Hospital shoes and their owners: expressed team identity among healthcare staff by signs of their footwear

ABSTRACT Fashion is a way to express identity and affiliations with specific social networks, and sociocultural organisations of health care facilities are no exception. Employees in hospitals must adhere to strictly regulated dress code policies, albeit shoes are one of few markers that are not regulated. The aim of this study was to analyse the expressed team identity among healthcare staff by studying signs of personality traits they share with colleagues, as found in their choice of footwear. A total of 213 images of hospital footwear, posted on Instagram, were analysed utilising thematic content analysis. The results show that choice of footwear signals seven different personality traits: the anonymous, an understated conformist; the discreet standout, a subtle individualist; the doer on the move, an active and ready contributor; the naturist, a barefoot enthusiast; the superior tourist, a temporarily elite visitor; the outsider, an unconventional maverick; and the legend, a battle-scarred veteran.


Introduction
Footwear is often regarded as an extension and expression of self.According to Belk (2003), footwear, besides being an extension of self, also 'acts as a repository of memory and meaning in our lives ' (p. 27).This means that shoes are prosthetics and props for self-presentation that signal social status, gender, and cultural capital.For staff in healthcare, shoes in everyday practice are a very explicit and identity-marking form of expressed meaning.This is due to the fact that shoes are oneof fewmarkers in an often strictly regulated dress code policy for employees (Wilson, Loveday, Hoffman, & Pratt, 2007).Footwear and its role as a marker of 'self' in healthcare practices needs to be further addressed, not least because it relates to standards of professional uniforms signifying identity and is therefore a part of an overall marker of status within and between the healthcare professions.
2. Review of the literature Timmons and East (2011) showed that all healthcare professionals have their own hierarchies of status, but medicine is acknowledged by all the other professions to be the profession with the most status.Signs of identities are socially shared mental representations of personality traits.Language is an example of such a sign, attributes such as clothing and shoes are another (Ehala, 2018).Further, Ehala claims that there is visible anatomy of belonging expressed by these signs that shapes a core understanding of identity.He explains: The sign of identity, like a linguistic sign, has two parts: the signal and the meaning.By reading the identity signals that other people send, people reach conclusions about the beliefs, attitudes and likely behaviors of the people who send these signals, i.e. about their identities.(p. 3) When addressed as a sign in the context of identity and the conclusions people draw from footwear, the meaning of shoes in the hospital setting and what they signal regarding beliefs, attitudes, and likely behaviours is of great importance to elaborate on.Bellezza, Gino, and Keinan (2014) stressed that individuals in professional settings make an effort to learn and adapt to written and unwritten dress codes as standards of behaviour.Further, Eckel and Grossman (2005) elaborated on team identity as the shaping of a person's attitudes, values, and norms by the groups to which she belongs: a person's social identity 'is determined in part by the different groups she is identified with and whether she is of the same group(s) as the identifier' (p.374).Teams are therefore often described as more than the collection of different individual identities; together they form a cohesive unit.In a hospital setting, this team identity usually refers to intradiscipline inclusivity among peers in a clinical setting (Weaver, Peters, Koch, & Wilson, 2011).
In this aspect conformity with social norms regarding dress codes is driven by a desire to gain social acceptance and status among coworkers and team members in a socially organised hierarchy in the work setting.However, Bellezza et al. (2014) have also shown a potentially positive outcome of nonconforming behaviours, which they labelled as the 'red sneakers effect'.Across a series of field studies, they showed that nonconformity with social norms regarding dress codes also can lead to attributions of greater status and competence within a context.Nonconformity to dress codes in relation to expressed team identity is therefore complex.Deviating from the norm signals both higher inferences of status and competence as well as possibly less attractive signs of status and competence among team members, especially as modern healthcare is organised in multidisciplinary healthcare teams who rely on effective teamwork.Weller, Boyd, and Cumin (2014) stress that adaptability in a team enables the participants to respond with a team-oriented approach.Further, they stress that the willingness to take other's ideas and perspectives into account is aligned with having the team's goals in focus, rather than the individuals'.
Fashion is a way to express an identity and affiliations with specific social networks (Buse & Twigg, 2015;Cherry & Mellins, 2011).In contemporary society, and with the tremendous increase in the use of the Web, social media platforms are used to narrate and discuss fashion (Chittenden, 2010;Titton, 2015).Moreover, Rocamora (2011) argued that personal fashion blogs represent a space for identity construction.In recent years, self-portraits, or also called 'selfies,' have increased in popularity (Souza et al., 2015) and developed into a 'selfie culture' (Giroux, 2015).Furthermore, Palmgren (2009) analysed how gender and identity are constructed via selfies of today's outfit in Swedish blogs.She emphasised that women who posted today's outfit used a sexually provocative posture.In the selfie culture, many subcultures have formed.One comprises selfies of shoes and footwear and uses hashtags such as #shoefie and #shoeselfie.On Instagram alone, those two hashtags are applied to more than 600,000 posts each.Pearson (2018) argued that analysing shoefies may provide insights into social networks and social presence.However, little has been previously known about footwear in hospitals and how it relates to team identity.The aim of this study was to analyse the expressed team identity among healthcare staff by studying signs of personality traits they share with colleagues, as found in their choice of footwear.

Research design
A straightforward archival and cross-sectional observational study with descriptive design was chosen to access data material of freely accessible shoe selfies published on the web.The study followed the principles described by Salzmann-Erikson and Eriksson (2012): identification of online venue, collection of data, analysis, and reporting.

Setting: identification of online venue
Some specific criteria for inclusion were selected in the search for Twitter accounts: an account in the native language of the researcher; determined focus on footwear; hospital environment; freely available online.No specific exclusion criteria were set.Only one Twitter account met the criteria for inclusion.

Data collection
A purposeful sampling strategy was used to identify relevant hashtags or accounts.No specific hashtag was found to be relevant, but one account was found 'sjukhustoffeln' (Eng.The hospital slipper).This account published images of hospital slippers without exposing personal features other than the lower body parts.The account had more than 400 followers and had published over 200 images.The researchers discussed the relevance of that account and agreed that it was the most suitable way to collect data for the study's purpose.An extension (Batch Media Saver from Instagram) was installed in Chrome (version 76) to facilitate the downloading of all images from the account (N = 219).The images were downloaded 12 February 2019 at 9:38 am.

Data analysis
All 219 images were printed out in colour (nine images on each A4 sheet).Both researchers used scissors from Fiskars to cut all images one by one.The images were then piled with the image facing down.The researchers sat facing each other across a table as images were turned over in sequence, one by one.The researchers looked at each image for only a few seconds.In addition, individual laptops were used to make descriptive and/or analytic notes while scanning the images.The scrolling was paused continuously to allow the researchers to insert analytic memos.After viewing approximately half of the images, the researchers read each other's notes and engaged in iterative and reflexive discussions.Some notes were clear in their intent to the other researcher, while others required further clarification of the brief and initial thoughts before a consensus could be reached.At this point, estimating that saturation had been reached, a decision was made to continue scanning the entire data set.During the second half of scrolling, some more notes were jotted down to clarify previous notes.After completing the scanning process, the researchers agreed that much of the second half of the data set was redundant.Again, the notes and the images were compared and discussed based on similarities and differences.From these discussions, seven preliminary themes were agreed upon.Each theme was allocated an envelope.The pile of images was turned over and the analysis started from the top again; hence the whole data set was deductively placed in one of the seven envelopes.Researcher 1 took one image and assigned the image a number (1-7), while researcher 2 confirmed the choice.This procedure was followed for every other image as positions were switched to be the confirmer.An eighth pile was temporarily created, used for images that did not adhere to any of the seven themes.After sorting the images into the seven respective piles based on their thematic similarities, the researchers tallied the distribution of images in each pile (see Table 1).Six images were placed in the eighth pile.After conducting iterative and reflexive discussions for each of the six images, the researchers decided to exclude them all for various reasons.One was a montage of other images already included in the data set; three images visualised piles of shoes without any connection to a specific owner (for example, a box of forgotten shoes); one image did not contain any shoe at all; and the last image was excluded as it showed multiple people's shoes in which each of the different shoes could have been categorised in different themes.The next step was to deepen the analysis within each theme.The researchers analysed all of the images individually, organised by theme, in order to search for heterogeneity within each theme.The goal was to choose three images that would typically represent the theme and also represent potential subthemes.The researchers took turns and presented the heterogeneity in terms of subthemes for each other.Based on this step, the narrative of the 'presentation' was written down as a tentative description of the subthemes.The listening researcher was able to confirm, add ideas, and also have a role as a critical reviewer of the interpretation.

Rigour
To meet the purpose of the study, an image analysis of freely accessible data on the Web was considered to be the most suitable for collecting data.However, with regard to transferability in qualitative studies in general, Lincoln and Guba (1985) held that it is rather a matter of providing a 'data base that makes transferability judgments possible on the part of potential appliers' (p.316).Instagram, with one billion users, is one of the largest social media platforms and has also come to be a legitimate source for data collection by academic scholars (Lup, Trub, & Rosenthal, 2015;Sheldon & Bryant, 2016).To enhance credibility, the researchers reviewed the written text, themes, subthemes, and cross-checked them with the entire data set to ensure the accuracy of the overall interpretation.The themes in the results are illustrated using a few links to images as examples from the data presented in Table 1.

Ethical considerations
The data were freely available on the Web, and the topic did not concern any aspect of health; hence, this research is not considered as human subject research (SFS, 2003).However, ethical considerations cannot be overlooked.Thus, with regards to Eysenbach and Till's (2001) publication, which proposed three questions that researchers' can use as guidance: first, whether the posting is private or public; second, the size of the website; third, the level of perceived privacy of the website or user and the members.These directing areas have guided the ethical considerations in this study.To ensure accessibility, the researchers confirmed that the images were publicly available on Instagram and did not require a login.Moreover, Instagram is a large website for publication of freely accessible images with the opportunity to conceal the content by changing the account settings to 'Private.'However, an ethical dilemma arose as it was not possible to obtain full assurance that the wearers had approved the posting of the images.Most of the images are visualised in a way that it is not possible to recognise who the wearer is, since only the footwear is posted.

Result
The results presents seven themes, these themes demonstrate the breadth and hierarchical interplay of footwear choices in the team and the construction of team identity.Examples of footwear for each category are given in Table 1.

The anonymousan understated conformist
The first theme of footwear is termed the anonymous an understated conformist, due to the inconspicuous appearance.Shoes that fit this theme are characterised by their anonymous appearance with regard to style and colour and their appropriateness in the context.The most prominent in this theme were ordinary slippers and clogs.Variations occurred but in a modest way, for example, some slippers had ankle straps while others did not.What regard to the colour, the anonymous wearer uses white, black, and brown slippers.A key feature of the anonymous is also the matter of balance between new and worn out.Images displayed the anonymous footwear as depicting a perfect balance of being intact but not too shiny and worn but not too frayed.The anonymous wearer extends the low-key profile by harmonising the rest of the outfit with similar discretion.Hence, those adopting this style perpetuate a mainstream hospital dress code and reproduce a team adherence by their use of 'the classic,' thus, forming a 'normcore' identity among coworkers.

The discreet standouta subtle individualist
Footwear characterised as a subtle individualist, the discreet standout has several similarities with the anonymous wearer in that the shoes are functional and appropriate and within acceptable cultural boundaries for the hospital norm of dress code.However, the key difference is that footwear is the opposite of the normcore.The discreet standout is highly aware of how to use footwear to discreetly draw attention by using a mixture of matching shoes and socks.One image displayed a pair of red shoes with red socks, while another displayed a pair of typical clogs but in shining gold.Another example of discreet standout was a person who had pulled the pants up so that the socks were exposed.The socks were white with inverted coloured 'plus' signs, a connotation to the Red Cross Society.It signals belonging to a team, being a trustworthy collaborator who is capable of adhering to hospital cultural dress code but who also posits a cultural capital that has the stamina to express a personal twist.For the discreet standout, membership in the team is unquestionable.The team comes first and foremost, but unlike the anonymous, the discreet standout signals convincingly that it does not want to get lost or drowned in the collective and cohesive unit of the team.These wearers have their own voices and want to be heard, seen, and respected as valuable players, members, and coworkers in the team.

The doer on the movean active and ready contributor
Wearing sneakers at work is a way of importing the wearer's outside hospital identity to signal to express one's own persona as adhering to an active and healthy lifestyle.The choice of wearing sneakers, especially strongly colourful ones, was a way to signal an identity of being active, a doer on the move, an active and ready contributor.Sneakers fortify the idea of a coworker who is connected to the Greek mythology of being powerful and salubriousstrong and fit enough to 'jump in,' ready to serve and to fulfil one's obligations, no matter what.
Hence, sneakers signal the strength of the individual, but in the hospital context the purpose of such strength is to provide immediate care as needed, for both patients and colleagues.The choice of using strong colouring on sneakers is thus a way to signal 'I am here and ready to serve,' just as rescue leaders at accident scenes use special vests to signal their status among others.The appearance of sneakers varies from being brand new to more well-worn.Regarding the colour of sneakers, the majority were colourful, but there were also sneakers in white, grey, or black/white colouring.Hence, it is possible to signal more or less explicitly, depending upon the choice of colour.For example, one image was a pair of apricot-coloured sneakers and identically coloured shoelaces, but the wearer showed the lower part of the calf, and thus strengthened the overall look of the shoes.Many of the sneakers were typically sports-related brands, the most prominent being Nike, Puma, and Asics.

The naturista barefoot enthusiast
The naturist's choice of footwear is grounded in the idea of maximising the feet and minimising the wear; thus, the 'bare foot' is the key feature for a barefoot enthusiast.Several images display a sandal that is, per se, not an inappropriate work shoe.However, when socks have been removed, the shoe becomes secondary and sets the bare foot in front.In other images, the naturist also wears less appropriate sandals to display the feet, as the footwear is usually designed as something more to be expected on the beach, featuring a minimal arch over the footrest that allows as much foot as possible to be visible.In this arrangement, 'the naked foot' becomes an important decorative surface to display.The naturist theme is characterised by painted toenails and well-groomed feet as the main focus of attention.Even if feet in hospital settingsat a first glancemight not have a sexual focus, the connection to traditional foot fetishism and the sexualisation of the female foot is a recurring notion in all the pictures in this theme.Naturists explicitly want to show off their feetand as much of them as possible.This foot eroticism can be regarded as a way of showing female power within the team.Showing off a naked erotic foot might be connected to feminist subversion that signals resistance and counterforce to hierarchical structures within both the clinical settings and the team.

The superior tourista temporarily elite visitor
The next theme, the superior tourist uses shoes that are highly unsuited for hospital activities and functionality.
Examples of shoes in this theme are dark-coloured, or black, and well-polished dress shoes or high-heeled pumps; typically shoes suitable at a gala dinner to mark its temporarily elite visitor status.The shoe itself signals that the wearer is only a temporary visitor while conducting an achievement that others are not capable of.Wearing these kinds of shoes in the hospital environment signals that the wearer is irreplaceable in a very important job, that s/he did not have the time to change to more appropriate shoes.Thus, not only does the uniqueness of the wearer's footwear confer a sense of superiority, but it also sets the wearer apart from the working team by signalling an external position.The shoe authorises the wearer to be 'above and beyond' the coworkers and their ordinary status as they are stationed in the hospital.Wearing these kinds of shoes signals a step in on borrowed timejust a tourist.

The outsideran unconventional maverick
One theme was identified from the inappropriateness of the footwear in relation to hospital policies, norms, and values.The displacement, as an unconventional maverick, was not only inferred from the overall look, but also in relation to the functionality, design, and material.Just as the discreet standout is an extension of the anonymous, the outsider is an extension of the superior tourist.The key difference is that the footwear of an outsider is taken to the extreme, thus not connected to any specific contextnot even outside the hospital environment.One image displayed a pair of slippers, which had the form of a blue/white fish.The conspicuousness is further fortified as the wearer is barefoot, which makes the overall look imprudent, with a pair of living feet in a pair of dead fish.Another image within the same subtheme displayed a slipper in a seemingly appropriate form, influenced by the traditional Birkenstock, although the material is fuzzy and fluffy.It signals resilience and a subversion of the decorous dress code.Hence, the outsider uses footwear to mock the governance of a hegemonic hospital authority, thus putting the outsider into a position of self-empowerment.

The legenda battle-scarred veteran
A key feature of the legendary footwear is that, although they appear as ordinary, anonymous hospital slippers and clogs, they have never been replaced since their first use during the initial shift decades ago, bearing the scars of battle-worn veterans.This footwear has never replaced, even when falling apart, and they have never been properly cleaned.If it is ripped, thorn, marked, and worn down to its heel it tells a greater story, with the owner in the midst of the story, a story of legends and gods working among ordinary people doing ordinary things in ordinary jobs.The stories the legend shoes tell us are imprinted in the dirt and the stains from the harsh hospital realities of long hours, sleep deprivation, emergency outbreaks, love affairs, and hospital politics.The legend shoes were here in the midst of all thisand came out on the other side, living to tell the story.The shoes are legendary and tell a story about hospital life itself as well of their owner.

Discussion
This study set out to describe expressed team identity among healthcare staff by analysing signs of personality traits they share with colleagues, found in their choice of footwear.Prior studies in fashion research have noted that footwear is a marker of a self and acts as a repository and gives meaning in our lives (Belk, 2003;Wilson et al., 2007).However, a comprehensive literature search revealed that previous investigations into footwear in a hospital environment are limited.The results show that choice of footwear signals seven different personality traits.The most obvious finding to emerge from the analysis is that footwear is a remarkably strong component to signal cultural attachments.The conformity with social norms of hospital culture was chiefly found in the anonymous, the discrete standout, and the doer on the move.The interpretation is that the three identified personality traits conform to a dress code that signals team identity and helps gain social acceptance within the context of a culturally situated hierarchy (cf.Bellezza et al., 2014;Eckel & Grossman, 2005;Weaver et al., 2011).However, being subordinated in this way also makes space for a variation to the extent one wishes to mark their identity.An understated conformist, a subtle individualist and an active and ready contributor may be viewed as existing on a continuum.On the one side, the anonymous are the least likely to express their own identities, while discreet standout are more prone to signalling individualism but still adhering to hospital culture and its artefacts.On the other side of the continuum, the doers on the move still signal conformity but adopt external influences, for example, sporty sneakers.It is easy to overlook the value of the anonymous due to their unclaimed personality traits.The very strong connection may also be a matter of ethical valuesby minimising their own personalities, they signal a moral virtue that the work and the patients are prioritised.It could be stated that the anonymous are an understated conformist who posit the strongest social ties to the hospital culture and thereby withhold the cultural counterweight.
On the contrary, a barefoot enthusiast, a temporarily elite visitor, an unconventional maverick, and a battlescarred veteran share similar key features that differ compellingly from the previous personality traits.First and foremost, they all signal a high self-centrality and weak cultural ties to hospital regimen and appropriate dress code for its own sake.Rather than adhering to a work team identity, they use footwear to signal their alienation.These results reflect 'the red-sneakers effect,' a metaphor coined by Bellezza et al. (2014) to describe the way that nonconformity can signal status and competence.In this study, the superior tourist theme in particular demonstrated the power of nonconformity, as a temporarily elite visitor wearing high heels or polished black dress shoes signalled a hegemonic dominance and a sense of superiority over the working team.It is important to note that power can also be expressed in other ways, such as through exposing bare skin on the feet.Few studies have given attention to the female foot and its association with gendered power, although one study argues that the foot 'represents a symbolic form of feminine power, allowing women simultaneously to control and distance themselves from sexual intimacy' (Giannini, Slaby, Colapietro, Melemis, & Bowman, 1998, p. 496).However, more recent studies on feminine clothing have demonstrated how the miniskirt signals a protest against gendered subverts (Vincent, 2008), and similarly, Thomas (2008) held that the miniskirt symbolises a 'subversive relationship to social norms.'Continuing this line of reasoning, the naturist theme may represent a way for women to exercise feminine power in a male-dominated environment, as suggested by Carpenter (1977).
Another personality trait that also demonstrates nonconformity to hospital culture, values, and norms is revealed in the outsiders, who knowingly push the boundaries of social acceptance by wearing footwear that is not only inappropriate but also contemptuous towards the dedication in hospital practice.While many studies have demonstrated the positive effects of humour in hospital settings (McCreaddie & Wiggins, 2008;Sridharan & Sivaramakrishnan, 2016), expressions of disdain as a form of nonconformity have not been previously investigated in the literature.However, one publication by Bennett (2003) discusses humour in medicine and suggests that mocking superiors and established social norms can be a part of group life.Thus, the possibility that an unconventional maverick may either signal nonconformity by mocking the cultural norms and values of the earnest or use the footwear as an artefact in the manner of 'clown therapy' must also be considered (Dionigi, Flangini, & Gremigni, 2012).While Bellezza et al. (2014) used the analogy red-sneakers effect, we label this behaviour the 'pink-sneakers effect' as an analogy for how footwear can be used to the extreme and to make statements about one's cultural status.For example, wearing a pair of slippers formed as fishes or wearing a pair of tuxedo shoes is a highly subversive choice.Thus, the outsider and the legend share similarities regarding non-conformity of cultural dress codes.

Implication for practice and limitations
This study highlights the importance of shoes in team identity within hospital environments, which is an aspect that is often overlooked.With these findings it is possible for managers to become aware of choice of footwear signal personality traits.While this paper does not focus on nursing tasks and competence, as highlighted by previous studies (Ayasreh, Hayajneh, & Awamleh, 2022), the results can be used to develop targeted interventions aimed at building strong cultural attachments and team identity.A limitation is that we cannot present any demographics such as age and gender of the shoes' wearers.We are aware that that can have an impact on the choice of shoes.As with other studies, it cannot be concluded that the data are representative of other hospital settings, and therefore, the findings cannot be generalised.

Conclusions
In conclusion, the meanings of shoes in everyday hospital settings play a crucial role regarding signs of conformity and nonconformity with social norms and selfposition of social status in the work settings of a hospital hierarchy.The results stress that more research is needed regarding shoes as a marker of status within and between the healthcare professions.

Table 1 .
Identity and footwear: themes, images, and examples.