What color uniform should paramedics wear?

New Orleans EMS personnel wear navy blue shirts and pants with white lettering. Acadian Ambulance services a number of neighboring parishes; they wear light green tops and dark green pants. One thousand miles north of New Orleans and up-river, Hennepin EMS (Minn.) paramedics wear light brown shirts and dark brown pants. Bell Ambulance paramedics in Milwaukee wear a light blue shirt and navy pants while Gold Cross (Wis.) paramedics wear a white shirt over black pants.

Because of the variety in EMS uniforms, as well as some being very distinct and others being very similar from law enforcement, it is worth considering the impact of uniform color on patient interactions and EMS provider safety. Here is what we know about uniforms, the role uniform color plays in police-public interactions, and what, if anything, EMS can do with this knowledge.

Uniform power

That uniforms confer a power or status to the wearer is not an unknown concept [1]. In health care, physicians have been outwardly proclaiming their rank and stature via white coats for well over a century [2]. This use of white to convey authority also seems to have transferred to nursing. Regardless of age, patients judge a nurse as more professional when they are wearing all white [3].

Starting in the 1980s, hypotheses around the power of the police officers uniform began to be tested. Unsurprisingly, police officers in uniform were rated as more competent, intelligent, helpful and reliable [4].

A 2005 study showed that color matters. When compared to white/black, light blue/navy and khaki/khaki combinations, all black uniforms "evoke negative impressions from the citizen, producing negative attributions that the officer must overcome through behaviors" [5].

Although all navy uniforms were not tested in this experiment, many EMS organizations use a dark navy color scheme instead of white or light blue shirts. It would not be inappropriate to hypothesize that darker uniforms could force prehospital providers to overcome similar negative attributions faced by police officers wearing all black.

However, when comparing the actual level of aggression against police officers wearing different color uniforms, color does not matter. Specifically, officers wearing darker uniforms were not exposed to more violence compared to their light-uniform wearing counterparts when controlling for community contextual variables [6].

Uniform as a source of harm

Some EMS providers worry they look too much like other members of public safety. While EMS is just as dangerous as fire or police, the majority of line of duty deaths and long-term disability does not come at the hands of patients or bystanders.

EMS providers are at greatest risk of death from motor vehicle collisions [7]. The most common nonfatal injury diagnoses are sprains and strains, something that increasingly out of shape providers may be facilitating [7]. Although untested, mental health issues likely contribute heavilty to both death and disability within EMS.

Any decision to change uniforms for the safety of providers must consider these actual risks and must prioritize the types of changes that will increase protections such as reflective vests, enforcing seat belt adherence, stab vests and even ambulance redesign.

To argue that EMS is simply caught in the crossfire and would not have been harmed had they been wearing less "police-like" uniforms in Boston, Illinois, Maine and Detroit is a short-sighted argument that twists the reality of those events.

Those still concerned with the well-being of providers that may be mistaken for other arms of public safety should consider implementing, and enforcing, protocols such as ensuring police presence on potentially dangerous scenes or training providers in proven de-escalation techniques [8].

Patient safety and uniforms

While the primary purpose of this article was to discuss provider safety as it relates to uniform design, it would be careless to forgo any mention of the threat provider uniforms pose to patients. A 2016 Ohio study showed that EMS providers had a ten-fold increased risk of testing positive for methicillin-resistant Staphylococcus aureus (MRSA) colonies when they didn’t wash their hands after removing their gloves [9]. And while every provider knows they should wash their hands, according to a 2014 study, just over one-in-four in the prehospital setting manage to actually perform such a task [10].

So if providers are only washing their hands between 25 percent of patients, how often do they sanitize their boots, belt, stethoscope and radio between calls" Let alone between shifts" Per a 2011 study in Infection Control and Hospital Epidemiology, it takes water temperatures over 140F, or the "hot" setting on most domestic machines, for 10 minutes to decontaminate uniforms of MRSA [11].

Does every provider wash his or her uniform on the hot setting after each shift"

Applying systems thinking to uniform selection

If an EMS agency is making a change to their uniforms, they must apply the same systematic logic that is a standard practice for implementing new protocols or making a capital expenditure. Uniforms are part of the first impression the community will have on the responding crew. They must represent the importance of that role.

In some communities, simple changes like a new shirt color or reflective wording may provide more of a benefit than a complete overhaul. In other communities, the most value occurs in ensuring providers are appropriately labeled and that only providers which have received adequate training are put in situations where their attire could cause confusion over "which team" they are on.

Uniforms serve as not only a marker of rank and skill, but also act as method for communicating directly with the community [1]. As such, we must choose our words and colors wisely.

References
1. Hertz, C. (2007). The Uniform: As Material, As Symbol, As Negotiated Object. Midwestern Folklore, 32(1, 2): 43-56.

2. Hochberg M.S. (2007). The Doctor's White Coat — a Historical Perspective. AMA Journal of Ethics, 9(4): 310-314.

3. Albert, N.M., Wocial, L., Meyer, K.H., Na, J., Trochelman, K. (2008). Impact of nurses' uniforms on patient and family perceptions of nurse professionalism. Applied Nursing Research, 21(4): 181-190.

4. Singer, M.S., Singer, A.E. (1985). The Effect of Police Uniform on Interpersonal Perception. The Journal of Psychology: Interdisciplinary and Applied, 119(2): 157-161.

5. Johnson, R.R. (2005). Police uniform color and citizen impression formation. Journal of Police and Criminal Psychology, 20(2): 58-66.

6. Johnson, R.R. (2013). An Examination of Police Department Uniform Color and Police–Citizen Aggression. Criminal Justice and Behavior, 40(2): 228-244.

7. Reichard, A.A., Marsh, S.M., Moore, P.H. (2011). Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehospital Emergency Care, 15(4): 511-517.

8. Compton, M.T., Bakeman, R., Broussard, B., Hankerson-Dyson, D., Husbands, L., Krishan, S., …Watson, A.C. (2014). The Police-Based Crisis Intervention Team (CIT) Model: II. Effects on Level of Force and Resolution, Referral, and Arrest. Psychiatric Services, 65(4): 523-529.

9. Orellana, R.C., Hoet, A.E., Bell, C., Kelley, C., Lu, B., Anderson, S.E., Stevenson, K.B. (2016). Methicillin-resistant Staphylococcus aureus in Ohio EMS Providers: A Statewide Cross-sectional Study. Prehospital Emergency Care, 20(2): 184-190.

10. Bledsoe, B.E., Sweeney, R.J., Berkeley, R.P., Cole, K.T., Forred, W.J., Johnson, L.D. (2014). EMS provider compliance with infection control recommendations is suboptimal. Prehospital Emergency Care, 18(2): 290-294.

11. Lakdawala, N., Pham, J., Shah, M., & Holton, J. (2011). Effectiveness of Low-Temperature Domestic Laundry on the Decontamination of Healthcare Workers’ Uniforms. Infection Control and Hospital Epidemiology, 32(11): 1103-1108.

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