Barriers of students' adherence to dress code policy in clinical settings: dental students' viewpoint.

Medical universities have called for a professional dress code to preserve the dignity of the medical profession, creating a sense of respect, tranquility, and trust in healthcare recipients and improve patient safety. This study aims to explain the reasons behind poor adherence to the professional dress code by students of the dentistry school. A qualitative study was conducted to explain the viewpoints of dentistry students of Tehran University of Medical Sciences (TUMS). Twenty-three in-depth interviews with dentistry students of different genders, study years, living in different accommodations, and having different tuition payment status were conducted. Conventional content analysis was used to analyze the data. One hundred and twenty initial codes were extracted. They were categorized into common causes of non-adherence to the TUMS Dress Code and specific causes of not following a specific section of the dress code (hygiene, jewelry, and makeup sections). The codes of common causes were categorized into 4 main categories including defects in education, management shortcomings, changes in societal culture, and personal factors. All components of the educational system must be aligned with each other to overcome the barriers against the students' adherence to professional dress and put forward appropriate interventions at the policymaking, regulatory and educational levels.

Introduction

The doctor-patient relationship plays a central role in providing high-quality health services (1). In the educational-clinical setting of the dentistry schools, this relationship is established between the patients and undergraduate or postgraduate students. Evidence shows that when both sides of a relationship (in this case the patients and dental students) do not know each other, they use the available information to form their judgment (2); therefore, the verbal and nonverbal elements of the patient-doctor relationship are of particular importance (3).

The clinicians’ appearance and wardrobe choices are parts of their non-verbal behavior. Clothing in the clinical settings not only provides physical security at the individual level, but also acts as an important means of transmitting personal and social messages at the social level (4), and reflecting the traditions, values, and beliefs of the professional community (5). Studies have also shown that patients value their doctors’ appearance and even consider it as a measure of their competence and trust ability (6, 7).

Since professional dress codes can help to develop a successful doctor-patient relationship (8) and may be considered as a subset of the professionalism concept, many medical universities around the world have regulated dress codes (9, 10). In Tehran University of Medical Sciences (TUMS), the dress code was approved at the university council (11) and was delivered to all the schools. In this guideline, the articles are categorized under three sections of clothing, jewelry and makeup, and hygiene.

Previous studies have indicated that while the majority of students appreciate the importance of professional dress code (7), they don’t adhere to it (12, 13). Kaveh et al. studied the factors influencing students’ adherence to the dress code based on the theory of reasoned action. They did not take into account the students' views on the non-compliance reasons (12); while, their viewpoints can point out the barriers to adherence to dress code in the clinical setting. Knowing these barriers can help with improving the students’ professional conduct. Thus, this qualitative study aims to explain the barriers to adherence to professional dress code based on the students of the TUMS dentistry school viewpoint.

Method

The qualitative approach using conventional content analysis (14) technique was used to study students’ viewpoints on non-adherence to professional dress code.

The study subjects were selected from among the undergraduate and postgraduate students of the dentistry school of TUMS, from October 2018 to March 2019. The inclusion criteria were studying in the clinical phase of dental education and signing informed consent to enter the study. The following variables were taken into account in the convenience sampling method to guarantee maximum diversity:

Study year: undergraduate/postgraduate student

Gender: male/female

Living condition: living with family or in student house/university dormitory

Tuition fees: yes/no

The information was collected mainly through a semi-structured in-depth interview in a quiet, stress-free location, preferably selected by the interviewees. The interviews were guided by a list of questions including “Have you ever read the “University Dress Code”?” “What do you think about the dress code?” “In your opinion, do your peers follow the dress code in the clinical settings of dental school?” and “what are the barriers against adherence to the dress code in the clinical settings?”

Interviews were conducted on 23 students and recorded. After each interview, the record was transcribed verbatim; which was repeated as needed. After the initial codes were extracted, the main categories were identified based on similarities. The analysis of the last two interviews indicated data saturation.

The length of the interview sufficient time was dedicated to interviews to increase the acceptability of the study and the reliability of the interviews and attempts were made to establish good communication with the participants. In addition, respondents were assured that their information would remain confidential and that the individual results would not be declared to any authority.

It is noteworthy that in 10% of the interviews, the coding process was performed for a second time independently by a Ph.D. student of medical ethics with good knowledge of the subject, and the results were compared with the researcher’s codes. The agreement was obtained after discussions on the points of disagreement.

Although the generalizability of qualitative studies is inherently impossible (15), attempts were made to use alternative approaches for this purpose. For example, the maximum diversity was considered in sampling and the researcher tried not to interfere with the interview process, for instance by avoiding playing the role of a consultant. During the interviews, the researcher balanced between her roles of being an interviewer and a researcher.

Written informed consent was obtained from all participants after they were clearly informed of the research objectives. Their right to leave the research was also considered during the study. Their personal information was kept confidential. This study was reviewed by the Ethics Committee of TUMS and approved with the code IR.TUMS.VCR.REC.1395.1651.

Results

Twenty-three students participated in this study. Their demographic characteristics are presented in Table 1. They were asked about their prior knowledge of the dress code policy of TUMS in the clinical settings. Only 1 participant had never heard about the policy, 4 had heard about it but had never read it carefully, 5 had read it but were unable to remember its contents, and the remaining 13 were familiar with its contents.

Table 1

The demographic characteristics of the participated students

		number	%
Gender	female	13	52/56
	male	10	48/43
Study level	undergraduate	16	57/69
	post graduate	7	43/30
Living status	with family	10	48/43
	student house	4	39/17
	university dormitory	9	13/39
Tuition fees	yes	4	39/17
	no	19	6/82

Except for one participant who believed that the dress code was not respected by students and four others who believed that a few students respect the dress code, the other participants stated that the dress code policy was relatively followed by most students. All the participants mentioned that the lack of cleanliness of the white coats was more noticeable than other articles of dress codes, pointing out the reasons for not following the guidelines. In the content analysis of the interviews, 60, 45, and 15 initial codes were extracted about the causes of non-adherence to the clothes, jewelry, and makeup, and hygiene sections of the TUMS Dress Code, respectively. Further study of the codes showed that most of them were common between the three sections. Therefore, the codes were categorized in to common and section specific causes of non-adherence. The matching codes in different categories were merged. Finally, 27 codes were extracted from the common causes and classified into 4 main categories. The specific causes were related to causes of non-adherence to hygiene, jewelry, and makeup, which will be described.

The main categories of common causes are described below.

(Table 2 shows the subcategories, codes and participant quotes in this category.)

Table 2

The common causes of students’ non-adherence in “Defects of Education” category

Subcategory	Code	Participant quote
lack of understanding of the dress code policy basis	Inadequate training	Scientific reasons to justify dress code adherence have not been explained to the students.
	Inappropriate training time	A single-session about the dress code was held when the clinical practice had not yet been initiated.
	Lack of understanding of their professional duties	The students do not know their position in the medical profession, so they do not strive to preserve dignity and respect for the medical profession.
Inappropriate role models		The students follow their instructors' wardrobe choices because they consider it as a sign of their success and wealth.
	Postgraduate and senior students	Residents' attire, which is often not in accordance with the Dress Code attracts the attention of undergraduate students.
	Dentists	Dentists' dress in private practice is very different from the “University dress code” and since many students work during their training, they consider that attire as the custom of the dental profession.
	Social network	Students' perceptions of the dentist attire are what they see in movies and social media advertisements, which is modern and appealing and differs from the “University Dress Code”.

1. Lack of understanding of the dress code policy basis. Several respondents mentioned that the basis for the code was unclear to them. Three main codes leading to these viewpoints were inadequate training, inappropriate training time, and lack of understanding of their own professional duties.

Some pointed out that rules for professional dress codes are officially taught to the students before they enter the clinical wards, which is why they do not understand the importance of the subject and forget about it.

Some argued that students did not find themselves responsible to adhere to their duties as dental and medical professionals and obtaining patients' trust.

2. Inappropriate role models. Everyone emphasized that students are mainly influenced by role models, and their non-adherence to the dress code is the reason the students don’t see the need for it as well.

2-1. Academic professors. Some students mentioned that they look into the faculties who do not adhere to the dress code themselves, and therefore these students did not take the subject seriously.

2-2. Postgraduate and senior students.

2-3. Dentists. Some respondents mentioned that students follow dentists’ wardrobe choices in private clinics.

2-4. Social network: Some interviewees pointed out the effect of images and videos of Iranian and foreign dentists in the media, adding that their clothing was different from the one accepted by the university.

Some of the discussed reasons pointed out the management shortcomings in the field. Table 3 shows subcategories, codes and participant quotes in this category.

Table 3

The common causes of students’ non-adherence in “Management shortcomings” category

Subcategory	Participant quote
Lack of clarity of the dress code	It's not clear what the dress code wants from us. Do our sleeves matter? What about the color.
	Compliance with other rules and guidelines is supervised, but no one cares about the dress code.
Failure to take appropriate measures.	The dress code poster at the entrance of each clinical ward is small and does not attract people's attention.
	A certain time is set for students to take their clothes to the laundry. This time overlaps with their classes.

1. Lack of clarity of the dress code

2. Lack of supervision: Although all the interviewees disagreed with the strict regulations and coercion regarding dress and appearance, most of them pointed out a lack of proper supervision in this regard in the clinical environment.

3. Failure to take appropriate measures. Some pointed out that the management has taken no measures to improve adherence to the dress code. Others attributed the problem to a lack of communication. Some others mentioned non-addressing adherence to the dress code in the final evaluation of students. A group of students also reported bad planning for washing the white coats at the school, as the reason behind poor hygiene and non-adherence to the dress code.

(Table 4 shows the subcategories, codes and participant quotes in this category.)

Table 4

The common causes of students’ non-adherence in “Changes in societal culture” category

Subcategory	Code	Participant quote
Cultural Effects	Change in dress culture	Intuitively, young women and girls in our society wear more makeup compared with the Europeans. The same view can be seen in clinical settings. The definition of beauty has changed in modern society.
Patients	Lack of reaction to the inappropriate appearance	Patients usually do not object to students who dress inappropriately because they are worried about their treatment.
	Inappropriate reaction to choices in accordance with the dress code	My friend had no makeup, so her patient thought she was not a dental student. If patients have the right to choose a dental student, they will choose the more beautiful ones.

1. Cultural effects: All respondents, both male and female, considered non-adherence to be influenced by the societal culture of clothing. They argued that the dental school and the clinical environment is a small part of the community, adding that the new clothing culture contradicts the professional dress codes in some subcategories.

2. Patients: Two codes were extracted from the interviewees’ comments, indicating how patients are influenced by societal culture.

2-1. Lack of reaction to inappropriate appearance. Some students pointed out that patients do not react to the inappropriate appearance of those responsible for their treatment, mainly due to their lack of awareness of their rights and/or concerns about the possible impact of their reaction on the treatment process.

2-2. Inappropriate reaction to choices in accordance with the dress code. Some students believed that their patients' image of a good physician was influenced by what they have seen in private practice and social media, and therefore may not respect the students who adhere to the guidelines.

(Table 5 shows the subcategories, codes and participant quotes in this category)

Table 5

The common causes of students’ non-adherence in “Personal factors” category

Subcategory	Code	Participant quote
Age Requirements	Sense of self-determination	Young people want to express themselves in every way possible
	Focus on beauty	The behavior of young people is affected by their love of beauty and they wear clothes that they find most beautiful. They use makeup for the same reason.
	Attracting others’ attention	They are wearing attractive clothes and makeup since they need more attention.
	Love of comfort	Some students prefer cool casual and informal dresses to be comfortable.
Habits		I know someone who is always a messy student and his character is also seen in his clothing.
Lack of familiarity with social life skills		Some students do not know the skills of respecting others and so they don't care to win respect for the medical profession.
Lack of acceptability	Lack of feedback from students	About the dress code, we were never asked to make it easier to execute.
	Considering the dress code stringent	This code is too stringent for women and many of its comments are not necessary for clinical practice.
	Disregard to the dental education environment	Considering the nature of the activities, the dental students’ clothing gets dirty easily and he/she can't wash the white coat during the day. Therefore, a dental student should be expected to have a clean white coat in all sections.
	The unacceptability of the material and style proposed by the school	I don't like the model of the white coat proposed in my school, and I never wear it.
Lack of interest in thefield of study		We have no incentive to adhere to the codes in the university. Patients have to accept us.
False Pride		She/he is proud of her/his education in dentistry and does not follow the rules.
Instrumental view towards patients	Sense of irresponsibility	Students look at the patients as a course they have to pass, and the mentors' satisfaction with their clinical performance is more important than the patients.
	Lack of motivation	We have no incentive to adhere to the dress code in the university. Patients have to accept us.

1.Age Requirements:

The following codes were extracted from the students' comments and are in accordance with their age.

1-1. Sense of self-determination: Some claimed that they did not follow the guidelines in order to maintain and show their identity, thereby practice their autonomy.

1-2. Focus on beauty: Many participants noted that they preferred to appear in the clinical wards wearing dresses that they find beautiful. However, their definitions of beauty and fashion were different from the model presented by the “University Dress Code”.

1-3. Attracting others’ attention.

1-4. Love of comfort: The interviewees claimed the love of comfort was a strong contributor to non-adherence. They believed that their peers were too lazy and comfort-loving to wear the right dress, ID badges, and proper shoes, or to wash their white coats.

2. Habits: Some respondents linked non-adherence to the dress code to being used to opposing behaviors, arguing that the training provided in this regard was not adequate to change habits and create correct behaviors.

3. Lack of familiarity with social skills:

Some believed that family and school have not prepared the students to enter the community, stressing that many of those who did not adhere to the dress codes have never learned social life skills such as respecting others and laws.

4. Lack of acceptability: Some respondents claimed that some students did not adhere to the guidelines as they did not accept it.

4-1. Lack of feedback from students: Some believed that as the students’ opinions had not been taken into account during the code development and revision, they did not accept and hardly adhere to its terms.

4-2. Considering the dress code stringent

4-3. Disregard to the dental education environment: Some students believed that because some terms of the code did not take into account the dental education requirements, it was unacceptable and unimportant to students.

4-4. The unacceptability of the material and style proposed by the school. The participants mentioned that they were given a white coat by the school, which its style and fabric did not fit them. Moreover, while no particular color was assigned for the women’s scarf in the “University Dress Code”, the dentistry school has considered a particular color for undergraduate students. This was not acceptable for some students.

5. Lack of interest in the field of study: Some respondents believed some of their classmates had chosen their field of study because of its prestige and future income. They were not interested in the tasks of this job. Therefore, they did not care about the goals of adherence to professional dress.

6. False pride: According to some interviewees, being accepted and studying in the field of dentistry and related specialties has led to pride and selfishness among students. Therefore, they do not accept or follow the laws.

7. Instrumental view towards patients: Some interviewees stated that patients were considered as an educational tool. Therefore, students did not care about certain goals mentioned in the dress code such as stimulating a sense of respect, tranquility, and trust in the service recipients. They again pointed out the negative influence of their role models, specifically the faculty members, in reinforcing this perspective. According to them, some academics paid more attention to their patients in their private offices and behaved differently in educational settings.

Some participants pointed out that since students played no serious role in patient management and the residents and professors were responsible for the treatment and students’ mistakes, they felt no responsibility other than learning. Therefore, they regarded the patients only as a training model. This feeling was also the reason behind their lack of interest in trying to stimulate their trust by adhering to the professional dress codes.

As noted earlier, all interviewees acknowledged that non-adherence to the cleanliness of the white coats was more evident than other sections of the “University Dress Code” in the dentistry school. The reasons behind this behavior were similar to many of those mentioned earlier, such as lack of understanding of the basis and importance of the code, inappropriate role models, lack of sense of responsibility toward patients, lack of motivation, inadequate administrative planning, lack of supervision, lack of patients’ reaction, love of comfort or laziness, habits and lack of familiarity with social life skills. However, some students stated two extra points:

1. Stress from the educational environment: For example, one interviewee said, “Stress for passing the course sometimes does not let one care about having a clean white coat and even paying attention to his/her bad dress choice.”

2. Fatigue from heavy educational tasks: Some stated that they did not use the university’s washing system, and as they were tired from the heavy educational tasks, they did not clean their white coats themselves. This was more common among students who were away from their families.

Lack of recreational programs in the education system. Some respondents believed that facial make-up for women or specific hairstyles for men was fun, and dentistry students used these easy and accessible tricks to blow the steam off their heavy curriculum. They complained about the lack of excitement, cheerfulness, and appropriate recreational programs in their school’s program, considering it as one of the causes of inappropriate appearance in some students.

Discussion

The barriers against adherence to the professional dress code, based on the results of this study, can be summarized in 4 main categories, namely defects of education, management shortcomings, changes in the societal culture, and personal factors.

The proper implementation of any policy in a system requires apt training. However, according to the students of dentistry, little effective training in this field, whether formal or informal, has been provided so far. Previous studies have shown that various factors influence adherence to the dress code (12), then It is not sufficient just to raise awareness of the issue (13), and even having a positive attitude toward it may not be a sufficient factor for adherence to it (2). So it seems that more attention should be paid to professional dress education to transform the knowledge and attitude into appropriate behavior.

Lack of understanding of professional duties is a sign of an educational deficit. Lorestani et al. (16) in 2010 also introduced this factor as one of the barriers to the internalization of adherence to professional dress code by the medical students of TUMS (16). This shows that the efforts in professional behavior training have failed to meet the goals.

The impact of role modeling in professional behavior training is more important than formal training (17, 18). Bramstedt et al. found that teaching ethics and dress code rules had little effect on students’ perception of professional dress; rather, students were more influenced by their educators in clinical settings, which is in line with the findings of the present study (19). In fact, the inactive behavioral role modeling, which is an integral part of the education process, occurs unconsciously. Indeed, students generate their attitudes and behaviors based on various conditions they are exposed to; this might have a debilitating effect on the formal training of professional behavior (20).

From the students’ point of view, the problems at the management level also act as a barrier against students’ adherence to the dress code. Asaju attributed this non-adherence to the lack of leaders' tendency toward implementation of the dress code (13). He believed that different components of the educational system should plan a single proper intervention and coordinate with each other to achieve the final goal. In addition, establishing communication between the executive authorities and the students can help to take and implementing appropriate measures in this regard (21). However, the managers should be careful about unnecessary or discriminatory interventions and prevent stress in the educational setting.

The results of this study confirm that personal wardrobe choices are influenced by the social environment (22) and peers (12, 23). When people understand social support for the dress code, they will be more likely to adhere to it (12). Because of the changes in fashion trends over the years, the present study shows a lack of social support for the dress code, building a barrier against its adherence.

Patients’ opinion reflects the viewpoints of the community. Bahrami et al. studied the professional dress choices of the dentists from the patients’ perspective (24). They reported that more than 50% of the patients did not support the dress code. In the present study, similarly, the participants mentioned that most patients do not support the dress code. Although 80% of the Iranians believe the wardrobe choice influences one's trust in physicians (5, 6), their definition of professional clothing is a narrow definition. Whiteness, cleanliness, and formality of a professional dress are three components considered important by the patients (6, 24).

Therefore, it seems that in reviewing the dress code in clinical settings, it is good enough to emphasize more on what is stated as the primary purpose, namely infection prevention, and patient and clinicians safety as well as the creation of a sense of respect, tranquility, and trust in service recipients; that is, the additional cases should be addressed in other regulations or guidelines.

Interviewees also found that personal factors may also result in non-adherence to the professional dress codes. Some of these factors result from the students’ pre-college education, or requirements of youth, or their educational experience.

The rapid social and technological changes in recent years have reformed the preferences of the new generation (7). The youth’s preferences may be in conflict with professional appearance guidelines; so those who are expected to adhere to those guidelines may find it unacceptable. This is not specific to the school investigated in this study; similar results have been reported in studies conducted in other schools (7, 25). As a result, a dress code designed in the past would not be acceptable for the third-millennium generation now entering university, as they may consider it old, outdated, and not acceptable. Urging students to follow guidelines that they do not accept causes frustration and stress (25). As a result, it would be more acceptable if the policymakers achieve the adherence to dress code goal by planning for students' education on the effects of proper clothing on the doctor-patient relationship or prevention of possible infection/contamination.

In line with the Heidarzadeh et al. study, most of our participants believed that adherence to dress code is at an appropriate level (8). It seems that alteration in social culture and personal preferences have changed the participants' view towards considering the proper wardrobe the same as common clothing.

It is noteworthy that while this study was conducted in the dentistry school and the clinical environment of that school is different from general and specialized hospitals, it seems that the mentioned students’ perspective is not specific to this context. However, it must be taken into account that although the media have made similarities in clothing in different geographical parts, cultural differences are still effective in clothing. This point should be considered in generalizing the results of this study to the students across Iran.

Conclusion

Based on the findings of this study, all components of an educational organization must be aligned with each other to overcome the barriers against the students’ adherence to the professional dress code. On the one hand, by taking into account the social evolution and the morale of the youth, transparent policies and proper planning should be adopted. On the other hand, there should be a maximum will to internalize belief in dress code through appropriate educational methods. Therefore, a review of the dress code contents as well as its teaching, and evaluation methods are needed to improve formal education in this field. The training should also be performed at the correct time in order to maximize the effect. Moreover, by raising the academic staff’s awareness of their inspiring role in this field and providing the students with appropriate feedback, we can use the benefits of the informal curriculum to enhance formal education.