Cosmetic surgery in the perception and acceptance of nursing students

Introduction

Cosmetic surgery is a subspecialty of plastic surgery that deals primarily with the maintenance, restoration, or enhancement of a person’s physical appearance achieved through surgical procedures [1]. Globally, there is an upward trend in the pursuit of beauty through modification of physical appearance [2–4]. According to the British Association of Aesthetic Plastic Surgeons, nearly 27,000 procedures took place in 2019, a decrease of 7.5% from the previous year [5]. The American Society of Plastic Surgeons reported that 15.6 million cosmetic surgeries were performed in 2020 [6]. Several factors may cause the growth in cosmetic surgery [7]. Developing self-confidence, having a beautiful body, achieving a happy marriage, and fulfilling expectation of friends, low self-esteem, and self-rated physical attractiveness are some of the subjective reasons identified for engaging in a cosmetic surgery procedure [8, 9]. As a result, this accounts for the increase in cosmetic surgery done annually [10]. The understanding and acceptance of cosmetic surgery is important among the public; it is even more important for nurses because they form a crucial part of a successful cosmetic surgery practice and are the care givers’ closest to, and spending most time with, cosmetic surgery patients [11, 12]. Furthermore, the community’s rehabilitation of cosmetic surgery patients depends on the appointed nurse’s clinical experience and judgment [13]. The most important problem of patients undergoing cosmetic surgery is the absence of non-judgmental and informative nurses [14]. Therefore, if nurses present with inadequate knowledge of cosmetic surgery and lower acceptance of it, wound healing and recovery may be less than ideal or even be compromised leading to inconsistency in patients [13]. Perception and acceptance of cosmetic surgery among nursing students as future professionals is vital for proper nursing care. Their misconceptions regarding cosmetic surgery may affect the specialty by negatively altering patient care [15].
A study carried out on nursing students found that half of them were accepting of patients undergoing cosmetic surgery [16]. Furthermore, the majority of the students stated that they would provide the same amount of care regardless of whether a patient was undergoing cosmetic surgery or not. There are only a few studies on cosmetic surgery among nursing students [14, 17].
Nursing students doing undergraduate, graduate, and doctoral degrees learn the perioperative patient care practices of cosmetic surgery within the scope of the nurse’s duties, powers, and responsibilities for minor and major surgical procedures in surgical nursing courses in Northern Cyprus. After graduation, they put into practice what they learned during the education process and take care of their patients in the perioperative period. In line with this, this research aims to determine the perception and acceptance of cosmetic surgery in nursing students.
The research questions that were answered are as follows: • Do nursing students have adequate perception regarding cosmetic surgery? • What is the level of acceptance of nursing students regarding cosmetic surgery?

Material and methods

The descriptive study was carried out at a University, Faculty of Nursing, Health Science Graduate School Master and Doctorate Nursing Programs, located in Northern Cyprus. The language of the departments was English. The universe of the study comprised 600 nursing students. A compulsory surgical nursing module was being offered as part of its curriculum to nursing student in the second year, also in masters and doctorate programs, wherein the students were being taught about cosmetic surgery, its types, and how to care for all surgical patients, including those who had cosmetic surgery.

Sample selection

Nursing students who had completed a surgical nursing course and were proficient in English were included in the study. First-year nursing students were not included in the study because they did not meet the inclusion criteria of completing the surgical nursing course.
To determine the sample size, the power analysis method was used. This method is suitable for ascertaining a given test’s effect at the desired level of significance. A population of 600 students was considered at a 95% confidence level and a margin of error given at 5%. A sample size of 230 was obtained.

Study tools

The study tools included 2 questionnaires. The first questionnaire was divided into 2 parts, the first of which focused on the respondents’ demographic information (gender, age, academic year, and religious background). The other half included correct answer/wrong answer/I don’t know options to test respondents’ perception of cosmetic surgery (concept, types, and risk). The researcher formulated these questions based on the existing literature [2, 9, 11, 14, 17].
The second questionnaire was the Acceptance of Cosmetic Surgery Scale (ACSS) developed by Henderson-King and Henderson-King (2005). This multi-dimensional scale assesses several aspects of attitudes and perspectives toward cosmetic surgery. The Acceptance of Cosmetic Surgery Scale consists of 3 subscales: Intrapersonal, Social, and Consider. The 5-item Intrapersonal sub-scale (1, 2, 4, 5, and 14) assesses views on cosmetic surgery’s self-oriented advantages. The 5-item Social sub-scale (9, 11, 12, 13, and 15) assesses social motivations for cosmetic surgery. The Consider sub-scale, which has 5 items (3, 6, 7, 8, and 10), assesses whether the respondent would consider cosmetic surgery. All the items in the ACSS are appraised on a 7-point Likert scale. The score range on the ACSS is 15–105. It was suggested that it is permissible to compute a total acceptance score by calculating the mean of all 15 items in the original study. Higher scores on the sub-scales and the total scale indicate a more positive attitude and greater acceptance of cosmetic surgery. The Acceptance of Cosmetic Surgery Scale is suitable for use among the general population. This scale has a good level of internal consistency, convergent validity, and reliability [3, 18, 19]. The Cronbach’s  coefficient ranges from0.91– to 0.93 across all items [18]; in this study it was very strong, at 0.96.

Ethical consideration

Approval was obtained from a University Health Sciences Ethics Committee with decision date 28.01.2021 and number YDU/2021/87-1264. Permission was also obtained from a University Faculty of Nursing to carry out the research. Online consent forms were obtained from the participants.

Data collection

Data was collected between 31 January and 1 April 2021 using questionnaires that were available online and completed electronically. Participants accessed the link of the questionnaires through a social media platform. Participants who accessed the link did so voluntarily and were aware that the information given would be treated as confidential and anonymous. No incentive was provided. It took 15–20 minutes to complete the questionnaire.

Data analysis

The Statistical Package for Social Sciences 22.0 (SPSS) was used for data analysis. Mean, standard deviation, frequency, percentages, and Cronbach’s  value were obtained. The Acceptance of Cosmetic Surgery Scale was evaluated by computing the mean across all 15 items and summing it. The independent sample t test was used to determine the relationship between age and acceptance of cosmetic surgery and one-way analysis of variance (ANOVA) was used to determine if any significant difference existed between gender, academic year, religious background, and acceptance of cosmetic surgery. When the ANOVA-F test was significant, a post hoc analysis using the Tukey HSD test was performed to determine the group from which the differences originated.

Results

The average age of the participants was 25.32 ±3.74 years (minimum = 19.00, maximum = 40.00). Majority of the respondents were age 29 and below (91.9%). The number of females in the study (61.7%) was greater than that of men (37.0%). Most of the participants were in their third year of undergraduate education (37.9%). Christianity represents approximately 81% of the total study population. There are 5 information resources from which the participants obtained their information. The highest percentage was from the Internet (41.3%), while the lowest percentage was via medical consultation (4.3%). A larger proportion of the nursing students considered the information to be reliable (73.9%), while about one-fifth of the participants did not consider their source of information to be reliable (20.4%). The majority of the respondents said that they did not have a relative or friend who had undergone cosmetic surgery (62.6%). When asked if they had gone through any type of cosmetic surgery before, about 214 (93.0%) of the nursing students answered no, while 16 (7.0%) answered yes. For the respondents who said no, thinking that natural beauty is better (28.3%), being afraid of surgical complications (27.6%), and being unable to afford it (26.2%) ranked highest as the commonest reasons. Regarding the risk of cosmetic surgery, 116 (50.4%) of the nursing students were aware of the associated risk of cosmetic surgery, while 114 (49.6%) of the nursing students did not know or were not sure of the risk involved in cosmetic surgery. For respondents who were aware of the associated risk, bleeding (10.4%), surgical site infection (8.7%), and death (7.0%) ranked highest as the most mentioned.
Table 1 shows the nursing students’ perception of cosmetic surgery. It was found that the majority of the nursing students gave correct answers in statements about cosmetic surgery. The most frequently known items were “Is cosmetic surgery focused on enhancing appearance, so it is called cosmetic surgery?” (Yes) (96.1%) and “Is it cosmetic surgery that improves the appearance of a person?” (Yes) (78.3%), respectively. Two hundred and twenty-three students (97.0%) felt that females undergo more cosmetic surgery than men. The majority of the nursing students (97.3%) were aware of the types of cosmetic surgery. Liposuction (72.2%), breast reduction (67.4%), and rhinoplasty (63.5%) ranked highest as the most common cosmetic surgeries of which nursing students were aware. Awareness regarding other forms of cosmetic surgeries included tummy tuck (37.4%), breast augmentation (52.2%), Botox (53.5%), facelift (30.0%), and laser (49.1%).
Sixty-four (27.8%) nursing students agreed that “cosmetic surgery is a good thing because it can help people feel better about themselves”, while 7 (3.0%) of the nursing students strongly disagreed with that item. Even if a procedure was done for free, 12.6% would strongly not consider trying it. One-third of the students (32.6%) somewhat agreed that “cosmetic surgery can be of great benefit to people’s self-image”, while 31 (13.5%) remained neutral. Nineteen (18.3%) of the nursing students strongly agreed that they would never have any kind of cosmetic surgery even if it was for interpersonal, social, or consider reasons (Table 2).
The mean score for the item “If cosmetic surgery can make someone happier with the way they look, then they should try it” (5.31 ±1.30) and “Cosmetic surgery can be of great benefit to people’s self-image” ranked highest (5.27 ±1.30). The mean score for the item “I would think about having cosmetic surgery to keep looking young” ranked lowest (4.15 ±1.81).
The mean score for the interpersonal scale was 25.73 ±5.88, which is a significantly high value. The average score for the overall scale was 71.29 ±21.672, which showed that the nursing students had a moderate acceptance regarding cosmetic surgery (Table 3).
Table 4 shows the relationship between sociodemographic variables and acceptance of cosmetic surgery. A statistically significant difference was found in the age (p = 0.004), academic year (p < 0.01), and having a relative with cosmetic surgery (p < 0.01). For age, students aged 29 years and below had a higher acceptance of cosmetic surgery (M = 73.02; SD = 21.77) compared to the age group 30 years and above (M = 62.77; SD = 18.21). For academic year, a Tukey HSD revealed significant differences between students in the postgraduate year and those in other years. More specifically, in the postgraduate year (M = 57.85; SD = 26.65), the acceptance of cosmetic surgery score was significantly lower than the score in second year (M = 72.92; SD = 17.61, p = 0.030), the score in the third year (M = 75.42; SD = 18.51, p < 0.01), and the score in the fourth year (M = 74.12; SD = 21.83, p = 0.001). Students who had a relative who had undergone cosmetic surgery had a higher acceptance of cosmetic surgery (M = 79.77; SD = 18.29) compared with students who did not have such a relative (M = 67.50; SD = 22.53) or who were not sure that they had such a relative (M = 70.75; SD = 15.54). No significant difference existed between gender, religious background, and acceptance of cosmetic surgery among nursing students.

Discussion

Interest in cosmetic surgery is associated with body image, self-esteem, individual propensities, and psychological factors, such as psychopathological traits [20–22]. Public access to cosmetic surgeries has greatly increased because of advances in medical technology coupled with rapid growth of web-based mass media and social media [20]. In this study it was determined that most of the nursing students were interested in cosmetic surgery. The rate of correct answers was in high percentages. This was very consistent with studies done in Nigeria to determine the awareness of healthcare workers, and medical and nursing students to cosmetic surgery, where the level of awareness was about 94.4%. Nevertheless, there were varying levels of awareness with regard to the different forms of cosmetic surgery. Liposuction (72.2%), breast reduction (67.4%), and rhinoplasty (63.5%) ranked highest as the most common cosmetic surgeries of which nursing students were aware [2]. In a study it was reported that the most commonly mentioned procedure among professionals in the banking and civil service sector was liposuction (88.2%) [23]. Social factors may heighten the pressure to have a cosmetic procedure because women and men are constantly reminded that they can and should look better [24]. The desire to seem more appealing and compete in terms of beauty with other females in the quest of marriage and the desire to look younger than their spouse have been found to be motivating factors affecting interest in cosmetic procedures [25]. As a result of similar reasons, it was thought that the students were interested in cosmetic surgery.
Only 16 of the respondents had previously undergone cosmetic surgery. The participants who did not undergo cosmetic surgery felt that natural beauty is better, whilst some of them were afraid of surgical complications. Just over one-fourth (26.9%) stated that they could not afford a cosmetic surgery procedure, which is very consistent with the findings from a study in Nigeria where the participants felt that cosmetic surgery is very expensive and is more acceptable among people of high economic class [2].
From our study, the overall acceptance of cosmetic surgery was found to be 71.29%, which was higher than the 60.89% that was found in undergraduate nursing students in North Korea [26]. This disparity might be related to participant differences because undergraduate students accounted for 82.6% of the participants in this study; the remaining 17.4% were graduate nursing students who were actively engaged in a social life through their work, marriage, or other kinds of commitment. They had most likely already undergone some degree of internalization of societal standards. Our findings indicated that intrapersonal reasons are a greater determinant for acceptance of cosmetic surgery than social reasons and consideration reasons. These conclusions are consistent with results from studies in which intrapersonal reasons were found to be more important than social reasons among genders [14, 27, 28].
There was no statistically significant difference between religion and acceptance of cosmetic surgery (p = 0.55). However, respondents who selected other forms of religion by stating they were liberal or atheist had a higher acceptance of cosmetic surgery than those who chose Christianity, Islam, or Buddhism as their religious background [27, 29].
An Iranian study and a Singaporean study observed that a higher education level was positively correlated with an interest in cosmetic surgery [27, 30]. This is in sharp contrast to the results of our study, which found that postgraduate nursing students had a lower acceptance of cosmetic surgery in comparison to other academic years.
The results of this study show that students who had a relative had undergone cosmetic surgery had a higher acceptance of cosmetic surgery compared with the other students who had not had a relative or who were not sure that they had had a relative who had undergone cosmetic surgery. In a similar study conducted on students of a nursing faculty in Turkey, it was discovered that there was a difference between students who had family and friends who had cosmetic surgery and those who did not [14]. In the studies, it was indicated that having friends or a family member who had undergone cosmetic surgery provided an indirect experience to the individual [2, 25, 29, 31, 32]. Increased acceptance of cosmetic surgery among the patient population without increased acceptance among nurses could result in inconsistencies in patient care [19].

Conclusions

The perception and acceptance of cosmetic surgery among nursing students was good, but there was a deficit in knowledge in the aspect of the risks and complications associated with it. Furthermore, their overall acceptance towards cosmetic surgery was moderate, which calls for further refinement. There is a great need for nurses to have a high acceptance of cosmetic surgery because this can also contribute to enhancing societal approval of it.
The results obtained from this study can be useful in preparing the students for their chosen profession, because there is a greater likelihood that the perception and acceptance of the public regarding cosmetic surgery will grow in correlation with the perception and acceptance of nurses because they play an important role in the care of the patient.
The authors declare no conflict of interest.