Professional Dress vs. Employee Diversity: Patient Perceptions of Visible Tattoos and Facial Piercings

Purpose:

Nurses are expected to dress in a professional manner.  One aspect of professionalism includes dress and grooming. Many changes have occurred over the last several years in dress and grooming standards for nurses. Nurses no longer wear caps and all white uniforms and there is a trend towards more casual attire. Other issues, such as the presence of visible tattoos and facial piercings for direct care providers have become more prevalent resulting in dilemmas for human resource and nursing managers. Despite this, few studies have investigated patient, family and nurses perceptions of visible tattoos and facial piercings and how these new trends impact the nurse-patient relationship. More research is needed in this area, specifically related to newer trends such as visible tattoos and facial piercings and their impact on patient safety.  The purpose of this study was to explore the perceptions of patients, family/visitors and nurses of visible tattoos and facial piercings in health care workers.

Methods:

A descriptive survey design using a convenience sample of employees, patients and families/visitors at three hospitals in the western United States serving a large geographical area of rural inhabitants. Institutional review board approval was received and completion of the survey was considered consent. The survey contained a total of 20 quantitative items plus demographics and two qualitative questions.  This study examined 10 items about professional attire that were based upon literature review, expert opinion and goals of the hospital. Respondents indicated their agreement on a Likert-type scale (1 = strongly disagree; 5 = strongly agree; 0 = no opinion).  The demographic questions included age, education, ethnicity and presence of a tattoo or facial piercings.  Two open ended questions asked respondents to ‘describe the characteristics of nurses who are professionally dressed’ and ‘describe the characteristics of nurses whose dress and appearance is unprofessional’.  

A hard copy of the survey was distributed to all waiting areas.  Family members and visitors present in the waiting area were approached and given a copy of the survey.  Blank copies of the survey were also left in the waiting area with the volunteer staff to encourage participation.  Completed surveys were collected at the end of the day.  Patients were approached in their inpatient room and service areas (radiology, outpatient services, and Emergency room) and given a copy of the survey.  Completed surveys were folded and sealed to be picked up a few hours later.  A copy of the survey was distributed to all areas of the hospital (inpatient and outpatient) where nursing staff were present. Nurses were instructed to fold and seal completed surveys and they were picked up before the end of the shift. The survey took approximately 10 minutes to complete. It has a Flesh Kincaid reading level of 8.0.  Results were anonymous. 

Descriptive statistics were conducted.  One item, ‘it makes me uncomfortable when my nurse has a visible tattoo’ was not normally distributed.  Log10 transformation was completed and no significant change to the results were identified. The open ended questions were analyzed using a thematic analysis by two researchers independently and then compared for rigor.  Mean and standard deviation scores are reported by respondent type (patient, family/visitor, nurse) and stratified by presence of tattoo or piercings.  Scores are also reported by level of education and ethnicity. 

Results: 

All respondents agreed that the nurses dressed professionally (4.2 out of 5).  Most also agreed that they could distinguish nurses from other professions (M = 3.5-3.7) and respondents reported that nursing appearance was important (M = 3.5-3.7). Respondents also indicated that they felt safe when nurses were dressed professionally (M = 3.3-3.5).  Not surprisingly, nurses cared more about the color and style of the uniforms than patients and families.  

Respondents were more likely to agree that facial piercings were not acceptable (M= 3.8-4.2) and excessive jewelry should not be worn (M = 2.6-3.8). However, visible tattoos and artificial nails seemed less objectionable (M = 2.7-3.1 and 2.5- 3.0 respectively). The qualitative analysis revealed that in addition to other themes (reported elsewhere) visible tattoos and facial piercings were common descriptors of unprofessional dress.  These themes were found in both patient and nurses responses.

Respondents who reported they had piercings and tattoos were more likely to report that facial piercings were acceptable compared to those without piercings and tattoos (2.1 and 1.7) and were more comfortable with nurses who had visible tattoos (3.5 and 2.7 respectively). 

Bivariate analysis revealed that patient age was moderately significant positive relationships and tattoos, feeling safe and importance of professional dress (.404, .343 and .433 respectively).

Conclusion:

Professionalism in nursing has been widely debated. There is a delicate balance between professionalism, tolerance for diversity and patient centered care. With an increasing diversity of the workforce, it is important to understand patients’ perceptions of facial piercings and tattoos. This study identified that patients, families and nurses value professional dress and it makes them feel safe.  The study also identified that facial piercings and tattoos were not considered professional for healthcare professions.  This finding was more prevalent in older subjects and those who did not have piercings and tattoos. More research on professional dress is needed in more diverse populations.