The past is not simply the past, but a prism through which the subject filters his own changing self-image.
—DORIS KEARNS GOODWIN
Thanks to the previous author of the chapter—Linda Stevenson, PhD, RN, FNP.
Nursing image—how is it perceived? What does it mean to be a professional nurse? How does the public view nursing? How does nursing define and view itself? What role does the public image of the nursing profession play in the current shortage?
Historically, nurses have struggled to define the image of nursing and the professional role of the nurse. There are many different views and opinions, but nurses are definitely gaining ground when it comes to defining the profession of nursing. The annual Gallup survey for professions noted that for honesty and ethical standards nursing has been rated at the top of the list for the past several years. Eighty three percent of the American public rate the standards held by nurses as either high or very high (Saad, 2008). The image of nursing is evolving and changing with nursing being promoted as an intellectual, autonomous profession that demands a high level of commitment, focus, and a dedication to continued education and scholarly activity.
Modern-day nursing has many dimensions, one of which includes the debate surrounding its identification as a profession. One ongoing challenge in nursing is to diligently foster and enhance the public image and the self-image of the nurse. In this chapter, the development of nursing into a profession is discussed, and the present and future dimensions of nursing’s “image” are explored. Historical knowledge about our “rites of passage” gives us an appreciation of where nursing is today as a profession and what the future of nursing may hold for the recent graduate in this complex and evolving health care world.
Professional Image of Nursing
What Do We Mean by the “Image” of Nursing?
Nursing has been identified as an “emerging profession” for at least 150 years. The historical context of nursing’s image is often traced back to Florence Nightingale, the “founder of nursing.” Florence Nightingale is recognized as a nurse, statistician, and writer who became known for her groundbreaking work during the Crimean War. Nurse Nightingale was also called the “Lady with the Lamp,” as she was reported to have made rounds on her patients at night by the light of a lantern. International Nurse’s Day is celebrated each year on her birthday, May 12, and the Nightingale Pledge is still solemnly repeated by new nursing graduates around the world. Even though much has been written about Florence Nightingale’s many contributions, she is undeniably remembered as the pioneer of nursing education (Bostridge, 2008).
The image of professional nursing continues to evolve and is significantly affected by the media, women’s issues and roles, and a high-technology health care environment. How nursing views itself in the evolution of the profession and how actively nurses are involved in the definition process will continue to determine the image and role of nursing in the future.
Nurses are professionals who are science driven, technically skilled, and caring (Dukes, 2003). Dombeck (2003) noted that “the portrayal of nurses generally parallels the portrayal of women in the media” (p 351). That image of nursing has continued to demonstrate a general lack of knowledge regarding the role of professional nurses (Ward et al, 2003). As more men enter the profession and there is a push to increase minorities in nursing, will the image of nursing change (Critical Thinking Box 9-1)?
Nurses should be thought of as autonomous and competent decision makers within their nursing practice areas. Throughout the 1990s, a nationwide advertising campaign supported by the National Commission on Nursing Implementation Project produced radio and television ads that said, “If caring were enough, anyone could be a nurse.” Nurses of America, an advocate organization sponsored by the National League for Nursing (NLN), implemented a very successful program directed toward improving the image of nursing as depicted on television, on radio, in print, and on lecture circuits. Consultants were contracted to work with executives, politicians, and celebrities on presenting nursing in a positive manner. This approach reinforced the image of the modern-day professional nurse as having critical thinking, decision-making, and problem-solving skills.
In a 2002 study, Turow and Gans found that on U.S. television programs, it was common for only physicians to be heard when health care policy was discussed; nurses and other health care team members were noticeably absent. The American Academy of Nursing (www.aannet.org, 2008) through the Raise the Voice campaign has brought nursing policy innovators to the forefront of health care policy debates. A concentrated effort by individuals and organizations is raising awareness of what nurses do and heightening the image and voice of nursing as a profession. As noted by Groves (2007), accurate portrayals of nurses as professional members of the healthcare team are rare, but it takes time to change perceptions. The continued trend of building a positive, intelligent, competent, and professional image of nursing must continue. Nurses who are new to the profession need to be aware of the extraordinary challenges and opportunities that they will face. It is equally important for nurses to improve the self-image of the professional nurse. The behaviors and ethics displayed by nurses on a day-to-day basis can do much to elevate the present and shape the future image of nursing (Cohen & Bartholomew, 2008).
Nursing associations are working together to promote a positive image and deal with nursing shortage issues. Nurses for a Healthier Tomorrow, an alliance of 37 nursing organizations, has launched a national media campaign that demonstrates, through print and broadcast media, the many opportunities for the career of nursing. One tangible example of this effort is the website www.nursesource.org. Sigma Theta Tau International, the International honor society for nursing, is the coordinator of Nurses for a Healthier Tomorrow. Check out their website at www.nursingsociety.org. The American Nurses Association published a flyer titled Every Patient Deserves a Nurse, along with other promotional materials for the lay public. The promotional message of these materials reinforces the positive image of nurses as patient advocates and critical resources both to patients and families, while also emphasizing the right of people to a safe health care environment.
In 2002, the Johnson and Johnson Company developed a nationwide campaign to support the nursing profession. This program, titled “The Campaign for Nursing’s Future,” was developed along with health care leaders and nursing organizations such as the National Student Nurse’s Association (NSNA), the American Nurse’s Association (ANA), the American Organization for Nurse Executives (AONE), the National League for Nursing, and Sigma Theta Tau. The goal of this program is to increase the number of young adults entering nursing through raising the visibility of nurses of varied races, gender, and roles. The website for the campaign can be found at www.discovernursing.com.
The negative images of nursing, those of the “naughty nurse” or the “Nurse Ratchet” that are depicted in the media are still prevalent, but these erroneous portrayals do offer professional nurses the opportunity to educate the public in what nurses truly do. Nursing is not the only profession that struggles with a skewed media image. Some of these erroneous depictions may be related to the largely female population who seek these professions; consider the sexual media images that are often illustrated by flight attendants, massage therapists, or secretaries (www.truthaboutnursing.org, 2009). Other occupations that suffer from poor media portrayals include the “mad scientist” role (chemist or researcher), construction worker (often a sexual male image), or consider the negative images that both female and male lawyers are often faced with! Devaluation of the nursing profession by demeaning or comical images only extend the nursing shortage and further discourage talented people from entering the nursing profession. It is up to each individual to continue to display professional role modeling and provide public education on what nurses really do to empower the professional image of nursing (Cohen & Bartholomew, 2008).
How can nurses change the image of nursing? How can the image of nursing become more congruent with the actual role the nurse plays in today’s health care? Nurses outnumber all other professions in health care. Mee (2006) suggests that nurses can promote the professional image of nursing by the following:
One by One. During the first 60 seconds that a patient sees the nurse, a lasting impression may be formed. Take a moment before meeting a new patient and portray confidence in your role and a respect for the patient from the beginning. Many health care institutions require nurses to wear nursing uniforms in a distinct color that separates them from nurse assistants and respiratory therapists.
Personal Interaction with the Public.
Have a quick response ready in case someone asks about nursing. Present nursing in a positive image and relate what an important role nurses have in society as health care providers.
Public Speaking and Community Activities.
Consider speaking at or visiting schools on Career Day. You don’t have to be an expert at public speaking to discuss the role of the nurse with local community groups. A brief, interactive presentation at an elementary or high school can stimulate interest in nursing early—for both male and female students!
Participation in Political Activities.
Increase the positive visibility of nurses through politics by becoming actively involved as a nurse lobbyist. Be aware of the current health care issues on the community, state, and national level. Get to know the elected officials and talk to them about the role of the nurse. This may be a valuable opportunity to present nursing in a very positive manner. Remember that most elected officials do not understand the role nurses play in health care (Mee, 2006).
Creating a professional image incorporates effective communication skills, positive attitude, and professional appearance. When you first meet patients, family members, or potential employers, your professional appearance has an impact on how they perceive you as a nurse. Dress appropriately and be prepared to ask and answer questions that reflect a confident, positive image (Larson, 2006).
The image of nursing continues to evolve as the many roles of nurses are portrayed through the media in the restructuring of health care environments and in a variety of settings, from emergency rooms to war zones. Studies continue to verify that competent nursing care affects mortality rates in critical care patients, and the future for many nursing jobs lies in the expanding role of nursing into emergency and disaster preparedness and integration of technology and informatics into practice settings (Health Resources and Services Administration [HRSA], 2009). The role and image of the nurse will continue to change as the many facets of health care delivery evolve during this century. The current nursing shortage will play a significant role in the creation of the future image and role of the nurse. How will nurses respond to these changes? How will you present yourself as a professional?
What Constitutes a Profession?
There are many ways to describe a “professional.” What meaning does the word have for you as a graduate professional nurse? Controversy over the definition of the term professional as it relates to nursing is not a new issue. Strauss (1966), a noted sociologist, found the word professional used in reference to nursing in a magazine article published in 1892 titled “Nursing, a New Profession for Women.” The nurses of the 20th and 21st centuries owe a great deal to Isabel Adams Hampton (later Isabel Hampton Robb) for her visionary focus in the late 1800s. She was an outstanding advocate for the professionalization of nursing. In the textbook Nursing Ethics (1901), she wrote:
In Caplow’s classic work from the early 1950s, The Sociology of Work, several steps in the process of “becoming professional” were defined further, and the value of forming an association that defined a special membership was addressed. Caplow suggested that making a name change to clarify an area of work or practice would subsequently produce a new role. With the creation of this new role, the group would then establish a code of ethics and legal components for licensure to practice and educational control of the profession (Caplow, 1954). This process of becoming professional was taking place in nursing in 1897 with the establishment of the ANA. Other aspects of professionalization were also beginning to develop. For example, the Code for Nurses was suggested as early as 1926, although it was not written or published by the ANA until the early 1950s. Revisions were made in 1956, 1960, and 1976, with changes made in 1985 that included interpretative statements. In the summer of 2001 at the ANA convention, delegates again updated the code and changed the name to the Code of Ethics for Nurses with Interpretive Statements (www.ana.org/ethics/ecode.htm).
Almost 20 years after Caplow’s work, Pavalko (1971) described eight dimensions of a profession. Pavalko’s dimensions of a profession and their specific application to nursing are examined in more detail later in this chapter. Nursing continues to apply these dimensions to support nursing’s move away from the occupational focus to a professional focus. Is nursing a profession or semiprofession?
By responding to the questions in Critical Thinking Box 9-2 (which presents Levenstein’s model, a fourth model of professionalism), you will identify common themes in describing a profession. What are your thoughts about the nursing profession in light of these criteria?
Others have written about professions and their development, but these sociological models present some logical characteristics for you to use to examine professionalism. According to Henshaw, a noted nursing leader and researcher, a profession includes “self-regulation and autonomy with ultimate loyalty and accountability to the professional group” (cited in Talotta, 1990). Nursing is a dynamic profession and continues to strive to enhance a professional image—which leads us to the next question.
Is Nursing a Profession?
Eunice Cole, a past president of the ANA, described nursing as a dynamic profession that has established a code of ethics and standards of practice, education, service, and research components. The standards for both the professional and practical dimensions of nursing are continually reviewed and updated. Nurses, strong in numbers but splintered professionally in many ways, represent the largest group of health care providers in the United States. There are more than 3 million registered nurses in the workforce with an average age of all licensed RNs increased to 47 years in 2008 from 46.8 years in 2004, which demonstrates a stabilizing of age. Although the number of RNs younger than 40 dropped steadily between 1980 and 2004, there was an increase in 2008 and they now comprise 29.5% of all RNs. Most RNs are actively practicing nursing (84.8%—highest in the history of the survey) and most are working full time (63.2% vs. 58.4% in 2004—the first increase since 1996). The majority of nurses (45.4%) complete their initial education preparation at the associate degree level. A little more than one-third (33.7%) have a bachelor’s degree, up from 31% in 2004, noting a trend of increasing education. There was significant growth (46.9% increase since 2000) in the numbers of RNs with a master’s or doctoral degree in nursing or a related field (HRSA, 2010).
Examine the issues that challenge nursing as a profession by using Pavalko’s eight dimensions to describe a profession.
1 A Profession Has Relevance to Social Values.
Does nursing exist to serve self or others? Nursing historically had its roots in true altruism with lifelong service to others. As nurses, we focus not only on the treatment component of patient care, but also on wellness and health promotion issues, as a part of our nursing practice. The goal is to shift the focus of health care so that primary prevention becomes more valued. As this shift occurs, nurses will become increasingly important because of their ability to be teachers of health promotion activities and managers of wellness, activities that have an impact on social values.
2 A Profession Has a Training or Educational Period.
According to Florence Nightingale, a nurse’s education should involve not only a theory component, but also a practice component. An educational process for any professional is critical because it transmits the knowledge base of the profession and, through research and other scholarly endeavors, advances the practice of the profession. The diversity of educational programs for nurses has stimulated debate regarding the entry practice level for registered nurses. Some questions surrounding the issues include the following:
How critical is it to complete a 4-year bachelor of science in nursing (BSN) program to handle the challenges of the health care environment, complex patient-family needs, and the expanding community-based settings for clinical work?
Will the doctor of nursing degree that was pioneered at Case Western University become the minimum background for entry into the profession? Will the practice doctorate in nursing (DNP) degree clarify or confuse advanced-practice roles in nursing?