conclave attire presentation [read-only] khakis and polo shirt most preferred for male pts;...

Conclave 2013 - What You Wear to Work: Appropriate Attire and Professional Image for Our Doctoring Profession

10/7/2013

Property of Ingram & Fell. Do not copy without permission. 1

What You Wear to Work: Appropriate Attire and Professional Image

for Our Doctoring Profession

APTA National Student Conclave

Louisville, KY

2013

Speaker• Debbie Ingram, PT, EdD, FAPTA

– University of Tennessee at Chattanooga

Moderator• Janice Kuperstein, PT, PhD

– University of Kentucky

Panelists• Paul Rockar, PT, DPT, MS

– President of APTA BOD

• Sharon Dunn, PT, PhD, OCS

– VP of APTA BOD

• Kathy Mairella, PT, DPT, MA

– APTA BOD member

• Josh D’Angelo, SPT

– President APTA Student Assembly

• Mike Muscarella, President of KY Chapter

Objectives

• Examine evidence in the literature regarding professional attire

• Identify practical professional attire for physical therapy settings

• Appreciate the professional image (or lack thereof) portrayed when choosing clinic attire

Does it really matter what you wear and how you look? • First impressions make a difference. We mostly

remember what we see:

• 83% visual

• 11% auditory

• 3% smell• Pease B., Pease A. (2004). The Definitive Book of Body Language. New

York, NY: Bantam Books.


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Stakeholders

• Physical Therapists

• Physical Therapist Assistants

• Students

• Patients/Families/Public

• Health Care Providers/Employers

• Referral Sources

• Payors

Fashion Show

Images from our clinical experiences

Quiz 1

What do you remember about these models?

Describe the projected images.

Healthcare Literature

• Since the days of Hippocrates, doctors have been aware of the importance of their appearance. “Even in primitive societies, the way the healer dressed was part of the paraphernalia and ritual of healing.”

• Menahem S, Shvartzman P. Is our appearance important to our patients? Family Practice. 1998;15(5): 391‐397

• Multiple studies indicate patients prefer physicians wear formal or professional attire

Patient Preference of White Coat

– Survey of patients in the waiting room of an internal medicine outpatient clinic

– Asked questions related to their preference for physician attire as well as their trust and willingness to discuss sensitive issues

– 76.3% preferred white coat

• Followed by surgical scrubs, business attire (suit), and causal attire (jeans and shirts)

– Trust and confidence was closely associated with patient preference for professional attire.

– Patients made trust and confidence decisions based on pictures of physicians they had never met

» Rehman et al, 2005

Patient Preference of White Coat

• 586 adult patients (combination of inpatients and outpatients; various ages)

• Regardless of demographic characteristics, patients preferred physician in white coat

• Patients felt need to identify the physician besides just wearing a badge

• Least confidence in physician casually dressed in jeans

» Gherardi et al, 2009


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Surgeon Attire (In Office)• Comparison of older patients, students, and surgeons’ preferences for physician attire

• Surgeons and students preferred:

– Male in his 50’s wearing white coat, white dress shirt, conservative hair, gray dress pants, brown leather belt, stethoscope in pocket, and outdoor shoes

• Patients preferred:

– Male in his 20’s wearing white dress shirt, conservative hair, belt, neat beard

» Rowland et al, 2005

Least desired

• Same study (Rowland et al, 2005)

– Least confidence and preference

• Colorful attire

• Casual shoes

• Stethoscope hanging around the neck

• Unkempt hair

• Casual slacks

Surgeons’ Attire

• Study of 38 surgical inpatients, 38 surgeons, 334 non‐hospitalized people

• Surgeons and patients preferred surgeons wear white coats when seeing patients; public did not

• Surgeons indicated scrubs and clogs OK to wear when seeing patients; patients and public did not

• Tennis shoes and jeans not preferred by any group Major et al, 2005

Patient Preferences in Podiatry Clinics

– Patients in podiatry settings (private clinic, hospital clinic)

• 96% either preferred white coats or were indifferent to their presence

• 68% felt that professional attire inspired confidence» Budny et al, 2006

“What is the uniform of evidence‐based dressing?”

• Study of 275 outpatients

• Evidence based medicine suggests ties and lab coats do not pass the infection control tests

• Physicians varied attire over 7 month period

• Patients preferred and had confidence in physician wearing lab coat, dress shirt and tie; minimum of 2 our of 3 were necessary

» Nair, et al., 2002

Infection Control

• Concern with healthcare associated infections

– “disease‐causing bacteria can survive on clothing”

• Guidelines in Great Britain recommend:

– Short‐sleeved shirts, no lab coats, no ties (functionless)

• Pre & post test responses of 100 inpatients

– Once told about the possibility of infections, patients changed preference from formal, semiformal and white coat to smart‐casual and scrubs

» Shelton et al, 2009


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Demographic Differences• Cultural differences may influence patient preference

– Study in TN compared patient opinions from large teaching hospital clinic (n=285; higher indigent population; higher African American population) vs suburban private practice (n=211).

• Nametag, white coat, stethoscope most desirable

• Sandals, clogs most undesirable

– Differences:

• Casual attire (scrubs, tennis shoes, clogs, blue jeans) not desirable at suburban private practice

• Younger patients more accepting of clogs, earrings on men

» Keenum et al, 2003

Less Formal Attire in Other Countries

• 202 inpatients and 249 outpatients‐New Zealand

• Patients preferred semiformal attire over formal suits and/or white lab coat.

• Facial expression of a smile positively influenced preference

• Patient age influenced preference; older patients preferred white coat

• Jeans and casual attire least preferred– Lill MM, Wilkinson TM, 2005

Identification

• Study of 75 inpatients in the UK

• Majority said it was difficult to distinguish between healthcare workers

• Some indicated it was difficult to distinguish doctors from the general public in a hospital setting; some physicians didn’t introduce themselves, etc.

» Palazzo et al, 2009

Color Coding Trends

• Difficulty for public to recognize different healthcare workers/professionals

• Move to solid colored scrubs in designated colors by department

» http://timesfreepress.com/news/2012/jan/13/erlanger‐employees‐are‐now‐color‐coded‐department‐/

Pediatric Research

• Survey of 112 hospitalized children and their parents

• Preferred multi‐colored scrubs with designs & improved relationships

» Festini et al, 2008

What about Physical Therapists?

How a physical therapist presents himself/herself in a professional manner impacts the success of the patient‐therapist relationship. The patient’s initial view of the therapist may be largely influenced by the way the therapist chooses to dress.

A professionally and appropriately dressed physical therapist may convey the idea that he or she is well‐informed and meticulous, whereas an unkempt appearance might be perceived as evidence of disorganization.


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So…what should we wear?

• Physical therapists provide services to patients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes.

• According to the Guide to Physical Therapy Practice, the duties of a physical therapist include:– (1)diagnosing and managing movement dysfunction and enhance

physical and functional abilities, (2)restoring, maintaining and promoting not only optimal physical function but optimal wellness and fitness and optimal quality of life as it relates to movement and health, (3) preventing the onset, symptoms and progression of impairments, functional limitations and disabilities that may result from diseases, disorders, conditions or injuries.

» APTA Guide to Physical Therapist Practice

Practicality

• Physical therapists work in a variety of settings to include: – hospitals, outpatient clinics or offices, rehabilitation facilities,

skilled nursing, extended care or sub acute facilities, home health settings, education or research centers, schools, hospices, corporate or industrial health centers, athletic environments, fitness centers and sports training facilities.

• Due to the extensive practice settings and hands‐on treatment approach, work clothing must be comfortable and functional, as well as professional

Patients’ Perception Regarding PT Attire

• To determine patient preference, perceived practicality, and confidence in physical therapists

• Survey instrument developed by the authors

– 6 pictures of male PT wearing various attire

– 6 pictures of female PT wearing similar attire as male pictures

• Surveys distributed in outpatient, rehab hospitals, acute care and skilled nursing facilities

• 193 subjects

Ingram et al, 2011

Requested Demographic Information

• Gender

• Race

• Age

• Occupation

• City, state

• Highest education/ degree earned

• Physical Therapy setting type

• Primary payor

A B C D E FA B C D E F


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Fashion Show

Results

• Patients most preferred PT attire: scrubs

• Patients choice for most practical PT attire: scrubs

• Most confidence in PTs wearing scrubs; did not have confidence in PT wearing business suit

Preference Differences• Differences by setting:

– OPs preferred collared polo shirt and khakis

– Patients in acute care, rehab & SNFs preferred scrubs

• No differences by patient gender

• Differences by patient age:

– Younger patients (ages 18‐35) preferred T‐shirt and shorts for the male PT

• Differences by patient education level:

– High school graduates preferred scrubs

– College graduates preferred collared shirts/khakis

Interesting Findings

• Patients preferred the female PT wear a lab coat if not wearing scrubs

– Khakis and polo shirt most preferred for male PTs; T‐shirt and shorts preferred over lab coat

Companion Study

• Clinic Directors’ Opinion Regarding PT Attire

• 70 participants‐representing OP, AC, SNF, rehab settings

• Most preferred and practical: khaki slacks & polo shirts; Low preference for shorts

• Differences by setting: OP directors preferred khaki slacks & polo shirts; IP directors preferred scrubs

» Ingram et al, 2012


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Additional Professional Image Considerations

First Impressions?

http://static.neatrorama.com/images/2007-09/tattooed-doctor.jpg

First Impressions

http://static.neatrorama.com/images/2007-09/tattooed-doctor.jpg

Tattoos and Piercings

• ~45 million Americans have tattoos

– 16% of all adults

– 36% of adults 25‐29 years old

2003 Harris Interactive Poll

New York Times, 1/16/12

http://www.tattoo-hand.net


• 2001 nationally representative online poll – 1,009 adults – 1 in 6 adults have or have had a tattoo or body piercing

Millner & Eichold, 2001

• 2006 telephone survey report – 500 respondents 18‐50 years – percentage of persons with body art or considering body art increased as the year of their birth increased

Laumann & Derick, 2006


• Found in a variety of

– Age groups

– Ethnic groups

– Socioeconomic groups

– Profession

http://sturgiszone.com


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• Used to be associated with

– Lower socioeconomic groups

– Certain religions

– Certain ethnic groups

– Military

• Now considered mainstream

http://photoblog.piercingmap.com/images

Why do people get tattoos or body art?

• Self‐expression– Sometimes related to life status change

• Adulthood, military, gang induction

• Esthetics– Fashion accessory

• A desire to be different

• An expression of uniqueness

• A statement of independence

• A way to make life experiences stand out

Armstrong, et al, 2007 & 2008Forbes, 2001

Gardyn, 2001

• 85% of respondents believed that people with body art should realize that it is likely to create career and personal obstacles.

• 75% supported an employer’s right to impose dress codes limiting body art.

Seiter and Sandry, 2003

• Explored the employment of people with body piercings

• Respondents viewed people with body piercings as “having issues related to credibility and hiring appeal.”

Attitudes Towards Tattooed People

• Surveyed Population

– Health care providers (MDs, RNs, LVNs)

– Medical and Nursing Students

– N = 513, across 22 U.S. states

• Attitudes toward tattooed adolescents and adults

– Assuming these could be patients

• Questionnaires

Stuppy, Armstrong & Casals-Ariet, 1998

Armstrong Tattoo Scale

• 16 pairs of contrasting adjectives representing beliefs about persons with tattoos

– Ugly or Beautiful

– Impulsive or Deliberate

– Crude or Refined

• Then rated from 1 (strongly agree negative) to 7 (strongly agree positive)

• Cronbach’s alpha ranged 0.92 – 0.95



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Representations of Tattooed People

• Professional Men

• Non‐Professional Men

• Professional Women

• Non‐Professional Women

• Adolescents (13‐18 yrs)


Respondents

• 56% married• 83% female• 68% worked in an inpatient setting• Professionals’ age range 20‐66 years (mean 37, SD = 9.9) with average of 5 years education beyond high school

• Students approximately 10 years younger• 8.5% reported having one or more tattoos• 25% reported having family members with tattoos


Attitudes Towards Tattooed People

• No respondent groups had mean scores reflecting a positive attitude

• MDs and RNs rated tattooed people less favorably than students

• Womens’ attitudes were consistently less favorable than those of men, especially related to tattooed professional women

• Attitudes toward tattooed adolescents were less positive that attitudes toward adults


Physicians and Facial Piercings

• Vanderbilt Medical Center

• Photos of models with and without piercings

– Likert scale surveys exploring attitudes (N=319)and competency (N=301)

– Eyebrow, nose stud and lip labret piercings, male earrings

• Emergency department patrons and medical school faculty physicians

Newman et al, 2004


• Mean ER respondent age was 40 years

– 24.8% had tattoo(s)

– 15.7% had nontraditional piercing(s)

• “It would bother me to have a physician with this type of jewelry care for me or my family in the emergency department/primary physician.”

– 31.3% ER; 34% PCP Nose Stud

– 20.4% ER; 24.1% PCP Male Earring

– 40.1% ER; 41.7% PCP Lip Labret

Newman et al, 2004


• Age differences

– 50 and older: more likely to find all 3 types of piercings inappropriate

• Ex: 63.2% nose stud

– Under 50: large percentage also felt it inappropriate

• 41.3% nose stud

• 23.8% male earring

• 45.3% lip labret

Newman et al, 2004


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• Subjects with one or more tattoos or body piercings were less likely to find physicians with piercings inappropriate– But still, significant percentage felt inappropriate

– 33% nose stud; 17.5% male earring; 39.2% lip labret

• No association with level of post‐secondary education

Newman et al, 2004


• Same female model with piercing/without piercing

– 44.4% and 68.8% rated competent by ER respondents

– 47.8% and 69.8% rated trustworthy by ER respondents

Newman et al, 2004

Faculty Physicians’ Opinions

• 432 of 796 surveys returned

• Mean age 49.5 years

• 24.8% female

• 2.1% had a tattoo and 5.6% had a nontraditional piercing

Newman et al, 2004

Faculty Physicians’ Opinions

• Overall, physicians felt that the piercings were inappropriate.

• 73.5% felt an eyebrow piercing was inappropriate

• 24% would be bothered by a male colleague with an ear piercing

• 58.2% would be bothered by a colleague with a nose piercing

• 58.7% would be bothered by a colleague with an eyebrow piercing

Newman et al, 2004

Attire study: Jewelry, Hair & Makeup

• 2 MD family practice clinics in Knoxville, TN

• Seven physical characteristics significant for male physicians and 4 for females

– Male (same for older and younger respondents):

• Undesirable: earrings, long hair/ponytails

– Female (same for older and younger respondents):

• Undesirable: lipstick and short hair

Barger Stevens, et al, 2003

Nursing Personnel Policy Addressing Body Art

• Evidence‐based model to develop a personnel policy

• Systematic literature review and telephone survey of 15 hospitals

Sowart, Kuntz & Armstrong, 2010


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Nursing Personnel Policy Addressing Body Art

• Results– No literature relating to prevalence of body art among nurses

– No literature relating to effect of nurses’ body art

– 13 of 15 hospitals shared their body art policy• None had rationale or references to support their existing policies

Sowart, Kuntz & Armstrong, 2010

Clinic Directors’ Perceptions of PT Physical Appearance

• 118 directors responded (86% were PTs)

• Outpatient, home health, acute care, and inpatient rehab sites mostly in the south

– Accepted for CSM 2014: Fell, Ingram, English, Nethery, Williams

Results

• 94% preferred male control photo

• 96% preferred female control photo

• 79% least preferred male with facial piercings

• 73% least preferred female with facial piercings

• Younger directors were more confident in male with long hair and female with tattoo

• Older directors uncomfortable and not confident in female with facial piercings

Additional Study

• Completed study of 158 patients using similar survey instrument.

• Plan to submit these findings.


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More Than Just Image?

• Yes!

• Attitudes can impact patient care

Negative Attitudes Impact Patient Care

• Healthcare providers with more negative attitudes toward patients with cancer

– Avoid the patients

– Not plan assertive treatment goals

– Not implement rehabilitation strategiesBurns, 1988

Negative Attitudes Impact Patient Care

• Clients with HIV/AIDSGoldenberg & Laschinger, 1991

Jemmott et al, 1992

Laschinger & Goldenberg, 1993

Tessaro & Highriter, 1994

Tsai & Keller, 1995

• Over 50% of nurses studied would refuse assignment to patients who are HIV positive, if given the option

Wiley et al, 1990

References• American Physical Therapy Association. APTA Vision Statement for Physical Therapy 2020.

http://www.apta.org/Vision2020/. Accessed May 2, 2011.

• American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd Edition. Alexandria, VA: APTA; 2001.

• Armstrong ML, Robetrs AE, Koch JR, Saunders JC, Owen DC. Investigating the removal of body piercings. Clinical Nursing Research. 2007; 16(2):103‐118.

• Armstrong ML, Robetrs AE, Koch JR, Saunders JC, Owen DC, Anderson RR. Motivation for contemporary tattoo removal. Archives of Dermatology. 2008; 144(7):879‐884.

• Barger Stevens AR, Keenum AJ, Silver Wallace L. Patients’ attitudes regarding physical characteristics of family practice physicians. Southern Medical Journal. 2003; 96(12):1190+.

• Brosky ME, Keefer OA, Hodges JS, Pesun IJ, Cook G. Patient perceptions of professionalism in dentistry. Journal of Dental Education. 2003; 67(3):909‐915.

• Budny A, Rogers L, Mandracchia V, Lascher S. The physicans’ attire and its influence on patient confidence. JAPMA. 2009;96(2):132‐138.

• Burns N. Selecting a tool for measuring cancer attitudes. In Instruments of Clinical Nursing Research (Frank‐Stromborg M. ed.), Appleton & Lange, Norwalk, CT, pp. 297‐309.

• Dorwart SD, Kuntz SW, Armstrong ML. Developing a Nursing Personnel Policy to Address Body Art Using an Evidence‐Based Model. J Cont Educ Nurs. 2010; 41(12):540‐546.

References• Fell N, Ingram D, English L, Nethery H, Williams C. Clinic directors’ perceptions of physical

therapist physical appearance. Accepted for Presentation at APTA Combined Sections Meeting, 2014.

• Festini F, Occhipinti V, Cocco M, Biermann K, Neri S, Giannini C, Galici V, de Martino M, Caprilli S. Use of non‐conventional nurses’ attire in a pediatric hospital: a quasi‐experimental study. J Clin Nursing. 2008;18:1018‐1026.

• Forbes GB. College students with tattoos and piercings: Motives, family experiences, personality factors, and perception by others. Psychological Reports. 2001; 89:774‐786.

• Gardyn R. Ink me, stud. American Demographics. 2001; 232:9‐11.

• Gherardi G, Cameron J, West A, Crossley M. Are we dressed to impress? A descriptive survey assessing patients’ preference of doctors’ attire in the hospital setting. Clin Med. 2009; 9(6)519‐24.

• Goldenberg D, Laschinger H. Attitudes and normative beliefs of nursing students as predictors of intended care behaviors with AIDS patients: a test of the Ajzen‐Fishbein Theory of Reasoned Action. Journal of Nursing Education. 1991; 30(3):119‐126.

• Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient preference, perceived practicality, and confidence associated with physical therapist attire: a preliminary study. PTJ‐PAL. 2011; 2‐8.

• Ingram D, Fell N, Grubb M, Higgins J, Royal A. Physical therapy clinic directors’ perspective on physical therapist attire. PTJ‐PAL. 2012;13‐20.

References• Jemmott LS, Jemmott JB, Cruz‐Collins M. Predicting AIDS patient care intentions among

nursing students. Nursing Research. 1992; 41(3):172‐177.

• Keenum AJ, Wallace LS, Stevens AR. Patients’ attitudes regarding physical characteristics of family practice physicians. South Med J. 2003; 6(12):1190‐4.

• Laumann AE, Derick AJ. Tattoos and body piercings in the United States: A national data set. Journal of the American Academy of Dermatology. 2006; 55(3):413‐421.

• Lill M, Wilkinson T. Judging a book by its cover: descriptive survey of patients’ preferences for doctors’ appearance and mode of address. BMJ. 2005;331:24‐31.

• Major K, Hayase Y, Balderrama D, Lefor AT. Attitudes regarding surgeons’ attire. Am J Surg.2005;190:103‐106.

• Millner VS, Eichold BH. Body piercing and tattooing perspectives. Clinical Nursing Research. 2001; 10(4):424‐441.

• Nair B, Attia J, Mears S, Hitchcock K. Evidenc‐based physicians’ dressing: a crossover trial. MJA. 2002;177(11/12):681‐682.

• Newman AW, Wright SW, Wrenn KD, Bernard A. Should physicians have facial piercings? J Gen Intern Med. 2005; 20:213‐218.

• Palazzo S, Hocken DB. Patients’ perspectives on how doctors dress. J Hosp Inf.2010;74:30‐34


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References

• Rehman S, Nietert P, Cope D, Kilpatrick A. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118:1279‐1286.

• Shelton CL, Raistrick C, Warburton K, Siddiqui KH. Can changes in clinical attire reduce likelihood of cross‐infection without jeopardizing the doctor‐patient relationship? J Hosp Inf. 2010;74:22‐29.

• Stirn A. Body piercing: medical consequences and psychological motivation. Lancet. 2003; 361:1205‐15.

• Stuppy DJ, Armstrong ML, Casals‐Ariet C. Attitudes of health care providers and students towards tattooed people. Journal of Advanced Nursing. 1998; 27:1165‐1170.

• Takeda MB, Helms MM, Romanova N. Hair color stereotyping and CEO selection in the United Kingdom. Journal of Human Behavior. 2006; 13(3):85‐99.

• Tessaro I, Highriter M. HIV and the work intentions of public health nurses. Public Health Nursing. 1994; 11(4):273‐280.

• Tsai Y, ikeller ML. Predictors of Taiwanese nurses’ intention to care for patients who are HIV positive. Clinical Nursing Research. 1995; 4(4):442‐464.

• Wiley K, Health L, Acklin M, Earl A, Barnard B. Care of HIV infected patients: Nurses’ concerns, opinions, and precautions. Applied Nursing Resesarch. 1990; 3(1):27‐33.

Discussion

• We have now heard about various elements of appearance that influence your patients' impression of you as a health professional. How do these elements affect the emergence of physical therapists as members of a "doctoring profession"?

Discussion

• In what ways might the appearance of an individual clinician or of the members of the practice affect clinical outcomes? How might this affect the other aspects of the practice?

Discussion

• The last decade has seen tattoos, facial piercings, and less conservative, more casual attire become mainstream. How can young adult physical therapists navigate their professional appearance when these elements may increase rapport and trust with some patients (who view these things positively), but significantly inhibit rapport and trust for other patients who view them as negatives?

Discussion

• Do you believe patient adherence may vary with the appearance of staff? If so, in which direction? Given the evidence of variation among different demographic groups, how does this inform decisions about developing clinic policies?

Discussion

• Are there specific issues in appearance that are likely to influence the hiring decision?

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