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Keywords:

  • job performance;
  • literature review;
  • nurses;
  • perception;
  • professional identity;
  • public image;
  • self-concept

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

Aim

To discuss the actual public image of nurses and other factors that influence the development of nurses' self-concept and professional identity.

Background

Nurses have become healthcare professionals in their own right who possess a great deal of knowledge. However, the public does not always value the skills and competences nurses have acquired through education and innovation.

Design

Discussion paper.

Data sources

We identified 1216 relevant studies by searching MEDLINE, CINAHL and PsycINFO databases in the period 1997–2010. Finally, 18 studies met our inclusion criteria.

Discussion

The included studies show that the actual public image of nursing is diverse and incongruous. This image is partly self-created by nurses due to their invisibility and their lack of public discourse. Nurses derive their self-concept and professional identity from their public image, work environment, work values, education and traditional social and cultural values.

Implications for nursing

Nurses should work harder to communicate their professionalism to the public. Social media like the Internet and YouTube can be used to show the public what they really do.

Conclusion

To improve their public image and to obtain a stronger position in healthcare organizations, nurses need to increase their visibility. This could be realized by ongoing education and a challenging work environment that encourages nurses to stand up for themselves. Furthermore, nurses should make better use of strategic positions, such as case manager, nurse educator or clinical nurse specialist and use their professionalism to show the public what their work really entails.

What is already known about the topic

  • The professionalization of nurses and the public image of the nursing profession is the subject of ongoing international debates.
  • A negative public image has a negative impact on nurses' self-concept and the development of their professional identity.
  • The professional aspects of the work nurses perform remain invisible in the media, partly as a result of the dominant position of the medical profession.

What this paper adds

  • A discussion of the influence of the public image on the self-concept and the professional identity of nurses in an era of nurse professionalization.
  • An analysis of other factors that influence the self-concept of nurses, such as work environment, work values, education and traditional social and cultural values.
  • A discussion of the relationship between public image and nurses' self-concept, professional identity and work performance.

Implications for practice and/or policy

  • Nurses should work harder to communicate both their professionalism and their contribution to the healthcare system to the public.
  • To be given due recognition, nurses could profit from using social media, such as the Internet and YouTube.
  • In the curriculum of nursing schools, more attention should be given to performance and empowerment of nurses.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

The professionalization of nurses through education and innovation has proven to be the focus of one of the most significant and ongoing discussions in the history of nursing. Worldwide, nurses have developed themselves into professionals with a great deal of knowledge, as witnessed by the development of nursing protocols and guidelines. Despite these developments towards professionalization, previous studies on this subject have shown that nurses are not given due recognition for the skills they have by the majority of the public. The essence of nursing is not always clear and nurses still suffer from (gender) stereotypes (Bridges 1990, Hallam 1998, Warner et al. 1998). A stereotype can be defined as ‘a cognitive representation or impression of a social group that people form by associating particular characteristics and emotions with the group’ (Smith & Mackie 2007). Bridges (1990) identified 34 different stereotypes of nurses, most of which have negative connotations. Bridges' study also showed that the media often depict nurses working at the patient's bedside and performing repetitive and routine tasks, mostly as the doctor's handmaiden (Bridges 1990). Other studies indicate that the portrayal of nurses in the media might give a clue as to how their public image is perceived (Kalisch & Kalisch 1983, Warner et al. 1998, Gordon 2005). These studies show that the public image of nurses does not always match their professional image; nurses are not depicted as autonomous professionals and the public is not aware that nowadays nursing is to a great extent a theory-based and scholarly profession (Dominiak 2004). The nursing discipline has undergone tremendous developments over the last 30 years of the 20th century and in the first decade of the 21st century, in particular, with respect to professionalization. The professionalization of nursing is closely intertwined with a focus on the development of nursing theory (Meleis 1997), nursing research and nursing practice, which ideally are interrelated. Research can validate theory, which then may change nursing practice (Donahue1998). Nightingale and Henderson have been visible forces for nursing across boundaries, in respectively the 19th and the 20th century. Moreover, the nursing profession has developed numerous types of education programmes in the last decades, which resulted in a variety of nursing levels, like bachelor, master and doctoral degrees. Even the most respected news media sources belittle nursing, so readers do not get a sense that nurses are educated life-saving professionals (Summers & Summers 2009).

Although the phenomenon of nursing and its characteristics are carefully considered, this has not yet resulted in a public image that recognizes the scientific and professional development of the nursing profession. The aim of this paper is to discuss the current state of affairs regarding the public image of nurses worldwide and to analyse the potential influence of this image on the development of nurses' self-concept and professional identity. A search of the literature is performed and recent publications on these themes are brought together to broaden this discussion.

Background

Although Florence Nightingale saw nursing as an independent profession that was not subordinate but equal to the medical profession (Nightingale 1969), for a long time nursing was seen as inseparable from the medical profession. The medical (male) dominance strongly influenced the role development, the image and the position of nurses (Hallam 2000, Gordon 2005, Fletcher 2006). Previous studies on this subject show that nurses have always been strongly aware of their subordination to the medical profession and are still experiencing high levels of dissatisfaction with their professional status. Twaddle and Hessler (1987) investigated how the domination of nursing by others originated. They found that in the Western civilization, domination began in the early 1900s, when medicine became a dominant force and care of the sick became institutionalized. The study of Walby et al. (1994) shows that the nursing and medical professions in Western Europe have a complicated relationship, which amongst others is mediated by hierarchy and subordination. The workplace studies of Adamson et al. (1995) and Aiken and Sloane (1997) demonstrated how the impact of medical dominance on autonomy and job satisfaction of nurses led to decreased patient outcomes. Adamson et al. (1995) examined the influence of perceived medical dominance on the workplace satisfaction of Australian and British nurses. The results of their study show that medical dominance is an obstacle to the workplace satisfaction of both Australian and British nurses, who experienced a high degree of dissatisfaction with their professional status. Historically, nurses deferred to physicians, for reasons that include the disparity of power between the genders (Summers & Summers 2009). However, understanding nursing and the development of nursing and medicine cannot be separated from understanding the societal context, as Kalisch and Kalisch (1995) demonstrate in their study on American nursing.

The traditional role and image of nurses can be seen as the expressions of an oppressed group. The dominance of the oppressor, in this case the physician, marginalizes the oppressed group and may lead to the development of low self-concept, which can in turn lead to negative self-presentation (Fletcher 2006, 2007). Self-concept is closely related to professional self-concept, which is a prerequisite for the vocational and academic development of the identity of a profession (Arthur 1995, Arthur & Randle 2007).

The idea of being subordinated to the medical profession is not the only factor that influences the self-concept and professional identity of nurses. Other determinants include work environment, work values, education and culture. Professional identity and self-concept can undergo changes due to interactions with colleagues, other healthcare professionals and patients. Work environment and work values can also play a role in this respect (Mills & Blaesing 2000, Ewens 2003, Allen 2004). Education and the acquisition of knowledge are likely to have an impact on nurses' job satisfaction and self-concept (Arthur 1992, Pask 2003). Furthermore, international differences in traditional cultural and social values need to be taken into account when measuring nurses' professional identity and self-concept (Fealy 2004, Thupayagale-Tshweneagae & Dithole 2007).

There is a strong need for a discussion on the image, the self-concept and the professional identity of nurses in a global context. The outcomes of such a discussion can help nurses develop strategies to achieve a public image that reflects their scholarship and professionalism. This paper looks at the characteristics of the international development of these important issues.

Data sources

Search methods

A literature search was performed using the databases MEDLINE, CINAHL and PsycINFO. The search strategy aimed to retrieve suitable studies published between 1997 and 2010. The search terms used were nurses, nurse*, perception, public image, professional image, stereotyp*, self concept, power, public opinion and social identification. Original research was included if it was published in English and available as a full-text article. The research design of the studies had to be clear, with sample, instrument(s) and statistical method explicitly described.

Search outcome

The first search resulted in 1216 citations. After screening these on title, 287 abstracts were included for further assessment. The first author assessed the abstracts on their relevance for the purpose of the study, which resulted in 58 articles. These were reviewed by all authors and finally 18 articles were included in this discussion paper. Relevant studies included studies that examined the role of the public image of the nursing profession, studies that analysed the way nurses develop their self-concept and professional identity or studies that looked at the influence of the public image on nurses' self-concept and professional identity. Figure 1 shows a flow chart of the selection process.

image

Figure 1. Flow chart of study selection process.

Download figure to PowerPoint

The included studies were heterogeneous with respect to design, sample and setting. The samples vary from 1957 RNs to five communication professionals. The settings were a university nursing school, the clinical setting of a hospital or a variety of settings. The included studies were conducted in Australia (3), Brazil (3), Sweden (3), USA (3), Taiwan (2), Hong Kong (1), Israel (1), Japan (1) and Norway (1).

Data abstraction and synthesis

A keyword analysis was performed based on the concepts of public image, professional identity and self-concept. Next, a content analysis of the included studies was conducted to systematically identify the main characteristics of the studies on the basis of the terms public image, self-concept and professional identity. Extracted data included author(s), year and country of publication, study design, quality of the study, sample, instrument(s), data analysis, aim of the study, outcomes on public image, outcomes on self-concept and professional identity and comments. The main characteristics of the 18 included studies are presented in Table 1.

Table 1. Characteristics of the included studies
Reference Study designSample/instrument Data analysisAimPublic imageComments
Public Image

 Ben Natan and Becker (2010)

Quantitative methods

Descriptive survey

309 adults 18–50 years

McCabe questionnaire

Descriptive statistics, inferential statistics; t-tests parametric tests; Spearman correlation

To clarify factors that influence the choice of ideal careers and nursing careers among the general populationThe public has a major misperception of nurses' work. Careers in nursing are perceived as tedious and lacking challenges, creativity, responsibility, high wages, status and comfortable working conditionsNursing schools need to promote the nursing profession among the public. Lectures by nurses are very significant. Research is necessary to examine why people who are intrinsically motivated to choose a care-giving profession do not choose a career in nursing.

 Dahlborg-Lyckhage and Pilhammar-Anderson (2009)

Qualitative design

Discourses from 1999–2003

Documents, reports, Campaigns, TV series

Discourse and content analysis

To explicate the predominant discourse in the field of Swedish nursingThe media play a major role in disseminating prevailing conceptions and conventions pertaining to the nursing profession. The media present nursing in ways that neglect the official requirements of the professionHealth care seems to be more heavily influenced by the media than by the official requirements of nursing. Therefore, the public could receive low expectations of the competences of nursing

 De Araujo Sartorio and Pavone Zoboli (2010)

Qualitative study within the scope of descriptive ethics

18 nurse teachers

Semi-structured and unstructured interviews

Hermeneutic-dialectic method

To identify the ethical image of nursingFive distinctive perspectives of an ethical nurse emerged as follows: good nurses fulfil their duties correctly; good nurses are proactive patient advocates; good nurses are prepared and available to welcome others as persons; good nurses are talented, competent and carry out professional duties excellently; good nurses combine authority and power sharing in patient careSome perspectives pointed to traits from the past. This caused some concern, because students should not start their careers with the shadows of historical hurts. Faculty should make the teaching and work of nursing healthier

 Donelan et al. (2008)

Qualitative disproportionate stratified sampling design

1604 respondents age 18 and older

Survey: Computer-Assisted Telephone Interviewing

Stratification scheme and sample balancing

To examine the influence of societal demographics, perceptions of the nursing shortage and media influences on perceptions of nursing careersImages of nurses are partly shaped by personal experience with nurses, but also by exposure in the media (TV, news). This exposure is more helpful than harmfulThe nursing profession is highly respected. Nevertheless, a shortage of nurses persists. Implementing a workforce strategy is essential to understand and maintain the public's support for the nursing profession

 Huffstutler et al. (1998)

Qualitative survey

831 interviews with non-nursing university students, professional persons, other non-nursing individuals

Interviews with three open-ended questions

Secondary analysis technique

To evaluate the perceptions of nursing's image by non-nursing university students, professionals, and other non-nursing individualsStudent opinions of nursing were significantly affected by parents, friends and guidance counsellors. The meaning and practice of nursing care is not entirely understood by the various individuals who were interviewedNurses need to be agents of change and educate the public about the many different possibilities available in basic nursing and advanced practice preparation

 Kalisch et al. (2007)

Quantitative descriptive comparative design

Nursing websites

144 in 2001

152 in 2004

Internet Nursing Image Tool

Descriptive statistics; Pearson X2 tests; non-parametric tests, interrater reliability

To analyse the image of nursing on the Internet and to research whether this image underwent changes from 2001–2004One of the major influences on the image of nurses is the largely inaccurate and negative portrayal of the nursing profession. This image has an impact on the quality and quantity of the work performedThis study reveals a relatively positive image of nursing on the internet. Unfortunately, a downward trend in the depiction of nurse characteristics is evident. The Internet offers nurses the opportunity to demonstrate the best aspects of their profession

 Kemmer and Silva (2007)

Qualitative cross- sectional descriptive study

5 Communication professionals

Semi-structured interviews

Collective subject discourse Descriptive analysis

To further the understanding of the social representations of nurses and the nursing profession by communi-cation professionalsThe media transmit a distorted image of nurses. Nurses are depicted as the doctor's shadow and not as professionalsTo give more visibility to the nursing role professionals need to position themselves strategically and to educate the public on nursing (TV, internet, news, press). Invisibility diminishes nurses' ability to change the directions of health care
Self-concept and professional identity

Arthur et al. (1999)

Quantitative design

1957 RNs from 11 countries

Questionnaires: PSCNI; TIQ; TISQ; CAQ

Correlation and reliability analysis; anova

To compare the caring attributes of RNs from eleven different countries with their views of themselves and their perceptions of technological influences on their practice.Participants valued professional interaction with colleagues and believed in their skills and flexibility as nurses. They felt respected by other professionals, but were less convinced that their career was going in the direction they had envisioned before startingNurses worldwide have much in common, but still retain individual cultural features related to caring and their practice as nurses. Future studies are recommended to examine, respect, preserve and nurture these unique characteristics

 Fagerberg and Kihlgren (2001)

Qualitative longitudinal study

27 nursing students 19 nurses

Interviews and diaries

Phenomenological hermeneutics

To understand how nurses experience the meaning of their identity as nurses, as students and two years after graduationThe context in which nurses work is very important for the development of their identity, skills and expertise as nurses. All nurses narrated their stories from one dominant perspective, which is understood as their professional identityParticipants did not shift their dominant perspective over time. It may be understood as the nurses' life paradigm

 Fagermoen (1997)

Mixed Method Survey + focus groups

767 nurses + 6 nurses

Questionnaires + interviews

Hermeneutical analysis

To identify the values underlying nurses' professional identity as expressed by what is meaningful in nurses' workWorking as nurses maintains and enhances their self-concept both as nurses and as persons. The value of altruism or care for the patients' health and well-being appeared to be an overriding value; a moral point of view on which they based their practiceShortage of personnel and time were perceived to affect the opportunities for providing quality nursing care, which in turn was experienced as a strain and for some created a feeling of meaninglessness

 Gregg and Magilvy (2001)

Grounded theory

Design

18 nurses

Interviews

Observations

Theoretical memos

Constant comparative analysis

To explore the process of establishing the professional identity of Japanese nursesNurses' work contributes to their professional growth and satisfaction. Participants identified themselves as nurses through integrating a nurse into self. The findings acknowledge the inseparability of identification with nursing and commitment to nursingNurses as educators and role models are essential to the process of establishing a professional identity
Reference Study designSample/instrument Data analysisAimPublic imageSelf-concept Professional identityComments
Public image, self-concept and professional identity

DeMeis et al. (2007)

Qualitative studies

27 nursing professionals

Interviews

Content analysis

Interpretative phenomenological analysis (IPA)

To present narratives of professional identity among nurses in Brazil and search for meanings of care and their place in nursing activitiesNursing is still influenced by traditional values. Nursing is seen as a profession of low social status and as a domestic activity that does not require qualificationsNurses posses a low professional self-esteem, caused by a negative public imageWith the process of increasing professionalization, nurses acquire higher academic qualifications and technical knowledge, but care is delegated to socially less-valued professionals

 Liu (2010)

Qualitative study

20 nurses

Web-based online forum open-ended questions

Thematic analysis

To explore nurses' perceptions of their work role on the basis of the perspectives of Chinese gender roles and cultureIn Chinese culture, the traditional gender roles have a strong influence on the public image of physicians and nurses. Nursing is still seen as a feminine, caring occupation, with low professional status and subordinate to physiciansNurses' perceptions of their role and work environment are strongly influenced by culture and gender stereotypesA more gender-sensitive work environment in health care is recommended. Nurses could contribute by asking the government to implement gender equality education programmes

 Öhlén and Segesten (1998)

Qualitative Survey

8 RNs

Semi-structured interviews

Concept analysis

To highlight the concept of professional identity of nurses to promote theoretical clarity and examine implications for nursing practiceNurses are part of a social struggle for power where ideas are created through gender segregation. The stereotypical image of the nurse in the media is an expression of this struggleProfessional identity is developed through interaction with other nurses and has a strong impact on nurses' self-esteem and empowerment. The professional self-image of the nurse is also based on the ideas of people, in general, regarding nursesProfessional personal development and growth of nurses should be made possible through the development of personal self-care skills and increased possibilities for nurses for sharing experiences with other nurses in a narrative and reflective way

 Takase et al. (2001)

Quantitative descriptive correlational design

80 RNs

IWS; PNIS; Six-Dimension Scale of Nursing Performance

Desc. statistics; Pearson; Crohnbach α coefficient

To investigate nurses' responses to the image discrepancy between the public and nurses and its relationship with their self-concept, job satisfaction and performanceThe media project distorted images of nursing. The public's perception of the nursing profession tends to be influenced by these nursing stereotypesNurses perceive their public image more negatively compared with how they see themselves, which causes image discrepancy. This can lead to job dissatisfaction and low job performancesThe development of counteractive measures to public stereotypes could lead to improvement of nursing practice, which can change the public's attitude towards nursing

 Takase et al. (2002)

Quantitative

Descriptive

Correlational study

80 RNs

PNIS; Self-esteem scale; IWS; Six Dim. Scale of Nurs. Performance; Descr. Stat; Crohnbach; anova; Pearson

To identify the relationships between nurses' perception of common public stereotypes of their profession, nurses' self-concept, self-esteem, job satisfaction and job performanceThe public still has a stereotypical image of nurses, which influences the development of nurses' self-conceptNurses who perceive their public image more negatively tend to report a more negative self-concept. The greater the self-concept, or job satisfaction, the greater the performance and the engagement in and interaction with society and other healthcare membersNurses need to develop the necessary preventive measures to counteract the multifarious effects of nurse stereotyping

 Takase et al. (2006)

Mixed Method

Correlational design

346 nurses + 6 in focus groups

PNIS; Task Perf. Scale; Paired t-test; regression

To examine how the relationship between nurses' perceived public image and self-image is associated with their job performance and turnover intentionsThe public tends to view nurses as feminine and caring professionals, not as leaders or independent professionals. This image is also a result of nurses' invisibility in the mediaNurses perceive a lack of understanding from the public. The relationship between self-image and perception of the public image as being caring predicts job performanceThe nursing profession needs to improve its public image and its self-image to solve turnover problems and to resolve the current nursing shortage

 Tzeng (2006)

Quantitative study

Cross-sectional design

488 participants (students, staff and faculty members)

Nursing Image Questionnaire

Descriptive and ordinal Logistic regression analysis

To investigate the perceived images and expected images of Taiwanese nursesNurses are frequently portrayed in prime time sitcoms and dramas as subservient, inept and insignificant. The public perception of nursing does not match the perception of nurses themselvesThe incorrect portrayal of nurses is partially responsible for public perceptions of nursing and for how nurses perceive and use power. The public image of nurses is a mirror of nurses' perceptions of selfNurses should do more to improve their image. If they have a negative image of themselves, the image they project to the public is equally negative

Subsequently, the articles were judged on their substantive concepts to identify the main themes. Five main themes were identified: (1) work environment and work values; (2) education and career choice; (3) traditional values, culture and gender; (4) caring; and (5) identity and performance. The themes and related studies are presented in Table 2.

Table 2. Themes and related studies
Themes identified in the included studiesRelated studies
Work environmentArthur et al. (1999), De Araujo Sartorio and Pavone Zoboli (2010), Fagerberg and Kihlgren (2001), Fagermoen (1997), Gregg and Magilvy (2001), Öhlén and Segesten (1998), Takase et al. (2001)
Education & career choiceBen Natan and Becker (2010), Dahlborg-Lyckhage and Pilhammar-Anderson (2009), De Araujo Sartorio and Pavone Zoboli (2010), DeMeis et al. (2007), Donelan et al. (2008), Fagerberg and Kihlgren (2001), Gregg and Magilvy (2001), Huffstutler et al. (1998), Kalisch et al. (2007), Liu (2010)
Traditional values, culture & genderDahlborg-Lyckhage and Pilhammar-Anderson (2009), De Araujo Sartorio and Pavone Zoboli (2010), DeMeis et al. (2007), Huffstutler et al. (1998), Kemmer and Silva (2007), Liu (2010), Öhlén and Segesten (1998), Takase et al. (2001)
CaringArthur et al. (1999), Ben Natan and Becker (2010), Dahlborg-Lyckhage and Pilhammar-Anderson (2009), DeMeis et al. (2007), Donelan et al. (2008), Fagerberg and Kihlgren (2001), Fagermoen (1997), Huffstutler et al. (1998), Liu (2010), Öhlén and Segesten (1998), Takase et al. (2006)
Identity & performanceBen Natan and Becker (2010), Donelan et al. (2008), Huffstutler et al. (1998), Kalisch et al. (2007), Kemmer and Silva (2007), Liu (2010), Takase et al. (2002, 2006), Tzeng (2006)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

Nurses' depiction in the media

The image of nursing is determined by how nurses themselves and others (the public) perceive nursing. Earlier studies have indicated that the public image of nurses often differs from nurses' own image of nursing. This public image is predominantly based on misconceptions and stereotypes, which find their origins in distorted images of nurses in the media. The media plays a part in perpetuating the stereotype of the nurse as angels of mercy, the doctor's handmaiden, battleaxe and sexy nurse (Bridges 1990, Hallam 1998, Gordon & Nelson 2005). Due to such images, the public views nurses as feminine and caring, but not necessarily as autonomous healthcare providers (Takase et al. 2006, Kemmer & Silva 2007). Kalisch and Kalisch (1981, 1982a,b,c, 1983) have conducted extensive research on the image of nursing in the media (newspapers, TV, films, novels). They identified six images of nurses corresponding to six different periods: (1) Angel of Mercy (1854–1919); (2) Girl Friday (1920–1929); (3) Heroine (1930–1945); (4) Mother (1946–1965); (5) Sex Object (1960–1982); and (6) Careerist (1983–Present). The presence of these stereotypical images is confirmed by Gordon (2005), who analysed the image of nurses in advertising campaigns and found that even though much has changed for women in the 20th century, images of nurses still rely on images of angels. Nurses are generally prized for their virtues, not their knowledge. In contrast, the study of Stanley (2008), who analysed the image of nurses in feature films made in the Western world, shows a more nuanced picture. Stanley (2008) examined 36,000 feature film synopses and found that while early films portrayed nurses as self-sacrificial heroines, sex objects and romantics, more recent films portray nurses as strong and self-confident professionals. A recent study of Kelly et al. (2012) discussed how nurses and nursing identities are constructed in video clips on YouTube. Three nursing identity types could be found as follows: the nurse as ‘a skilled knower and doer’, the nurse as ‘a sexual plaything’ and the nurse as ‘a witless incompetent individual’. Although the results of these studies show a rather heterogeneous picture of the image of nursing, the stereotypical images of nurses nevertheless remain persistent.

We have identified several aspects of these stereotypical images in the studies discussed in this paper and, as can be expected from the outcomes of previous studies, the results show that the actual public image of nursing is diverse and incongruous and tends to be influenced by nursing stereotypes (Öhlén & Segesten 1998, Takase et al. 2002). With respect to male nurses, men were either portrayed as the second sex in nursing care (Dahlborg-Lyckhage & Pilhammar-Anderson 2009), or as nurses with different work patterns who are not influenced by marriage (Liu 2010). Öhlén and Segesten (1998) demonstrate that male nurses experience uncertainty from other people meeting a male nurse as a result of stereotyped images.

The media's projection of images of nurses, in ways that neglect the official requirements of the profession, also has an impact on the view of the public on nursing (Takase et al. 2001, Dahlborg-Lyckhage & Pilhammar-Anderson 2009). Nurses seem to be viewed as feminine and caring, not as autonomous healthcare providers (Takase et al. 2006, Kemmer & Silva 2007). Moreover, nursing is seen as a profession with limited career opportunities (Huffstutler et al. 1998, Ben Natan & Becker 2010). Donelan et al. (2008) report more positive findings. They demonstrate that the nursing profession is highly respected by the American public, but nevertheless, the authors conclude that a nursing shortage persists in the USA. The study of Kalisch et al. (2007) also shows that nurses are seen as qualified, skilled and respectable professionals. The limitation is that, in their study, Professional Nursing Organizations and job sites are populating nursing on the internet. From the results of the studies, we may carefully conclude that the image of nurses in the media does not (yet) meet the professional image of nursing.

Defining image, self-image, self-concept and professional identity

In the included studies, the concepts image, self-image, self-concept and identity were used incongruously, even by the same author in the same study, thus making it difficult to come to a uniform definition. Self-image and self-concept, for instance, were used interchangeably, as were professional image and professional identity. For the sake of clarity, this paper restricts its focus to the terms self-concept and professional identity and uses the definition of Tajfel and Turner (1986) on self-concept, in general, which reads as follows: ‘the way we think about ourselves’. With respect to the self-concept of nurses, in specific, we rely on the definition of Takase et al.: ‘nurses’ self-concept can be defined as information and beliefs that nurses have about their roles, values and behaviours' (Takase et al. 2002, p. 197).

The Social Identity Theory of Tajfel and Turner (1986) argues that the self-concept of an individual or a group (e.g. nurses) is derived from the perceived image of the group by society. When you assume that society thinks well of you, it will boost your self-concept and vice versa. Self-concept (the way we think about ourselves) can be used as an umbrella term, with self-image (the way we see ourselves), self-esteem (the way we feel about ourselves) and self-presentation (the way we present ourselves to others) as underlying concepts (Tajfel & Turner 1986). We chose to use the concept of self-concept throughout this paper because it applies mostly to the professional self (the profession), rather than to the psychological self (the person). Therefore, it can be linked to professional identity. Nurses' professional identity is defined as ‘the values and beliefs held by nurses that guide her/his thinking, actions and interactions with the patient’ (Fagermoen 1997). The included studies show that professional identity can be reflected in the nurse's professional self-concept, which is also based on the general public opinion on nurses (Öhlén & Segesten 1998, DeMeis et al. 2007). Congruence exists between the public image and nurses' self-concept: nurses who perceive their public image to be negative are likely to develop low self-concept (Öhlén & Segesten 1998, Gregg & Magilvy 2001, Takase et al. 2002). In turn, nurses' negative self-concept and presentation influence the public's opinion (Tzeng 2006).

Work environment and work values

In 7 studies, work environment and work values were mentioned as factors of influence on nurses' professional identity. Nurses learn from their work experiences and professional interaction with colleagues, in particular, is highly valued. In the study of Arthur et al. (1999), the professional self-concept, technological influences and caring attributes of 1957 Registered Nurses in 11 countries were examined. They found that the sample as a whole valued professional interaction with colleagues and believed in the skills of nurses. This view is shared by Gregg and Magilvy (2001), who also found that nurses learn from their work experiences. Through interaction with other nurses, they learn things about nursing and about themselves and working as a nurse may also contribute to their personal growth and self-concept (Gregg & Magilvy 2001). The Swedish nurses in the study of Öhlén and Segesten (1998) mentioned that they develop their professional identity through interaction with other nurses and by sharing their experiences in a narrative and reflective way. Takase et al. (2001) found that the participants in their study evaluated their performance as nurses positively and that this positive self-concept is related to the professional socialization process. Nurses develop a professional identity through the skills, knowledge and values inherent in their profession. The study of Fagermoen (1997) showed that working as nurses maintains and enhances their self-concept, both as nurses and as persons.

Education and career choice

Next to work environment, education and the presence of preceptors also contribute to nurses' job satisfaction and self-concept. The nurses in the study of Fagerberg and Kihlgren (2001) mention that the influence of preceptors during education and in the work was very important. This view was shared by the participants in Gregg and Magilvy (2001) study on nurses in Japan. Some participants considered their (basic) nursing training to be low-level education, but most participants felt they had gained positive influences from their education, including continuing education after becoming a nurse. In contrast, De Araujo Sartorio and Pavone Zoboli (2010) found that the nurse teachers in their study seemed to be driven by historical scars that still influence their focus on the actual role of nurses and which in turn might have detrimental effects on the teaching and work of nurses.

Although nurses see themselves as well-trained professionals, the public still sees nursing as a low-status profession that is subordinate to the work of physicians, does not require any academic qualifications and lacks professional autonomy. The public is oblivious to the different levels of education and professionalism involved in nursing (DeMeis et al. 2007, Dahlborg-Lyckhage & Pilhammar-Anderson 2009, Liu 2010). The study of Huffstutler et al. (1998) shows that even though many of the respondents believe that education is important for becoming a nurse, the majority does not have a clear conception of the meaning and practice of the nursing profession. In a study on Israeli nurses, Ben Natan and Becker (2010) found a positive correlation between the image of nursing and the decision of students to choose a nursing career. They discovered that the more positive the image of nursing, the higher the chance that students would opt for a nursing career. Their findings also revealed that nursing is seen as a profession that has limited career opportunities and that the characteristics of nursing are incompatible with the characteristics of an ideal career.

However, these results contrast with the findings of Donelan et al. (2008), who performed a national survey of the public's opinion of nursing and a national survey of Registered Nurses in the USA on their own opinion of nursing. Donelan et al. (2008) found that the public was more positive about a career in nursing than the nurses themselves. The qualifications the public named most frequently with respect to nursing included ‘highly knowledgeable, qualified, skilled’. Kalisch et al. (2007) share this view as a result of their study on the image of nurses on the Internet. With respect to education, nurses are described as being knowledgeable and skilled and more nurses who hold a doctoral degree are mentioned than in the past. However, we must keep in mind that these results are biased by the fact that the subjects were Professional Nursing Organizations, job sites and resource/Website directories.

Traditional values, culture and gender

The nursing profession continues to suffer from the influence of traditional values and cultural and social norms with respect to gender and professional status. Öhlén and Segesten (1998) found that a stereotypical image of nurses is an expression of the tradition of viewing nursing as a part of the female sphere of the family. As a result, nurses are struggling for power in a gender-segregated society. In Brazil, for instance, nursing is still seen as a female and domestic vocation related to the social universe of the ‘house’. Nursing remains a predominantly feminine and domestic activity that has a low social status and is discredited by society. People look at the doctor who gets all the credits (DeMeis et al. 2007, Kemmer & Silva 2007). The online forum used by Liu (2010) to explore nurses' perceptions of their work role on the basis of Chinese cultural and gender roles shows similar results. Participants mentioned that they would not encourage their children, especially their sons, to become nurses. The author argues that one of the main underlying reasons for this negative view of nursing is to be found in the traditional norms and values in Chinese culture. The Chinese caring system, where persons with lower status should care for those with higher status, qualifies nurses as caregivers with low professional status and as subordinates to physicians. Nursing is still seen as a feminine, caring sub-professional occupation rather than a profession (Liu 2010). The study of Dahlborg-Lyckhage and Pilhammar-Anderson (2009) on predominant discourses in Swedish nursing shows that the image of nurses in gendered discourse has been mainly negative. Nursing was, and sometimes still is, portrayed as a female profession, with nurses playing supporting roles to physicians and occupying a subordinate position with regard to decision-making and delegating tasks. These studies show that the public in various countries has a strong tendency to regard nurses as ‘subordinate to doctors’ (Huffstutler et al. 1998, Takase et al. 2001, De Araujo Sartorio & Pavone Zoboli 2010) or as ‘the doctors shadow’ (Kemmer & Silva 2007). Öhlén and Segesten (1998), however, believe that awareness of this process may create opportunities for nurses to develop professionally.

Caring

Caring was the most commonly identified factor of influence on the development of nurses' self-concept and professional identity (mentioned in 11 studies). The nursing profession is strongly associated with caring, both by the public and by nurses themselves. However, a discrepancy exists in the interpretation of the concept of caring. The studies show that nurses consider caring to be part of their professional identity, whereas the public associates caring with feminine qualities and unprofessionalism. Today's nurses try to gain recognition for the importance of caring in a society where caring is undervalued (Öhlén & Segesten 1998). Nurses are viewed by the public as feminine and caring professionals, but they are not recognized as leaders or independent healthcare professionals (Takase et al. 2006). The results of the study of Huffstutler et al. (1998) indicate that nursing is seen as the profession most closely associated with caring. Despite the technological developments in health care, nurses are considered to be caring persons and thus the most important requirement for becoming a nurse is to be able to care for others.

With regard to nurses themselves, the extensive study of Arthur et al. (1999) showed that nurses in all 11 countries believe in a confidential relationship between nurses and their patients based on truthfulness and respect. Despite their individual cultural features, nurses across the world do have much in common when it comes to caring and their practice. Nurses believe that the primary responsibility of nurses is to perform nursing care for patients and to ensure their patients' well-being (Fagerberg & Kihlgren 2001, Dahlborg-Lyckhage & Pilhammar-Anderson 2009). Fagermoen (1997) shows that for most of the nurses in her study, the value of care for the patients' health and well-being appears to be an overriding value, on which they base their practice. Positive correlations have also been found between choosing nursing as a career and intrinsic factors, such as caring for others, helping others and feeling responsible for others (Ben Natan & Becker 2010). In contrast, the study of DeMeis et al. (2007) showed that nurses themselves may also consider caring to be an unprofessional activity. The respondents state that when nurses reach higher professional standards, patient care is delegated to a socially less-valued professional category that requires lower academic qualifications.

Identity and performance

Nine studies mentioned the poor communication of nurses with the public and the invisibility of nurses in the media. A common theme in these studies is that nurses should do their best to improve the negative image of their profession, whereby keeping the goal to recruit new students in mind. The studies emphasize the shortage of nurses, which is partly caused by nurses themselves, who do too little to recommend their careers to others (Takase et al. 2006, Donelan et al. 2008). Nurses need to counteract the effects of nurse stereotyping and improve the public image of their profession. A stereotypical public image is also partially responsible for the way nurses perceive and use power. Nurses need power to improve their visibility (Takase et al. 2002, Tzeng 2006). According to Kemmer and Silva (2007), nursing professionals have partly inflicted their invisibility in the media on themselves. As long as nurses do not feel responsible for the distorted images of the roles they have performed and are still performing in health care and as long as they do not take a stand to correct these images, their invisibility will continue. Nurses need to raise public awareness about the various roles and opportunities both basic and advanced nursing practice have to offer. To give more visibility to the nursing role, a strategy needs to be developed, which will use the (social) media (Internet, TV, internal news, press) to inform the public (Kalisch et al. 2007, Kemmer & Silva 2007).

Implications for nurses

Around the world, nursing baccalaureate, master and doctoral degree programmes prepare nurses for a variety of nursing roles. Nurses are educated to develop nursing theories and conceptual models, conduct nursing research and test nursing theories (Meleis 1997). As a result, nursing is becoming more scholarly. The public needs to become aware that nursing research exists and that it is important to patient health. This awareness, in turn, will have a positive effect on the public image of nursing and will empower nurses.

This paper, however, shows that the public is not always aware of the qualifications nurses need for their profession. The public image of nursing is, to a large extent, affected by the invisibility of nurses and the way they present themselves. Ineffective communication skills influence the public perception of nurses. Nurses should work harder to communicate their professionalism to the public and they need to make clear what they really do. As nurses see caring for patients as a core value in nursing practice, it is important to demonstrate to the public that this entails more than just sitting by the patient's bedside, as portrayals of nurses in the media would sometimes lead the public to believe. Nurses could use discourse and new (social) media to present their profession to the public (Kalisch et al. 2007, Ben Natan & Becker 2010).

Recommendations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

We argued in this paper that, to become more visible inside and outside healthcare organizations, nurses should present themselves more clearly to the public. This could be achieved by pursuing higher education and by working in a challenging work environment that offers nurses the opportunity to break away from the daily routine and that challenges them to deepen and broaden their knowledge and skills. Job rotation, gaining professional autonomy, opportunities for interprofessional learning and peer consultation could help nurses to become more visible within their organization and on a macro level, within society. Nurses could, for example, create a more challenging work environment by embracing a more active attitude that includes participation in representative bodies and unions. Interaction with other nurses and working as a nurse may contribute to the development of their self-concept and identity as a nurse. Out of their professional identity, nurses can also adopt and develop new leadership roles. Nursing research can be helpful to further the profession and research outcomes could be used to improve the development of professional identity. Another strategy that could help nurses is to participate in the development of cross-national knowledge about nursing practice. It would be very interesting to examine in which countries nurses are ‘doing well’ in respect to public image and consequently represent their professionalism in the eyes of society.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

This discussion paper gives an overview of the current state of affairs with regard to public image, self-concept and professional identity of nurses. The findings show a rather diverse picture of the actual view of the public on the nursing profession. The heterogeneity of setting, sample and population of the studies makes it quite difficult to explain these differences. Furthermore, traditional cultural and social values determine the way the public perceives the nursing profession. The self-concept of nurses and their professional identity are determined by many factors, including public image, work environment, work values, education and culture. Virginia Henderson (1978) already stated that ‘nurses self-image is often at odds with the public's image and what nurses do is at odds with what nurses and the public think they should do’. A negative public image may challenge nurses to look for successful strategies to improve their self-concept and to show their invaluable contribution to the healthcare system. One of the strategies is to promote nursing by giving lectures to spread information on the profession. As educators and role models, they can establish a professional nurse identity. Professional development of nurses could also be realized by sharing their work experiences with other nurses. In addition, nurses should make better use of strategic positions, such as case manager, nurse educator or clinical nurse specialist to show what their work as healthcare professionals entails. The public should be able to identify with nurses and the work they do. In the media, nurses are hardly seen as professional advisors or experts. A convincing number of nurses is needed to change the public opinion. Kalisch and Kalisch (1983) state that nurses can intervene in four steps: (1) getting organized; (2) monitoring the media; (3) reacting to the media; and (4) fostering an improved image. Unless nurses themselves establish a public image and professional identity that recognizes the value of their professional and educational development, the problem of a ‘fuzzy’ and inaccurate image will continue to exist.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

We would like to thank Sonja Hintzen of the University Medical Center Groningen for her constructive advice and editing services.

Author contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References

YH and PR were responsible for the study conception and design; YH performed the data collection; YH and PR performed the data analysis; YH, PR and GJ were responsible for the drafting of the manuscript.

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE: http://www.icmje.org/ethical_1author.html):

  • substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
  • drafting the article or revising it critically for important intellectual content.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Discussion
  5. Recommendations
  6. Conclusion
  7. Acknowledgements
  8. Funding
  9. Conflict of interest
  10. Author contributions
  11. References