The Opinion of Patients and Nurses About the Professional Appearance in Nursing

1 Lidija Galović

2,3Nikolina Farčić

2 Ivana Lasić

3 Ivana Barać

3,4Zvjezdana Gvozdanović

1 Osijek-Baranja County Health Centre, Osijek, Croatia

2 University Hospital Centre Osijek, Osijek, Croatia

3 Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University, Osijek, Croatia

4 General Hospital Našice, Našice, Croatia

https://doi.org/10.24141/2/7/2/1

Author for correspondence:

Nikolina Farčić

University Hospital Centre Osijek, Osijek, Croatia E-mail: nikfarcic@gmail.com

Keywords: nurses, opinion, professional appearance, nursing

Abstract

Aim. To examine the opinion of patients and nurses about professional appearance in nursing in relation to gender and age and to examine how they perceive professionalism.

Methods. Respondents in the cross-sectional study were nurses and patients. An anonymous question- naire created for the purpose of this research was used to collect data.

Results. A total number of 764 respondents partici- pated in the research. Male respondents show signif- icantly more agreement with the statement that the physical appearance of the female nurse (p=0.003)

/ male nurse (p=0.005) affects the satisfaction with the health care provided. Respondents of older age groups show significantly more agreement with the statement that a female nurse dressed in a skimpier uniform will attract the attention of male patients and that during working hours she should cover the tattoo/piercing, unlike younger respondents. Com- pared to medical workers, patients show significantly more agreement with the statement that the physi- cal appearance of female nurses is not related to their expertise (p=0.001), and that they would feel more comfortable if they were taken care of by a female nurse that is properly dressed (p=0.05). Both female and male nurses show significantly more agreement with the statement that the uniform should not put them in an uncomfortable situation (p=0.004).

Conclusion. Most respondents believe that both fe- male and male nurses should be properly dressed in the workplace and respect the provisions of profes- sional appearance.

Introduction

It is general knowledge that each individual creates their own opinion about certain things or people based on the physical appearance, character traits, and/or behaviour of these things/people. The opin- ion of people is greatly influenced by the environ- ment in which they live and work, work experience, but also many other factors that contribute to the unique opinion of each person. The media, which present different situations every day, play a signifi- cant role in creating the opinion. The professional ap- pearance of both male and female nurses contributes to the formation of public opinion about nursing as a profession. The survey on the opinion of general population and nurses themselves provides useful information needed to create a better image of nurs- ing as a profession and to improve the reputation of nursing in society. Different types of research which provided an insight into the image of the nursing profession based on the appearance at workplace (1- 4) were conducted. The uniform presents nurses as responsible, educated, and competent for providing health care in accordance with the level of education

(1). Various studies indicate that wearing an uneven

uniform does not contribute to professional reputa- tion (2-4). Godsey et al. (2020) conducted a survey investigating registered nurses’ perceptions of fac- tors contributing to the inconsistent brand image of the uniform within nursing profession. Among other answers, respondents stated the increasingly fre- quent use of nurses’ uniforms by other professions as one of the reasons, as well as the lack of identifi- cation cards with visible qualifications of the person wearing them, which contributes to the non-distinc- tion of the nurses among each other as well as from other healthcare workers (5). Creating a confidential, professional, and therapeutic relationship with pa- tients and their families partly depends on the way all involved interpret nurse’s appearance (6). Cha et al. state that many patients admit the existence of a link between the nurse’s uniform and the credit they put into nurse’s work, as well as the public’s percep- tion of nursing (7).

Aim

The aim of this research is to examine the opinion of patients and nurses about professional appearance in nursing in relation to gender and age and to exam- ine the way they perceive professionalism.

Methods

The cross-sectional study included patients from two family medicine practices and one dental practice, as well as nurses using the Internet and participating in online groups, partly from the Osijek Clinical Hospital Centre, of both genders and all ages. The research was conducted from February to April 2022. Data were collected online using an anonymous ques- tionnaire designed and adapted exclusively to the needs of this study. The questionnaire consisted of two parts and contained a total of 18 questions, in which the respondents gave their opinions for male and female nurses separately. The first part included questions in terms of socio-demographic character- istics of the respondents: gender, age, level of edu- cation, years of work experience, whether they are a nurse by profession. The opinions of patients and nurses about the professional appearance of male and female nurses were examined in the second part. Respondents’ agreement with each statement on a five-point Likert scale from ‘I strongly disagree - 1’ to ‘I strongly agree – 5’ was examined.

Statistics

Categorical data are represented by absolute and rela- tive frequencies. Numerical data are described by the median and limitations of the interquartile range as well as the arithmetic mean and standard deviation. Differ- ences in categorical variables were tested using the χ2 test. The normality of distribution of the numerical variables was tested with the Kolmogorov-Smirnov test. Due to deviations from normal distribution, numerical variables between two independent groups were tested with the Mann-Whitney U test. Numerical variables in the case of 3 or more independent groups

were tested with the Kruskal-Wallis test due to devia- tion from the normal distribution, and post hoc tests were used for the variables tested with the Kruskal- Wallis test. All p values are two-sided. The significance level was set at α = 0,05. The SPSS statistical program (version 22.0, SPSS Inc., Chicago, IL, SAD) was used for statistical analysis.

The research was approved by the Ethics Committee of the Faculty of Dental Medicine and Health Osijek (2158/97-97-10-22-30) and the Committee for Ethi- cal and Status Issues of Nurses for Health Care of the Clinical Hospital Centre Osijek (R1-1050-2/2022). Each respondent voluntarily participated in the re- search and could leave the research at any time. Ano- nymity was ensured for each respondent.

Results

A total of 764 respondents participated in the re- search, of which 203 (26.6%) were men and 561 (73.4%) were women. The arithmetic mean age is

Number of respondents (%)

Table 1. Socio-demographic characteristics of the respondents

33.7 years (SD=10.2) in the interval from 18 to 69 years. There were 485 (63.5%) nurses by profession included in the research (Table 1.).

Gender

Age

Table 2. shows variables (assertions) used in the research.

Men show significantly stronger agreement with the statement that the physical appearance of female nurse (Mann-Whitney U test, p=0.003, U=49214) / male nurse (Mann-Whitney test, p=0.005, U=49630) affects satisfaction with the health care provided, and strongly agree with the statement that the phys- ical appearance of the female nurse (Mann-Whitney U test, p=0.001, U=48469) / male nurse (Mann- Whitney U test, p=0.005, U=49850,5) is not related to her/his expertise, which shows statistically signifi- cant stronger agreement compared to women in our research. Compared to men, women show significant-

Table 3. Respondents’ opinion on the physical appearance of female and male nurses in relation to gender

Statement

2

3

8

9

10

12

13

Female nurse (FN) and male nurse (MN)

FN MN FN MN FN MN FN MN FN MN FN MN FN MN

Opinion / median (interquartile range)

p*

Male

4 (2 – 5)

4 (2 – 5)

5 (3 – 5)

5 (3 – 5)

5 (4 – 5)

5 (4 – 5)

5 (4 – 5)

4 (3 – 5)

3 (2 – 4)

3 (2 – 5)

3 (1 – 5)

3 (1 – 5)

2 (1 – 4)

1 (1 – 2)

Female

3 (2 – 4)

3 (2 – 4)

4 (3 – 5)

4 (3 – 5)

5 (5 – 5)

5 (4 – 5)

4 (3 – 5)

4 (3 – 5)

2 (1 – 3)

2 (1 – 3)

2 (1 – 3)

2 (1 – 3)

2 (1 – 3)

1 (1 – 2)

0.003

0.005

0.001

0.005

< 0.001

0.20

0.04

0.16

< 0.001

< 0.001

< 0.001

< 0.001

0.001

0.87

*Mann-Whitney U test; 1 – I strongly disagree, 2 – I mostly disagree, 3 – I neither agree nor disagree, 4 – I mostly agree, 5 – I strongly agree

ly stronger agreement with the statement that the uniform should not put the female nurse in an uncom- fortable situation (Mann-Whitney U test, p<0.001, U=46979,5). Men show significantly stronger agree- ment with the statement that a female nurse dressed in a skimpier uniform will attract the attention of male patients (Mann-Whitney U test, p=0.04, U=51933,5). Women show statistically significant less agreement with the statement that a female nurse (Mann-Whit- ney U test, p<0.001, U=42906,5) or a male nurse (Mann-Whitney test, p<0.001, U=39840) dressed in skimpier uniform is more accepted in their work envi- ronment, as well as with the statement that a female nurse (Mann-Whitney U test, p<0.001, U=44331,5) or a male nurse (Mann-Whitney U test, p<0.001, U=44433,5) should adequately cover a visible tat- too/piercing and the statement that they would feel more comfortable if they were cared for by a nurse with heavy makeup (Mann-Whitney U test, p=0.001, U=48366) (Table 3.).

Respondents within the 18-29 years age group show significantly less agreement with the state-

ment that the physical appearance of a nurse af- fects the overall satisfaction with the health care provided, in contrast to the respondents within the 40-49 years age group (Kruskal-Wallis test, post hoc p=0.042). Furthermore, the respondents within the 50-59 years age group show significantly stronger agreement with the given statement in contrast to the respondents within the 18-29 years age group (Kruskal-Wallis test, post hoc p=0.029).

Respondents within the 40-49 years age group (Kruskal-Wallis test, post hoc p=0.045) and 50- 59 years age group (Kruskal-Wallis test, post hoc p=0.049) show significantly stronger agreement with the statement that a female nurse dressed in skimpier uniform will attract the attention of male patients, in contrast to respondents within the 18- 29 years age group. Respondents within the 40-49 years (Kruskal-Wallis test, post hoc p=0.007) and 50- 59 years (Kruskal-Wallis test, post hoc p=0.001) age groups show significantly stronger agreement with the statement that a female nurse should adequately cover a visible tattoo/piercing during working hours, compared with the respondents within the 18-29 years age group who completely disagree with the above stated (Table 4.).

Respondents who are not medical professionals show significantly stronger agreement with the statement that the physical appearance of a female nurse is not related to her competence (Mann-Whit- ney U test, p=0.001, U=46979,5). Respondents in the field of medical profession show significantly stronger agreement with the statement that the uniform should put neither a female (Mann-Whitney U test, p=0.004, U=51933) nor a male nurse (Mann- Whitney U test, p=0.01, U=46979,5 ) into an uncom- fortable situation and they also show significantly stronger disagreement with the statement that a female (Mann-Whitney U test, p<0.001, U=44331,5) or a male nurse (Mann-Whitney U test, p<0.002, U=44331) should adequately cover a visible tattoo/ piercing during working hours, in relation to respon- dents who are not medical professionals and have a neutral attitude regarding the stated claim. Respon- dents who are not medical professionals show sig- nificantly stronger agreement with the statement that they would feel more comfortable if they were cared for by a nurse who is properly dressed (Mann- Whitney U test, p=0.05, U=49630) (Table 5.).

Respondents who are healthcare professionals show significantly stronger agreement with the statement

Table 4. Respondents’ opinion on the physical appearance of female and male nurses in relation to age

2

5

6

9

11

12

Female nurse (FN) and male nurse (MN)

FN MN FN MN FN MN FN MN FN MN FN MN

Opinion / median (interquartile range)

Statement

18 – 29

years

3 (2 – 4)

3 (2 – 4)

5 (4 – 5)

5 (4 – 5)

4 (3 – 5)

5 (4 – 5)

4 (3 – 5)

4 (3 – 5)

4 (3 – 5)

4 (3 – 5)

1 (1 – 3)

2 (1 – 3

30 – 39

years

3 (2 – 4)

4 (2 – 5)

5 (4 – 5)

5 (4 – 5)

5 (3 – 5)

5 (4 – 5)

5 (4 – 5)

4 (3 – 5)

5 (3 – 5)

5 (3 – 5)

2 (1 – 3)

2 (1 – 4)

40 – 49

years

3 (2 – 5)

3 (2 – 5)

5 (4 – 5)

5 (4 – 5)

5 (3 – 5)

5 (4 – 5)

5 (4 – 5)

4 (3 – 5)

5 (4 – 5)

5 (4 – 5)

3 (1 – 4)

3 (1 – 4)

50 – 59

years

4 (2.75 – 5)

4 (3 – 5)

5 (4 – 5)

5 (4 – 5)

5 (4 – 5)

5 (4 – 5)

5 (4 – 5)

4.5 (3 – 5)

5 (3.75 – 5)

5 (4 – 5)

3 (1 – 4.25)

3 (1 – 4)

60 +

years

3 (1 -4.75)

3.5 (1 – 5)

4.5 (3.25 – 5)

5 (4.25 – 5)

4 (2.25 – 5)

5 (4.25 – 5)

5 (4 – 5)

5 (4.25 – 5)

5 (4 – 5)

5 (4.25 – 5)

4 (1.25 – 5)

3.5 (1.25 – 5)

p*

0.007

0.03

0.03

0.001

0.01

0.02

0.003

0.01

0.18

0.004

< 0.001

0.02

*Kruskal-Wallis test; 1 – I strongly disagree, 2 – I mostly disagree, 3 – I neither agree nor disagree, 4 – I mostly agree, 5 – I strongly agree

Table 5. Comparison of the opinions of patients and female/male nurses on the physical appearance of female and male nurses

Opinion / median (interquartile range)

Statement

Female nurse (FN) and

male nurse (MN)

Female nurses and male nurses

p*

Patients

1

3

8

10

11

12

FN MN FN

MN FN MN FN MN FN MN FN

MN

4 (4 – 5)

4 (4 – 5)

4 (3 – 5)

4 (3 – 5)

5 (5 – 5)

5 (5 – 5)

2 (1 – 3)

2 (1 – 3)

4 (3 – 5)

4 (3 – 5)

2 (1 – 3)

2 (1 – 3)

4 (3 – 5)

4 (3 – 5)

5 (3 – 5)

5 (3 – 5)

5 (4 – 5)

5 (4 – 5)

3 (1 – 4)

3 (1 – 4)

5 (3 – 5)

5 (3 – 5)

2 (1 – 4)

3 (1 – 4)

0.09

0.04

0.001

0.21

0.004

0.01

< 0.001

< 0.001

0.05

0.30

< 0.001

< 0.001

*Mann-Whitney U test; 1 – I strongly disagree, 2 – I mostly disagree, 3 – I neither agree nor disagree, 4 – I mostly agree, 5 – I strongly agree

that the physical appearance of a male nurse leaves the first impression on a patient and is important in gaining trust in his work (Mann-Whitney U test,

p=0.04, U=51933), compared to respondents who are not healthcare professionals (Table 5.).

Discussion

The results of this research show that the majority of respondents believe that both female and male nurses should be properly dressed, and there are no significant differences in the opinions of the re- spondents in relation to gender and age when the statement about the connection between physi- cal appearance and the first impression left by fe- male and male nurses is taken into account. In this research respondents from the medical profession express the opinion that there is a connection be- tween physical appearance and the first impression left by female nurses. Wills et al. (2018) state in their research that female nurses project their character through personal appearance. They also state that a patient forms an impression of a nurse within the first 12 seconds of their meeting. The results of their research also show that professional appearance leaves a lasting impression on the patient and ex- presses professionalism and competence (8). Similar results are shown in the work by Porr et al. where they note that the public perception, according to which a registered nurse is considered a professional health care provider based on the appearance of the uniform, has been maintained for generations (9). This especially applies to the female nurse-patient meeting and the impression during the first few mo- ments of the meeting. Professionalism is primarily expressed in the appearance of registered female nurses, with uniforms being the main factor (9).

The results of the conducted research indicate that men show significantly more agreement with the statement that the physical appearance of female nurses affects satisfaction with the health care pro- vided, but also that the physical appearance of fe- male nurses is not related to their competence. In the conducted research Sparrow states that the uniform of female nurses, in addition to contributing to self- confidence, also instils security and confidence in patients (10).

Non-medical respondents agree that the nurse’s physical appearance is unrelated to her competence in this study. The results of a study conducted at the Colleague of Health Sciences in the United Arab Emirates show that the majority of nursing students agree with uniforms presenting nurses as skilled

and qualified, while a few surveyed students be- lieve that uniforms and appearance are not related to one’s knowledge and professional skills (11). One of the aims of a study carried out in Italy was to explore views of healthcare workers on the im- portance and meaning of their own nursing uniform. Professionalism (17.5%), identity (14%) and recog- nition (8.3%) were chosen more often (12). Sofer et al. state that people generally have a practice of combining positive characteristics with generally es- tablished specific appearance (13), while Bringsén et al. state that this also means that people with a non-specific appearance for a certain profession or situation have a much greater possibility of being associated with more negative characteristics that later lead to negative social perceptions (14). This is supported by the results of this research, where women and respondents from the medical profes- sion are of the opinion that both female and male nurses dressed in skimpy uniforms are not accepted in their working environment. The reason for this may be the creation of negative opinions and preju- dices based on appearance.

According to the results of this research, respond- ents over 60 years of age agree that both male and female nurses should have their hair neatly combed during working hours. Also, they are of the opinion that both male and female nurses should have their nails trimmed at the level of the fingertips. Pamela

J. Carter writes about the same in Lippincott’s Text- book for Nursing assistants: A Humanistic Approach to Caregiving. It is stated that the hair should be neatly arranged and not touch the face (15). It is recommended that nurses keep their nails short be- cause long nails can potentially contribute to a faster spread of infection, as dirt and various bacteria of- ten remain under the underside of the nail (16,17). In addition, it is recommended to avoid artificial and gelled nails because they are more difficult to clean, and precisely because of this, they contain a greater number of pathogenic microorganisms than natural nails (16). Research have shown that after washing hands, significantly more pathogens remain on gel nails than on natural nails (18).

According to Prlić, the uniform must not hinder the nurse at work or put her in an uncomfortable situ- ation (19). The results of this research show that significantly more women than men agree with this statement. Respondents in the conducted research who work as nurses are of the opinion that the uni-

form should not put neither the female nor the male nurse in an uncomfortable situation.

As Muff (1982) points out, there are six most sig- nificant stereotypes related to nurses. They are pre- sented as: angels of kindness, doctor’s maids, ghosts in white, untamed, oppressors and sex symbols (20). In this research as well, men when compared to wom- en, show significantly stronger agreement with the statement that female nurses dressed in skimpier uniforms will attract the attention of patients of the opposite sex.

Although stigmatization of tattooed healthcare workers is still present, research show that it is mini- mal. The results of this research show that women do not agree with nurses being demanded to adequate- ly cover a visible tattoo/piercing. In contrast, Williams et al. (2019) showed, in the results of their research conducted among nursing students in America, that tattoos present in visible places pose problems for them during their stay in faculty premises and clin- ics where they perform practice. In the conclusions of the research, recommendations for covering tattoos in visible places were given (21). Furthermore, the results of this research show that patients are un- decided about the need to cover tattoos/piercings in visible places. Conversely, in a 2012 American study by Westerfield and colleagues, patients expressed a more negative view of tattooed female nurses than tattooed male nurses (22).

The female respondents in this research do not agree with the statement that they would feel more com- fortable if they were cared for by a nurse with more make-up. In 2012, Sotgiu, Nieddu, Mameli et al. con- ducted a study that researched preferences of Italian patients in relation to doctors’ clothing. Patients rat- ed long flowing hair, visible tattoos, and piercings as inappropriate for men, and wearing pants and using excessive make-up for women (23). Although the re- sults of their research are related to doctors’ clothing, they indicate a general agreement among patients that health professionals should look professional and without excessively visible body features and decorations.

Conclusion

Men show significantly stronger agreement with the statement that the physical appearance of a female/ male nurse affects satisfaction with the health care provided. Men and respondents of older age groups show significantly stronger agreement with the statement that a female nurse dressed in a skimpier uniform will attract the attention of male patients.

Respondents from the medical profession and wom- en show significantly stronger agreement with the statement that the uniform should not put the fe- male/male nurse in an uncomfortable situation and significantly stronger disagreement with female/ male nurse being obligated to adequately cover a vis- ible tattoo/piercing during working hours in relation to respondents who are not medical professionals and respondents of older age groups. Respondents who are not medical professionals show significantly stronger agreement with the statement that they would feel more comfortable if they were cared for by a properly dressed nurse.

The majority of respondents of all characteristics of opinion share the opinion that both female and male nurses should be properly dressed at the workplace, adhering to the provisions of professional appear- ance, which affects the perception of professional- ism in the nursing profession.

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MIŠLJENJE PACIJENATA I MEDICINSKIH SESTARA/TEHNIČARA O PROFESIONALNOM IZGLEDU U SESTRINSTVU

Sažetak

Cilj. Cilj ovog istraživanja bio je ispitati mišljenje paci- jenata i medicinskih sestara o profesionalnom izgle- du u sestrinstvu u odnosu na spol i dob te ispitati kako percipiraju profesionalizam.

Metode. Provedeno je presječno istraživanje u ko- jem je sudjelovalo 764 ispitanika, medicinske sestre i tehničari iz Kliničkog bolničkog centra Osijek te pa- cijenti iz ordinacija obiteljske i dentalne medicine u Semeljcima. Za prikupljanje podataka upotrijebili smo anonimni anketni upitnik kreiran u svrhu ovog istraži- vanja. Podaci su obrađeni deskriptivnom statističkom obradom.

Rezultati. Statistički su značajne razlike između mišljenja ispitanika u odnosu na spol i dob. Muškarci su mišljenja da fizički izgled medicinske sestre

/ medicinskog tehničara utječe na zadovoljstvo pruženom zdravstvenom njegom i nije povezan s nji- hovom stručnošću, dok su žene mišljenja da uniforma ne smije dovoditi medicinsku sestru u neugodnu situaciju. Stariji su ispitanici mišljenja da fizički izgled medicinske sestre / medicinskog tehničara utječe na zadovoljstvo pruženom zdravstvenom njegom. Paci- jenti se u odnosu na medicinske djelatnike značajnije potpuno slažu da fizički izgled medicinskih sestara nije povezan s njihovom stručnošću i ugodnije bi se

Zaključak. Većina ispitanika smatra da bi medicin- ske sestre / medicinski tehničari trebali biti propisno odjeveni na radnom mjestu i poštovati odredbe profe- sionalnog izgleda.

osjećali kada bi o njima skrbila medicinska sestra koja        

je propisno odjevena. Medicinske sestre / medicinski tehničari značajnije se potpuno slažu da ih uniforma

Ključne riječi: medicinske sestre, medicinski tehničari, mi- šljenje, profesionalni izgled, sestrinstvo

ne smije dovoditi u neugodnu situaciju.