Stereotypes in the Healthcare Industry: Do They Care About Your Hair?

An Honors Thesis (HONRS 499)

By

Julia Buben

Thesis Advisor

Dr. Cynthia Thomas

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Ball State University

Muncie, Indiana

May 2010

Gradation Date: May 8, 2010

Abstract

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Stereotyping is a phenomenon that is ingrained in our culture. Stereotyping can have

devastating physical and emotional effects on people; however, the resulting impact of labeling

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someone can be reduced through education. At the beginning of my sophomore year I decided to wear

my hair in dreadlocks. I wore them because I liked the look of dreadlocks and had always wanted to

wear this hairstyle. At the same time, I was beginning clinical rotations in nursing school, and quickly

realized that the combination of my hairstyle and the expected appearance was not compatible. People

judged me differently on the basis of my "new look." I knew I was the same person on the inside, but on

the outSide, my appearance conveyed something different. I was not alone and was aware that other

people were subjected to the same negative effects of stereotyping. While stereotyping or labeling

occurs in all professions, it is especially difficult in the healthcare profession because ofthe patient-

provider relationship. This paper discusses stereotyping of people that occurs from body piercing,

tattooing, obesity and wearing alternative hairstyles within the healthcare industry. Healthcare

providers are encouraged to avoid judging their patients negatively on the basis of outward appearance

because the patient-provider relationship may be damaged.

Acknowledgements

I would like to thank Dr. Cynthia Thomas for advising me through the work of this paper. Her immediate

excitement about my topic and excellent editing skills made this paper a success.

I would also like to acknowledge Alexis Pawlarczyk for supporting me through it all . Thank you for your

recommendations, positive encouragement, and emotional support.

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Introduction

Stereotype casting is present in every profession, including the healthcare industry. Intelligence,

gender, ethnicity, sexual orientation, and outward physical appearance are commonly the subject of

stereotyping. In the work environment, employees are expected to conform in appearance to industry

standards leaving little room for individualism. Stepping outside the accepted standards opens the door

for stereotyping to occur. Outward personal appearances such as hairstyles, body piercings, tattoos,

and body weight are subject to the negative impact of stereotyping. Recognizing personal biases and

participating in education programs will help reduce stereotyping in our society.

Review of literature

Stereotyping is a learned phenomenon and is the processing and categorizing of information

about others, or an instrument for gathering data (Chan, 2010). Impressions are formed immediately,

often based on visual information. A categorization process occurs quickly once a first impression is

made. Franzoi, (1996), believed this was a natural process and people could not endure without

engaging in a form of social categorization. The process of labeling is second nature and occurs almost

without conscious consideration. Stereotyping is one step beyond merely categorizing others because it

includes a belief system. Learning begins at a young age and continues throughout life; people develop

beliefs about others according to the thoughts and beliefs ofthose around them. The strength of

stereotyping is usually reinforced by the degree of acceptance. Most people tend to gravitate towards

others that share similarities within the population they belong. A stereotyped behavior can be

maintained when people are unwilling to bypass the original thought or perception encountered, even

when additional information is discovered (Chan, 2010). This behavior is then ingrained and imbedded

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in the person's memory and conceptualized, creating future impression formation and categorization to

fit into these preconceived ideas and beliefs (Franzoi, 1996; Pickering, 2001).

The results of stereotyping range from being helpful or hurtful to the victim. Stereotyping

assists humanity because it frees the mind to consider other seemingly more important information and

alleviates the necessity to thoroughly process the impressions other people are providing (Franzoil,

1996). The negative aspect to stereotyping is the restraint the behavior creates by grouping people into

perceived categories without sufficient evidence. Failure to acknowledge the unique qualities in people

plays a role in forming impressions, leaving humanity destined to form unreasonable conclusions,

inhibiting a fair opinion of others (Franzoi, 1996). A lack of information during a first encounter may

open the door for stereotyping to occur, placing the individual into defined categories. Research has

confirmed that people gravitate towards the use of stereotyping behaviors unless evidence is present to

explain the contrary (Franzoi, 1996). Unfortunately, research also indicates that in spite of new

information compiled through multiple interactions, stereotype labeling remains (Gawronski, 2003).

Stereotyping is unhealthy because once made, the allowance for individual adaption is gone. In

addition, once labeling is accomplished, a person is likely to believe more is known about the individual

than is true.

Outward appearance and superficial features guide humanity in coming to conclusions more so

than individual personality traits. A nurse can be characterized as caring by smiling and outwardly

appearing kind, or by performing caring actions such as cradling a crying child or comforting a patient

after a difficult procedure. However, if the nurse has a visible tattoo or unusual hairstyle, (both outward

appearances) the nurse may be the victim of stereotyping and perceived as being tough and uncaring.

The priority will be given to the stereotyped impression regardless of kind deeds and actions the nurse

subsequently performs. This is only true when the person judging the character of the nurse has a

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strong opinion and association with tattoos and unusual hairstyling, indicating negative attributes. The

strong association prevents even multiple instances of caring to overcome the original bias (Chan, 2010;

Gawronski,2003).

Stereotyping may be considered an easy means of misinterpreting people. Instead of being

open-minded to new and different ideas about people, humans have the propensity to make quick

judgments, which can lead to becoming prejudice (Kruglanski, 2004). Correll, (2007); Kruglanski, (2004);

and Shih, (2009) found that black people are often stereotyped as being less intelligent, more aggressive

and more criminally minded than white people. Chang, (2007) believed that black people are also

stereotyped as being more athletically talented; however, white people are viewed as materialistic and

selfish. Asian people are stereotyped as being smart, introverted, and rule-followers (Chang, 2007;

Rochlen, 2008; Shih, 2007). There are also gender stereotypes, such as men being perceived as "bread­

winners," and not as stay at home parents, which is stereotypically a female role (Rochlen, 2008).

Sanchez, (2009) reported that gay men are believed to lack masculine traits such as being

competitive, or involving themselves in contact sports (Sanchez, 2009). Women, according to

stereotyping, should not participate in math and science professions, but should remain in more caring

roles such as nursing or teaching (Logel, 2009). Wentura, (2003) and Hess, (2006) found that older

adults are stereotyped as being closed-minded, slow in movement, and physically isolated, while

suffering from health problems, and possessing a poor memory. Football players are stereotyped as

being tough, enduring pain, and denying emotional issues (Steinfeldt, 2009). All these stereotypes

formed by beliefs in the American culture can lead to unrealistic and untrue judgments of others.

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Stereotyping within healthcare

Healthcare personnel desire to convey to patients that appearance is important. Physicians are

generally male, portray an image of being smart, donning a white lab coat over dress pants, with a

nametag (Bianchi, 2008; Gjerdingen, 1989; Newman, 2005). Nurses however, are portrayed as typically

female, conservatively dressed, kind, caring, and approachable (Festini, 2009). Physicians and nurses

are viewed by patients as competent and professional (Bianchi, 2008; Gjerdingen, 1989; Newman,

2005). When healthcare employees have an outward appearance that differs from the expected

cultural norm, a negative stereotype is applied.

Menahem and Shvartzman (1998) studied the importance of physician and nurse appearance

from the perception of the patient. Menahem and Shvartzman's (1998) findings suggested that patients

perceived clean, well-dressed physicians to be caring, while untidy, carelessly dressed physicians were

perceived as being unqualified and uncaring. The perception portrays an image of a healthcare

professional's physical appearance as a powerful symbol of job success, and that appearance affects

confidence and communication, concluding that appearance is crucial (Stein, 2007).

Mehahem and Shvartzman, (1998) found that a good personal appearance was not a substitute

for needing excellent clinical skills, but appearance was an important component in the development of

the physician-patient relationship. The relationship between a healthcare provider and patient is very

delicate. Trust is an important factor to the patient physician/nurse relationship. Research studies have

found that a negative or positive outward appearance changes the anxiety and comfort levels of

patients (Rizk, 2008). The healthcare industry has specific judgments and biases related to tattoos, body

piercings, extreme hairstyles, and overweight employees. These four distinguishing characteristics have

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become more prevalent and accepted in modern society, but still produce strong negative stereotyped

images.

Hairstyles

Hairstyles play an important part in stereotyping because they are one of the most obvious

images when looking at a person's outward appearance. Hair is one of the first things noticed and used

in impression formation (Mesko, 2004). The hairstyle may seem like it is an irrelevant piece in the

overall assessment of a person, when actually it is all that a person needs to trigger impression­

formation and a stereotyping, however inaccurate it may be (Brebner, 2009). Basic stereotyping

behavior indicates that men should have short hair, and women long hair (Brebner, 2009). However,

research also shows that women with large hairstyles are perceived as being powerful and authoritative

(Wilson, 2010). Blonde-haired women are often stereotyped as being incompetent (Takeda, 2006),

feminine, emotional, and pleasure-seeking, while brunettes are considered to be more intelligent than

other hair colors women wear (Mesko, 2004). Redheaded women are stigmatized as having a hot

temper, being clownish or wild, but also intellectually superior (Takeda, 2006; Heckert, 1997).

Redheaded males are perceived as being wimpy (Heckert, 1997). Balding men are stereotyped

as having greater intelligence although they are also considered less attractive, while men with short

hair are viewed as strong and physically active (Mesko, 2004). Stereotyping behaviors concerning hair

correlate with race as well. African American women who wear their hair in an afro style, braids,

dreadlocks, and knots are often perceived as being bold, rebellious, self-confident, and spiritually

conscious (Patton, 2006). Straight hair worn on white women indicates a bias towards increased sex

appeal (Patton, 2006). Beards, a hairstyle not altogether uncomplimentary in healthcare, elicit a

particular impression, which develops into a stereotype. Some people consider beards to be Ita sign of

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masculinity, strength, intelligence, and desirability," while others believe a beard represents

"recklessness, dirtiness, lower mental competence, and inferior intellectual ability, as well as a reduced

social maturity," (Stein, 2007). Evidence confirms that people associate certain beliefs about others

based on individual hairstyle.

Healthcare employees are expected to conform to a standard of acceptable hairstyles in an

attempt to avoid offending the patient. An important objective for healthcare workers is to develop an

appearance that demonstrates professionalism. Professionalism can be equated with a neat, clean

conservative appearance. When the conservative appearance is missing, the person is in jeopardy of

being judged or stereotyped. Rizk, (2008) warned nursing students to be aware that appearance outside

the normally accepted for the profession will increase the risk of clinical competence being judged solely

based on the outward appearance.

Tattoos and body piercings

The healthcare profession perceives tattoos and body piercings as health risks and a threat to

patient safety, but overtly the outward appearance gives a negative image of the caregiver. There is a

growing concern that people with body modifications (tattoos and body piercings) are likely to have

Hepatitis B, Cor HIV, extracted from a dirty needle (Halliday, 2005; Rizk, 2008). It is possible to develop

these diseases during body piercing or the tattooing procedure, but studies indicate that self-reporting

of Hepatitis B, C or HIV disease transmission is lacking (Halliday, 2005; Rizk, 2008). The concern for

infection posing a health risk to the safety of patients is legitimate, although not well-grounded or

pervasive in occurrence. Well-maintained body modifications should not be a threat to the safety of

patients (Rizk, 2008).

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In a recent study of the perception others have on tattooed individuals, participants indicated a

negative opinion in regards to attractiveness and caring personality traits. Those without tattoos were

considered more athletic, physically attractive, motivated, honest, more generous, and intelligent

(Resenhoeft,2008). Tattoos clearly heighten interpersonal opinions. Tattooed women reported

negative responses from physicians, nurses and the general public (Rizk, 2008). Fellows, (2006) found

that greater than half of the 100 healthcare employer participants interviewed believed that visible

tattoos and body piercings should prevent potential employees from being hired because the

appearance would greatly impact patients' perception of care.

Why do people perceive tattoos and body piercing negatively? Many individuals opposed to

body modifications place stereotypes on those individuals as being rough, gruff, and un-educated. A

participant comment from the Fellows, (2006) study indicated how strong the feelings were: liThe desire

for a good personal appearance has gone by the wayside. We are selling a product, healthcare, and

people expect to see professionalism as well as receive it. I grew up in an era where tattoos were only

worn by bikers, servicemen, or trashy people, and body piercing was only for ladies to wear their

earrings in" (p.4). The assumptions made regarding body modifications correlating with people

engaging in more risky behavior and fewer health promoting behaviors may not be factual. Research

has found that in an Emergency Department tattooed patients were no more likely than non-tattooed

patients to have an injury, illness, or psychiatric/chemical dependency issue (Rizk, 2008).

Tattooing is another image that is perceived negatively. A study of 1,010 participants concluded

that one in seven people have at least one tattoo and 20 million Americans with tattoos considered

themselves to have a 'soccer Mom image' or were 'average' (Fellows, 2006; Rizk, 2008). The majority of

people with tattoos and body piercings consider themselves adventurous and the tattooing art as a form

of self-expression and outward display of personal identity (Halliday, 200S). In an article titled, Are

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Tattoos and Body Piercings Acceptable in the Workplace?, a radiology technologist of 10 years stated, "A

tattoo on someone's arm does not brand him or her as unfit for imaging or treating patients. There is a

stereotype that tattoos and piercings are the special domain of miscreants and criminals. In reality

individuals have many reasons for inking themselves," (Greer, 2009, p.56). For this woman, having a

tattoo actually meant a sense oft rust was given to her by patients because the patients believed they

could be honest about themselves and their personal histories with her.

However, not everyone thinks the same way. Elizabeth Greer, a director of radiology at

University of New Mexico believes that working in healthcare means being part of a unified team with

matching goals and standards (Greer, 2009). The individuality demonstrated through tattoos and body

piercings sets healthcare providers apart from colleagues. Body art can be distracting to patients and

coworkers, and when it is excessive, it raises concerns about hygiene and patient safety. Greer says, lilt

should not be necessary to follow up on comments such as, 'The technician with all those piercings

scared me,III(Greer, 2009, p. 57}. Patients also questioned the cleanliness of a tattooed nurse. While

these examples are distressing, they indicate the reason healthcare management has implemented

strict policies regarding body modifications.

Body weight

Body weight does not evoke quite the same stereotypes as hairstyles, body piercings, and

tattoos mainly because people rarely make a conscious decision to become obese. Nevertheless, just as

people with body art and extreme hairstyles are stereotyped negatively in the healthcare industry, so

are overweight employees and patients. Obese employees may possibly be judged more harshly

because of the association between weight and good health. Although the healthcare industry should

be aware that many factors may contribute to obesity, evidence suggests that the individuals who

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stereotype against obese people fail to recognize this truth. Addressing Negative Attitudes to Weight

found that overweight individuals are not only subjected to discrimination in employment situations,

but also were stereotyped as being emotionally impaired, socially handicapped and possessing negative

personality traits (Williams, 2009).

Study findings by Williams, (2009) indicated body weight reflects many aspects of an

individual's character, such as motivation, willingness to work, ambition, personal control, and

discipline. The situation is even more heinous from the results of 81 employers' attitudes toward

employing obese people. The results indicated that 15.9% of employers believed that obese applicants

should be barred from employment and 43.9% believed that obesity was a valid medical reason for not

employing people (Williams, 2009). In another study concerning physicians' opinions of obese patients,

67% surveyed stated obese people lacked self-control, 39% thought obese people were lazy, and 34%

believed they were unhappy (Williams, 2009). Other physicians have perceived obese patients as weak­

willed, ugly, and awkward, and many nurses indicated a preference to not care for obese patients (Stein,

2007).

Patients' perceptions of obese healthcare workers mirror a similar mindset towards other

biases. One researcher wrote, "Any health professional, especially one who is recommending healthy

eating and regular exercise, needs to be aware of the impression physical appearance makes, although it

does not always accurately portray how hard or how little he or she works to maintain a healthy

weight," (Stein, 2007, p. 30). Unfortunately, studies have indicated patients perceive an obese provider

negatively. Patients place emphasis on the appearance of hairstyle, bodyweight, and body

modifications. The critical message is that biases and stereotypes towards outward appearance should

never dictate patient care .

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In 2005, the Employment Law Alliance (ELA) found that 39% of Americans believed employers

should have the right to deny employment to potential employees based on appearance (Le., clothing,

body weight, body art, and hairstyle (Fellows, 2006). Judgmental ideas form a barrier in creating a

caring and trusting relationship between healthcare provider and patient. The appropriate professional

appearance in healthcare will look different to everyone. Healthcare professionals are powerless to

justify outward appearance to patients. However, patients should not need to justify their appearance

to healthcare providers. A therapeutic relationship is holistic and culturally sensitive, bypassing personal

preference and seeing the true character of a person. One author stated, "Most healthcare

professionals have significant deficits in the area of cultural competence and holistic care," (Halliday,

2005).

Personal story

I experienced this stereotyping behavior for two years as a nursing student wearing dreadlocks

as a hairstyle. I first put my hair in dreadlocks because I liked the way they looked on other people; the

hairstyle was different and intriguing. My life up to that point was rather conventional: I was not a rebel,

I did not do many things out of the ordinary, and I played by the rules of society. For me, putting

dreadlocks in my hair was saying, "This is what I want to do, so I am going to do it, regardless of what

other people think." I knew the decision would be a commitment, but I did not realize the effect it

would have on my life. Many of my close friends were very accepting; they did not perceive me as

different or unusual because of my dreadlocks. My parents were rather shocked when I came home for

the first time with my new hairstyle; they did not expect their daughter to look so unconventional.

Several customers at the hardware store where I worked stopped having such friendly conversations

with me when I showed up to work with dreadlocks. Shortly after I put dreadlocks in my hair, a fellow

student exclaimed, "Gross! Why would you do that to you hair? You are so dirty!" Most people did not

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express such overt opinions openly. More often people would state, "You put strange things like

peanut butter in your hair don't you?" Many of my friend's parents were particularly concerned about

my hair, informing me of their opinion, "You know you won't ever get a job with hair like that!" It was

not easy to be criticized and not respond negatively.

I perceived a societal bias forming against me and believed I had to justify myself to others

because of my hairstyle, especially when I was around healthcare professionals. Simply entering a

hospital created extreme augmentation of being judged. I was judged on my appearance when in fact I

was an Honors student, who often led Bible study groups, preferred classical music, and enjoyed

knitting. However, no one knew this about me from the image the dreadlocks created. People formed

conclusions that I was dirty, lazy, strange, and more than likely involved in illicit drug use. My character

was the same before, during and after I cut off the dreadlocks. Yet I was subjected to uncomfortable

stares by other nurses, inappropriate comments by physicians, and received questions from patients

concerned about the dreadlock hairstyle. I finally realized the decision to wear dreadlocks was

negatively impacting the ability to assume the role of a professional care provider. I was confronted

with conflicting decisions to maintain the dreadlocks or remove them, conforming to the pressure of

being stereotyped as a person I was not.

Eliminating stereotyping behaviors

Negative stereotyping will never become obsolete in healthcare, however preventing the effects

from damaging the relationship between professional and patient is essential to providing quality care.

Currently, minimal steps have been taken to reduce the effects of negative stereotyping in healthcare.

Three things are crucial to changing the culture; (a) becoming aware of personal judgments and biases;

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(b) participating in continuing education concerning negative stereotypes; and (c) appreciating unique

and positive differences in others.

Personal attentiveness to thoughts, feelings, judgments, and biases can reveal reasons why

people develop stereotyping. It is often easier to continue making negative judgments and stereotyping

without discovering the underlying reasons. Realizing how judgments are formed creates a greater

likelihood of generating new, realistic strategies for interacting and forming impressions. Asking

personal questions such as, "Why do I think an overweight physician is not reliable?" "What makes me

perceive dreadlocks so negatively?" and "What in my past has taught me to think particular thoughts

and feelings about tattoos?" This personal inquiry can help uncover personal biases. Admitting the

truth about feelings and judgments concerning the outward appearances of others is necessary to

creating change, but realizing it is not sufficient, action must follow.

Increasing education and participation in learning strategies is a beginning to change and opens

the mind to truth in regards to forming impressions about others. Becoming aware of common negative

stereotypes that are unfairly placed or wrongfully conceptualized can relieve the false validity people

easily give to these ideas. Research articles, books, pamphlets, and seminars are superfluous to help

people change negative attitudes. Interacting with those who are different and unique allows reality

based impressions to be formed and wrongly placed negative stereotypes to be reduced and prevented.

Asking respectful questions related to a tattoo or hairstyle is an easy way to begin. Instead of

responding negatively or avoiding a person who outwardly looks different, allowing the relationship to

continue through positive communication devalues biases. Exchanging derogatory comments and

demeaning jokes for creative thought, questions, and conversation is definitely a move in the right

direction. It is easy to forget that all people have differences, making them distinctive individuals.

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Final thoughts

Since I have been the victim of prejudice and judgments I have had to re-evaluate how I want to

be perceived by others. I cut my dreadlocks off after two years because I was ready to try something

different and because I had learned a lesson about humanity. I knew that although I did not want to

become a conformist to society and its stereotypes, my future success as a nurse would be

compromised if I kept my hair in dreadlocks. As much as I hoped I could prove to other healthcare

providers that I was just as good of a nursing student as any of my fellow classmates, I discovered the

harsh reality about first impressions and negative stereotyping in regards to outward appearance,

specifically my hairstyle. I was fighting a battle I knew I was going to lose. It was an easy temptation for

me to look at the many doctors and nurses who reacted disapprovingly towards my hairstyle and

negatively judge them, thinking they are closed-minded and cold-hearted. I would have been falling

prey to the same issue of stereotyping if I reacted in that way. Rather, the lesson I have learned and

want to pass on is that first impressions can easily be wrong. Forming stereotypes on the basis of

outward appearance is a simple way to misconstrue a person's character. My experience as a victim of

negative stereotyping has changed the future of my professional nursing practice. I cannot look at a

patient anymore without wanting to know more about the true character on the inside instead of being

satisfied with only knowing what I see on the outside. Each patient is unique and deserves respect,

which I can show by not forming stereotypes against them based on outward appearance.

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