Underwear, Tattoos, and Patient Safety

As one healthcare system lays down the law with strict rules around employee dress—to the point of mandating underwear—it's worth asking what dress codes are really for. And is it time to relax them?

Between the influx of new residents straight out of med school and rising summer temperatures, employees may be baring more than they normally would (or perhaps should). What's the appropriate dress code policy for your organization?

Earlier this month, Akron, OH-based Summa Health System enacted a particularly restrictive dress code that not only bans visible tattoos and body piercings—which are standard strictures in dress codes—but also lists acceptable hair colors, stipulates that men's beards be kept shorter than a half-inch, requires female employees to wear hosiery with dresses or skirts, and insists that all employees must wear underwear, and that "the color, design, and style [of these garments] not be visible through clothing."

The policy has drawn objections from some employees and garnered local attention.

Summa Health's spokesperson, Mike Bernstein, declined my request for an interview, but he sent a statement saying that his organization "[has] a thorough dress code policy in place that is reviewed on a regular basis and updated as needed," and that "the specific requirements of the policy are designed with the best interests and safety of our patients in mind as well as to ensure the image we portray as an organization is characteristic of our outstanding reputation in the community" He says the new dress code is representative of the feedback the organization has received from patients.

Decoding the Dress Code
Jennifer Henley, institutional board member at the National Association for Health Care Recruitment and vice president of client services for NAS Recruitment Innovation says that dress codes help organizations convey a desired impression. "I think staff dress codes are really to promote a consistent, professional image throughout the organization," she says, adding that she believes that most healthcare workers are comfortable with most dress codes.

"Healthcare professionals are there to help their patients feel safe and comfortable, and to provide them care. I think they'll honor any particular guidelines that are in place."

But rules regarding employee dress are a contentious topic for some healthcare workers.

"I'm never quite sure what hospitals are trying to do with dress codes," says Jean Ross, RN, co-president of National Nurses United. "And when it comes down to underwear, how do you police that? Has underwear really been an issue?"

She also questions whether strict policies on body art are realistic as a growing number of young people—as many as 40% by some estimates—have a tattoo.

"I know people have their own opinions about tattoos and piercings, but many healthcare workers, including nurses, physicians, radiology techs, social workers, and nurse's aides—have them. They're increasingly common. And I don't know why there's such uproar over them. If I were a patient and my nurse were competent and caring, and she also had a stud in her nose…I wouldn't care," Ross says.

Ross views dress codes and strict body art policies as an attempt by employers to establish control over their image. She remembers that a hospital where she worked 35 years ago was among the last to allow nurses to wear pants. "It was in a well-to-do suburb, and the feedback the patients gave was that one of the reasons they liked the hospital was that the nurses all looked so nice in their starched white dresses and caps," she says.

"Sometimes, [dress and body art policies are] meant to appeal to a certain demographic, but very often, people who make these policies have an idea in their minds about what's proper and what isn't."

Should Tattoos Remain Taboo?
Organizational image is one thing, but there is little science behind mandating that tattoos and piercings stay hidden or that hair be dyed a natural hue.

There is zero risk of a patient getting an infection from a healed piercing or tattoo, says Scott DeBoer, RN, who is medical consultant for Association of Professional Piercers and founder of Peds-R-Us Medical Education, as well a transport nurse with MedExpress Urgent Care in Chicago.

"The bigger [safety] issue is actually on [healthcare workers'] side—if a tattoo or piercing is not healed, there's a better chance of the clinician coming into contact with bacteria from the patient and the tattoo or piercing becoming infected. But not from a nurse or physician to the patient, no."

Tattoos generally take about 45 days to heal; most piercings take about six to eight weeks.

Despite the lack of health risks to patients, DeBoer says tattoos, piercings, and other non-traditional looks just don't fit most people's ideas of how a clinician should look. "If you talk to patients, they really prefer someone more traditional in appearance…. If you look at patient satisfaction surveys around physician appearance, it's clear that patients really aren't comfortable with body art."

What's the Right Policy?

When it comes to wearing underwear, neither DeBoer nor Ross can think of any risks for either the patient or medical staff associated with going commando.

But both point out that some more commonly accepted accessories can transmit bacteria to patients.

"Several of our hospitals have policies on fake nails," says Ross, since bacteria can hide under fake nails and it's possible to accidentally scratch a patient. "Something like that makes sense to me." She also says that it's common sense to not wear dangling earrings or hoops when working in pediatrics.

DeBoer points out that in parts of Europe, physicians are banned from wearing neckties due to the possibility of germs traveling on them.

So why the discomfort around tattoos, but diminished awareness around long nails and neckties?

"I think it's because it's just not the tradition," says DeBoer, echoing Ross's memories of nurses dressed in traditional attire. "If you look back at nursing, for hundreds of years it was nurses in all white dresses with the white cap. And maybe there's part of us that still wants to see that."

But here's something recruiters, HR leaders, and hiring managers should consider: The clinician shortage shows no signs of stopping. As tattoos, piercings, and funky hair color become increasingly popular, might it not make sense to consider adjusting dress codes to appeal to younger workers?

DeBoer thinks so. "With younger nursing staff, physician staff, body art, and untraditional fashion are just so commonplace. If there's a [clinician] shortage, there's a need to attract people. I'd say it's a good time to reconsider being choosy."