Concept Analysis: The Clarification of Body Adornment

Abstract

The aim of this paper is to clarify the concept of body adornment informed by Roach's (2002) caring theory, specifically the attribute of comportment. Caring is regarded as the essence of nursing. A caring demeanour is realised through adherence of professional dress which demonstrates respect for the dignity of a person as a human being (Roach, 2002). Implications of personal body adornment practices have not been considered within the context of nursing. The key words "body adornment", "body piercing" and "body tattooing" were utilised to retrieve peer-reviewed journals between the years of 1990 and 2010. This resulted in 133 articles from the fields of dentistry, medicine, nursing, and psychology all of which were reviewed to facilitate a thorough appreciation and understanding of this phenomenon. Body adornment is a statement of "Who I Am as an Individual" with implications for "Who I Am as a Professional". Clear antecedents, defining attributes, and consequences facilitate our awareness of the complexity of this phenomenon.

Headnote

Abstract

Aim. The aim of this paper is to clarify the concept of body adornment informed by Roach's (2002) caring theory, specifically the attribute of comportment.

Background. Caring is regarded as the essence of nursing. A caring demeanour is realised through adherence of professional dress which demonstrates respect for the dignity of a person as a human being (Roach, 2002). Implications of personal body adornment practices have not been considered within the context of nursing.

Data Sources. The key words "body adornment", "body piercing" and "body tattooing" were utilised to retrieve peer-reviewed journals between the years of 1990 and 2010. This resulted in 133 articles from the fields of dentistry, medicine, nursing, and psychology all of which were reviewed to facilitate a thorough appreciation and understanding of this phenomenon.

Results. Body adornment is a statement of "Who I Am as an Individual" with implications for "Who I Am as a Professional". Clear antecedents, defining attributes, and consequences facilitate our awareness of the complexity of this phenomenon.

Conclusion. Clarification of body adornment, may allow for an opportunity to understand contextual influences of body adornment, which may further influence how we care for ourselves as professionals, via the caring attribute of comportment.

Keywords: body adornment, caring, comportment, concept analysis, nurse-patient relationships

Introduction

Humans have been adorning their bodies for many millenniums. How we adorn ourselves personally and professionally reveals aspects of "Who we are"; hinting at culture, education, socioeconomic status, occupation, psychological well-being, and perhaps respect for others. An initial exploration of body adornment which reflects "Who am I as an Individual" is necessary prior to discussing how this phenomenon might affect the profession of nursing.

An examination of the research on professional attire does infer a necessity to differentiate RNs from other health care employees (DeKeyser, Woloski, & Margalith, 2003; Skorupski & Rea, 2006). This results in enhancement of the bodily presentation of the nurse (Tamlyn, 2005) and satisfies the patient's need to identify their caregiver (LaSala & Nelson, 2005; Newton & Chaney, 1996). Physical images of RNs, whether positive or negative, shape the general public's opinion of the profession and may influence the opportunity to demonstrate "a caring way of being". Roach (2002) suggests that a "caring way of being" may be best expressed by professional demeanour of dress and language defined as comportment within her theory. However, a clear understanding of how the concept of "body adornment" from an individual perspective may influence professional choices in dress has yet to be explored. Therefore, implications for the profession of nursing are unknown.

Clarifying the concept of body adornment may assist the individual RN to choose body adornment practices aimed at facilitating a professional bodily representation, while concurrently observing both the patient's and their own preference. Therefore, the purpose of this paper is threefold: first to clarify the concept of body adornment, secondly to understand how body adornment choices may influence the bodily representation of "Who am I as a Professional", and finally to articulate how comportment may be an ideal attribute to guide the pursuit of a professional bodily representation, which encompasses both patient preferences and the RN's choices, reflecting respect for the other as well as for one's personal self and as a professional.

Background

The primary objective of a concept analysis, as a method of inquiry, is to understand and clarify the composition and intent, of an abstract phenomenon (Walker & Avant, 2005). This analysis will be guided by Walker and Avant's (2005) typology of defining attributes, providing a description of the antecedents, consequences, and due to limitations in length, only a model case will be discussed. Paley (1996) contends that clarifying concepts as a means to creating theory is inarguably futile; conceptual clarification is only possible through the utilisation of a theoretical lens. Therefore, this concept analysis of body adornment will be situated within Roach's (2002), "Caring, The Human Mode of Being, theoretical lens.

Considered a Grand Theory, Roach's (2002) philosophical perspectives introduced the six C's of Caring (compassion, competence, confidence, conscience, commitment and comportment) as attributes of caring behaviours; only the attribute of "comportment" will be utilised as a lens to understand the concept of body adornment. Comportment is address and habiliments which are demonstrated and influenced by attitudes, knowledge, and skills of individuals and collectively by the profession, and as such is an ideal caring attribute that demonstrates intentional demeanour, through the use of professional address and dress (Roach, 2002). This caring attribute offers a practical means of revealing a bodily representation or behaviours of how a RN should dress and speak (Roach, 2002). Consequently, comportment may offer an opportunity to concurrently visually represent the intentionality of a nursing practice and demonstrate professionalism by a RN for the patient, while expressing the individual values of the wearer. Comportment focuses on two themes "Show patient and family who you are by your dress, manner and actions" as well as "Present yourself as someone who commands respect" (Roach, 2002, p. 48). "Who you are by your dress", as it relates to body adornment, will be used as the theoretical backdrop for this concept analysis.

Data Sources

A review of both the qualitative and quantitative literature was undertaken. Numerous databases were accessed to obtain a clear portrayal of body adornment (Academic Search Premier, Alternative Health Watch, Anthropology Plus, CINAHL Plus, Canadian Newsstand, Child Development & Adolescent Studies, Health Source, Humanities International Index, MasterFILE Premier, MEDLINE, PsycARTICLES, and SocINDEX). The key words attire, body adornment (including body piercing and tattooing), caring, comportment, and professional image were utilised to retrieve peer-reviewed English journals between the years of 1990 and 2010. Articles were excluded if their primary focus was theoretical; resulting in 133 articles from the fields of dentistry, medicine, nursing, and psychology.

A total of 18 studies were located: five examined body piercing and tattooing, seven studies addressed professional nursing attire, and the remaining studies focused on the identification and perceptions of caring behaviours in a number of groups (nursing clinicians, faculty, and undergraduate nursing students, as well as patients). Of value were seven research studies which addressed professional nursing attire (Kucera & Nieswiadomy, 1991; Lehna et al., 1999; Mangum, Garrison, Lind, & Hilton, 1997; Skorupski & Rea, 2006); two were of a qualitative nature and the remaining five had a quantitative design. Although all the researchers concluded that attire contributed to the perceived professionalism of the RN, there was a lack of agreement related to the use of the concept of body adornment, thus the impetus for this concept analysis.

Results

The initial step of this concept analysis was to grasp the nuance of the concept of body adornment. The origin of the word body is from the Old English word of "bodig" with similar usage found in Old High German language "boteh" corpse (Etymonline, 2006). The word body has 42 entries; used as a noun and a transitive verb (Webster's Online Dictionary, 2012). The word adornment also has numerous interpretations: "a decoration of colour or interest that is added to relieve plainness; the action of decorating yourself with something colourful and interesting (Webster's Online Dictionary). Adornment was first described in the Sumerian language (3100- 2500 BCE), with a noted increase in frequency in the 1200's (Etymonline, 2006).

Other historical examples include: (1) the 5,000 year old mummy found in Australia who had metal ear piercings thought to ward offevil spirits (evil spirits enter the body through the ears), (2) the documentation of nose piercing in the Middle East 4,000 years ago (Vassallo, 2006), as well as (3) the Old Testament also refers to piercings (Halliday, 2005; Vassallo). Various African tribes, the Inuit of Northern Canada, First Nations of the Pacific Northwest, as well as the ancient Aztecs and Mayans are or have been practitioners of lip piercings (Vassallo). Traditionally, body adornment was a symbol of virility and bravery (Armstrong, 1996); but the desire to adorn for beauty's sake is also well documented (Friede, 2001). Body adornment is a personal declaration, which leaves a visible impression of "Who I Am as an Individual".

Defining attributes

Defining attributes depict the foundational components of body adornment. Comportment suggests how we adorn our bodies professionally demonstrates "who you are by your dress" (Roach, 2002, p. 45). Three defining attributes for body adornment were derived based on the literature review. The first attribute is body decoration which includes enhancement of the natural body including but not limited to: hair (colour, cut, ornaments, removal, and style), clothing, footwear, and jewellery (bracelets, identification, and necklaces) (Friede, 2001; Halliday, 2005; Selekman, 2003; Smith, 2003). Body modification is the second attribute and can range from low invasive practices (piercings "ear"; minor tattooing "cosmetic AKA: intradermal pigmentation, micropigementation, and dermagraphics - examples are limited skin area tattooing of eyebrows, eyeliner, and lipliner"), moderate invasive practices (piercings "eyebrow, lip, and nose" and extensive tattooing), to extreme invasive practices (piercings of genitalia; plastic surgery - either reconstruction and/or cosmetic; scarification, and self-mutilation) (Armstrong, 2005; Canadian Dental Association, 2006; Carroll, Riffenburgh, Roberts, & Myhre, 2002; Chivers, 2005; Halliday, 2005; Jeffreys, 2000; Saunders & Armstrong, 2005; Soileau, 2005). The final attribute is body painting. This attribute is composed of henna, make-up and/or face painting, and the use of temporary tattoos (Friede, 2001; Halliday, 2005; Saunders, & Armstrong, 2005).

Antecedents

Ten causative antecedents of body adornment were identified, as well as numerous contributing factors. Contributing factors to the antecedents include: age, community, culture, education, gender, life experiences (challenges, successes, and/or trauma), lifestyle, male supremacy culture, profession, religion, sexual orientation, and socioeconomic status (Armstrong, 1998; Caliendo, Armstrong, & Roberts, 2005; Friede, 2001; Smith, 2003).

Embracing a personal viewpoint

This antecedent is reflective of a variety of perspectives. The first is, body as an art canvas - where individuals record their autobiographies "challenges" and "successes" on their skin, or to express themselves sexually (Armstrong, 1996; Armstrong, Owen, Roberts, & Koch, 2004; Caliendo et al., 2005). Another perspective is the extension of body decoration to increase physical attractiveness (i.e., cosmetic and reconstructive surgery) (Saunders & Armstrong, 2005; Selekman, 2003).

Enhancing subculture identity

Those members of a subculture often use body adornment to ensure recognition by individuals who do not belong to the group. Body adornment may be employed to transmit a message of fear or belonging, often seen in gang identification (Armstrong, 1996; Jeffreys, 2000). Also body adornment is utilised to imply sexual orientation or as transgender correction (Jeffreys).

Establishing belonging/ownership

Examples of this antecedent are found in a variety of contexts - religion and the political agenda. The burqa (a Muslim adornment) is worn to identify and protect the women of this culture/religion (Friede, 2001). Male circumcision is acknowledged as a symbol of acceptance into Judaism (Fox & Thomson, 2005). A negative expression of ownership is the "concentration camp tattooing" by the Nazis during World War II (Selekman, 2003).

Engaging in risky behaviour

Engaging in risky behaviour may be a means of coping with aversive mood states (Cooper, Agocha, Sheldon, 2000). Scarification and selfmutilation are examples of this antecedent (Jeffreys, 2000; Selekman, 2003). Self-mutilation is an attack on the skin or bodily organs in a deliberate, but non-suicidal manner. Individuals may experience "depersonalization" and feel "transformed" by the experience (Jeffreys, 2000; Carroll et al., 2002). Scarification, however, is termed "self-mutilation by proxy" - the scaring is carried out by another person (i.e., cosmetic surgeon; a piercer, or a sadomasochist practitioner) (Jeffreys).

Exercising proprietal rights

The feminist movement claims the privilege to have total freedom over one's body and reject male supremacy culture (Jeffreys, 2000). Another view (either positive or negative depending on one's perspective) is the practice of clitoral circumcision to prevent enjoyment of sexual intercourse by certain ethnic cultures (Fox & Thomson, 2005).

Rebelling against authority

Adolescents/young adults who choose to defy their parents/guardians are examples of this antecedent. They reject their authority's lifestyle as pretentious and/or extravagant (Armstrong, Masten, & Martin, 2000; Halliday, 2005). A socioeconomic trend in the 1970s in Britain led to the development of the" Punk cultural movement". This era was represented by the fascination in brightly coloured and cropped hair, with multiple tattoos and a moderate level of body piercings (Jeffreys, 2000).

Reflecting societal popularity

Many individuals choose to identify with celebrities (media, movies and sports). For example, Hollywood icons such as Angeline Jolie and Cher have both elected to adorn their bodies by cosmetic surgery and/or tattooing (Armstrong, 1999; Saunders & Armstrong, 2005).

Renewing faith in one's self

A traumatic experience often is life altering. Two examples where body adornment is seen post traumatic experience is with individuals who have experienced a rape and individuals who have had a mastectomy due to breast cancer (Halliday, 2005). Individuals may tattoo their body with depictions representing hope and survival as tributes to reclaiming one's spirit and control over life as part of their recovery. Some individuals have also pierced their genitalia post-rape as a means of reclaiming their bodies (Young, 2010).

Replicating tribunal beauty

Many individuals view other culture's body embellishment as beautiful. This is evidenced by examples of Caucasians with enlarged ear lobes or extensive images beautifying their skin (Jeffreys, 2000) reflective of indigenous cultures in Africa, Asian and America.

Resisting societal conformity

This is an example of individuals who reject the media's definition of beauty and/or glamour. They feel self-expression is more important than acceptance by society (Armstrong et al., 2004).

Derived definition of body adornment

Based on the previously defining attributes a definition of body adornment has been proposed "body adornment is any alteration or enhancement to the natural appearance of the human body including one or a combination of body decoration, body modification, and body painting, along a continuum" (Maykut, 2009, p. 15) from low to extreme invasive practices.

Consequences

Consequences of body adornment may be temporary or permanent. Outcomes may also be positive or negative, and are dependent on the perspective of the individual. The consequences have been categorised into three separate areas.

Physical

This consequence comprises a wide spectrum of outcomes. Negative sequelae include: airway obstruction (Chivers, 2002; Stirn, 2003), allergic reaction (Armstrong, 1996), deformities/disfigurement - unintended scarring, keloid development (Armstrong, 1998, 2005), aspiration of oral jewelry during breastfeeding (Armstrong et al., 2000; Stirn, 2003), dental problems (Canadian Dental Association, 2006), infections - bacteremia, cutaneous leprosy, HIV, HEP B & C, mastitis, necrotizing fasciitis, pseudomonas aeruginosa, septicemia, staphylococcal organisms, STDs and tetanus (Armstrong, 2005; Bryant, Chen, Camann, & Norwitz, 2005), rejection due to infection (Selekman, 2003), safety concerns (Smith, 2003), trauma - pain, bleeding, and bruising (Bryant et al., 2005; Caliendo et al., 2005), and urinary problems (Caliendo et al., 2005). However, there are also potential positive physical sequelae which include improved self-image (Caliendo et al., 2005) and sexual arousal enhancement (Bryant et al., 2005; Caliendo et al., 2005).

Psychological

Studies have suggested positive and negative psychological sequelae as a result of body adornment: acceptance/lack of acceptance Caliendo et al., 2005), addiction due to Body Dysmorphic Disorder (Caliendo et al., 2005), alterations in self-esteem/self-worth (Armstrong, Stuppy, Gabriel, & Anderson, 1996; 2002), discrimination (Stuppy, Armstrong, & Casals- Ariet, 1998), embarrassment (Armstrong et al., 2002), encouragement of high risk behaviours (Carroll et al., 2002), future relational impact (Caliendo et al., 2005; Selekman, 2003), lack of goal planning "living in the now" (Caliendo et al., 2005), regret (Armstrong et al., 2002, 2004), and self-image enhancement (Armstrong, 1996; Stirn, 2003).

Societal

A financial burden may be yet another potential consequence. The burden of costs may fall on society especially with the numerous negative health outcomes previously mentioned. However, the adorned individual may also experience financial hardship. As the amount of tattoos and piercings increase on an individual's body, discrimination (Stuppy et al., 1998) and opportunities for employment increase or decrease due to certain job standards (Smith, 2003).

Case example

Walker and Avant (2005) suggest identifying case examples as necessary to exemplify the concept in appropriate situations. The defining attributes will be abbreviated as body decoration (BD), body modification (BM), and body painting (BP) and utilised in a case example. A model case which has all defining attributes present is presented below.

Model case

Jane Doe is a RN employed full-time on a cardiovascular unit. She adheres to the healthcare agency's dress code policy. She wears a two piece scrub uniform (BD) which is clean, free from stains and tears, and is navy blue in colour, the colour designated to her particular nursing unit. Her footwear meets agency standards. She applies her makeup (BP) sparingly and with discernment. She does not apply scented body products (BP) which not only adheres to the policy on a scent free environment, but she recognises that scents may affect patient outcomes. Further adornment consists of her identification tag, a RN pin, and a second hand watch (all examples of BD). In her pierced ears she wears small stud earrings (BM).

Discussion

No systematic review of the literature has clearly outlined the concept of "body adornment" from an individual perspective, and therefore, consequences for the profession of nursing are not obvious. In this article a systematic approach was utilised to describe and explore the phenomenon of body adornment resulting in identification of a set of defining attributes, a derived definition of body adornment, antecedents, consequences, and a model case. However, there are limitations. The first limitation is related to the process of the literature search. For example, articles and unpublished dissertations not included in the data bases may have provided additional information. Secondly, the review only considered articles from English language journals and therefore, relevant articles in other languages were excluded. Thirdly, grey literature resources were not examined. Despite these limitations - body adornment is an important concept for RNs to be aware of and this review assists with this understanding of implications of body adornment on nursing practice.

First impressions count! Body adornment acts as symbolic communication, resulting in mental interpretations that influence future interactions and attitudes (Kalisch & Kalisch, 1986). Individuals often form an opinion of another based on their initial meeting. For example a professional appearance suggests competency and respect for one's self and others (Kalisch & Kalisch, 1986, 2005; Roach, 2002; Spragley & Francis, 2006). For example, if there is disagreement between verbal and non-verbal communication, the receiver will tend to regard the non-verbal behaviours as more trustworthy than the verbal message. It is important that RNs are aware that they communicate nonverbally with their patients, peers, and colleagues through their body adornment (Pearson, Baker, Walsh, & Fitzgerald, 2001; Skorupski & Rea, 2006). Their choice of body adornment communicates aspects of their professional competence, authority, professional image, selfesteem (Cohen, 2007; Skorupski & Rea, 2006), and their personal life. Registered nurses should acknowledge the desire of the patient to identify the RN as essential in their nursing practice, recognize antecedents which influence choices of body adornment, and express respect for self as a professional through their visible bodily representation (Roach & Maykut, 2010).

As there are several antecedents for body adornment and the reasons for RNs electing to adorn their bodies are rarely discussed with their patients, patients may interpret the body adornment in a manner that was not intended by the RN. As a result the patient may see the nurse as a person who defies authority and does not follow "the rules". Consequently, the patient may have many unanswered questions: Will my nurse follow the rules? Will my nurse give me the medication when I need it? Is this a person that can relate to me? Will I be able to tell who my nurse is and how competent are they? Many RNs may not appreciate the consequence of adopting a professional dress demeanour which might be in direct opposition to the patient's need to identify and relate to their caregiver (Cohen, 2007; Newton & Chaney, 1996). Caring affects both the quality of patient care and outcomes (Duffy & Hoskins, 2003; Felgen, 2003).

Dressing in a manner which includes acceptable professional attire as prescribed by agency policies may augment professionalism within the nursing discipline (Dodge & Mensch, 2004; Mensch, 2005) and take into account the patient's desire to identify and respect the RN (Rush & Cook, 2006; Spragley & Francis, 2006).

Body adornment should not distract but foster a positive mental interpretation thus, promoting affirmative interactions and attitudes with the general public and within the discipline of nursing. The provision of culturally competent and ethical nursing care may address the development of positive personal opinions and intentions of all health care practitioners when choosing body adornment practices while ensuring the creation of strategies to enhance therapeutic relationships with others.

Conclusion

The concept analysis of body adornment establishes a foundation for a deeper appreciation and understanding of the key factors related to this phenomenon. The previously mentioned antecedents, defining attributes, and model case suggest that "body adornment" reveals nuances involved in creating a professional bodily representation for a RN. This concept analysis supports Roach's (2002) statement "who you are by your dress" (p. 48). Body adornment while requiring refinement as a concept specific to nursing theory should be viewed as a measurable component of Roach's (2002) theory; and thus, operationally defined using the attributes, antecedents, and consequences.

Body adornment choices reflect, "How to dress for one's self and others professionally", and thus may be helpful in shaping a professional bodily representation for a RN grounded in a caring theory. The nursing practice setting, our personal beliefs and values, agency specific policies, as well as the recipient of care preferences (reflective of a patient's personal interpretation of the message conveyed by the bodily presentation of the RN) should inform the choice of body adornment. Observance to body adornment, suitable to the profession and those we care for, reveals respect for the dignity of a person as a human being (Roach, 2002). Although a relationship between comportment, as a caring attribute as theorized by Roach (2002), and professional bodily representation has been proposed, substantiation of this claim requires further examination and evidence. If comportment theoretically exemplifies the epitome of a professional bodily representation then understanding body adornment as a human expression is necessary. Inclusion of body adornment, reflective of comportment, may allow for an opportunity to genuinely care for ourselves as professionals while allowing for the positive identification and connections between other RNs, our patients, and our healthcare colleagues.

Acknowledgments: The initial ideas for this concept analysis were written as part of the author's doctorate proposal during her educational pursuit of a Doctor of Nursing Practice at Frances Payne Bolton School of Nursing at Case Western Reserve University. Influential in facilitating the initial thoughts of this analysis were Dr. Deborah Lindell and Dr. Elizabeth Madigan (advisor). Thank you to Dr. Cheryl Pollard for suggestions in the initial draftof this manuscript. And finally a heartfelt thanks is extended to Sister Simone Roach - committee member and friend, who continues to be instrumental in mentoring me on my journey of caring.

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