Investigation of Students ' Attitudes toward Professional Dress Code and the Level of Adherence to This Code at Kerman University of Medical Sciences , Kerman , Iran

Aazam Heidarzadeh Mina Mobasher , Hossein Safizadeh , Nozar Nakhaei , Ali Akbar Haghdoost , Majid Fasihi Harandi , Mansooreh Azzizadeh Forouzi 1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Geriatric Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. 2 Medical Ethics and History of Medicine Research Center, and Medical Ethics Department, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 3 Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 4 Research Center for Social Determinants of Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 5 Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 6 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 7 Department of Medical-Surgeical Nursing, Nursing Research Center, School of Nursing and Midwifery Razi, Kerman University of Medical Sciences, Kerman, Iran.


Introduction
owadays, professional commitment in medical settings has gained much prominence and is defined as behaviors leading to building trust and confidence in the relationships among the medical staff, patient, and community (1). The appearance and the way the medical staff dress have significant effects on the patient's first impression of the medical staff (2). It is not only the knowledge or skill that make a good and productive relationship, but also certain behavioral codes that are effective in preserving the dignity and effectiveness of the health care providers. The professional attire of the healthcare providers is one of the parameters which is in accordance with the culture and beliefs of each community and is influential in the medical settings (3). It should be noted that the implementation of the professional dress code should be accompanied by respecting the professional ethics which is very influential in professional behavior. The professional ethics establishes the professional behavior of individuals, which in turn, creates trust, confidence, and hope in the recipient of health care services and results in the improvement of the service quality and the related organization (4). McKenna et al. (2007) showed that professional dress code helped develop a successful doctor-patient relationship, and therefore, provided the foundation of a highquality care service (5). Furthermore, professional dress code is regarded as an essential part of developing successful professional communication (6). Jabbal and Porter emphasized the effect of medical students' attire on making relationships with the patients (7). The results obtained from another study also revealed the importance of the physician's dress as an effective nonverbal communication tool leading to an appropriate doctor-patient relationship (8). In addition, psychologists often highlight the importance of physical appearance and its impact on one's first perceptions and relationships (5). Over the centuries, the long white coat has become the universal symbol of the medical profession (3) since it is not only protect the individuals against microorganisms but also symbolizes one's competence and status (9). Moreover, the patients care about the appearance and dress of the medical staff and consider it as a criterion for assessing the competence and dignity of the medical personnel (3). In the same line, Semnani and Shahpouri (2007) reported that the psychiatrist's appearance was effective in improving the physician-patient relationship (10). According to the results of another study, the participants favored formal clothing, such as suits for male professors rather than jeans and T-shirts (11). All care providers in any clinical settings should attempt to build proper communication with the patients and help them get rid of their tiredness as a result of their disease. In this regard, the professional attire and behavior of the students in clinical centers should be in line with those of physicians, nurses, and paramedics. This accordance protects patient's privacy, respects customary, religious and social standards, develops a positive professional image, and adheres to the standards of infection control (12). Given the fact that the hospital environment is an educational setting, it requires freedom from issues related to ethical issues. Universities in different countries have their own dress codes in the clinical settings, and Iranian Medical Universities are no exception. However, it should be noted that despite the presence of the dress codes in universities, some students do not adhere to them. Moreover, to the best of our knowledge, there is a dearth of research in this regard; therefore, this study aimed to investigate the students' attitudes regarding the professional dress code and the level of adherence to this code at Kerman University of Medical Sciences, Kerman, Iran

Methods
This descriptive cross sectional study was conducted to investigate the students' attitudes regarding the professional dress code and the level of adherence to this code at Kerman University of Medical Sciences, Kerman, Iran, in 2013. The study population included all students (n=5280) studying in different major and programs at Kerman University of Medical Sciences. However, the study sample was obtained at 360 people using the Cochran formula (N=5280, Z=1.96, q=p=0.05,d=0. 5).
After obtaining the required permission from the Department of Student Affairs, determining the sample size in each faculty, and obtaining the written consent from the students, the researcher distributed the questionnaires randomly among the students at university and dormitory campuses. The convenience sampling was performed and the students from all majors and programs with one semester of clinical experience from each faculty were included in this study. The participants were studying at faculties, such as Medical (n=70), Health (n=58), Paramedical (n=52), Nursing and Midwifery (n=35), Dentistry (n=30), Pharmacy (n=30), and Management (n=30), as well as Sirjan and Zand Universities of Medical Sciences (n=15 and 10, respectively), and International University (n=30).
The data collection tool was designed based on Dress and Behavior Code Guidelines for the Students of Medical Sciences in Clinical Settings. This questionnaire consists of two parts including female (18 items) and male (19 items) professional attire. The participants were asked to complete the questionnaires based on a 5-point Likert type scale ranging from completely agree (scored 5) to completely disagree (scored 1). Moreover, the instrument has a minimum and maximum scores of 18 and 90 as well as 19 and 95 for females and males professional attire, respectively.
In addition, the respondents were required to rate the level of other students' adherence (%) to professional dress code. A column was inserted in front of each questionnaire item for the participants to rate the level of other students' adherence (%). The obtained results were classified into three categories, namely the levels lower than 25%, from 25 to 75%, and higher than 75%. The validity of the male and female questionnaires was separately assessed using the content validity. In addition, 10 experts in clinical and basic sciences as well as medical ethics were asked to give their comments as totally appropriate, moderately appropriate, and inappropriate in this regard. Furthermore, 30 male and female students were asked to give their comments on the final version of questionnaire to estimate the reliability of the questionnaire. It should be noted that male and female students assessed the male and female questionnaires, respectively. Eventually the Cronbach's alpha coefficients of male and female questionnaires were obtained at 0.89 and 0.85, respectively.
The data analysis was performed in SPSS software (version18) through mean and standard deviation.

Result
According to the obtained results, out of 368 participants, 224 (60.9%) students were female. In addition, the mean age of the females and males were 22.13±2.77 and 22.45±3.4, respectively.
Moreover, the mean score of female students' attitudes towards professional dress code was 72.04±13.49, and the items, "Wearing sharp perfumes" and" Wearing Chador or scarf based on Islamic practices" obtained the highest mean scores. On the other hand, the item" Wearing clean, white, and buttoned coats" obtained the lowest mean score. Regarding the results obtained from the investigation of other students' level of adherence to the dress code, the majority of the female participants believed that more than 75% of the students adhere to professional dress code during their education. Moreover, the items" Wearing clean, white, and buttoned coats" and "Wearing socks to keep the feet healthy" obtained the highest and lowest level of adherence (%), respectively (Table1).
The mean score of male students' attitudes in this study was obtained at 74.12±10.77. Moreover, the items "Wearing slippers and sandals" and "Not wearing sharp perfume obtained the highest mean scores. However, the item" Dressing should be based on students' professional attire" obtained the lowest mean score. In addition, the majority of the male respondents stated that more than 75% of the other students adhere to professional dress code. According to the male students' attitudes, the items, "Not wearing no make-up and tattoo", "Not wearing ties or bows", and " Not wearing slippers and sandals" obtained the highest level of adherence to professional dress code by other students (%). On the other hand, "Wearing socks to keep the feet healthy" and "Wearing clean and white shoes" obtained the lowest level of adherence in this regard (Table 2).

Discussion
The results obtained from this study revealed the positive attitudes of students regarding the dress code and professional attire. In a study conducted by Lorestani (2010), the medical students under study reported the moderate level of adherence to the professional dress The dressing code and appearance of individuals are of utmost importance in Iranian context in which the civil laws are based on Islamic religion and Quran. The adherence to the dressing code in educational settings not only signifies the adherence to the religious and national civil laws in Iran which make a calm environment, but also display a positive image of professional conduct and behavior.
Although the students' had positive attitudes towards professional dress code, the issue of Hijab and Chastity obtained the lowest scores in this study. The lower scores in this regard can be attributed to the Islamic nature of Iranian society in which Hijab is an inevitable part and there is no necessity to highlight it in professional dress code. However, there is a need to conduct further research in this regard. The participants stated that the majority of the students adhere to the professional dress code, and the items "Wearing white, clean, and buttoned coats" and" Not wearing make-up or tattoos" obtained the highest mean scores.
In the same line, Lorestani et al. (2010) conducted a study to compare the interns and practitioners' attitudes toward professional dress code. The results revealed that 210 (62.3%) and 58 (17.2%) medical students obtained the moderate and high scores, respectively. Moreover, 90% and 70% of the participants had positive attitudes toward "Wearing white coat and name badges" and "Wearing simple and formal clothing", respectively. On the other hand, the majority of the students reported that "Wearing jeans and sneakers" destroys the physicians' dignity (3).
Thompson et al., conducted a study to investigate the American students' attitudes regarding professional dress code. The results revealed that the majority of the students preferred wearing suit at workplace (13). In another study, most of the physicians had positive attitudes regarding wearing white coats, name badges, shirts, and shoes; on the other hand, they were not in favor of wearing sandals, jeans and sneakers. Additionally, the older physicians preferred the conventional dress (white long coats), compared to younger ones; moreover, this study considered the physicians' attire as an important part of the doctor-patient relationship in which the patients' attitudes were positive regarding wearing the conventional physicians' attire, such as proper shoes and clothes, shirt and tie, as well as tidy and smart pants.
Furthermore, a study was conducted by Sudhir et al., to investigate the dental students' attitudes towards professional dress attire. According to the results, 42.6% and 38.7% of the female and male students preferred the casual attire, respectively. In addition, 54.1% and 34.9% of the male and female students highlighted the need for change in dental attire, respectively (14). This study suffered from some limitations, such as lack of access to the students in the study setting. Accordingly, the student were asked to complete the questionnaires when they had no classes and enough time.

Conclusion
The results of this study showed that students had positive attitudes towards professional dress code, and they reported higher levels of other students' adherence to this issue. The identification of the students' attitudes toward professional dress code and the higher levels of adherence to this issue pave the way on the maintenance of this positive view among students and the enhancement of the students' adherence in terms of wearing clothes based on the dress code in clinical settings. Accordingly, the Islamic values and professional attire codes are respected, and the patients are impressed greatly when referring to any clinical settings.
finding of Kerman University of Medical Sciences. The authors express their gratitude to the faculty directors, students, and Research Deputy of Kerman University of Medical Sciences who contributed conducting this study.