A recent study led by nurses in a rural Maryland hospital setting examined how patients older than 46 years might view care providers with visible tattoos or body piercings other than in the earlobes-a relevant issue today, considering that body modification is an increasingly common practice. According to a 2010 Pew Research report, Millennials: A Portrait of Generation Next (http://bit.ly/8NoHQx), about 38% of adults born between 1981 and 1991 have tattoos, and about 23% have piercings in locations other than an earlobe (compared with 15% and 1% of people older than 45 years having tattoos and piercings, respectively).

The researchers tabulated the responses of 150 patients to a survey in which respondents looked at color computer images of male and female health care providers dressed in uniforms (scrubs). The respondents were given a number of terms with which to describe the practitioners: caring, confident, reliable, attentive, cooperative, professional, efficient, and approachable.

Findings showed that men with tattoos were rarely perceived more positively in relation to these terms, and women with tattoos were almost never perceived more positively, than were men and women without tattoos. The sex of the patients, 22% of whom had tattoos themselves, didn't affect the results.

Similarly, male practitioners with visible piercings were almost never deemed more professional or approachable, and women with visible piercings other than in the earlobe were viewed even less favorably, than were their counterparts without piercings, in terms of confidence, reliability, attentiveness, cooperation, professionalism, efficiency, and approachability. Although the small sample size, the use of images rather than in-person evaluations, and the rural mid-Atlantic setting limits generalizability, the study raises several intriguing questions for providers relating to dress codes.

Sandy Summers, executive director of The Truth About Nursing, a nonprofit organization that works to improve nursing's media image, believes that it's easier for some of us to accept alternative lifestyles until we get sick, which is "when we become more risk averse and look for conventional markers of responsibility and expertise in health providers." But, she adds, "We shouldn't squelch individual expression, which can undermine work environments. Many patient concerns can probably be allayed with a friendly display of provider competence. Yet patient confidence affects health, and the nursing image is especially fragile because it has been plagued by so many stereotypes."

The authors of the study advise nursing administrators to review their policy on displays of tattoos and piercings, although strict dress codes are rarely popular or successful. Perhaps a moderate approach that considers both freedom of expression and patient sensitivities is the best way to address the issue, suggests Summers. "It seems fair to ask providers to consider body modifications that are less likely to unsettle most of their patient population or that can be concealed while on duty." -Gail M. Pfeifer, MA, RN, news director

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