Some rules on physical appearance in hospitals and other institutions can be off-putting to nurses, especially students entering the profession. “Why can’t I wear nail polish?” they might ask, or “Why do I have to cover up a tiny butterfly tattoo on the back of my neck?” Sometimes, these rules are based on concerns about infections, backed by rigorous scientific studies. But in many cases, the rules are based on less definable concerns, such as concepts of nursing professionalism or what is thought to bother patients.
The rules vary widely by institution, and they are evolving as social norms change. For example, a growing number of young nurses wear tattoos and piercings, pressuring hospitals to relax rules. Also, the Civil Rights Act of 1964 protects discrimination against racially based hairstyles such as afros and dreadlocks.
The following is an analysis of some of the most controversial rules, based on dress codes posted on institutions’ websites and nurses’ comments on message boards.

Banning Nail Polish and Gel
Some hospitals and nursing schools ban all form of nail polish, which can upset some nurses. For example, a nurse on the allnurses.com discussion forum wrote that a ban on all nail polish would make her seriously consider finding a new job. “I think that ‘no nail polish’ is a pretty ridiculous requirement,” she wrote. “Seeing a cheerful color on my nails brings a smile to my face.”
Such bans are based on studies showing that when the polish chips, infections can lodge inside the crevices. That’s enough reason to ban all nail polish, according to Beverly Malone, PhD, RN, CEO of the National League for Nursing. “Patient safety should be the paramount concern,” she says.
However, many institutions only ban long fingernails and artificial nails, which have been shown to have higher risks of infection than ordinary nail polish. And other hospitals, focusing on the problem of chipping, simply ban chipped nails or require new polish on nails every four days, to reduce the risks of chipping. But this requires strict enforcement.
The problem is that rules that are nuanced may be difficult to carry out, and enforcement relies on frontline managers who may be less than enthusiastic about them. “A policy that says ‘NO…but!’ is no policy at all,” another nurse wrote about nail standards on allnurses.com. “If they make allowances (4 day changes, etc.), they might as well just shut up about the issue and everyone can wear what they want.”
The introduction of gel and shellac nails over the past few years has only complicated matters. These polishes last longer than traditional products and are touted as chip-free. Although they are still too new to be well-studied for infection risks, some hospitals have included them in bans of artificial nails, and this has caused uproar among some nurses.
Tess Walters, a manicurist in Logansport, Indiana, says a ban on gel nails at a nearby hospital brought in six nurses who needed emergency redoes. “Hospital policies lump gel polish together with artificial nails,” Walters says, adding that “sweeping policies make for disgruntled employees.”

Excluding Unusual Hairstyles
Many hospitals and nursing schools ban hair in bright, unnatural colors, and some specifically ban unusual styles. “Extreme trends such as dreadlocks, Mohawks, and long spiked hair is not acceptable,” according to the University of Utah Health Care’s dress code. Other institutions are more easy-going: “There are 3 nurses on my unit that have locks and I never heard a problem about it,” according to a comment on an allnurses.com forum discussing nurses with dreadlocks. “Personally, I think if the unit and region is culturally diverse then it won’t be a problem.”
Hairstyles that can be pulled up or tied back don’t appear to present problems with infection control. But, Malone says unusual looks may offend some patients and staff. When hospitals formulate rules, “patients’ views and the professionalism of nurses ought to be major considerations,” she says.
However, Malone doesn’t think the rules should impinge on natural hairstyles, such as dreadlocks, worn by African Americans who choose not to straighten their hair. According to the Equal Employment Opportunity Commission (EEOC), Title VII of the Civil Rights Act makes a distinction between racially based hairstyles and ones that could be worn by anyone, such as Mohawks or green hair.
The EEOC compliance manual, which carries out Title VII, prohibits employers from restricting hairstyles that involve “racial differences in hair textures.” However, a federal judge in Alabama recently denied an EEOC lawsuit against an insurance company that terminated a dreadlocked employee, arguing that African Americans have a choice to wear other hairstyles besides dreadlocks. The case, EEOC v. Catastrophe Management Solutions, is being appealed.
But even hairstyles not protected by Title VII are flourishing in some places—perhaps because employers have no interest in being strict, or because they prize the nurse’s skills and patients don’t seem to mind. Another nurse on allnurses.com says she has worn spiked hair and a rattail in a wide variety of health care settings for about 20 years, and she now works in a rural Appalachian community. “The little old country Baptist preachers’ wives often comment on how much they like my hairstyle,” she asserts.

Curbing Tattoos
Hospital rule-makers have had to contend with a surge of young employees with tattoos. A 2012 Harris survey found that 38% of Americans in their 30s had at least one tattoo. Minorities in particular seem to have them. A 2006 study published in the Journal of the American Academy of Dermatology found that 38% of Hispanics and 28% of blacks had tattoos, compared with 22% of whites.
“Tats” were traditionally for males, but the Harris survey found that as of 2012, more women than men wore them. However, most female tattoos aren’t visible. According to a 2010 Pew Research Center survey, only 13% of tattooed women had art that could be seen outside their clothing.
Unlike nail polish, tattoos don’t present safety issues like harboring germs, but they can upset patients and other staff. According to a 2012 study in The Journal of Nursing Administration, patients tend to have negative attitudes toward health care workers—especially women—who have tattoos. Moreover, certain tattoos, such as depictions of demons, may strongly offend some patients.
Hospitals typically prohibit visible tattoos but often allow employees to cover them up under long sleeves, Band-Aids, or larger bandages. “I’m not saying get rid of your tattoos,” Malone says. “Just cover them up when you’re at work. You’re in a professional setting.”
Some hospitals soften the rules on covering up. The radiography school at Akron Children’s Hospital calls for covering up “to the extent possible,” and Rochester General Hospital calls for covering “inappropriate” tattoos.
A few, though, have stricter rules. For instance, the nursing school of Missouri Southern State University not only bans visible tattoos but won’t allow students to cover them up, either. In 2009, the policy drew many protests from applicants, according to The Joplin Globe. A spokesman for the school told the Globe that a bandage put over the tattoo “could become wet or soiled, and there is the potential for cross-contamination.” The school’s 2014-2015 student handbook shows the tattoo rule is still in place.
Like employees with green hair or a Mohawk, people with tattoos basically don’t have any Title VII protections either, according to Robert G. Brody, an employment attorney in Westport, Connecticut. In a 2010 analysis, he wrote that the law “does not include ‘tattooed’ as a protected classification.”

Rules on Body Piercings and Earlobe Gauges
Body piercings are now common among younger women in particular. According to the 2010 Pew Research Center survey, 35% of women and 11% of men under age 30 have a piercing somewhere other than in an earlobe.
The eyebrows, nose, top of the ear, lips, and tongue may be pierced. In addition, holes in the earlobes can be stretched and fitted with round ornaments, or “gauges,” which are as much as 1½ inches in diameter. Piercings don’t seem to present much of an infection hazard for patients, but items like large nose rings could be grabbed by patients, and the sight of these adornments can be off-putting to some people.
Basically, piercings don’t have Title VII protections from employers’ actions. Hospital rules typically state that “visible” piercings are prohibited, but it’s not clear what that means exactly. Does it mean that piercings will be allowed if the jewelry is removed and replaced with clear or skin-color pieces—the equivalent of a Band-Aid over a tattoo? Or, does it mean that only piercings under the clothing will be allowed?
Children’s of Alabama, a hospital in Birmingham, meant the second interpretation, according to Deborah Wesley, RN, MSN, the hospital’s chief nursing officer and coauthor of its rules. But some institutions specifically allow some camouflaging. “Ear gauges must be covered/non-conspicuous,” according to the nursing student guidelines at Tarrant County College. Alternatively, Lancaster General Health in Pennsylvania allows gauges that are solid, don’t exceed ¼ inch in diameter, and don’t have jewelry connectors.

Rulemaking and Enforcement
When making rules on appearance, hospitals have to balance the conflicting demands of patient safety, patient satisfaction, and employee satisfaction, says Wesley. To make sure employee satisfaction has a role, staff nurses at Children’s of Alabama develop the first draft of the dress code, which is then sent to leadership for approval, she adds.
This process produced a rule on tattoos that is unusually tolerant. “Tattoos that consist of nudity, profanity, or are racial in nature are not allowed,” the Children’s of Alabama rules state. As a result, tattoos “have not been an issue for us,” Wesley says. “We understand that newer generations have evolving views on this.”
For rules to be respected by staff, they have to be enforced in an equitable way, she argues. Management has to understand the rules and believe in them. At Children’s, “the rules are managed at the unit level,” Wesley said. “Our frontline leaders know these policies and procedures.”
“We have really tried to find a balance,” she says.
Leigh Page is a Chicago-based freelance writer specializing in health care topics.

Leigh Page

Leigh Page is a Chicago-based freelance writer specializing in health care topics.

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