This paper presents a literature review of the public image of nurses and the nursing profession. Drawing on sources including Gallup polling data, peer-reviewed nursing journals, and advocacy organization guidelines, the paper explores the gap between how nurses perceive themselves and how the public perceives them. Topics include declining Gallup honesty ratings, self-image versus public image among Australian nurses, longitudinal studies of nursing students' guiding images, ethical definitions of the "good nurse," marketing campaigns aimed at recruitment, and historical representations of nurses from antiquity through the modern era. The paper concludes that nurses and their advocates must actively work to correct public misconceptions and raise the profession's profile.
The nursing profession has always attempted to project a positive, clean, and healthful image. Throughout history, the nursing industry has tried to portray nurses as angels of mercy and as ethically upstanding, helpful healthcare professionals — just a few steps below doctors in terms of medical authority. Lately, however, the image of nurses has changed, and not always for the better. This paper critiques the image of nurses through a review of the available literature.
The highly respected Gallup Poll ranks nurses at the top of several important professions in terms of "honesty and ethical standards" (Gallup, 2010). In a 2010 polling project, eighty-one percent of respondents rated nurses "very high" or "high." The second-ranked group was military officers, at 73%; third were druggists or pharmacists, at 71%; and fourth were grade school teachers, at 67% (Gallup, 2010).
In 2008, nurses ranked at the top with 84% of respondents rating them "very high" or "high," and in 2009 that figure was 83% (Gallup, 2010). One can see that while nurses consistently rank first for honesty and ethical behavior, the percentage has been gradually slipping — from 84%, to 83%, and down to 81% in 2010.
In an American Nurse Today article, Cohen (2007) acknowledges that nursing has appeared in the Gallup Poll's top ten "most honest and ethical" professions list. But Cohen wonders whether being highly ranked in the eyes of others is truly "relevant to the concern" nurses have about their image (p. 1). The author asks what truly matters to patients and caregivers, and what nurses "care about and look for in our colleagues" (Cohen, p. 1). Moreover, what impact do these perceptions have on the image of nurses? A central concern in Cohen's article is the need for nurses to take control of their image — including reconsidering workplace attire. Wearing clothing "adorned with cartoon characters" like SpongeBob and Snoopy, produced by manufacturers outside the nursing field, demeans the profession, according to Cohen and image consultant Sandy Dumont (p. 1).
To improve the image of nurses, Cohen lists several steps for professional accountability: leaders must define "unacceptable workplace behaviors" and hold nurses accountable; nurses should introduce themselves by name and title; proper appearance standards should be posted in written guidelines "and followed through with consequences for those who don't comply"; staff should participate in developing the list of unacceptable behaviors; nurses should write health-related articles for local newspapers; nurses should speak to community groups about the profession; and nurses should be trained in communication skills that allow them to "respond to negative colleagues in a manner that confronts and stops behaviors that affect nurses' image" (Cohen, p. 2).
How do nurses perceive themselves? An article in the Journal of Advanced Nursing explains that nurses are very concerned about their public image. The article's authors sampled the opinions of 346 Australian nurses and found that nurses "rated their aptitude for leadership" in a more positive light than they believed the public viewed them (Takase et al., 2006, p. 333). The authors assert that the public has held a "stereotypical view of nursing" — one that tends to regard nurses "as less intelligent than doctors, dependent on doctors, powerless and underpaid" (Takase, p. 334).
The study aimed to determine how nurses perceive their public image compared with their self-image, and whether the gap between the two affects job performance. The results of the 346 returned questionnaires show that nurses perceived themselves as caring leaders, and believed that the public sees them as "feminine and caring professionals" but not as "leaders or professionals who were independent in their practice" (Takase, p. 340). In a separate focus group addressing the same issues, the consensus was that the public has "a fuzzy image" of nurses. As one nurse put it: "They [the public] don't necessarily have an appreciation for what we actually do for the patients… I just don't necessarily think people really do know what we do…" (Takase, p. 340).
Another article in the Journal of Advanced Nursing (Spouse et al., 2000, p. 730) reports a longitudinal study following eight nurses from pre-registration through their four-year program. At the conclusion of the study, seven of the eight students reported that their "preconscious guiding images that influenced their actions as nurses" appeared to be not something learned along the way, but rather part of their personality (Spouse, p. 734). This "knowledge" was distinct from the practical "know-how" that comes with mastering the "technical tasks" of nursing (Spouse, p. 734). The study concludes that the "interpretative frameworks" nursing students bring to their learning situations influence the achievement of their career goals — and that their perceptions of what nurses do "inform not only their career choices but also the way in which they will engage" in their careers (Spouse, p. 737). In this case, students' images of good nursing practice "were congruent with those of the curriculum," and their images of how they intended to practice nursing "informed their attitudes and their relationships with patients," directly impacting the way in which they practiced (Spouse, p. 737).
Nursing is not merely a "vocation," a "profession," or a "job," according to an article in the journal Nursing Ethics (de Araujo Sartorio et al., 2010). Nursing is "by nature" a "moral endeavor," and most, if not all, nursing professionals strive to be seen as a "good nurse." The authors of this article set out to interview and test 18 nursing instructors at a university nursing school in Brazil. The results are straightforward; the five perspectives these 18 instructors agreed upon were: good nurses fulfill their duties properly; nurses are "proactive patient advocates"; competent nurses are always prepared and available to welcome others as persons, not just patients; nurses are "talented, competent" professionals who carry out their responsibilities "excellently"; and nurses combine "authority with power sharing in patient care" (de Araujo Sartorio, p. 687).
In the discussion section, the authors reported that it was difficult for some within the study group to define "ethics"; consequently, they tended to define "what was not ethical" rather than what was ethical. This difficulty may be connected to a "professional practice concerned with the struggle against a past and a history" that was not focused on creating "new patterns for the good nurse of today" (de Araujo Sartorio, p. 693).
Alison Faust, editor of Imprint, insists that nursing image committees should emphasize the "importance of little actions that make up what we know of the nursing profession today" (Faust, 2009, p. 20). There are important and "wonderful" large-scale things that nurses do that "influence everyone involved," but nurses must also attend to small gestures — such as taking the hand of a family member visiting a sick relative and offering some "overdue comfort." Faust quotes the words of Florence Nightingale: "Never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself" (Faust, p. 20).
"Campaigns and strategies to improve nursing's image"
"Nursing imagery from antiquity to modern media"
In conclusion, Darbyshire makes a valid point when he asserts, "If the public does not understand the breadth and complexity of nursing work, it cannot fight for the social and financial resources that allow nurses to do that work" (p. 74). This paper reviewed the positive and negative aspects of the image of nurses as reflected in the available literature. It seems clear that nurses and those who advocate on their behalf must work proactively to refine their public image, reach out to communities, and correct the misinformation and misrepresentations that persist in the public consciousness.
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