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Perceived Professionalism of a Dietitian Is Not Influenced by Attire or White Coat

A Prospective, Randomized Online Study

Tadros, Farah J. BS; Benoit, Teresa H. BS; Folsom, Susannah C. BS; Lim, Charissa M. BS; Tanner, Marty BS; Arbeau, Timothy BS, RPhT; Solch, Rebecca J. BS; Langkamp-Henken, Bobbi PhD, RDN

Author Information
doi: 10.1097/TIN.0000000000000251


STUDIES have examined the relationship between physician dress and perceived characteristics of professionalism.1–3 In 2019, Varnado-Sullivan and others2 examined the impact of physician attire on perceived attributes and found that physicians were thought to be kinder and warmer when not wearing a white coat, especially when paired with professional attire. Additionally, a white coat did not increase perceptions of professionalism. In a large multicenter study of physician dress in the United States, patients gave the highest composite score to photographs of male and female physician models wearing business professional attire (collared shirt and tie or blouse and dress pants) and a white coat versus no white coat or casual attire or scrubs with or without a white coat. The composite score consisted of perceived attributes of being knowledgeable, trustworthy, caring, approachable, and comfortable.3 In a 2015 systematic review of earlier studies, the impact of attire on perceived professionalism of a physician was reported in 7 studies of which 4 found a positive association between business professional attire or white coat and professionalism.1

Personal attributes, which include personal presentation and attire, have been deemed important contributors to overall perceived professionalism of a dietitian; however, few studies have examined this relationship.4,5 Within the profession, dress codes tend to differ based on the workplace and setting of practice. Traditionally, most major health care facilities require business professional attire with a white coat whereas many community agencies and settings allow dietitians to wear very casual attire (eg, khakis and a collared knit shirt).5 More recently, dress code policies in hospitals and clinics have allowed scrubs coordinated by color with a white coat or without a white coat for the various health care providers.6

Although white coats continue to be worn in clinical/health care facilities in the United States, there are grounds for discontinuing this practice. For some patients the presence of a health care provider, most often wearing a white coat, is associated with “white coat syndrome.”7 This syndrome occurs when a patient experiences elevated blood pressure because of the presence of a doctor or other health care provider.7,8 Additionally, research continues to emerge showing an association between wearing a white coat and the risk of transmitting infection, especially in an acute care setting where the coat may be exposed to contaminated body fluids.9,10 In 2007, the United Kingdom National Health Service released a document on uniform and workwear policies in which white coats were no longer recommended during patient care contact, claiming they harbor bacteria that can potentially result in infection.11 Following this ban, the American Medical Association aimed to take similar steps; however, health care providers fought the change since the white coat stood as a sign of accomplishment and professionalism.12,13

Based on the existing differences in dress code and the potential advantages and disadvantages associated with white coats, it was of interest to determine whether patients/clients perceive dietitians differently based on what they are wearing. Individuals might not even be conscious of perceptions and biases related to dress. Confidence, success, and trustworthiness can be judged within 5 seconds of meeting an individual, in which minor manipulations to attire can alter first impressions.14 Attire worn with or without a white coat likely factors into first impressions. This opens the discussion as to how a known cue of first impressions (ie, attire) contributes to the perception of professionalism. Therefore, the primary objective of this study was to determine which form of dress (business professional with a white coat, business professional without a white coat, scrubs with a white coat, or scrubs without a white coat) was seen as the most professional when delivering nutrition information to a patient. Secondary outcomes examined attire, white coat, the interaction between attire and white coat, and participant demographics on scores for total professionalism and subcharacteristics of total professionalism (empathy, competent, approachable, credible, organized, effective, professional, and confident).


Study design and study population

This prospective, randomized study was conducted in the spring of 2020 using an online format where participants viewed 1 of 4 videos and answered questions about professionalism. The questionnaire consisted of 21 questions plus 1 video and directions and took approximately 5 minutes to complete. The questionnaire could only be viewed and completed 1 time from a specific IP address and participants were blinded to the true purpose of the study until they completed the questionnaire. The study protocol was submitted and approved by the University of Florida Institutional Review Board (IRB-02). All study participants provided online informed consent.


Participants were recruited using, a national health volunteer registry that was created by several academic institutions and supported by the US National Institutes of Health as part of the Clinical Translational Science Award program.15 ResearchMatch has a large population of volunteers who have consented to be contacted by researchers about health studies for which they may be eligible. Through ResearchMatch, a total of 41131 individuals were sent the study eligibility criteria and invited to participate. Of these individuals 1168 agreed to be contacted. An email with a link to the online questionnaire was then sent to these individuals.

Recruitment was also done using several Facebook pages and groups. A total of 18 Facebook pages affiliated with the study site and 4 dietitian-focused groups were sent a recruitment image and text to post on their Facebook page. The image and text, which included a link to the questionnaire and research contact information, stated that the questionnaire was for a study on professionalism in the dietitian/nutritionist profession.

Participants were included in the study if they were English-speaking, between the ages of 18 and 85, and currently residing in the United States. Participants who consented to participate but never viewed the randomly assigned video, because they did not meet inclusion criteria or stopped participating before they were randomly assigned to a video, were not included in the study. After viewing a video, participants were further excluded from data analyses if they responded that they knew the dietitian in the video or if they did not complete the entire questionnaire.

Video development

To assess perceptions of professionalism based on attire with or without a white coat, 4 videos were created. Each video featured a young, white, female dietitian wearing 1 of 4 outfits (business professional with a white coat, business professional without a white coat, scrubs with a white coat, or scrubs without a white coat) (Figure 1). A white, female actress was intentionally selected to accurately represent the current demographics of dietitians within the United States (ie, 94% female and 81% white).16 In the videos, the dietitian counsels a patient. The scene is shot from the head of a bed to simulate a hospital setting. The camera shot included a side curtain, a plant, and the feet of the patient under a white sheet. The camera was operated to move as if the patient were responding to the dietitian with head movements. In the videos, the dietitian recites a script discussing iron deficiency and foods that can help restore iron status. The script was based on the 2015-2020 Dietary Guidelines and was reviewed by 2 dietitians affiliated with the study site. The actress had memorized the script but had it available on a clipboard for reference. For quality control, each of the 4 videos was filmed several times to ensure consistency in the script reading. After filming, the videos were edited to improve flow using Adobe Premiere Pro, version 14.0.17 Each video was 1 minute in length, and was tested on multiple devices (computer, iPad, and smartphone) to ensure quality and compatibility with various platforms.

Figure 1.
Figure 1.:
Still images taken from videos of the dietitian in each of the 4 types of dress: business professional with a white coat (A); business professional without a white coat (B); scrubs with a white coat (C); and scrubs without a white coat (D). This figure is available in color online (


An original questionnaire was designed on Qualtrics software, version January 2020, an online program where surveys and questionnaires can be created and shared with multiple people.18 The first page of the questionnaire consisted of an informed consent that included the purpose and description of the study, questionnaire instructions, and participant rights. The stated purpose was to assess perception of dietitian professionalism. The actual purpose of the study (impact of attire) was intentionally not mentioned in the consent form to avoid affecting perception or bias toward appearance but was explained after completion of the questionnaire. After reading the consent form, participants either agreed or disagreed to participate in the research study.

For those who agreed to participate, questions pertaining to the inclusion criteria and demographic data (age, region, education, etc) were displayed. If participants did not meet the inclusion criteria, they were directed to a page thanking them for participating and they were unable to continue. For those who continued on, participants were asked whether they worked or studied in a health field, whether their field of work or study required them to wear professional attire, had they ever received nutrition counseling from a dietitian, and if so, when they had last received the counseling. At this point in the questionnaire, the participants were told to imagine they were in a nutrition consultation with a dietitian. They were then asked to view a randomly assigned video. The videos were directly embedded into the Qualtrics questionnaire and were programed to be randomly displayed on the questionnaires. After watching the video, participants were provided with the definition of a dietitian along with definitions of 8 subcharacteristics of professionalism as defined by Packer and colleagues5: empathetic (sensitive to the feelings, thoughts, and experiences of others), competent (able, capable, qualified, experienced, and skilled), approachable (friendly, agreeable, sociable, and open-minded), credible (reliable, trustworthy, and sincere), organized (prepared, efficient, and structured), effective (productive, useful, valuable, and contributing), professional (expert, polished, practiced, and sharp), and confident (secure, self-assured, and optimistic).5 They were asked to rate the dietitian in the video on each characteristic using a 5-point rating scale. Each characteristic had 5 ratings from which to choose. For example, the ratings for empathy were “empathetic” as the desirable score, followed by “somewhat empathetic,” “neither empathetic nor insensitive,” “somewhat insensitive,” and “insensitive” as the least desirable score.5 The ratings were later rescored with 1 being the least desirable score for the characteristic and 5 being the most desirable. After rating the dietitian on each characteristic, the participants were asked whether they knew the dietitian in the video. Finally, participants were asked what the dietitian in the video was wearing. Then the true purpose of the study was explained. Participants were unable to go back to previous questions and change their answers.

Sample size

Based on a previous study, an initial convenience sample of 250 was obtained.5 The study was then paused to estimate a final sample size based on collected data. Based on these data, it was determined that a total of 488 participants would be needed to observe a mean difference ± SD of 0.25 ± 0.587 in the total professionalism score between the 4 different levels assuming power of 0.80 and .05 α. This would provide an effect size of 0.43. Based on initial study completion rates, it was determined that an additional 100 participants or 588 total participants would be required to obtain the required sample size of 488. Investigators were blinded to the intervention when the sample size was calculated, and this method of determining sample size was approved by the Institutional Review Board prior to starting the study and then again when the new sample size was requested.

Statistical analysis

Data from participants who completed all questions and did not know the dietitian were analyzed. The total professionalism score (primary outcome) represents the mean score of the 8 subcharacteristics: empathy, competent, approachable, credible, organized, effective, professional, and confident, with a score of 5 representing the most desirable total professionalism score. Cronbach's α for the 8 subcharacteristics included in the total professionalism score was 0.87. To determine the effect of attire and white coat, total professionalism scores were square root (5-x) transformed and analyzed using a 2-way analysis of variance. To test the effect of attire, white coat, the interaction between attire and white coat, and participant demographics on total professionalism and subcharacteristic scores (secondary outcomes), a general linear regression model was used. Prior to analysis, a Pearson correlation was used to determine whether any demographic characteristics were correlated with each other. Work or study in a health profession and work or study in a field requiring professional attire were significantly correlated (r = 0.39, P < .001). Work or study in a field requiring professional attire was chosen to remain in the model, as authors believed this characteristic would adequately capture those who work or study in a health profession. The final model included attire, white coat, the interaction of white coat and attire, age, sex, region of the United States, ethnicity, race, education, work or study in a field requiring professional attire, and whether they had ever received dietary counseling. Post hoc tests with the use of Tukey's honestly significant difference test for multiple comparisons were conducted on outcomes that had significant effects. All data were checked for normality and homogeneity of variances. Demographic differences between groups were compared using the χ2 test. Participant demographics are described as counts with percentages and continuous data are reported as means ± standard error. Significance was denoted as P ≤ .05. Statistical analyses were performed using SigmaPlot, version 14.019; SAS, version 9.420; and SPSS, version 26.21


A total of 522 participants were recruited and randomized into the study between March and May of 2020 (Figure 2). The main reasons participants were excluded from analyses after being randomly assigned to watch 1 of the 4 videos were failure to complete the survey (n = 41) or familiarity with the actress in the survey video (n = 7). A total of 474 participant responses were analyzed. Participants who completed the study were primarily white (86%) and female (77%) from the southern region (45%) of the United States who worked or studied in a profession that required professional dress (55%). There were no statistically significant differences in participant characteristics across the 4 groups.

Figure 2.
Figure 2.:
Flow diagram of participants recruited and randomized online and included (n = 474) and excluded (n = 48) from analyses for the 4 study groups based on attire and white coat.

When the total professional score was examined by attire (professional dress vs scrubs), white coat (with vs without), and the interaction between attire and white coat using a 2-way analysis of variance, no differences in total professionalism scores were observed (P > .05). The mean scores ± standard error of the mean for business professional attire with and without a white coat were 4.46 ± 0.05 (n = 132) and 4.45 ± 0.06 (n = 107), respectively, and the scores for scrubs with and without a white coat were 4.47 ± 0.06 (n = 110) and 4.51 ± 0.05 (n = 125), respectively. Because there was a significant difference between groups in the percentage of participants who correctly recalled what the dietitian was wearing (Table), the 2-way analysis was rerun using data for those who were able to correctly recall the attire and white coat (n = 397). Again, no differences in total professionalism scores were observed (P > .05, see Supplemental Table 1, available at:

Table. - Demographics, Field of Work or Study, Nutrition Counseling, and Recall of Dress of 18- to 85-Year-Old Participants Recruited Online Across the United States From March to May of 2020 to Score Perceived Professionalism of a Dietitian Wearing Business Professional Attire or Scrubs With and Without a White Coat (n = 474)
Scrubs Business Professional Attire
Characteristic No White Coat (n = 125)n (%) White Coat (n = 110)n (%) No White Coat (n = 107)n (%) White Coat (n = 132)n (%) P Valuea
Age group, y .535
18-30 53 (42) 32 (29) 40 (37) 44 (33)
31-50 26 (21) 32 (29) 25 (23) 31 (23)
51-70 40 (32) 36 (33) 32 (30) 43 (33)
71-85 6 (5) 10 (9) 10 (9) 14 (11)
Sex .582
Female 93 (74) 87 (79) 85 (79) 99 (75)
Male 30 (24) 23 (21) 19 (18) 33 (25)
Prefer not to sayb 2 (2) 0 (0) 3 (3) 0 (0)
Regionc .360
Northeast 24 (19) 17 (15) 21 (20) 22 (17)
South 55 (44) 55 (50) 45 (42) 56 (42)
Midwest 24 (19) 17 (15) 16 (15) 35 (27)
West 22 (18) 21 (19) 25 (23) 19 (14)
Ethnicity .112
Hispanic/Latino 7 (6) 13 (12) 6 (6) 6 (5)
Non-Hispanic/non-Latino 118 (94) 97 (88) 101 (94) 126 (95)
Race .130
White 103 (82) 102 (93) 91 (85) 113 (86)
Otherd 22 (18) 8 (7) 16 (15) 19 (14)
Level of education .869
High school or GEDe 16 (13) 9 (8) 13 (12) 16 (12)
Bachelor's or associate degree or TC 68 (54) 59 (54) 54 (50) 65 (49)
Master's or doctoral degree 41 (33) 42 (38) 40 (37) 51 (39)
Work/study in health profession .910
Yes 48 (38) 41 (37) 37 (35) 46 (35)
No 77 (62) 69 (63) 70 (65) 86 (65)
Work/study in field requiring professional dress .625
Yes 70 (56) 65 (59) 54 (50) 71 (54)
No 55 (44) 45 (41) 53 (50) 61 (46)
Received nutrition counseling .622
Yes 45 (36) 41 (37) 35 (33) 54 (41)
No 80 (64) 69 (63) 72 (67) 78 (59)
Time since counseling .210
In the last year 12 (10) 14 (13) 5 (5) 22 (17)
In the last 5–10 y 27 (22) 20 (18) 20 (19) 26 (20)
>10 y 6 (5) 8 (7) 11 (10) 8 (6)
N/A 80 (64) 68 (62) 71 (66) 76 (58)
Correctly recalled dress <.001
Yes 115 (92) 77 (70) 84 (79) 121 (92)
No 10 (8) 33 (30) 23 (21) 11 (8)
Abbreviations: GED, graduate equivalency degree; N/A, not applicable; TC, technical certificate.
aData were analyzed and proportions were compared using the χ2 test.
b“Prefer not to say” (n = 5) were not included in the statistical analyses.
cStates were grouped into regions based on the US Census Bureau.
d“Other” group includes American Indian/Alaska Native (n = 2), Asian (n = 24), Black/African American (n = 12), Native Hawaiian/other Pacific Islander (n = 4), and multiracial (n = 23).
eIncludes 1 participant who selected “some high school.”

When the relationship between the interventions and demographic characteristics (Table) and the total professionalism score were examined using multiple linear regression, attire, white coat, and the interaction between attire and white coat did not predict the total professionalism score (P > .05). However, there was a significant effect of ethnicity (P = .0004) and education (P = .0299) on the total professionalism score. On average individuals who identified as Hispanic/Latino scored all 4 videos higher (4.78 ± 0.07) than non-Hispanic/non-Latino (4.45 ± 0.03) for total professionalism. Additionally, those with a high school/graduate equivalency degree (GED) scored total professionalism higher (4.66 ± 0.06) than those with a graduate degree (4.38 ± 0.05). Age, sex, region of the United States, race, work, or study in a field requiring professional attire and ever received dietary counseling did not predict the total professionalism score (P > .05).

No significant relationship was observed between attire, white coat, or the interaction of attire and white coat and each subcharacteristic score (P > .05) when the demographic characteristics were included in the model.


Professionalism in dietetic practice is deemed important for the furtherance of trust, education, and practice; therefore, it is necessary to explore factors that contribute to positive perceptions of professionalism.4 The purpose of this research study was to measure the impact of dietitian attire with and without a white coat on participant perception of professionalism. Results showed that attire and white coat do not influence or predict the total professionalism scores for a dietitian. Previous research examining the impact of attire and white coat on professionalism of health care providers showed mixed results.1,5 Differences between studies may be due to the definition of professionalism or the study design used to examine the relationship.

There is not a universal definition of professionalism for health care providers and dress is only one determinant of professionalism. Dart and colleagues4 conducted a systematic review of the literature and international competency standards for training dietetic professionals to ascertain a global definition of professionalism. Through this process, personal attributes, which would include dress, was one of the major themes. Others have defined professionalism of dietitians related to dress using a mean professional characteristic score.5 This score represents the average score of 8 characteristics (ie, empathy, competent, approachable, credible, organized, effective, professional, and confident). This was the scoring system used in the current study.

In addition to how professionalism is defined, study design can also impact results. Most studies examining the relationship between dress and professionalism present multiple photographs of a model in different attire with and without a white coat. Participants are then asked which set of clothing is the most professional.1,2,5,22 However, when participants are simultaneously presented with photographs of all sets of clothing, the study is more likely examining preference for one type of dress over the other. The current study is novel in that the exact purpose of the study was not disclosed and only one video of a brief diet instruction by a dietitian wearing 1 of 4 combinations of attire and white coat was randomly assigned for participant viewing. With this study design unconscious perceptions of professionalism were more likely tested. The videos would also capture personal aspects of professionalism related to the actress, which may confound results. To address this, the videos were taped multiple times and edited to reduce differences in presentation. Additionally, in case attire was difficult to discern under a white coat, especially when not told to focus in on dress, data from only those participants who were able to correctly identify attire and white coat were analyzed. As was observed with the primary analysis, attire, white coat, or the interaction did not influence the total professionalism scores for a dietitian.

To further examine perception of professionalism, attire, white coat, and participant characteristics were examined in a single model. There were no relationships between attire, white coat, or the interaction between attire and white coat, and perception of total professionalism or any of the subcharacteristics of total professionalism. However, ethnicity and level of education did seem to influence scores. These data suggest that perceived professionalism is influenced more by the characteristics of the participant than by what the dietitian is wearing and that there is a need to understand how sociodemographic factors influence perceptions of professionalism.

The blinding of participants to the true purpose of the study and complete randomization of the videos contribute to the strengths of this study. A notable limitation of this study is that the tool used to assess total professionalism was pilot tested but never validated.5 Data from the current study showed that the subcharacteristics of total professionalism that were used to define total professionalism had relatively high internal consistency, thus demonstrating good scale reliability. Another potential limitation of the current study is that the actress in the video was intentionally a white female based on demographics of US dietitians. Perceived professionalism may have been different with the combinations of dress if the dietitian in the video was a different sex or of another racial or ethnic group. For example, white, female physicians were perceived to be more professional when wearing professional attire with a white coat; whereas, female African American physicians were rated more negatively with the same dress.2 However, in a recent randomized study examining physician sex and race on simulated patient evaluations, no differences in satisfaction or physician confidence based on sex or race were observed.23 Results did not suggest that patient-physician race concordance (ie, patient and physician share the same race) affected satisfaction or physician confidence scores.23 Patient-dietitian race and sex concordance and perceived professionalism need to be investigated.

Dietitian-focused and health care–related groups were specifically targeted for recruitment, which could have potentially introduced bias related to professional preference for one type of dress over another. However, this does not appear to be the case. There was no relationship between the total professionalism score and whether the participants worked or studied in a health profession or field that required professional attire. Another potential limitation of this study is that the video scenario was designed to simulate a hospital room; however, because participants were recruited through social media and a web-based registry for clinical trials, it is possible that study participants may not have ever experienced an acute care environment. If the simulated diet instruction took place in a community setting instead of a hospital, scores for total professionalism may have been different. Packer and colleagues5 reported that clients in WIC clinics gave higher professional characteristic scores to a photograph of a dietitian wearing professional attire (suit) and semi-casual (khaki pants with knit collared top) with and without a white coat than did hospitalized patients. Regardless of the setting, only 37% of participants in the current study responded that they had received nutrition counseling. Thus, these data may not be reflective of the majority of clients seen by a dietitian.


Personal attributes, which include dress, have been deemed important contributors to overall perceived professionalism of a dietitian. Results from this study suggest that business professional with a white coat, business professional without a white coat, scrubs with a white coat, and scrubs without a white coat do not influence or predict the total professionalism scores for a dietitian and that perceived professionalism was influenced more by the characteristics of the participant than by what the dietitian was wearing.


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attributes; dietetics; dress code; impressions; practice

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