University of Groningen From student nurse to nurse professional ten Hoeve, Yvonne

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From student nurse to nurse professional

ten Hoeve, Yvonne

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ten Hoeve, Y. (2018). From student nurse to nurse professional: The shaping of professional identity in nursing. Rijksuniversiteit Groningen.

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The nursing profession: public image,

self-concept and professional identity

A discussion paper

Yvonne ten Hoeve Gerard Jansen Petrie Roodbol

CHAP

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ABSTRACT

Aim

To discuss the actual public image of nurses and other factors that influence the deve-lopment 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 competen-ces nurses have acquired through education and innovation.

Design

Discussion paper.

Data sources

We identified 1216 relevant studies by searching MEDLINE, CINAHL and PsycINFO data-bases 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 in-congruous. 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 health care orga-nizations, 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.

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INTRODUCTION

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 nur-sing. 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 sub-ject 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, Black & Parent, 1998). A stereotype can be defined as ‘a cognitive representation or impression of a so-cial 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 repeti-tive and routine tasks, mostly as the doctor’s handmaiden (Bridges, 1990). Other stu-dies indicate that the portrayal of nurses in the media might give a clue as to how their public image is perceived (Gordon, 2005; Kalisch & Kalisch, 1983; Warner et al., 1998) These studies show that the public image of nurses does not always match their profes-sional image; nurses are not depicted as autonomous profesprofes-sionals and the public is not aware that nowadays nursing is to a great extent a theory-based and scholarly professi-on (Dominiak, 2004). The nursing discipline has undergprofessi-one 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 va-lidate theory, which then may change nursing practice (Donahue,1998). Nightingale (1820-1910) and Henderson (1897-1996) have been visible forces for nursing across boundaries, in respectively the 19th and the 20th century. Moreover, the nursing pro-fession has developed numerous types of education programs 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 analyze the po-tential influence of this image on the development of nurses’ self-concept and profes-sional identity. A search of the literature is performed and recent publications on these themes are brought together to broaden this discussion.

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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) do-minance strongly influenced the role development, the image and the position of nur-ses (Fletcher, 2006; Gordon, 2005; Hallam, 2000). 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 professi-onal 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, Greenwell, Mackay and Soothill (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 stu-dies of Adamson, Kenny and Wilson-Barnett (1995) and Aiken and Sloane (1997) de-monstrated how the impact of medical dominance on autonomy and job satisfaction of nurses led to decreased patient outcomes. Adamson et al. (1995) examined the in-fluence 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 defer-red 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 oppres-sed 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; Fletcher, 2007). Self-concept is closely related to professional self-concept, which is a prerequisite for the vocatio-nal 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 in-clude work environment, work values, education and culture. Professional identity and self-concept can undergo changes due to interactions with colleagues, other health care professionals and patients. Work environment and work values can also play a role in this respect (Allen, 2004; Ewens, 2003; Mills & Blaesing, 2000). 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).

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There is a strong need for a discussion on the image, the self-concept and the professi-onal 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 develop-ment of these important issues.

Data sources

Search methods

A literature search was performed using the databases MEDLINE, CINAHL and PsycIN-FO. The search strategy aimed to retrieve suitable studies published between 1997 and 2010. The search terms used were nurses, nurse*, perception, public image, profes-sional 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 re-viewed 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 nur-ses’ self-concept and professional identity. Figure 1 shows a flow chart of the selection process.

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).

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Data abstraction and synthesis

A key word analysis was performed based on the concepts of public image, professional identity and self-concept. Next, a content analysis of the included studies was conduc-ted 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.

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 Ta-ble 2.

Figure 1 - Flow chart of study selection process

Potentially relevant studies identiﬁed and screened for retrieval

(n = 1216)

Studies retrieved for evaluation

(n = 287)

Studies retrieved for more detailed evaluation

(n = 58)

Studies included in the literature review

(n = 18)

Studies excluded, after full text analysis

(n = 40)

Studies excluded, after abstract analysis

(n = 229)

Studies excluded, after title analysis

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2

Tab le 1 C ha racter is tics o f t he inc lud ed st ud ies R ef er enc e St udy des ig n Sa m ple/ ins tru m en t D at a anal ys is Aim Publ ic im age , s el f-c onc ep t and pr of es si on al ide nt ity C om m ent s Ben N at an & B ec ker (2009 ) Quant itat iv e m et hods D es cr ip tiv e s ur vey 309 adul ts 18 -50 y ear s McC abe ques tio nnai re D es cr ipt iv e s ta tis tic s, inf . sta tis tic s; t-te st s; par am et ric tes ts ; S pear m an c or rel at io n To clar ify fa ct or s t ha t in flu enc e t he choi ce o f i de al car eer s and nur si ng c ar eer s am ong the gener al popul at io n The publ ic has a m ay or m is per cep tio n of nur ses ’ w or k. C ar eer s i n nur si ng a re per cei ved as tedi ou s and l ac ki ng c hal lenges , cr eat iv ity , r es pon si bi lit y, h ig h w ages , s tat us and co m for tabl e w or ki ng c ondi tio ns Nur si ng s chool s need to pr om ot e the nur si ng pr of es si on a m ong the publ ic . Le ct ur es by nur ses ar e v er y si gn ifi can t. R es ea rc h i s nec es sar y t o ex am ine w hy peopl e w ho ar e int rins ic all y mot iv at ed to c ho os e a c ar e-giv ing pr of es si on do no t c hoos e a c ar eer in nur si ng Dahl bo rg & Ly ck hage (2009 ) Quali ta tiv e d es ign Dis cour ses fr om 1999 -2003 Doc um ent s, repor ts , ca m pa ign s, TV s er ie s; D is cour se and c ont en t anal ys is To e xpl ic at e t he pr edo m in ant di sc our se i n t he fi el d of Sw edi sh nur si ng The m ed ia play a m ajor ro le in d is se m ina ting pr ev ai lin g c onc ep tio ns and conv ent io ns per tai ni ng t o t he nur si ng pr of es si on. T he m edi a pr es en t nur si ng in w ay s t ha t negl ec t the of fic ia l r equi re m en ts of the pr of es si on Heal th c ar e s ee m s t o be m or e hea vi ly in flu enc ed by the m ed ia than by the of fic ia l requi re m ent s o f nur si ng . T he ref or e, the publ ic coul d get lo w ex pec tat io ns o f t he co m pet en ces of nur si ng De Ar auj o S ar tor io & Pav one Z ob ol i (2010 ) Qual itat iv e s tudy w ithi n the s cope o f de sc rip tiv e et hi cs 18 nur se t ea cher s Sem i s truc tur ed and uns truc tur ed i nt er vi ew s H er m eneut ic -d iale ct ic m et hod To ident ify the et hi cal im age of nur si ng Five di st in ct iv e per spec tiv es o f an et hi cal nur se e m er ged: good nur se s ful fil thei r d ut ie s co rre ct ly , ar e pr oac tiv e pat ie nt adv oc at es , are prepared and av ai labl e t o w el co m e ot hers as per sons , ar e t al en ted, c om pe tent and c ar ry out pr of es si on al dut ie s ex cel lent ly ; c om bi ne aut hor ity and pow er s har in g i n pa tient c ar e Som e per spec tiv es poi nt ed t o t rai ts fr om the pas t. Th is c au sed s om e con cer n, bec aus e st udent s s houl d no t s tar t t hei r c ar eer s w ith the shadow s of hi st or ic al hur ts . F ac ul ty s houl d m ak e the teac hi ng and w or k of nur si ng heal thi er Donel an , B uer haus , De sRo ch es , Di ttu s & Du tw in (2008 ) Qual itat iv e d is pr opor tio nat e st ra tif ied s am pli ng d es ign 1,604 r es pondent s age 18 and ol de r Sur vey : C om put er A ss is ted Te le phone I nt er vi ew ing St rat ifi cat io n s che m e and sa m ple b alan cing To ex am ine th e in flue nc e o f soc ie tal de m og raphi cs , per cept io ns of the nur si ng shor tage and m ed ia in flu enc es on per cept io ns o f nur si ng c ar eer s Images of nur se s ar e par tly s hape d by per sonal ex per ie nc e w ith nur ses b ut al so by ex pos ur e i n the m edi a (T V, new s) . T hi s ex pos ur e i s m or e hel pf ul than har m ful The nur si ng pr of es si on is hi gh ly re spec ted. N ev er thel es s a s hor tage of nur se s per si st s. Im pl em en tin g a w or kf or ce st rat egy is es sent ia l to under st and and m ai nt ai n t he pu bl ic ’s sup por t f or the nur si ng pr of es si on Huffs tu tle r, S te ve ns on , M ul lin s, H ac ket t & La m ber t (1998 ) Qual itat iv e s ur ve y 831 int er view s w ith non - nur si ng uni ver si ty s tudent s, pr of es si on al per son s, ot her non -n ur sing ind iv idu als Inter vi ew s w ith thr ee open -ended ques tio ns Sec ondar y anal ys is tec hni qu e To e val ua te t he per cept io ns of nur si ng ’s im age by non -nur si ng uni ver si ty s tudent s, pr of es si on al s, and o ther non -nu rs ing ind iv idu als Student opi ni ons of nur si ng w er e s ig ni fic ant ly af fec ted by par ent s, fr ie nd s and g ui da nc e couns el lor s. T he m ea ni ng and pr ac tic e o f nur si ng c ar e i s not ent ire ly under st ood by the va riou s ind iv idu als w ho w er e int er view ed Nur ses need to be agent s of c han ge and educ at e the publ ic about the m any di ffer ent po ss ibi lit ies av ai labl e i n ba si c nur si ng and adv anc ed pr ac tic e pr epar at io n Table 1 - Char act eris

tics of the included s

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Processed on: 28-12-2017 PDF page: 34PDF page: 34PDF page: 34PDF page: 34 34 Tab le 1 C on tinu ed R ef er enc e St udy des ig n Sa m ple/ ins tru m en t D at a anal ys is Aim Publ ic im age , s el f-c onc ep t and pr of es si on al ide nt ity C om m ent s Kal is ch , B egeny & N eu m ann (2007 ) Quant itat iv e des cr ip tiv e C om par at iv e des ig n Nur si ng w ebs ites 144 in 2001 152 in 2004 Inter net N ur si ng Im age T oo l D es cr ipt iv e s ta tis tic s; Pear son X 2 tes ts ; N onpar am et ric tes ts , Int er rat er rel iabi lit y To a nal yz e t he i m ag e of nur si ng on the I nt er net and to res ear ch w het her thi s i m ag e under w ent c hanges fr om 2001 t o 2004 One of the major inf lue nc es o n th e i m ag e o f nur ses is the la rgel y i na cc ur at e an d negat iv e por tray al of the nur si ng pr of es si on . T hi s im age has an i m pa ct on the qual ity and quant ity of the w or k per for m ed This s tudy rev eal s a rel at iv el y pos iti ve i m age of nur si ng on t he in ter net . U nf or tu nat el y, a dow nw ar d t rend i n the depi ct io n of nur se char ac ter is tic s is ev id ent . T he Int er net of fer s nur ses the oppor tuni ty to de m ons trat e t he bes t a spe ct s o f t hei r p rof es si on Kemm er & S ilv a (2007 ) Qual itat iv e c ro ss -s ec tion al des cr ip tiv e st udy 5 C om m uni cat io n pr of es si on al s Sem i s truc tur ed i nt er vi ew s C ol lec tiv e s ubj ec t di sc our se ; D es cr ip tiv e anal ys is To fur ther the under st andi ng of the s oc ia l r epr es ent at io ns of nur se s and the nur si ng pr of es si on by c om m uni ca tio n pr of es si on al s The m ed ia tr ans m it a di st or ted i m age of nur ses . N ur se s ar e depi ct ed as th e doc tor ’s shadow and not as pr of es si on al s To giv e m or e vi sibil ity to th e nu rs in g ro le pr of es si on al s need t o pos iti on the m sel ves st rat egi cal ly and to educ at e t he publ ic on nu rs ing (TV , i nt er net , new s, pr es s) . I nv is ib ilit y D im in is he s nur ses ’ abi lit y t o change t he di re ct io ns o f heal th c ar e Arthur et al . (1999 ) Quant itat iv e des ig n 1957 R N s f ro m 11 count rie s Ques tion na ire s: P SC N I; TI Q; TI SQ ; C AQ C or rel at io n and r el iabi lit y anal ys is ; A N O VA To co mpa re th e c ar ing at tribu te s o f R N s f ro m elev en di ffer ent c ount rie s w ith t hei r vi ew s of the m sel ves and thei r per cept io ns of te chnol og ic al inf lue nc es o n t he ir pr ac tic e Parti cipa nt s v alue d p ro fe ss ion al int er ac tion w ith c ol leagues and bel iev ed i n t hei r s ki lls and fle xi bi lit y as nur ses . T he y f el t r es pec ted by ot her pr of es si on al s, but w er e l es s conv in ced that thei r c ar eer w as goi ng in the d ire ct io n they had env is io ned be for e s tar tin g Nur ses w or ld w id e hav e m uc h i n com m on but st ill r et ai n i nd iv id ual c ul tur al fea tur es rel at ed to car in g and thei r p rac tic e a s nur se s. F ut ur e st udi es ar e r ec om m ended to ex am ine, res pec t, pr es er ve and nur tur e t he se uni qu e char ac ter is tic s Fager ber g & K ih lgr en (2001 ) Qual itat iv e l on gi tudi na l s tudy 27 nur si ng s tudent s 19 nur ses Inter vi ew s and di ar ie s Pheno m enol og ic al her m eneut ic s To u nder st and how nur ses ex per ie nc e t he m ean in g of thei r i dent ity a s nur se s, as st udent s and tw o y ear s af ter gr aduat io n he c ont ex t i n w hi ch nur ses w or k i s v er y im por tant for the dev el op m ent of thei r i dent ity , sk ills and ex per tis e a s nur ses . A ll nur ses nar rat ed t hei r s tor ie s fro m one do m inant per spec tiv e, w hi ch i s under st ood a s thei r pr of es sion al ide nt ity Par tic ip ant s di d n ot s hi ft thei r do m inant per spec tiv e ov er ti m e. It m ay be under st ood as the nur se s’ li fe par adi gm Fager m oen (1997 ) Mix ed M et hods Sur vey + fo cus gr oups 767 nur ses + 6 nur ses in foc us gr oup s Ques tion na ire s + int er view s H er m eneut ic al anal ys is To id ent ify the v al ue s under - ly in g nur ses ’ pr of es si on al id ent ity a s ex pr es sed by w hat is mea ning fu l in nu rs es ’ w or k Wor ki ng a s nur se s m ai nt ai ns and enhanc es th eir s elf -c on cept bot h as nur ses a nd as per sons . T he v al ue o f al trui sm or c ar e f or the pat ie nt s’ he al th and w el l-bei ng appear ed t o be an ov er rid ing v al ue ; a m or al poi nt of v ie w on w hi ch t hey bas ed thei r p rac tic e Shor tage of per sonnel and ti m e w er e per cei ved t o a ffe ct the oppor tuni tie s for pr ov id ing qual ity nur si ng c ar e, w hi ch i n t ur n w as e xper ie nc ed a s a s trai n and f or s om e cr eat ed a f eel ing of m ea ni ng le ss nes s Tabel -1 (Continued)

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Tab le 1 C on tinu ed R ef er enc e St udy des ig n Sa m ple/ ins tru m en t D at a anal ys is Aim Publ ic im age , s el f-c onc ep t and pr of es si on al ide nt ity C om m ent s Gregg & M agi llv y (2001 ) Grounded t heor y des ig n 18 nur ses Inter vi ew s, o bs er vat io ns , theor et ic al m em os C ons tant c ompa ra tiv e anal ys is To e xpl or e t he pr oc es s o f es tabl is hi ng the pr of es si on al id ent ity o f J apanes e nur ses Nur ses ’ w or k c ont rib ut es to t hei r p rof es si on al gr ow th a nd s ati sfa cti on . P ar tic ip an ts id en tifi ed the m se lv es a s nur ses thr ough i nt egr at in g a nur se i nt o se lf. The find ing s a ck no w led ge th e ins ep ar ab ilit y o f ide nt ific at ion w ith n ur sing a nd co mm itmen t t o nu rs ing Nur ses a s edu cat or s and r ol e m od el s ar e es sen tia l t o the pr oc es s of es tabl is hi ng a pr of es sion al ide nt ity DeM ei s, de A lm ei a Souz a & Fer re ira d a S ilv a Fil ho (2007 ) Qual itat iv e s tudy 27 nur si ng pr of es si on al s Int er vi ew s Cont ent anal ys is Int er pr et at iv e Pheno m enol og ic al Anal ys is (I PA ) To p res ent nar rat iv es of pr of es sion al ide nt ity a mon g nur ses in B raz il and s ear ch for m eani ng s of c ar e and th eir plac e in n ur sing ac tiv ities Nur si ng is s til l i nf lu enc ed by tr adi tional v al ue s. N ur sing is s ee n a s a p ro fe ss ion o f low s oc ial st at us and as a do m es tic a ct iv ity that does not requi re qual ifi ca tio ns . N ur ses pos ses s a l ow pr of es si on al s el f-e st ee m , c au sed by a nega tive publ ic im age With the pr oc es s of in cr eas in g pr of es si on al iz at io n, nur se s ac qui re hi gh er ac ade m ic qual ifi cat io ns and tec hni cal know le dge, but c ar e i s del eg at ed to s oc ia lly les s v alue d p ro fe ss ion al s Liu (2010 ) Qual itat iv e s tudy 20 nur ses Web -bas ed onl ine f or um ; open -ended ques tio ns Th em at ic anal ys is To ex plor e nu rs es ’ per cept io ns of thei r w or k rol e on t he ba si s o f t he per spec tiv es o f C hi ne se gender rol es and c ul tur e In C hi ne se c ul tur e, the tradi tio nal gender rol es hav e a s trong in flu en ce on the p ub lic im age o f phy si ci an s and nur ses . N ur si ng is s til l s een a s a f em in ine , c ar ing o cc up at ion , w ith low pr of es si on al s ta tus and s ubor di na te t o ph ys ic ian s. N ur ses ’ per cep tio ns of thei r r ol e and w or k env iro nm ent ar e s trongl y i nf lu en ced by c ul tur e and gender s ter eo ty pes A m or e gender s en si tiv e w or k env iro nm ent in heal th c ar e i s r ec om m ended. N ur ses c oul d cont rib ut e by as ki ng the gov er nm ent to im pl em ent gender equal ity edu cat ion pr ogr am s Öhl én & S ege st en (1998 ) Qual itat iv e s ur vey 8 RNs Sem i s truc tur ed int er view s C onc ept anal ys is To h ig hl ight the c on cept of pr of es sion al ide nt ity o f nur ses to pr om ot e theor et ic al c la rit y and ex am in e i m pl ic at io ns for nur si ng pr ac tic e Nur ses ar e par t of a so ci al s truggl e f or pow er w he re i de as ar e cr eat ed thr ough gender seg regat io n. T he s ter eot ypi cal im age of the nur se in the m ed ia is an ex pr es si on of thi s st ruggl e. P ro fe ss ion al ide nt ity is d ev elop ed thr ough i nt er ac tio n w ith o ther nur ses and ha s a s trong i m pa ct on nur se s’ s el f-es teem and em pow er m en t. T he pr of es si on al s el f-im age o f the nur se is al so bas ed on the i de as of peopl e in gener al regar di ng nur ses Prof es si on al per sonal dev el op m en t and gr ow th of nur ses s houl d be m ade pos si bl e thr ough t he dev el op m ent of per so nal s el f-c ar e sk ills and in cr ea se d po ss ibili tie s f or nur ses for shar in g ex per ie nc es w ith ot her nur ses in a nar rat iv e and r ef le ct iv e w ay Table 1 - Char act eris

tics of the included s

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Processed on: 28-12-2017 PDF page: 36PDF page: 36PDF page: 36PDF page: 36 36 Tab le 1 C on tinu ed R ef er enc e St udy des ig n Sa m ple/ ins tru m en t D at a anal ys is Aim Publ ic im age , s el f-c onc ep t and pr of es si on al ide nt ity C om m ent s Takas e, K er shaw & B ur t (2001 ) Quant itat iv e des cr ip tiv e co rre lat ion al d es ign 80 RNs IWS; P N IS ; S ix D im en sion Sc al e of N ur s. P erf or m anc e D es cr ipt . s tat is tic s; P ear son; C rohnbac h α coef fic ie nt To inv es tig at e nur ses ’ res pons es to the im age di sc repan cy bet w een t he publ ic and nur ses and i ts re lat ion sh ip to th eir s elf -conc ept , j ob s at is fa ct io n and per for m an ce The m edi a pr oj ec t di st or ted im age s o f nur si ng . T he publ ic ’s per cep tio n o f t he nur si ng pr of es si on tend s t o be i nf lu en ced by thes e nur si ng s ter eot ypes . N ur se s per ce iv e t hei r publ ic im ag e m or e negat iv el y co m pa red w ith how they s ee t he m sel ves , w hi ch caus es im age di sc repanc y. T hi s c an le ad to job dis sa tis fa ct ion a nd low job p er fo rman ce s The dev el op m ent o f c ount er ac tiv e m ea sur es to publ ic s ter eot ypes c oul d lead t o im pr ov em en t o f nur si ng pr ac tic e, w hi ch c an change t he publ ic ’s at tit ude t ow ar ds nur si ng Ta kas e, K er shaw & B ur t (2002 ) Quant itat iv e des cr ip tiv e cor rel at io nal s tudy 80 RNs PN IS ; Se lf-es te em s ca le; IW S; Si x D im . Sc al e o f Nu rs in g Per for m anc e De cr . S ta tis tic s; C ro nb ac h; Anov a; P ear son c or rel at io n To id en tif y t he re lat ion -s hips bet w een nur ses ’ per cep tio n of c om m on publ ic st er eot ypes of thei r pr of es si on , nur ses ’ s el f-conc ept , s el f-es tee m jo b sat is fa ct io n and j ob per for m an ce The publ ic s til l ha s a s ter eot ypi cal im age of nur ses , w hi ch i nf lu enc es the dev el opm en t of nur ses ’ s elf -c on cept . N ur ses w ho per cei ve t hei r publ ic im age m or e negat iv el y t end t o r epor t a m or e n egat iv e s el f-conc ept . T he gr eat er the s el f-c onc ept , or jo b sat is fa ct io n, the gr eat er the per for m an ce and the engage m ent in and in ter ac tio n w ith so ci et y and o ther heal th c ar e m em be rs Nur ses need to dev el op the ne ces sar y pr ev ent iv e m ea sur es to count er ac t t he m ul tifa rio us e ffe cts of nur se s ter eot ypi ng Takas e, M aude & M ani as (2006 ) Mix ed M et hod C or re lat ion al d es ign 346 nur ses + 6 in foc us groups PN IS ; T as k P er for m an ce Sc al e Par ed t -te st ; r egr es si on anal ys is To e xam in e how the rel at io ns hi p be tw een nur ses ’ per cei ved publ ic im age and sel f-i m ag e i s a ss oc ia ted w ith t hei r j ob per for m an ce and tur nov er in tent io ns The publ ic tend s to v ie w nur ses as fe m ini ne and c ar in g pr of es si on al s not as le ader s or in dependent pr of es si on al s. T hi s i m age is al so a r es ult o f n ur se s’ inv is ibil ity in th e m ed ia . N ur ses per cei ve a l ac k of under -s tandi ng fr om the publ ic . The rel at io ns hi p bet w een s el f-im

age and per

cep tio n o f t he publ ic im age a s bei ng c ar in g pr edi ct s j ob per for m anc e The nur si ng pr of es si on need s to i m pr ov e i ts publ ic im ag e and i ts s el f-i m ag e t o s ol ve tur nov er pr obl em s and to r es ol ve t he c ur rent nur si ng s hor tage Tzeng (2006 ) Quant itat iv e s tudy Cr os s-se ct ion al d es ign 488 par tic ip an ts (s tudent s, sta ff a nd fa cul ty m em ber s) Nur sing Imag e Qu es tion na ire Des cr ip tiv e and or di na l l ogi st ic regr es si on anal ys is To inv es tig at e t he per cei ved im ages and ex pec ted im ages of T ai w anes e nur ses Nur ses ar e frequent ly por tray ed i n pr im e tim e si tc om s and dr am as as s ubs er vi ent , i ne pt and ins ign ific an t. The p ub lic p er ce pt ion o f n ur sing does not m at ch the per cept io n o f nur se s th em sel ve s. Th e in cor rec t por tray al of nur ses is par tia lly res pon si bl e f or publ ic per cept io ns of nur si ng and f or how nur ses per cei ve and us e pow er . T he publ ic im ag e of nu rs es is a m irr or of nur ses ’ per cept io ns of s el f Nur ses s houl d do m or e t o im pr ov e thei r im age. If they hav e a negat iv e i m age of the m se lv es , t he im age they pr oj ec t t o t he publ ic is equal ly negat iv e Tabel -1 (Continued)

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2

Table 2 - Themes and related studies

Themes identified in the included studies

Related studies

Work environment Arthur et al. 1999, De Araujo Sartorio & Pavone

Zoboli 2010, Fagerberg & Kihlgren 2001, Fagermoen 1997, Gregg & Magillvy 2001, Öhlén & Segesten 1998, Takase et al. 2001

Education & career choice Ben Natan & Becker 2010, Dahlborg-Lyckhage &

Pil-hammer-Anderson 2009, De Araujo Sartorio & Pavone Zoboli 2010, DeMeis et al. 2007, Donelan et al. 2008, Fagerberg & Kihlgren 2001, Gregg & Magilvy 2001, Huffstutler et al. 1998, Kalisch et al. 2007, Liu 2010

Traditional values, culture & gender Dahlborg-Lyckhage & Pilhammer-Anderson 2009, De

Araujo Sartorio & Pavone Zoboli 2010, DeMeis et al. 2007, Huffstutler et al. 1998, Kemmer & Silva 2007, Liu 2010, Öhlén & Segesten 1998, Takase et al. 2001

Caring Arthur et al. 1999, Ben Natan & Becker 2010,

Dahl-borg-Lyckhage & Pilhammer-Anderson 2009, DeMeis

et al. 2007, Donelan et al. 2008, Fagerberg & Kihlgren

2001, Fagermoen 1997, Huffstutler et al. 1998, Liu 2010, Öhlén & Segesten 1998, Takase et al. 2006

Identity & performance Ben Natan & Becker 2010, Donelan et al. 2008,

Huff-stutler et al. 1998, Kalisch et al. 2007, Kemmer & Sil-va 2007, Liu 2010, Takase et al. 2002, Takase et al. 2006, Tzeng 2006

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DISCUSSION

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 an-gels of mercy, the doctor’s handmaiden, battleaxe and sexy nurse (Bridges, 1990; Gor-don & Nelson, 2005; Hallam, 1998). Due to such images, the public views nurses as fe-minine and caring, but not necessarily as autonomous health care providers (Kemmer & Silva, 2007; Takase, Maude & Manias, 2006). Kalisch and Kalisch (1981, 1982a, 1982b, 1982c, 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 twentieth 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, Fealy and Watson (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 ne-vertheless remain persistent.

We have identified several aspects of these stereotypical images in the studies dis-cussed in this paper and, as can be expected from the outcomes of previous studies, the results shows that the actual public image of nursing is diverse and incongruous and tends to be influenced by nursing stereotypes (Öhlén & Segesten, 1998; Takase, Kershaw & Burt, 2002). With respect to male nurses, men were either portrayed as the second sex in nursing care (Dahlborg-Lyckhage & Pilhammar-Anderson, 2009), or as a 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 require-ments of the profession, also has an impact on the view of the public on nursing (Dahl-borg-Lyckhage & Pilhammar-Anderson, 2009; Takase, Kershaw & Burt, 2001). Nurses seem to be viewed as feminine and caring not as autonomous health care providers (Kemmer & Silva, 2007; Takase et al., 2006).

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Moreover, nursing is seen as a profession with limited career opportunities (Ben Natan & Becker, 2010; Huffstutler, Stevenson, Mullins, Hackett & Lambert, 1998). Donelan, Buerhaus, DesRoches, Dittus and Dutwin (2010) 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 United States. The study of Kalisch, Begeny and Neumann (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 beha-viours’ (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 (for example, 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 gene-ral public opinion on nurses (DeMeis, de Almeia Souza & Ferreira da Silva Filho, 2007; Öhlén & Segesten, 1998). 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 (Gregg & Magilvy, 2001; Öhlén & Segesten, 1998; Takase et al., 2002). In turn, nurses’ negative self-concept and presentation influence the public’s opinion (Tzeng, 2006).

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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 professi-onal 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 Magillvy (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 contri-bute to their personal growth and self-concept (Gregg & Magillvy, 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 experi-ences 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 pro-fessional identity through the skills, knowledge and values inherent in their profession. The study of Fagermoen (1997) showed that working as nurses maintains and enhan-ces 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 Magillvy (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 tea-ching and work of nurses.

Although nurses see themselves as well- trained professionals, the public still sees nur-sing 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 obli-vious to the different levels of education and professionalism involved in nursing (Dahl-borg-Lyckhage & Pilhammar-Anderson, 2009; DeMeis et al., 2007; Liu, 2010). The stu-dy 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 & 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 change 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 incom-patible with the characteristics of an ideal career.

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However, these results contrast with the findings of Donelan et al. (2008), who perfor-med a national survey of the public’s opinion of nursing and a national survey of regis-tered nurses in the USA on their own opinion of nursing. They found that the public was more positive about a career in nursing than the nurses themselves. The qualification the public named most frequently with respect to nursing included ’highly knowledgea-ble, qualified, skilled’ ( Donelan et al., 2008). 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. Although, we must keep in mind that these results are biased by the fact that the subjects were Professional Nursing Organi-zations, 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 in respect to gender and professional status. Öhlén and Se-gesten (1998) found that a stereotypical image of nurses is an expression of the traditi-on 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., 2001; 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 gen-der 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 tradi-tional 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 discour-ses in Swedish nursing shows that the image of nurdiscour-ses 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 posi-tion 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’ (De Araujo Sartorio & Pavone Zoboli, 2010; Huffstutler et al., 1998; Takase et al., 2001) 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 nur-ses’ self-concept and professional identity (mentioned in 11 studies). The nursing pro-fession 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

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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 un-dervalued (Öhlén & Segesten, 1998). Nurses are viewed by the public as feminine and caring professionals, but they are not recognized as leaders or independent health care 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. De-spite 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 featu-res, 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 (Dahlborg-Lyckhage & Pilham-mar-Anderson, 2009; Fagerberg & Kihlgren, 2001). 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 over-riding value, on which they base their practice. Positive correla-tions 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 invisi-bility 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 (Donelan et al., 2008; Takase et al., 2006). 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). Ac-cording 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 oppor-tunities 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).

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Implications for nurses

Around the world, nursing baccalaureate, master and doctoral degree programs prepa-re nurses for a variety of nursing roles. Nurses aprepa-re 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 aware-ness, 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 nur-ses 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 commu-nication 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 pa-tient’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 (Ben Natan & Becker, 2010; Kalisch et al., 2007).

RECOMMENDATIONS

We argued in this paper that, to become more visible inside and outside health care 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 en-vironment that offers nurses the possibility 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 repre-sentative 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.

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CONCLUSION

This discussion paper gives an overview of the current state of affairs with regard to pu-blic 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 hetero-geneity 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 pro-fessional identity are determined by many factors, including public image, work environ-ment, 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 health care system. One of the strategies is to promote nursing by giving lectures to spread information on the profession. As edu-cators and role models, they can establish a professional nurse identity. Professional development of nurses could also be realised 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 health care 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.

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