How should the nurse of the 21st century look? How can the image be changed uniform, control of social media, etc so the public can easily identify the Registered Nurse?

International Journal of Studies in Nursing; Vol. 3, No. 3; 2018

ISSN 2424-9653 E-ISSN 2529-7317

Published by July Press

30

Appearance of Nurses and Perceived Professionalism

Nikki L. Wills 1 , Brittany Wilson

2 , Eva B. Woodcock

3 , Samuel P. Abraham

4 &

Deborah R. Gillum

5

1 Orthopedic/Neuro Surgery, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA

2 Labor & Delivery, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA

3 Emergency Department, Goshen Hospital, Goshen, Indiana, USA

4 Nursing, Bethel College, Mishawaka, Indiana, USA

5 Nursing, Bethel College, 1001 Bethel Circle, Mishawaka, Indiana, USA

Correspondence: Samuel P. Abraham, Associate Professor of Nursing, Bethel College School of Nursing, 1001

Bethel Circle, Mishawaka, Indiana, 46545, USA.

Received: August 31, 2018 Accepted: September 13, 2018 Online Published: September 17, 2018

doi:10.20849/ijsn.v3i3.466 URL: https://doi.org/10.20849/ijsn.v3i3.466

Abstract

Background: After completing a literature review on the topic of appearance and professionalism a knowledge

gap was identified, relating to how individuals perceive professionalism based on appearance. First impressions

are how patients form opinions of their nurses. Professionalism is influenced by many variables, such as hair,

make-up, uniform, behavior, and image. Purpose: The purpose of this study was to explore perceptions of a

nurse’s appearance and projected professionalism. Method: A total of 120 students volunteered to participate in

the study. The research question was: “How do college students perceive the professional appearance of the

nurse?” This was a quantitative, cross-sectional, non-experimental study with a descriptive design. A qualitative

question was also asked to complement the quantitative data. The survey contained 3 demographic questions and

18 items based on the participant’s perception of the perceived professionalism using the given images. The data

collected were analyzed using descriptive statistics. Orem’s theory of self-care was used to guide this study.

Results: The results confirmed the complex nature of the nursing image. Participants perceived a nurse who took

extra time to improve appearance to be professional, trustworthy and least lazy. A not so prepared nurse was

perceived to lack confidence and also to be less compassionate.

Keywords: professionalism and appearance, nurse appearance and professionalism, professional nurses, nursing

attire, self-care

1. Introduction

Professionalism is perceived in many ways. The traits that make a person professional are up for debate.

Identifying how and why something is considered professional will help determine what characteristics a

professional nurse should possess. The purpose of this study was to determine the perceived professionalism of

the nurse based on appearance using Orem’s theory of self-care as the guiding theoretical framework.

1.1 Background

Nursing is an iconic profession that has been around for thousands of years. Hartfield et al. (2013) stated,

“Nurses have outperformed other professions in the Gallup Poll rating” (p. 108). Nurses are highly respected and

trusted health care providers. Many variables exist that influence a person’s perception of another individual.

There is a disparity in how registered nurses portray themselves in comparison with how patients perceive them

professionally. The appearance of the nurse and perceptions of professionalism are important questions that

require exploration in this study. Porr et al. (2014) noted, “The public notion according to which the registered

nurse (RN) is deemed a professional health-care provider by virtue of his or her uniform has persisted throughout

the generations especially during the first few moments of the nurse-patient encounter. Professionalism is

primarily conveyed by the RN’s appearance, with uniforms being the major factor” (p. 150).

Nurses wear uniforms in hospitals and at doctor’s offices while maintaining expectations of professionalism

through appearance and behavior when providing care to their patients. Nurses are in the unique role of being the

most trusted people in healthcare and maintaining trust is imperative when interacting with various individuals

and aggregates in a professional setting. Fogle and Reams (2014) claimed, “Professional dress was also found to

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impact confidence in the wearer’s ability and knowledge” (p. 52). When the nurse takes time to present a

professional appearance, the patient takes time to notice and associates that with confidence and competence.

Conducting this study on a college campus offered insight from students as to how they perceived a professional

nurse based on appearance. The modern nurse must be educated and licensed in the state where they are

practicing. By presenting a professional appearance, the nurse can leave a positive first impression. When

patients perceive professionalism, they feel that their health care needs are in the hands of capable and

well-educated healthcare professionals.

1.2 Problem Statement

Nursing is a professional career. Patients rely on nurses to help save lives every day. Therefore, the problem is

that many people do not know what influences the perception of the nurses’ professionalism. Patients form an

impression of the nurse within the first 12 seconds (Splendore, Burns, & Choby, 2016). How a nurse appears is a

key factor in how the patient will judge the nurse’s care ability (Splendore et al., 2016). Patients like to see a

nurse who appears professional, well-groomed, neat, clean hair, and conservative makeup for females (Splendore

et al., 2016). There is an association between the time the nurse spends on appearance and quality of

professionalism perceived by patients and their families.

1.3 Purpose Statement

The purpose of this study was to determine the perceived professionalism of the nurse based on appearance.

1.4 Research Question

How do college students perceive the professional appearance of the nurse?

1.5 Review of the Literature

1.5.1 Database Used

The evidence-based practice articles were found using the college library, OneSearch search engine, and the

Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. The articles were located using

keywords such as “professionalism and appearance,” “nurse appearance and professionalism,” “Professional

nurses,” and “nursing attire and professionalism.”

1.5.2 Professionalism

Akhtar-Danesh et al. (2013) defined professionalism as “knowledge, specialization, intellectual, and

responsibility” (p. 248). They also indicated that professionalism is expressed in “one’s image, attire, and

expression” (p. 248). Demonstrating professionalism increases the patient’s perceived perception of the nurse

being professional (Akhtar-Danesh et al., 2013). Nurses should want to be perceived as professional to be seen

as competent by patients.

Ghadirian, Salsali, and Cheraghi (2014) identified professionalism as being related to culture. Working in

healthcare a nurse interacts with people from different cultures. Culture competency is required for appropriate

care. Nurses must be perceived as professionals in all cultures (Ghadirian et al., 2014). A nurse must be aware of

how to be considered professional in other cultures.

Clavelle, Goodwin, and Tivis (2013) helped to demonstrate how a nurse’s image portrays professionalism. A

patient’s perception of a nurse is based on image, appearance, and ability to identify the nurse. The public

perceives nurses based on the idea of how a nurse should look. Professionalism is based on personal appearance

and hygiene (Clavelle et al., 2013). Patients feel more comfortable with a nurse who is seen as a professional.

Nurses should strive to look professional.

1.5.3 Appearance

Porr et al. (2014) used a quantitative survey to explore how appearance influenced perceived professionalism.

Porr et al. surveyed 43 patients on a medical-surgical floor ranging in age from 19-86 years old. Each participant

was shown different pictures of nurses and asked to evaluate the nurse’s appearance using 10 traits (Porr et al.,

2014). With the information gathered, the researchers were able to identify how the nurse conveyed

professionalism. Data exhibited that professionalism was conveyed by the RN’s appearance (Porr et al., 2014).

Appearance influences the professional image. Nurses should want to be seen as professional.

Professionalism has contributed to the nurse’s behavior, adherence to the Code of Ethics, and personal

appearance (Porr et al., 2014). Patients assess the RN’s professionalism within seconds of the first interaction

(Porr et al., 2014). Professionalism, attitude, mood, and trustworthiness are all based on the outward appearance

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of the nurse. Patients’ impression of the professional appearance of the nurse is contingent on how the nurse

looks (Porr et al., 2014).

A negative impression of the nurse’s appearance was shown to decrease the patient’s confidence in their nurse

(Porr et al., 2014). Appearance was demonstrated to directly correlate to the quality of care the nurse delivered.

When patients did not feel confident in the nurse providing their care, the following was seen: an increase in

suffering, a decrease in healing, and longer recovery times (Porr et al., 2014). A direct correlation between the

nurse’s appearance and quality of care delivered was noted.

Splendore et al. (2016) demonstrated the importance of the first impression. The study revealed how a person’s

first impression could influence how they perceived the nurse based on appearance. People do not get a second

chance to improve the first impression. Nurses need to make good first impressions. Respect comes from

professionalism in performance and appearance (Splendore et al., 2016). Nurses must be respected and trusted to

allow for the most successful outcomes.

While (2013) claimed nursing is iconic and conveys important messages. Nurses have a positive image to uphold.

The nursing field upholds the image of a professional through professionalism. A negative image of a nurse will

damage the work the nurse does (While, 2013). Nurses must uphold a positive image to convey positivity.

Nurses should be seen as positive members of the healthcare team.

Clavelle et al. (2013) gave insight on how a nurse should look. A nurse should be clean, neat in appearance,

knowledgeable, and be able to perform duties. A lot of pressure is placed on the nurse’s personal hygiene.

Nurses must properly care for themselves (Clavelle et al., 2013). The bottom line is nurses need care too.

1.5.4 Image

Hartfield et al. (2013) presented the idea that a nurse’s image is based on professionalism, confidence, trust, and

therapeutic relationships. The professional image of a nurse creates a public image of the nursing field. In

nursing, the image of the nurse makes an emotional connection with the patients (Hartfield et al., 2013). The

image is how the public views nurses. Conveying a positive image of the nurse is important for how the public

perceives the nursing field (Hartfield et al., 2013). Nurses should be seen as productive members of the care

team.

Pullen and Alley (2015) helped define a professional image. An image includes how a person looks; how a

person carries themselves; how a person thinks and acts; and how they communicate with others. A positive

professional image increases the perceived credibility of the nurse (Pullen & Alley, 2015). Nurses need to be

viewed as credible.

Appearance can create a positive or negative impression of a nurse (Pullen & Alley, 2015). A negative image is

created when a nurse wears wrinkled, dirty uniforms, has poor grooming, is unclean, has unkempt hair, and has

poor posture. A negative image of nurses decreases credibility to the patient (Pullen & Alley, 2015). Nurses

should create a positive image for patients.

Fogle and Reams (2014) defined what influences a positive image of a nurse. Patients are comfortable with a

nurse that represents a professional image. Their study indicated that patients like a clean, well-groomed nurse.

Patients did not like to see unkempt hair that was on the nurse’s shoulders. The study revealed that a positive

image of the nurse was perceived to be professional (Fogle & Reams, 2014).

Wocial, Sego, Rager, Laubersheimer, and Everett (2014) further defined that a nurse should be well-groomed,

clean, and wear conservative makeup to portray a positive professional image. A positive image creates positive

impressions. The nurses should make a good lasting impression on their patients.

1.5.5 Brand

Wocial et al. (2014) defined nursing as a brand. Emotions are attached to brands. In nursing, patients should feel

attached to their nurses. A nurse must be well-groomed, and clean to uphold a positive brand image (Wocial et

al., 2014). The nurses should want to create a positive brand for themselves.

1.5.6 Behavior

Wocial et al. (2014) outlined what behavior is deemed professional. Nurses were seen to be more professional

when the behavior was approachable, respectful, attentive, caring, reliable, and informative. Behaviors

negatively or positively affected how a nurse is perceived professionally (Wocial et al., 2014). Positive behavior

creates positive impressions.

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Akhtar-Danesh et al. (2013) warned a nurse could be perceived as unprofessional by spreading rumors, talking

about people behind their backs, or participating in gossip. A professional nurse should not display behaviors

that are deemed unprofessional. No nurse should be seen as unprofessional.

1.5.7 Communication

Swan and McGinley (2016) demonstrated that communication influences all aspects of care. When patients do

not trust or believe in their nurse, successful health care outcomes decrease. Communication can be both verbal

and nonverbal. Communication is vital when providing care to a patient. Nurses should strive for positive open

communication between them and their patients to better-serve their patient’s needs.

1.5.8 Character

Splendore et al. (2016) described how respect impacted care. Respect was conveyed through performance and

appearance. Nurses demonstrated character through their personal appearance. A patient judges a nurse’s

character within the first 12 seconds of meeting. Respect is formulated based on the appearance of the nurse. The

character is professionalism in action. Nurses should be seen as having a positive character.

1.5.9 Summary of the Literature Review

Professionalism is influenced by the way a nurse appears (Splendore et al., 2016). Many founding characteristics

of a nurse are based on their appearance. Professionalism is based on being well-groomed and projecting a

professional attitude (Wocial et al., 2014). A nurse should take time to improve their appearance and avoid the

unprofessional behavior. Patients perceive a nurse’s quality of care based on first impressions (Clavelle et al.,

2013). Appearance is a paramount issue for nurses. Though the patients’ perceptions were well documented, the

college students’ perceptions regarding a nurse’s appearance were not found in the search; therefore, the need for

this study.

1.6 Theoretical Framework

Orem’s theory of self-care was used to guide this study. Orem’s theory is based on the belief that a person needs

to engage in activities that maintain a high quality of life, health, and well-being (Orem, Renpenning, & Taylor,

2003). The theory is based on the idea that people who take time for themselves lead a higher quality of life and

have an increased overall well-being. This theory indicates that individuals who take care of themselves will be

more capable of helping others (Orem et al., 2003).

The basis of this theory was used when analyzing the appearance of the nurse and perceived professionalism. If

nurses maintained themselves, they can better care for patients. Predicting that a nurse who spends time

preparing their outward appearance for work, they will be perceived as more professional. The survey items used

in the study also included pictures of a nurse who spent (1) very little or no time, (2) a little time, and (3)

sufficient time on personal appearance.

1.7 Definition of Terms

1.7.1 Conceptual Definition

Self-Care is part of life that is necessary for health, human development, and well-being (Orem et al., 2003). It is

learned through human interactions and communication. It includes deliberate and systematic action to meet a

known need for care. Self-care agency is an acquired ability of a mature and maturing person to know own

human functioning and development. Self-care demands consist of the summation of care measures necessary to

meet all of an individual’s known self-care requisites. Nursing agency refers to the developed capabilities of

persons educated as nurses that allow them to act, to know, and to help patients meet their therapeutic self-care

demands and to regulate the development or exercise of the patient’s self-care agency (Orem et al., 2003).

1.7.2 Operational Definition

The appearance of the nurse was based on the neatness of hair, makeup, and what the uniform looked like.

Professionalism was perceived as neat, competent, respectful person. College students were those who attended

school after high school, ages 18 – 26 years.

2. Methodology

2.1 Research Methods and Design

This study was quantitative, non-experimental, with a descriptive design. It was survey-based. A qualitative

question was also added to further expand the findings. A cross-sectional sampling method was used because it

represented the population and helped provide an insight into how college students perceived professionalism in

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nurse’s appearance. Before research was conducted, the College Institutional Review Board (IRB) approval was

obtained.

2.2 Population and Sampling Frame

The target population for this study was college students. The sample size was 120 college students both male

and female who volunteered for the study. The convenience sampling method was used.

2.3 Geographic Location

The survey occurred at a college in northern Indiana, USA, outside the college library from mid-morning

through mid-afternoon. An area was set up outside the library for students to complete the survey either before or

after they entered the library. Store-bought candy was offered as an incentive for students to participate in the

survey.

3. Data Analysis

Data analysis occurred after all surveys were completed. Incomplete surveys were discarded. The frequency and

percentage were calculated for the demographic questions and described using a table. To analyze the data, the

mean was calculated for each of the 18 survey statements, and then the standard deviation for each mean was

calculated. The demographic data were categorized at the nominal level of measurement, and the data for the 18

Likert-type statements were categorized at the ordinal level of measurement. The one qualitative item produced

common themes. The quantitative data were entered into excel for analysis.

4. Survey Instrument

4.1 New Survey Instrument

After a thorough review of the literature, the survey instrument was created by the researchers. The Likert-type

scale used for perception statements were strongly disagree (1), disagree (2), agree (3), and strongly agree (4).

The responses were based on three pictures with varying amounts of time spent on appearance. There were 18

statements in the survey. There were also three demographic items at the beginning of the survey to obtain more

information about the population. One qualitative question was used to collect data to complement the

quantitative findings.

4.2 Instrument Reliability and Validity

This survey did not have established reliability as it was created for this study. However, it was peer-reviewed by

two peers and two nursing professors to obtain face-validity. Care was taken to protect from bias.

5. Informed Consent and Confidentiality

Informed consent was used for this survey. The data were kept anonymous by excluding the participants’ names

and other identifying information. Keeping the consent separate from the survey’s in different envelopes ensured

confidentiality. The National Institutes of Health (NIH) certificates entitled “Protecting Human Research

Participants” was completed by the researchers. Approval from the librarian was also obtained to use the lobby

prior to collecting data.

All collected data for this research were submitted to the School of Nursing, to be stored electronically for three

years. The School of Nursing staff scanned the data into the computer and stored it on discs. These discs will be

locked in a storage cabinet in a locked storage room. No one other than the nursing administrators or the research

coordinators will have access to the documents.

6. Results

The surveys were collected, and the results were tallied. The surveys were examined for completeness. The

frequency and percentage of the demographic items were calculated. Mean, and the standard deviation was

calculated for the survey responses. Common themes among the qualitative item were identified. The results

indicated what college students found to be the professional appearance of the nurse. A higher mean value

showed agreement in the opinion of what was professional, prepared, confident, trustworthy, compassionate, and

lazy. The standard deviation was calculated for each item to verify variability of the data. Results of the

quantitative study were compared to the literature. Orem’s theory of self-care determined perceived

professionalism through the appearance of the nurse.

6.1 Demographics

A total of 120 college students participated in this study with ages ranging from 18 to 26 years. Table 1

illustrates the descriptive statistics of the participants. The most common age range was 18-20 (61%). There

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were more females (59%) than males (41%) surveyed. Almost all participants, 119 (99%) had seen a nurse in

uniform.

Table 1. Descriptive statistics for participant demographics

Variable f %

Age range

18-20 73 61

21-23 38 32

24-26 9 7

Gender

Male 49 41

Female 71 59

Have you seen the nurses in their

uniforms?

Yes 119 99

No 1 1

Note. (N=120)

6.2 Response to Research Question

The research question was: “How do college students perceive the professional appearance of the nurse?” This

portion of the survey contained 18 items related to opinions of perceived professionalism using three pictures

varying in attentiveness. The items explored how people perceive each picture using terms such as

professionalism (Q1), preparedness (Q2), confidence (Q3), trustworthiness (Q4), compassion (Q5), and laziness

(Q6). The responses corresponded with a number related to the Likert-type scale rated 1 as strongly disagree to 4

strongly agree. The mean values demonstrated the agreement in responses and opinions. A mean of 2.5 or higher

indicated an agreement in opinion.

6.3 Picture A: Sufficient Time Spent on Personal Appearance

In Table 2, the statements had a mean from 1.87 to 3.25, and for Figure 1. Picture A, most of the participants

agreed, displayed professionalism (M=3.25, SD=0.57), and preparedness (M=3.25, SD=0.57). Other statements

ranked lower, including trustworthiness (M=2.83, SD=0.70), confidence (M=2.75, SD=0.77), and compassion

(M=2.43, SD 0.66). The lowest level of frequency was laziness (M=1.87, SD=0.71). Picture A was seen to be

professional and demonstrated preparedness while lacking in compassion. Picture A was seen to be the least

lazy.

Table 2. The appearance of the nurse and perceived professionalism Picture A

Variable M SD

I feel picture A shows professionalism 3.25 0.57

I feel picture A shows preparedness 3.25 0.57

I feel picture A shows trustworthiness 2.83 0.70

I feel picture A shows confidence 2.75 0.77

I feel picture A shows compassion 2.43 0.66

I feel picture A shows laziness 1.87 0.71

Note. (N=120). Student participants answered using a 4-point Likert-type scale, where 1 is the lowest agreement

(strongly disagree), and 4 is the highest level of agreement (strongly agree).

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Picture A Picture B Picture C

Figure 1. Image of a nurse based on time spent on personal appearance

Picture A: Sufficient Time Spent on Personal Appearance

Picture B: A Little Time Spent on Personal Appearance

Picture C: Very Little or No Time Spent on Personal Appearance

6.4 Picture B: A Little Time Spent on Personal Appearance

In Table 3, the statements had a mean between 2.31 and 2.81. As shown in picture B, most of the participants

agreed that the image displayed preparedness (M=2.81, SD=0.68), and professionalism (M=2.59, SD=0.69).

Other statements ranked lower, including confidence (M=2.61, SD=0.69), trustworthiness (M=2.57, SD=0.67),

and compassion (M=2.42, SD 0.62). The lowest level of agreement was laziness (M=2.31, SD=0.74). Picture B

was perceived as being prepared and confident. Picture B ranked lower in compassion and trustworthiness.

Picture B had less attentiveness in appearance than Picture A, and the results show this connection. Picture B had

a lower mean for all of the asked statements. Picture B was ranked lower than Picture A. When comparing

Picture B to Picture A, the research validated the assumption in that more attentiveness spent on appearance

would be perceived as more professional. Picture B demonstrated how less time spent on appearance could affect

the perceived professionalism of the nurse.

Table 3. The appearance of the nurse and perceived professionalism Picture B

Variable M SD

I feel picture B shows preparedness 2.81 0.68

I feel picture B shows confidence 2.61 0.69

I feel picture B shows professionalism 2.59 0.69

I feel picture B shows trustworthiness 2.57 0.67

I feel picture B shows compassion 2.42 0.62

I feel picture B shows laziness 2.31 0.74

Note. (N=120). Items were rated on a 4-point Likert-type scale ranging from 1 (Strongly Disagree) to 4 (Strongly

Agree), higher means indicate a higher level of agreement

6.5 Picture C: Very Little or No Time Spent on Personal Appearance

In Table 4, the statements had a mean from 2.23 to 2.74, and for picture C, most of the participants agreed that

the image displayed preparedness (M=2.74, SD=0.90), and professionalism (M=2.53, SD=0.91). Other

statements ranked lower, including trustworthiness (M=2.4, SD=0.80), laziness (M=2.39, SD=0.94). The lowest

level of frequency was compassion (M=2.23, SD=0.68). Picture C demonstrated that less attentiveness to

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appearance was viewed lower in professionalism. One interesting finding was that in picture C, having pockets

full of equipment needed for daily job tasks were perceived as being prepared.

Table 4. The Appearance of the nurse and perceived professionalism Picture C

Variable M SD

I feel picture C shows preparedness 2.74 0.90

I feel picture C shows professionalism 2.53 0.91

I feel picture C shows trustworthiness 2.4 0.80

I feel picture C shows laziness 2.39 0.94

I feel picture C shows confidence 2.24 0.86

I feel picture C shows compassion 2.23 0.68

Note. (N=120). Items were rated on a 4-point Likert-type scale ranging from 1 (Strongly Disagree) to 4 (Strongly

Agree), higher means indicate a higher level of agreement

6.6 Qualitative Themes

The qualitative question was, “Please describe in your own words how the nurse’s appearances portray

professionalism.” The images portrayed a nurse in various states of a professional dress with the focus on the

uniform. The model was not smiling in any of the pictures, maintaining a neutral facial expression that would not

skew participant impressions of the images. Recurring themes included smiling and uniform colors (see Figure

2). Participates did not want a nurse wearing dark, gloomy colors. It was discovered that people want a nurse

who looks approachable and friendly. The emerged themes were that they liked a nurse to be seen as a

professional but also caring and trustworthy. It is perceived that participants want a well-rounded nurse. A

surprising theme discovered was that some participants felt t

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