Westerfield, Heather V. MSN, RN, CMSRN; Stafford, Amy B. MSN, RN, CMSRN; Speroni, Karen Gabel PhD, RN; Daniel, Marlon G. MHA, MPH
Tattooing has become increasingly popular among all ages, occupations, and social classes.1 With the increasing number of individuals in the workforce electing to have tattoos and/or body piercings, hospital administrators must decide what policies to set forth supporting a professional environment. Literature on the perceptions of visible tattoos and body piercings on healthcare professionals including nurses is limited based on a search of articles dated 1988-2011, in PubMed, EBSCO host, PROQUEST, and the Cochrane Library using the following search terms: nurse, nursing care and body piercing, tattoo, patient satisfaction, perception of care, dress code. A recent study did report that many hospitals had no rationale or reference supporting policies addressing body art.2 Research conducted in the general population on perceptions of college students with tattoos and body piercing showed that having a tattoo hindered interpersonal perceptions.3 These perceptions included physical appearance, such as attractiveness, and personality traits, such as caring. The presence of a tattoo has been reported to diminish image and credibility.4 Patients have reported viewing facial piercing among physicians as inappropriate and negatively affecting perceived competence and trustworthiness.5
Research is warranted to evaluate patients’ perceptions of patient care providers with visible tattoos and/or body piercings. For purposes of this study, body piercing is defined as a piercing of the body anywhere other than the earlobes. Outcomes should be considered by hospital administrators in the development or revision of policies addressing visible tattoos and/or body piercings among healthcare workers.
About the Study
The study purpose was to explore patients’ perceptions of patient care providers with visible tattoos and/or body piercings. The hypothesis of this study was that patients would have a lower overall perception of patient care providers who had visible tattoos and/or body piercings. A modified version of the nurse image scale was used.6 The modified survey is referred to as the Tattoo and Body Piercing Patient Research Study Questionnaire. Content validity was conducted on the modified version of the instrument. Members of the Nursing Research Council of the healthcare system where the research was conducted evaluated the relevance and clarity of the questionnaire. Items were retained if at least 80% agreement occurred among the members regarding the relevance and clarity of an individual item. The content validity index of the final survey was 1.0.
This was a cross-sectional, computerized survey research study using computer-assisted self-interviewing on 150 patients hospitalized in a rural community hospital in the mid-Atlantic region. This study received institutional review board approval. Patients included in the study were 18 years or older and able to communicate in English and provide informed consent. Patients were excluded if they were in isolation because of infection control, or if they had an acute neurological or psychological deficit altering their ability to complete the survey.
A laptop, loaded with Snap Survey version 10 (Snap Surveys, Portsmouth, New Hampshire), was provided to patients eligible for the survey. After informed consent was obtained, patients were shown color pictures on the computer screen and were asked to provide survey responses by picture type (See Figures, Supplemental Digital Content 1, http://links.lww.com/JONA/A70 and Supplemental Digital Content 2, http://links.lww.com/JONA/A71). Four sets of pictures of male and female patient care providers dressed in uniforms (scrubs) were shown to patients via computer as follows: 1 male with a tattoo of the upper arm and 1 without; 1 female with a tattoo of the upper arm and 1 without; 1 male with a piercing of the eyebrow and 1 without; and 1 female with a piercing of the nose and 1 without. For each of the 4 picture sets, patients were asked to provide survey responses via computer specifying which patient care provider looked the most caring, confident, reliable, attentive, cooperative, professional, efficient, and approachable. Definitions of these concepts were provided to patients participating in the survey (Figure 1).
The sample size of 150 was based on an effect size of 0.85 to detect perceived differences by patients of patient care provider characteristics associated with having tattoos and body piercings, at an 80% power and α of .05.7 Means and frequencies were used to describe the sample and responses of the participants. To ascertain differences between groups (ie, age categories, gender) and response categories (including bivariable associations), exact χ2 methods were used. In instances of multiple comparisons, Bonferroni adjustments were incorporated. Analysis was completed using SAS version 9.2 (SAS Institute, Cary, North Carolina).
Of the 150 patients providing survey responses, the majority was female (68%, n = 102), white (77%, n = 116), and 46 years or older (72%, n = 108). Twenty-two percent responded that they had a permanent tattoo, of which half were visible when clothed. Only 6% (n = 9) indicated body piercings other than the earlobe, of which 44% (n = 4) were visible when clothed.
When patients evaluated pictures of a male patient care provider dressed in uniform with and without visible tattoos, the majority perceived no differences in caring (71%, n = 106), confidence (65%, n = 98), reliability (66%, n = 99), attentiveness (71%, n = 107), cooperativeness (69%, n = 104), professionalism (69%, n = 103), efficiency (69%, n = 103), and approachability (63% n = 95) (Table 1). The tattooed male was never perceived to be more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable than his nontattooed counterpart. Similar findings were demonstrated for female patient care providers with 1 exception (Table 2). Regarding perception of professionalism, the majority viewed the female patient care provider dressed in uniform without a tattoo as more professional (Table 2). Perspectives of professionalism significantly differed between male and female providers regarding tattoos, with patients specifying a lower perception of professionalism regarding tattooed female providers (P < .0001). The characteristic of professionalism when analyzed for patient care provider by gender and tattoo status was not significantly different according to patient gender.
Perceptions were less favorable regarding visible body piercings, other than the ear lobe, as compared with visible tattoos. For male patient care providers dressed in uniform with a visible body piercing, the majority of patients perceived no differences in caring (53%, n = 79), confidence (51%, n = 76), reliability (51%, n = 76), attentiveness (50%, n = 75), cooperativeness (51%, n = 76), and efficiency (51%, n = 76) (Table 3). Of note, the male with a visible body piercing was perceived to be less professional and approachable. As with the tattoo findings, the male with the body piercing was never perceived to be more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable than his nonpierced counterpart.
Participants’ perceptions were less favorable for female patient care providers dressed in uniform with a visible body piercing than for their male counterparts. The majority perceived no difference for only 3 characteristics: caring (51%, n = 77), attentiveness (52%, n = 78), and cooperativeness (51%, n= 77) (Table 4). Similarly, the visibly pierced female provider was not perceived to be more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable. Females without visible body piercings were considered to be more confident (50%, n = 75), professional (70%, n = 105), efficient (51%, n = 76), and approachable (55%, n = 82) than pierced female patient care providers (Table 4).
Study results suggest male and female patient care providers dressed in uniform with visible tattoos and/or nonearlobe body piercings are never perceived by patients to be more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable than their non–visibly tattooed or nonpierced peers. Because of lack of literature on patients’ perceptions of healthcare providers with visible tattoos and body piercings, this research was warranted and can be used to help guide nursing administrators regarding policy development and/or revision.
A limitation to the study is that patient perceptions may vary by other types of tattoo or body piercings than those shown in the study pictures to the study participants. Although the tattoos in this study were similar for males and females, the body piercings differed. To standardize perceptions, this survey research study was electronically based, and patients viewed pictures of patient care providers in uniform with and without tattoos or body piercings. Patients viewing patient care providers in person may result in differing patient perceptions on the characteristics evaluated in this research. An additional limitation is that the study was conducted in 1 site and should be replicated in various care settings and organizations. The rural setting of the organization in the mid-Atlantic region of the United States may have an impact on generalizability of findings as well.
Additional research is recommended using a prospective design in which patient care providers dressed in uniform with various visible tattoos and body piercings can be viewed in person by patients. Additional research is recommended in other hospital settings to negate the effect of cultural norms on findings as well.
Results of this study suggest that male and female patient care providers dressed in uniform with visible tattoos and/or nonearlobe body piercings are not perceived by patients to be more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable than their counterparts without visible tattoos or piercings. Gender bias may be a factor in regard to female providers with visible tattoos, as patients perceived them to be less professional than their male counterpart with a similar tattoo. Also, female patient care providers with visible nonearlobe body piercings are perceived by patients to be less confident, professional, efficient, and approachable than females with no body piercings. Nursing administrators should evaluate policies and practices regarding patient care providers displaying visible tattoos and/or body piercings while providing patient care.
The research team thanks Lois Sanger, MLS, Librarian, and also the Nursing Research Council for their support in verifying the content validity of the survey instrument.
© 2012 Lippincott Williams & Wilkins, Inc.