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Tattoos in Nursing

Do We Practice What We Preach?

Williams, Barbara Miller; Wright, Cindy; Leigh, Katherine H.; Armstrong, Brittney; Kelley, Sabrina

doi: 10.1097/CNJ.0000000000000496
Feature: education/practice

ABSTRACT: Tattoos have become increasingly popular in the United States among the general population. Furthermore, the popularity of body art, primarily tattoos, among nursing students generates issues about professionalism in academics and in clinical settings. Nursing faculty are faced with conflicting views on cultural awareness, professionalism, and self-expression. With nursing viewed as one of the most trusted professions, the policy of covering tattoos should be discussed, and more research is necessary.

Barbara Miller Williams, PhD, RN, is an assistant professor at Troy University's School of Nursing, Dothan, Alabama.

Cindy Wright, DNP, RN, is a nurse practitioner in Columbus, Georgia.

Katherine Leigh, DNP, RN, is an associate professor at Troy University.

Brittney Armstrong, DNP, RN, is an assistant professor at Troy University.

Sabrina Kelley, DNP, RN, is a family nurse practitioner and assistant professor at Troy University.

Accepted by peer-review 5/24/2017.

Published Ahead of Print on March 15, 2018

The authors declare no conflict of interest.

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As nurses and nurse educators, do we practice what we preach? When it comes to tattoos and acceptance of others, are we teaching one and doing the other? Most nursing programs require students to cover tattoos in clinical settings, yet educators also encourage students to exhibit nonjudgmental attitudes when providing patient care. Simply covering a tattoo with a bandage may seem like a plausible solution; however, a covering may raise more questions and concerns, not only among healthcare professionals but also among the patient population. In addition, nursing students need to have self-awareness. They will possess their own value system, but they must demonstrate acceptance of patients' life choices, regardless of contradictory beliefs. Although some tattoos are highly visible, generational perceptions are diverse, with some viewing tattoos as taboo. Tattooing, a form of body art, is increasingly popular in the United States, especially in young adults. A 2017 Pew Research Center study noted 38% of people ages 18 to 29 have at least one tattoo (USA Today, 2017). Given these statistics, this is an important topic to consider and discuss in nursing programs and healthcare facilities.

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NURSING SCHOOL VIEWS ON STUDENT TATTOOS

The negative stereotypical views associated with tattoos in society may diminish freedom of expression (Wittmann-Price, Gittings, & Collins, 2012). Nurses' and nursing students' decisions to be tattooed may be seen as a form of personal expression; however, when electing to attend a school of nursing, their freedom of expression may be censured.

To be in compliance with professional dress code, many healthcare organizations prohibit the exposure of body art, tattoos, and multiple piercings. Many policies require the employee to cover tattoos completely (Wittmann-Price et al., 2012). In reviewing schools of nursing dress code policies, many schools follow the body art and piercing policies of their affiliated clinical facilities, requiring students to cover visible tattoos and remove excess piercings (Florida State University, 2018; University of Texas, 2014 ; Wittmann-Price et al., 2012).

Students are taught to respect the differences of patients, whether cultural, religious, or personal beliefs. As noted, body art or tattoos are often seen as a form of self-expression. Do we have a double standard by not allowing nursing students to display their tattoos, while teaching tolerance of patients' diverse lifestyle choices?

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CULTURAL AWARENESS WITH PATIENTS

Our patients' trust and satisfaction are essential goals for healthcare. As nurses, we must consider and accept differences among patients when providing unbiased care. Although tattoos have been gaining in popularity in recent years, tattoos or other body art have been previously associated with stereotypes and risky behaviors (Schmid, 2013). Therefore, some people may view others with large or eye-catching tattoos with some ambivalence and distrust.

Westerfield, Stafford, Speroni, and Daniel (2012) reported on patients' perceptions of tattoos or body piercings. Their study had 150 hospitalized adult patient participants, who compared pictures of female and male providers with tattoos and body piercings, along with providers who did not have body art. Results revealed that patients perceived no difference between tattooed or pierced providers in caring, confidence, reliability, attentiveness, cooperativeness, professionalism, efficiency, or approachability. However, female providers with tattoos were viewed as less professional than the male providers who had similar tattoos. The study had limitations; it is obvious that more research is needed.

Credibility and competence are necessary for nursing students and nurses during patient encounters. Currently, most clinical areas require nurses to cover their tattoos in some fashion to present a more professional appearance. However, this is potentially encroaching on self-expression. Body art advocates may feel this practice denies a person's right to expression and may make this person feel like they are being judged on appearance (Ellis, 2015). Cultural awareness is a two-way street, and as nurse educators, we may need to consider all aspects of personal expression, professionalism, and patient acceptance, when developing or revising student dress code policies.

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PROFESSIONALISM IN NURSING

Nursing is an exceedingly inspiring and challenging profession. A positive image is essential to being a nurse. This is perceived differently across the profession. The nurse spends time with patients, families, managers, and the public. By portraying a positive image in all aspects of one's life, beginning with nursing school and continuing throughout a nursing career, nurses can work together to continue advancing the nursing profession. Nursing has often been regarded as the most trustworthy profession, and trust is deemed a necessary component of professionalism (Olshansky, 2011).

Professionalism, a multidimensional concept, is a crucial feature of professional occupations. The dynamic nature and the countless interpretations of this term lead to many definitions of the concept. Understanding professionalism's characteristics, antecedents, and its consequences can lead to promotion of a higher status of nursing and the importance and application of this concept to the nursing profession (Ghadirian, Salsali, & Cheraghi, 2014). Nursing is an occupation in which the role of the nurse is discussed and modeled by nursing professors, who believe the profession should be considered a highly trusting and specialized field of study and that they should be role models in the healthcare facilities and community (Thomas et al., 2010). Professionalism is an attribute that emphasizes personal integrity and honesty; it involves the ability to count on someone or something, and it is essential to a healthy society. By maintaining a professional image, a sense of trust of the nurse is nurtured in the patient and in society (Olshansky, 2011). Nurses believe professional image means more than just personal appearance; it involves effective communication skills and a professional attitude, as well, but the image of a nurse should exude self-esteem, self-worth, self-confidence, and pride. Therefore, alterations with tattoos may affect personal appearance, but the changes do not affect attributes related to professionalism. See sidebar: To Tatt or Not to Tatt? Nurses Respond for feedback on tattoos from healthcare professionals.

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RELIGIOUS IMPLICATIONS

Due to potential religious implications, Christian nurses may wish to consider biblical history. Some wonder if having a tattoo is a sin. Scripture addresses the topic. One Old Testament teaching states: “You shall not make any cuts in your body for the dead nor make any tattoo marks on yourselves: I am the LORD” (Leviticus 19:28, NASB). According to Jamieson, Fausset, and Brown (2009), this passage refers to God speaking of his covenant with the people of Israel. He is specifically telling them to stay far from the religious practices of the surrounding peoples. The prohibited religious practice reference is in regard to cutting or marking the body for dead relatives. The markings were considered a sign of respect for the dead, as well as a sort of propitiatory offering to the deities who presided over death and the grave. Tattooing, imprinting figures of flowers, leaves, stars, and other designs on parts of the body, was forbidden during that time.

However, this verse offers another perspective. “But the LORD said to Samuel, ‘Do not look at his appearance or at the height of his stature, because I have rejected him; for God sees not as man sees, for man looks at the outward appearance but the LORD looks at the heart’” (1 Samuel 16:7, NASB).

The New Testament also references the body. Jesus is recorded as saying, “Do not judge according to appearance, but judge with righteous judgment” (John 7:24) and “Do not judge so you will not be judged” (Matthew 7:1). It seems we are to accept others for who they are, look at the intent of a person's heart, not appearance. That applies to the person being cared for, as well as those providing the care. If we are to be accepting of others, as nurses and nurse educators, does that not include accepting of our students? How does this play out practically when, as nurse educators, we also must consider how patients view nursing students? Currently, this creates the dilemma of how much tattooing to cover.

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DISCUSSION

With the current explosion of tattoos, those in healthcare need to examine existing standards and policies to reflect current culture. According to Reyes, Hadley, and Davenport (2013), nurses are not as culturally diversified as the general population, with only 10% of registered nurses in the U.S. reporting minority status. Regional differences also exist–in some U.S. states, tattoos are more common, with fewer negative connotations. If one uses this data to consider awareness of diversity and cultural competence, healthcare professionals must deliberate about cultural barriers that may exist between nursing administrators, nursing faculty, nurses, and patients, and how effective change can occur. A call to action by professional nursing organizations for setting precedence on permitted visibility of tattoos can lead the charge for addressing diversity.

Some proposed solutions could be establishing committees for new policies or revisions, allowing visible, discreet, or nonoffensive tattoos, and patient education on individual and cultural diversity. More research is needed to understand patient perceptions, motivations for getting tattoos, workplace solutions, and discriminatory effects. Achieving a balance between personal expression and professionalism may be a beginning for both nursing students and nurses. Ultimately, change begins with tolerance for diversity so as nursing professionals, we exemplify complete acceptance and consistency by practicing what we preach.

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To Tatt or Not to Tatt? Nurses Respond

Using social media, JCN editors asked: What is your opinion about tattoos in the nursing profession? JCN wants your feedback. What restrictions are faced in nursing school or the workplace? What have clients said when they've seen a tattoo?

Nursing students, nurses, educators, and healthcare professionals replied. All responses were supportive in nature; no opposing views were posted.

  • In nursing school clinicals, I had to cover a small (golf ball sized) tattoo of a cross with a band aid.—Age 30, RN, Minnesota
  • My employer allows visible tattoos, as long as they aren't offensive.—Age 40, RN, Michigan
  • I have three visible tattoos on my wrists/arm. They have allowed me to connect with patients when I worked in chemical dependency and mental health. They've offered worried patients distraction, when they've ask about them. They've been ice breakers. Sure, they don't please everyone, but that's okay. They've been more help than harm by far.—Age 25, RN, Minnesota
  • I have a tattoo behind my ear of pink ribbon, with stars surrounding it. During nursing school, and one of my previous jobs, I was asked to cover it. My current unit manager does not mind. Most patients are curious; I get to share my story of family members who have been affected by cancer. I see it as a representation, honor, and expression of my personality. However, I've had previous experiences where I have been judged for having an ear/neck tatt, to the point where I was written up when my covering makeup smudged, and it became somewhat visible. Tattoos do not get in the way of my quality of care. No one should be judged on them.—Age 26, RN, oncology, Florida
  • My tattoos do not prevent me from caring for my patients. I have three visible ones; however, two are white and rarely noticed. The other has opened dialog and created a connection with some patients. I have been through one level of nursing school without a tatt, and one level with tattoos; however, these were white ones and unnoticed. Covering them would have called more attention to them. I also think it depends on the area and shift you work...certain areas and shifts, if not necessarily accepted, definitely are not as restrictive.—Age 40, RN, labor and delivery and emergency department, Oklahoma
  • At times, tatts have been a pathway of connection—teens and young moms I've encountered have been curious and asked. After talking about my tattoos, patients seem to feel a little more comfortable—like I'm also human—and that their humanity can be entrusted with me.—Age 40, RN, pediatric epilepsy, Missouri
  • My tattoos have never prevented me from saving a life. My employer doesn't allow visible tattoos. This policy also applied in the nursing school I attended. Many families I've encountered seemed more intrigued than repulsed. Oftentimes, the coverings used to hide the tattoos draw more attention to them, which sparks a conversation. I hope one day they will be more widely accepted, and employers change their policies to reflect the period in which we live.—Age 34, RN, pediatric intensive care, South Carolina
  • No visible tattoos are allowed, per the uniform code, at the college where I teach. Students have to cover with makeup if in a body area not covered by the uniform. An enterprising student realized his tattoo could be covered by a watchband. I was fine with that because the tattoo was no longer visible. Also, students have the option to wear a long-sleeve compression shirt under their scrub tops. Students with tattoos on forearms tend to wear those when in clinical.—Age 52, emergency department, nursing instructor, Mississippi
  • I had an attending ask my patient how she felt about my appearance. The patient replied, “I am a Christian woman, and I don't believe in judging people based on their appearance. We all have a right to express our individuality. All I care about is that my provider is competent and has my best interest in mind. If she can do that with tattoos and piercings, then she has every right to have them.”—Age 26, physician's assistant, Tennessee
  • As a profession, we need to move forward in supporting each other as professionals and consider ways to integrate changes in policies at the speed the profession will allow. To date, the American Nurses Association and the National Student Nurses Association have not set a precedent for changing, or addressing tattoos and piercings.—Age 60, JCN reviewer, PhD, RN, Indiana
Ellis A. D. (2015). A picture is worth one thousand words: Body art in the workplace. Employee Responsibilities & Rights Journal, 27(2), 101–113. doi:10.1007/s10672-014-9254-1
Florida State University College of Nursing. (2016). Undergraduate student handbook 2018-2019. Retrieved from https://nursing.fsu.edu/sites/g/files/upcbnu411/files/pdf-files/BSN/2018-2019%20Undergrad%20Handbook.pdf
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    Jamieson R., Fausset A. R., Brown D. (2009). Commentary critical & explanatory on the whole Bible. Christian Classics Ethereal Library; 2.0 edition.
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    University of Texas. (2014). Policy title: Student attire for clinical settings. Retrieved from https://nursing.uth.edu/acaddept/academicaffairs/documents/bsnpolicies/u4860.pdf
    Newman M. (2017, September 20). Report: More young people have tattoos and piercings than ever before. USA Today Network. Retrieved from https://www.usatoday.com/story/news/nation-now/2017/09/20/young-people-tattoos-and-piercings-report/686360001/
      Westerfield H. V., Stafford A. B., Speroni K. G., Daniel M. G. (2012). Patients' perceptions of patient care providers with tattoos and/or body piercings. The Journal of Nursing Administration, 42(3), 160–164. doi:10.1097/NNA.0b013e31824809d6
      Wittmann-Price R. A., Gittings K. K., Collins K. M. (2012). Nurses and body art: What's your perception? Nursing, 42(6), 62–64. doi:10.1097/01.NURSE.0000414627.23131.0b
      Keywords:

      body art; cultural competence; nursing; nursing education; tattoos

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