs should be taken off before leaving the clinical setting.²³ Wearing scrubs outside of the clinical setting may trigger apprehension in nonhealthcare workers because they associate scrubs with pathogens.²³ Heightened awareness about the transmission of infection during the COVID-19 pandemic may trigger an unsettled mindset in people when they see healthcare workers wearing scrubs in public.

Implications for managers

Nurse managers are key leaders who can bring about sustainable change by seeing the global picture of the processes involved, the personnel responsible, the policies required, the need to monitor the change, the anticipated challenges, the impact on quality, and the fiscal burden. Managers can be instrumental in advocating for change at different levels involving other stakeholders. Table 1 presents some areas where managers can initiate change and possible challenges they can expect. With the lack of evidence on transmission of organisms from scrubs to patients or the public, more research is needed in this area to build a body of evidence for the need to provide hospital-issued scrubs.^24,25

Nurse managers can explore the cost and feasibility of laundering scrubs in the hospital. Managers can involve the librarian to examine the evidence for contamination of scrubs, the impact of fabric on infection transmission, and ideal laundering practices. A hospital laundering policy can trigger several issues, such as handling, stocking, missing scrubs, and collection of dirty/used scrubs. The cost associated with used linen handling may be a barrier for effective implementation. Moore reported that 2% of hospital budget may be laundry-related and this doesn't involve scrubs.²⁶ Sanchez described the multiple factors that can impact the charges associated with laundry.²⁷ Although these authors limited their cost assessment to the laundry process itself, Lopes and colleagues went beyond the operational and personnel cost, analyzing the biologic, physical, ergonomic, and chemical hazards and accidents associated with hospital laundry and challenging leadership to address these issues.²⁸ Additional problems associated with laundering scrubs in the hospital may be related to having space for changing scrubs. A space with proper privacy where staff members can change and place their personal clothes in a secure area must be provided.

Nurse managers should have baseline information on a variety of aspects relating to hospital-issued scrubs, such as stocks, frequency of use, change in expense, and change in infection rates or patient satisfaction. Research is essential to evaluate the risks and benefits of providing hospital-issued scrubs. In times of distress such as COVID-19, staff support and safety are integral to maintain morale and prevent attrition. Managers of ICUs for critically ill and vulnerable patients may have additional challenges. Overall, nurse managers must work closely with leadership in departments such as infection control, quality improvement, risk management, human resources, administration, finance, and housekeeping. Based on the available evidence, each organization or unit is responsible for developing and implementing policies to suit their unique needs.

Although decisions regarding scrubs may occur at different levels of administration, nurse managers should make sure that systems are in place to prevent transmission of pathogens. Nurse managers have administrative, educational, budget, and staff management responsibilities and through all these aspects can influence change. A list of potential steps can be found in Table 2. Developing sustainable policies is important for successful implementation and compliance. It may be ideal for leaders of professional organizations to come together to develop policies regarding scrubs, so nurses can feel safe at work and on their commute.

Looking to the future

Scrubs are an important and convenient part of the daily life of a nurse. Although the use of scrubs used to be confined to the OR, currently all disciplines and most patient care areas use scrubs. They may even be considered a symbol of excellence, such as when a Magnet^®-recognized hospital designates one color of scrubs for the entire nursing staff. The COVID-19 pandemic may be a trigger for professional organizations to consider recommendations regarding scrubs for general use outside of the OR. This is an opportunity for nurse managers to review dress code policies to ensure the safety of patients and healthcare workers alike. There are also opportunities for research on different aspects of scrubs, including the type of material, contamination in relation to the duration of use, laundering efficacy and cost, and the use of scrubs in public places. Managers are key personnel in this ongoing dialogue to conduct research, develop evidence-based guidelines, and implement sustainable practice change.

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