Patients' Perceptions of Patient Care Providers With Tattoos and/or Body Piercings
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Attachment NK4EOg, JONA Vol 42 Number 3 pp 160-164
JONA
Volume 42, Number 3, pp 160-164
Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Patients’ Perceptions of Patient Care
Providers With Tattoos and/or
Body Piercings
Heather V. Westerfield, MSN, RN, CMSRN Karen Gabel Speroni, PhD, RN
Amy B. Stafford, MSN, RN, CMSRN Marlon G. Daniel, MHA, MPH
Objective: This study evaluated patients’ percep- Conclusions: Nursing administrators should develop
tions of patient care providers with visible tattoos and/or evaluate policies regarding patient care pro-
and/or body piercings. viders with visible tattoos and/or body piercings.
Background: As tattooing and body piercing are
increasingly popular, research that informs nursing Tattooing has become increasingly popular among
administrators regarding policies on patient care all ages, occupations, and social classes.1 With the in-
providers having visible tattoos and body piercings creasing number of individuals in the workforce elect-
is warranted. ing to have tattoos and/or body piercings, hospital
Methods: A total of 150 hospitalized adult patients administrators must decide what policies to set forth
compared pictures of male and female patient care supporting a professional environment. Literature on
providers in uniform with and without tattoos and/ the perceptions of visible tattoos and body piercings
or nonearlobe body piercings. on healthcare professionals including nurses is limited
Results: Patient care providers with visible tattoos based on a search of articles dated 1988-2011, in
and/or body piercings were not perceived by patients PubMed, EBSCO host, PROQUEST, and the Cochrane
in this study as more caring, confident, reliable, at- Library using the following search terms: nurse, nurs-
tentive, cooperative, professional, efficient, or ap- ing care and body piercing, tattoo, patient satisfaction,
proachable than nontattooed or nonpierced providers. perception of care, dress code. A recent study did report
Tattooed female providers were perceived as less pro- that many hospitals had no rationale or reference
fessional than male providers with similar tattoos. supporting policies addressing body art.2 Research
Female providers with piercings were perceived as conducted in the general population on perceptions
less confident, professional, efficient, and approach- of college students with tattoos and body piercing
able than nonpierced female providers. showed that having a tattoo hindered interpersonal
perceptions.3 These perceptions included physical ap-
pearance, such as attractiveness, and personality traits,
Author Affiliations: Staff Nurse (Ms Westerfield), EducatorY such as caring. The presence of a tattoo has been re-
Professional Nursing Practice (Ms Stafford), Chair of Nursing ported to diminish image and credibility.4 Patients
Research Council (Dr Speroni), and Biostatistician (Mr Daniel),
Shore Health System, Easton, Maryland. have reported viewing facial piercing among physi-
No funding was received for this research. cians as inappropriate and negatively affecting per-
The authors declare no conflict of interest. ceived competence and trustworthiness.5
Correspondence: Mrs Westerfield, 219 South Washington St,
Easton, MD 21601 (hvw@goeaston.net). Research is warranted to evaluate patients’ per-
Supplemental digital content is available for this article. ceptions of patient care providers with visible tattoos
Direct URL citations appear in the printed text and are provided and/or body piercings. For purposes of this study,
in the HTML and PDF versions of this article on the journal’s
Web site (www.jonajournal.com). body piercing is defined as a piercing of the body any-
DOI: 10.1097/NNA.0b013e31824809d6 where other than the earlobes. Outcomes should be
160 JONA Vol. 42, No. 3 March 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1Attachment NK4EOg, JONA Vol 42 Number 3 pp 160-164
consent. Patients were excluded if they were in iso-
lation 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 in-
Figure 1. Definitions of descriptive words used in survey. formed consent was obtained, patients were shown
color pictures on the computer screen and were
considered by hospital administrators in the develop- asked to provide survey responses by picture type
ment or revision of policies addressing visible tattoos (See Figures, Supplemental Digital Content 1,
and/or body piercings among healthcare workers. http://links.lww.com/JONA/A70 and Supplemental
Digital Content 2, http://links.lww.com/JONA/A71).
About the Study Four sets of pictures of male and female patient care
The study purpose was to explore patients’ percep- providers dressed in uniforms (scrubs) were shown
tions of patient care providers with visible tattoos to patients via computer as follows: 1 male with a
and/or body piercings. The hypothesis of this study tattoo of the upper arm and 1 without; 1 female with
was that patients would have a lower overall per- a tattoo of the upper arm and 1 without; 1 male with
ception of patient care providers who had visible a piercing of the eyebrow and 1 without; and 1 female
tattoos and/or body piercings. A modified version of with a piercing of the nose and 1 without. For each
the nurse image scale was used.6 The modified sur- of the 4 picture sets, patients were asked to provide
vey is referred to as the Tattoo and Body Piercing survey responses via computer specifying which pa-
Patient Research Study Questionnaire. Content va- tient care provider looked the most caring, confident,
lidity was conducted on the modified version of the reliable, attentive, cooperative, professional, efficient,
instrument. Members of the Nursing Research Coun-
and approachable. Definitions of these concepts were
cil of the healthcare system where the research was
provided to patients participating in the survey
conducted evaluated the relevance and clarity of the
(Figure 1).
questionnaire. Items were retained if at least 80%
The sample size of 150 was based on an effect
agreement occurred among the members regarding
size of 0.85 to detect perceived differences by patients
the relevance and clarity of an individual item. The
of patient care provider characteristics associated
content validity index of the final survey was 1.0.
with having tattoos and body piercings, at an 80%
power and ! of .05.7 Means and frequencies were
Methods used to describe the sample and responses of the par-
This was a cross-sectional, computerized survey re- ticipants. To ascertain differences between groups
search study using computer-assisted self-interviewing (ie, age categories, gender) and response categories
on 150 patients hospitalized in a rural community (including bivariable associations), exact 2 2 methods
hospital in the mid-Atlantic region. This study re- were used. In instances of multiple comparisons,
ceived institutional review board approval. Patients Bonferroni adjustments were incorporated. Analysis
included in the study were 18 years or older and able was completed using SAS version 9.2 (SAS Institute,
to communicate in English and provide informed Cary, North Carolina).
Table 1. Respondent Perceptions of Male Patient Care Providers by Tattoo Status (n = 150)
Healthcare Provider Characteristic Male With Tattooa Male Without Tattooa No Differencea Significance Testinga
Caring 1 (0.7) 43 (28.7) 106 (70.7) G.0001
Confident 8 (5.3) 44 (29.3) 98 (65.3) G.0001
Reliable 3 (2.0) 48 (32.0) 99 (66.0) G.0001
Attentive 4 (2.7) 39 (26.0) 107 (71.3) G.0001
Cooperative 2 (1.3) 44 (29.3) 104 (69.3) G.0001
Professional 2 (1.3) 45 (30.0) 103 (68.7) G.0001
Efficient 2 (1.3) 45 (30.0) 103 (68.7) G.0001
Approachable 3 (2.0) 52 (34.7) 95 (63.3) G.0001
a
Data are reported in raw numbers and percentages (%).
JONA Vol. 42, No. 3 March 2012 161
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2Attachment NK4EOg, JONA Vol 42 Number 3 pp 160-164
Table 2. Respondent Perceptions of Female Patient Care Providers by Tattoo Status (n = 150)
Healthcare Provider Female With Female Without No Significance
Characteristic Tattooa Tattooa Differencea Testinga
Caring 0 (0.0) 49 (32.7) 101 (67.3) G.0001
Confident 0 (0.0) 49 (32.7) 101 (67.3) G.0001
Reliable 0 (0.0) 53 (35.3) 97 (64.7) .0004
Attentive 1 (0.7) 52 (34.7) 97 (64.7) G.0001
Cooperative 0 (0.0) 51 (34.0) 99 (66.0) G.0001
Professional 0 (0.0) 80 (53.3) 70 (46.7) .4625
Efficient 1 (0.7) 52 (34.7) 97 (64.7) G.0001
Approachable 1 (0.7) 57 (38.0) 92 (61.3) G.0001
a
Reported in both raw numbers and percentages (%).
Findings (Table 2). Perspectives of professionalism signifi-
cantly differed between male and female providers
Of the 150 patients providing survey responses, the regarding tattoos, with patients specifying a lower
majority was female (68%, n = 102), white (77%, perception of professionalism regarding tattooed
n = 116), and 46 years or older (72%, n = 108). female providers (P G .0001). The characteristic of
Twenty-two percent responded that they had a professionalism when analyzed for patient care pro-
permanent tattoo, of which half were visible when vider by gender and tattoo status was not signifi-
clothed. Only 6% (n = 9) indicated body piercings cantly different according to patient gender.
other than the earlobe, of which 44% (n = 4) were Perceptions were less favorable regarding visible
visible when clothed. body piercings, other than the ear lobe, as compared
When patients evaluated pictures of a male pa- with visible tattoos. For male patient care providers
tient care provider dressed in uniform with and dressed in uniform with a visible body piercing, the
without visible tattoos, the majority perceived no majority of patients perceived no differences in car-
differences in caring (71%, n = 106), confidence ing (53%, n = 79), confidence (51%, n = 76), reli-
(65%, n = 98), reliability (66%, n = 99), attentiveness ability (51%, n = 76), attentiveness (50%, n = 75),
(71%, n = 107), cooperativeness (69%, n = 104), pro- cooperativeness (51%, n = 76), and efficiency (51%,
fessionalism (69%, n = 103), efficiency (69%, n = 103), n = 76) (Table 3). Of note, the male with a visible
and approachability (63% n = 95) (Table 1). The tat- body piercing was perceived to be less professional
tooed male was never perceived to be more caring, and approachable. As with the tattoo findings, the
confident, reliable, attentive, cooperative, professional, male with the body piercing was never perceived to
efficient, or approachable than his nontattooed coun- be more caring, confident, reliable, attentive, cooper-
terpart. Similar findings were demonstrated for female ative, professional, efficient, or approachable than his
patient care providers with 1 exception (Table 2). nonpierced counterpart.
Regarding perception of professionalism, the major- Participants’ perceptions were less favorable
ity viewed the female patient care provider dressed for female patient care providers dressed in uniform
in uniform without a tattoo as more professional with a visible body piercing than for their male
Table 3. Respondent Perceptions of Male Patient Care Providers by Body Piercing Status (n = 150)
Characteristic of Patient Male With Body Male Without Body No Significance
Care Provider Piercinga Piercinga Differencea Testinga
Caring 0 (0.0) 71 (47.3) 79 (52.7) .5678
Confident 1 (0.7) 73 (48.7) 76 (50.7) G.0001
Reliable 1 (0.7) 73 (48.7) 76 (50.7) G.0001
Attentive 0 (0.0) 75 (50.0) 75 (50.0) .9999
Cooperative 1 (0.7) 73 (48.7) 76 (50.7) G.0001
Professional 0 (0.0) 107 (71.3) 43 (28.7) G.0001
Efficient 0 (0.0) 74 (49.3) 76 (50.7) .9350
Approachable 0 (0.0) 83 (55.3) 67 (44.7) .2205
a
Reported in raw numbers and percentages (%)
162 JONA Vol. 42, No. 3 March 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3Attachment NK4EOg, JONA Vol 42 Number 3 pp 160-164
Table 4. Respondent Perceptions of Female Patient Care Providers by Body Piercing
Status (n = 150)
Characteristic of Patient Female With Body Female Without Body No Significance
Care Provider Piercinga Piercinga Differencea Testinga
Caring 0 (0.0) 73 (48.7) 77 (51.3) .8066
Confident 1 (0.7) 75 (50.0) 74 (49.3) G.0001
Reliable 0 (0.0) 75 (50.0) 75 (50.0) .9999
Attentive 0 (0.0) 72 (48.0) 78 (52.0) .6832
Cooperative 0 (0.0) 73 (48.7) 77 (51.3) .8066
Professional 0 (0.0) 105 (70.0) 45 (30.0) G.0001
Efficient 0 (0.0) 76 (50.7) 74 (49.3) .9350
Approachable 0 (0.0) 82 (54.7) 68 (45.3) .2885
a
Reported in raw scores and percentages (%)
counterparts. The majority perceived no difference 1 site and should be replicated in various care set-
for only 3 characteristics: caring (51%, n = 77), at- tings and organizations. The rural setting of the or-
tentiveness (52%, n = 78), and cooperativeness ganization in the mid-Atlantic region of the United
(51%, n= 77) (Table 4). Similarly, the visibly pierced States may have an impact on generalizability of
female provider was not perceived to be more caring, findings as well.
confident, reliable, attentive, cooperative, professional, Additional research is recommended using a
efficient, or approachable. Females without visible prospective design in which patient care providers
body piercings were considered to be more confident dressed in uniform with various visible tattoos and
(50%, n = 75), professional (70%, n = 105), efficient body piercings can be viewed in person by patients.
(51%, n = 76), and approachable (55%, n = 82) than Additional research is recommended in other hos-
pierced female patient care providers (Table 4). pital settings to negate the effect of cultural norms
on findings as well.
Discussion
Conclusions
Study results suggest male and female patient care
Results of this study suggest that male and female
providers dressed in uniform with visible tattoos
and/or nonearlobe body piercings are never per- patient care providers dressed in uniform with vis-
ceived by patients to be more caring, confident, reli- ible tattoos and/or nonearlobe body piercings are
able, attentive, cooperative, professional, efficient, not perceived by patients to be more caring, con-
or approachable than their nonYvisibly tattooed or fident, reliable, attentive, cooperative, professional,
nonpierced peers. Because of lack of literature on efficient, or approachable than their counterparts
patients’ perceptions of healthcare providers with without visible tattoos or piercings. Gender bias may
visible tattoos and body piercings, this research be a factor in regard to female providers with visible
was warranted and can be used to help guide nurs- tattoos, as patients perceived them to be less pro-
ing administrators regarding policy development fessional than their male counterpart with a similar
and/or revision. tattoo. Also, female patient care providers with vis-
A limitation to the study is that patient per- ible nonearlobe body piercings are perceived by pa-
ceptions may vary by other types of tattoo or body tients to be less confident, professional, efficient, and
piercings than those shown in the study pictures to approachable than females with no body piercings.
the study participants. Although the tattoos in this Nursing administrators should evaluate policies and
study were similar for males and females, the body practices regarding patient care providers displaying
piercings differed. To standardize perceptions, this visible tattoos and/or body piercings while providing
survey research study was electronically based, and patient care.
patients viewed pictures of patient care providers in
uniform with and without tattoos or body piercings. Acknowledgment
Patients viewing patient care providers in person The research team thanks Lois Sanger, MLS, Li-
may result in differing patient perceptions on the brarian, and also the Nursing Research Council for
characteristics evaluated in this research. An addi- their support in verifying the content validity of the
tional limitation is that the study was conducted in survey instrument.
JONA Vol. 42, No. 3 March 2012 163
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4Attachment NK4EOg, JONA Vol 42 Number 3 pp 160-164
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2. Dorwart SD, Kuntz SW, Armstrong ML. Developing a nursing sicians have facial piercings? J Gen Intern Med. 2005;20:213-218.
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164 JONA Vol. 42, No. 3 March 2012
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