The Nursing and Midwifery Council (NMC) Code (NMC, 2015) details the professional standards that midwives must uphold whether their practice involves direct care or when they are in leadership, education or research roles. The four key principles of the Code are: to prioritise people, to practise effectively, to preserve safety, and to promote professionalism and trust. In relation to prioritising people, midwives must treat women as individuals and ‘avoid making assumptions and recognise diversity and individual choice’ (NMC, 2015:4). Tattoos and piercings are becoming increasingly popular forms of body art, with Laux et al (2016) suggesting that up to 36% of people under the age of 40 have at least one tattoo. Anecdotal evidence suggests that tattoos, piercings and ‘creative’ hair styles and colours may have elicited negative opinions and assumptions of an individual's character and lifestyle choices in the past; however, in today's climate of greater acceptance, what if it is the midwife who has made these choices? Do negative assumptions work both ways, and does this impact on professional status?
With a dearth of research in the UK, studies from the US can be considered for transferability of findings. In a study by Resenhoeft et al (2008), 158 college students rated photographs of individuals with tattoos more negatively than images of those without tattoos, suggesting that tattoos have a negative impact on interpersonal perceptions. In phase 1 of the study, participants identified a model with a tattoo as less attractive and caring than a model without a tattoo, who was also perceived as more athletic and intelligent. In phase 2, the tattoo was smaller and less ‘intimidating’ (i.e, a dolphin, rather than a dragon), which resulted in less extreme reactions; however the model without a tattoo was still perceived as being more honest and religious. Recommendations from the study included educating students of the possible long term implications of having a tattoo in terms of impact on employability and perceptions of clients and senior work colleagues.
Another study conducted in the US (Verissimo et al, 2016) explored the impact of tattoos on the perception of professionalism and found that dental clients perceived dental hygienists with large visible tattoos as less professional than those with a smaller tattoo or no tattoo. Furthermore, dental hygienists with large tattoos could put clients off using the practice.
The above literature therefore suggests that individuals with tattoos and piercings are perceived less positively than those without. Furthermore, in a professional context, service users sometimes make negative assumptions regarding healthcare practitioners' professionalism as a result of their body modifications. With a dearth of UK-based studies, this article will consider the personal experiences of Justine, a midwife with tattoos and ‘colourful’ hair to see if her reality concurs with US-based research findings.
‘Whether you have 20 tattoos or none; whether you choose to go grey gracefully or dye your hair until you draw your NHS pension, the important thing is to do whatever is right for you, and to be true to yourself’
Justine's story
Becoming a midwife
For me, qualifying as a midwife was just a pipe dream: I had my first child when I was 18 years old and my GCSE results spelt ‘FUDGE’. As far as the idea of working towards a ‘proper’ career was concerned, it was put in a box, sealed with thick tape and packed away.
For the next 10 years, I dedicated my work life to the world of retail in part-time jobs, and while I made some great friends, gained life experience and learned new skills, I never looked forward to going to work. My motivation was that I had bills to pay and a child to raise, and I wanted to make sure my daughter had everything I could give her. A key skill I developed while working in retail was communication. It didn't matter who the customer was: the nice one, the complainer, the regular, the downright rude—I always felt confident when talking to people and trying to meet their needs.
One evening in 2001, when I was 27, my mum came to visit. Just before Dad picked her up that night, we were standing in the kitchen, washing up. Out of the blue, she asked me, ‘What are you going to do with your life? You don't want to stay at the food retailer's—you've got much more to offer’. I remember smiling, rolling my eyes, and saying, ‘I'm fine where I am, thanks Mum’ before my Dad turned up and she left. Four days later, my mum suddenly passed away. This was my first real experience of loss and it triggered a monumental change.
A few weeks after the funeral, I booked into night school to get the grades to apply to university. My tutors advised me to apply for nursing—their rationale being that midwifery had limited places. Despite this advice, I never aspired to become a nurse, so I bit the bullet and applied to do a midwifery degree. I like to think I made up for my rebellious behaviour at school by qualifying with a First class honours degree in 2007.
Nearly 11 years after qualifying, I still sometimes can't believe I am a health professional, and I am so proud of my achievements. I know my mum was my driving force to start with and my dear sister who passed away during my training gave me the strength and determination to finish it. I am so grateful to have had two such special ladies to guide me and was lucky to have such a supportive family.
Personal appearance and practice
At school I was rebellious: the weirdly dressed ‘gothic girl’ while all of my peers dressed in the latest fashions. I had bright hair, 100 bangles on my arms and a determination to break rules (without harming anyone, of course!). It has slowly dawned on me over the years that, while everything else in my life has changed—my career, my friends, my family and my experiences—the one thing that will never change is my inner self. The transition from checkout girl to qualified midwife changed many things, but not me as a person or the image that I felt suited me and that I enjoyed portraying.
I have always loved colouring my hair or getting a new tattoo. Qualifying as a midwife wasn't going to change me as a person when it came to my preference for individuality—to be honest, the thought of my appearance being of concern to others never occurred to me. My hair is always tied back for work, but it has been every range of colour from bright red, to dark purple and every colour in between. My skin is healthy and clean, but my eyes are used to their daily coating of black winged eyeliner and mascara. My little ritual of putting on make-up is one that I enjoy, and I like experimenting with it. I have tattoos, some of which are visible when I am in uniform, some not. None of my tattoos would be considered offensive: my children's names, a quote from my favourite film and a pentagram are easily seen, but there is no ‘love’ and ‘hate’ on my knuckles, no teardrop under my eye and no prison number. Modern tattoos are often visual representations of people's loves, beliefs and passions, and feminine body art in particular, such as unicorns, butterflies, names of loved ones past and present and symbols, may have a personal but positive meaning.
When I chose a rather bright, totally unnatural shade of red for my hair, a senior midwife where I work asked whether I had read the uniform policy and been spoken to about my unnatural choice of hair colour. My response was to ask her if, at 55 years of age, her ‘blonde’ highlights were natural. This was a genuine question on my part, with no sarcasm intended. My colleague did not take offence; in fact, I could see a glimmer of amusement in her eyes along with the realisation of what she had said. The NHS expects all staff to receive in-house training on equality and diversity, but I wonder whether this applies just to patients. Is it acceptable to comment openly on a colleague's chosen image, but face a disciplinary if you passed a similar comment or made a judgement openly about a patient?
In the past, unnatural red hair might have marked you out as unprofessional in other historic careers, or in professions not so respected by the general public. In 2018, however, a box of hair dye can be bought at the supermarket as easily as a box of cornflakes. Under the Local Government (Miscellaneous Provisions) Act 1982, as amended by the Local Government Act 2003, local authorities are responsible for regulating and monitoring businesses offering cosmetic body piercing and permanent tattooing. As ‘these procedures involve some degree of skin piercing, they carry a potential risk of skin infections, allergic or toxic reactions to various substances used on or in the skin and transmission of blood born viruses (such as hepatitis or HIV)’ it is important that practitioners are regulated to maintain appropriate standards of practice (Smith, 2010:2).
I don't know whether some women I have cared for have been surprised or unhappy about my non-traditional image of a professional. I have certainly never had any negative experiences or complaints; on the contrary, I have received many compliments! Working with a diverse caseload of women and their families, my aim is to provide good, individualised care and to develop a professional and trusting relationship with those in my care. I want to protect the good name and image of the midwife, but not by being stereotyped based on appearance. The main rules I stick to when it comes to appearance as a midwife are: look clean, look healthy, iron your uniform, polish your shoes and tie your hair back. Whether you have 20 tattoos or none; whether you choose to go grey gracefully or dye your hair until you draw your NHS pension, the important thing is to do whatever is right for you, and to be true to yourself.
Conclusion
According to The Code (NMC, 2015), midwives must uphold the reputation of their profession in their practice and behaviour and ‘avoid making assumptions and recognise diversity and individual choice’ (NMC, 2015:4). Albert Einstein (1940) once said that:
‘Great spirits have always encountered opposition from mediocre minds. The mediocre mind is incapable of understanding the man who refuses to bow blindly to conventional prejudices and chooses instead to express his opinions courageously and honestly’.
While research undertaken in the US suggests that health professionals with body art may be perceived as less professional than those without, in a society with increasing acceptance of the diversity of its members, shouldn't midwives with body art be able to celebrate their individuality and still provide a high quality service to women and their families as a member of a respected and autonomous workforce?