More than a makeover is needed to improve nursing's image


30th Anniversary Invited Editorial reflecting on Law Harrison L. (1990) Maintaining the ethic of caring in nursing. Journal of Advanced Nursing 15, 125–127

Does the public image of nursing reflect a profession that has lost its ethic of caring? Harrison detected signs of this in the United States of America (USA) in 1990, as reflected in her JAN editorial, and a similar case can be made today in the United Kingdom (UK). Television soap operas portray the seamy (and steamy) side of hospital life; documentaries with titles like Undercover Angels use hidden cameras to expose nursing malpractice; and anecdotes recycled as news items feature supposedly uncaring nurses much like those Harrison described.

Such is the deluge of media information, misinformation and opinion that the public image of nursing is hard to pin down. In the intervening years, digital technology and the globalization of mass communication have changed the media beyond recognition. There is so much data from so many sources. It would be a Herculean task to replicate the studies pioneered by Kalisch and Kalisch, who analysed representative samples of media portrayals of nursing in the USA (for example, in Kalisch et al. 1983).

I argued in 1985 in my book The Politics of Nursing (Salvage 1985) that it was time to drop the tired and demeaning stereotypes of nurses as angels, battleaxes and ‘sexpots’, and replace them with new images that reflected the value, complexity and reality of nursing. This would not only attract more recruits to the profession, but bring it recognition and higher status. My call for rebranding was nothing new. The 19th century British nursing reformers did just that in pursuit of such goals as the establishment of a professional register and improvements in nursing education. They may not have used the vocabulary of today's marketing gurus, but their approach had much in common. Many years and campaigns have passed since then, but what has changed?

With each decade British nurses have become better educated, better paid, and more expert and autonomous in their practice. These are impressive advances, even though it is hard to measure their impact on the quality of care or population health. Yet they do not seem to have been translated into greater job satisfaction for nurses, or a major change in the public image of nursing. In 2004, the weekly magazine Nursing Standard (owned by the Royal College of Nursing of the UK) was still campaigning to enhance the image and reputation of the nursing and midwifery professions. According to its branding consultants, the current image of the British nurse is worse than middle-of-the-road, ‘the equivalent of own-label food lines’ in supermarkets (Waters 2005). This dependable but drab representation seems to be supplanting the angels and matrons, though the ‘sexpot’ image remains popular, especially in pornography. Only there can you find the frilly hats, starched aprons and black stockings, all that nurses ever seemed to see of themselves in the mainstream media. Elsewhere they have virtually vanished along with many other nursing traditions.

The Nursing Standard initiative was inspired by a similar recent campaign in the USA that aimed to make nursing a more popular career choice and boost workforce morale. The image problem appears to be endemic and systemic in the USA as well as the UK. Indeed, it appears to be global: nurses in every continent and from many different cultures complain that their work is trivialized and undervalued. There are many reasons why the stereotypes are so intractable. Perhaps, they contain a grain of truth; perhaps, the public and policy-makers are ignorant of the reality; and other political, cultural and psychological forces maintain the status quo. After all, the angels, matrons and naughty night nurses are typical female stereotypes (angel, matriarch and whore) refracted through a nursing prism. This is no surprise given that 90% of nurses are women doing archetypal ‘women's work’. In the absence of a gender revolution that would consign sexism and its accompanying stereotypes to history, nursing leaders resort to half-hearted, failed attempts to recruit more men. Yet the caring, skilled, intelligent and proactive image of the nurse projected in their campaigns is equally selective. For every supernurse, there is an army of ordinary folk whose performance is average and who see nursing as just a job.

Dominant social values that are masculine and often macho block the assignment of higher status to the ethic of caring, while giving more power, status and reward to nurses/women is not high on most national leaders’ agendas. No one wants to do the dirty work in our sanitized western world, where serving others is seen as being for softies, whatever rhetoric is devoted to such work. In addition, nurses deal with disease, dirt and death, which are universally feared and inherently difficult to present in an appealing way. Moreover, there is no unity within the profession about its role and future. Some factions wish to include under the nursing umbrella anyone who does anything that could remotely be described as nursing (or midwifery), and want to be all things to all people, while others see the way forward in a high-powered portrayal of the advanced practitioner who can, and increasingly does, replace junior doctors. A widely diverse range of representations that reflects not only these currents of professional opinion and aspiration, but also the inexhaustible variety of what nurses do and who they are, is a marketing nightmare. The prerequisite of rebranding is a strong corporate message encapsulated in a strong, positive image – for which the required professional consensus is lacking.

However nursing is portrayed, whether by the profession itself or by others, the key difficulty may lie in Harrison's observation that caring, while we like to think of it as a universal value to guide nursing practice, is mediated by a host of factors including culture, healthcare costs, work-related stress and pressures on time. If prevailing socioeconomic conditions made it hard for American nurses to maintain the caring ethic in the 1990s, that challenge must be even greater now, worldwide, in an era of ever-increasing pressure on nurses and healthcare systems. Nurses are still ordered to care by societies that do not explicitly value and reward caring, or merely pay it lip service. It will take a lot more than an image change to ensure that caring – as a career – is truly cherished and rewarded.