Combatting negative images of nursing: popular images of nurses in the media are largely inaccurate and usually negative. It is imperative these images are replaced with more positive depictions, in order to enhance the profession as a whole.The need to attract people into nursing and to retain them once there, has never been greater. An effective strategy to achieve these aims is to ensure nursing is perceived as a well rewarded, autonomous, self-governing profession, and a distinct scientific discipline. Media depictions that sexualise nursing, or present the profession as a subservient adjunct to medicine, damage and oppress the profession, demeaning the role of the modern nurse.
This article will explore why society portrays the nurse in this way, the reality of the modern professional nurse, and strategies for nurses to change poor media depictions. Personal resilience is an important emergent tool that promotes individual strength in adversity. The widespread modeling of resilience by leaders and managers can empower nurses to modify poor media images. A resilient nursing workforce could result in improved recruitment and retention rates, and greater job satisfaction.
Most media images of nurses do not present nursing as a distinct, autonomous profession. Nursing practice is defined and governed by the Nursing Council and does not depend on physicians or any other group to describe or maintain its existence. The Council administers licensing and examinations, and promolgates an independent code of practice and ethics. (1) There is dearly a significant overlap with medicine, but nursing is not a subset of, or dependent on medicine.
New Zealand nurses are educated by nursing scholars, in three-year degree programmes in universities and technical colleges. The textbooks used are authored by nursing scholars, many of whom are at the cutting edge of health care research. From a total of 43,780 working nurses, 92 have PhDs in nursing and 660 have master's degrees. (2) These nurses are the theoretical and formal leaders of the nursing profession.
Nurses have autonomy in clinical settings. They are hired, and managed by other nurses. In hospitals, where over half of all nurses work, registered nurses (RNs) are governed by other nurses in a chain of command reaching up to the director of nursing. Well known American feminist authors Bernice Buresh and Suzanne Gordon condemn popular media depictions showing nurses reporting to physicians in hospitals. (3) They contend that physicians have no competency in most areas of nursing practice, and nurses have a duty to oppose any care plan that may compromise the patient's best interests.
The same structure exists in nursing homes. In public and community health positions, nurses are effectively autonomous within the scope of their professional duties. Nurses who are employed in physicians' private practices operate autonomously, often running nurse-led clinics. There are now 60 nurse practitioners (NPs) in New Zealand, 36 of whom are authorised to prescribe. This title recognises the higher contributions RNs make in heath. (4)
Historically, the media presents a contrary image of the nurse in practice. American nursing academic Bea Kalisch outlines the five dominant media stereotypes of nursing from the 20th and 21st century. (5) The "Angel of Mercy" was a great improvement over the previous, notorious, Charles Dickens character Sairy Gamp, who epitomised all things unprofessional. The Girl Friday of the 1920s gave way to the Second World War image of a heroine of the battlefield. The postwar years bring a wife/mother image.
This is the point, argues Kalisch, where nursing imagery begins to include the nurse as a sex object, due to the willingness of major television networks to sexualise nursing images, and the use of the nursing image in pornography. American NP Susan Roberts' work on oppressed groups lists the problems that occur from the media's devaluation of the nursing role. (6) She contends that nurses firstly need to accept that oppression exists within nursing, and secondly, that nurses have become devalued by the wider society. Roberts calls for nurse leaders to reject the notion of this devaluation and promote the proper cultural heritage of nursing.
The significance of the media in shaping our culture should not be underestimated. It not only reflects our needs, it invents them, even if we did not want them. It influences the way we feel about the world. Whether nurses like it or not, modern media, and especially popular television drama, has shaped society's perception of nursing. Gordon argues that the fictional media portrayal of nurses diminishes nursing's professionalism. (7) It highlights the importance of the physician and the secondary role of the nurse. Globally ER, and locally Shortland Street, are the leading hospital dramas of the last decade. They also predominantly present nurses as handmaidens to physicians. More galling is the depiction of physicians providing most of the significant care (even nursing care). Gordon extends her displeasure to the film industry and Hollywood. Nurse characters include Nurse Ratched of One Flew over the Cuckoos Nest, and the kind but intellectually challenged image of Nurse Betty. The trend is for the sexy, sadist, or brainless, perhaps a combination of the three. Gordon takes issue with the movie living Out loud, where nurses do achieve, but only by becoming a doctor. There is anger with the media and its ignorance of the nurses' role in health research. An exception Gordon referred to on her recent visit to New Zealand is Nurse Jackie, as depicted in the TV series of the same name and now playing in New Zealand. Nurse Jackie is portrayed as a very competent nurse, but flawed human being.
It is imperative nurses improve their image in the wider community. Kalisch contends that nurses have been uncomfortable with image promotion. (5) It's been considered improper to speak up about nursing. The challenge for modern nursing is to reshape the image of the nurse, the careerist. "Knowledgeable expert" needs to replace the current media image. Kalisch suggests multiple goals and strategies including ridding nursing of modesty and replacing it with self belief. Nurses must improve their leadership and media management skills, she says, specifically in the monitoring of, and reacting to misleading or false media images. Teaching nurses media management skills will assist them to write news releases; select photos; generate news stories. This process should begin at the undergraduate level. Christchurch nurse researcher Sandy Richardson maintains that many positive nursing stories go untold. (8) It is important to be proactive and have confidence in your own ability to record or tell your story. Richardson urges nurses to actively influence media images by building strong media relations, including commendation or protest, and letters to the editor. These are leadership skills that need to be introduced to the undergraduate and honed throughout a nurse's career. Nurse leaders can step up to the challenge to become the concerned health expert on nursing subjects, such as prevention and managing chronic illness. It is this positive image that will inspire the new graduate to stay in nursing.
Importance of leadership
Effective leaders use referent, expert and information power to get things done. (9) Leadership power has been defined as a capacity to act and create order from chaos, conflict or contradictions. (10) If proactive leadership influence is sustained, followers (such as the media) trust and respect the source of information. It has been contended that power emerges in every exchange, and effective leaders need to develop powerful partnerships with people outside nursing. (9) Get on chat shows or modern web-based sites such as BeBo. Write fiction and books for children or visit schools; My Daddy is a Nurse is one interesting example. (11) Check the public library shelves for outdated depictions of nurses. Nursing leaders need to show the way, but if each of us does one thing, together we can make a difference.
Quality control management has an important role in promoting nursing as a desirable profession. The American Nurses Association acknowledges that total quality control can effect work satisfaction of staff in acute care areas. (12) The four areas of focus for total quality control are: customer focus, total organisational involvement, the use of quality tools and statistics, and identifying key processes for improvements. (13) This management tool can take the role of gathering and responding to negative media images of nursing from an organisational perspective.
The concept of resilience is an important emergent personal and organisational management tool, which nurses can use to combat negativity and a perceived lack of status. Resilience is particularly important for nurses when they are dealing with stressful life events. (14) It is a normal part of a nurse's working life to witness tragedy, suffering and distress. Resilience is a process of positive adaptation in the face of significant adversity. (15) Resilience enables the individual to adjust and manage adversity, while maintaining control over their environment. Building personal resilience is a way to combat the stressors associated with nursing. (16) Key components in developing resilience include optimism, autonomy, empowerment, self care, and emotional awareness.
Resilience is a management skill that can be learned, and the key attribute to develop is hardiness. (17) This is achieved by a commitment to finding meaningful purpose in life, believing you can change your environment and manipulate events. Learning and growth can come from adversity and successes. Resilience is an important personal resource, and positive emotions are a factor in adapting to adversity. (18) Specific self development programmes to build resilience should be adopted by every nursing organisation. Such programmes would be of value in retaining nurses and easing the stress of transitional practice for the new graduate. A self development programme that has been promulgated includes building positive, nurturing professional relationships and networks, maintaining a positive attitude, developing personal insight, having a life balance that includes spirituality, and using reflective practice. (19)
Social support has been identified as a significant component in resilience, and the self management of stress. Two commentators encourage positive professional relationships for managing stress. (20) This professional support network becomes a system that can combat negativity. We each need a network of people who can be called on for guidance and support when needed. It is especially important to develop networks with people outside our immediate work area. These colleagues can take on the role of sounding board, especially when tensions are running high in the workplace. Professional networks should include relationships that are nurturing. Ideally, all collegial relationships would have some degree of nurturing but this is often not the case. (21) Nursing has historically been controlled by predominantly patriarchal forces that have more prestige and power. These forces have acted to oppress nurses. It may be going too far to compare the oppression of nurses with the abject destitution of Brazilian coffee workers, but behaviour patterns such as horizontal violence can arise from any type of oppression. (22)
Effective management has a role in identifying stress and stressors in the workplace, and providing mentoring relationships. Facilitating such relationships can provide nurses with the opportunity to develop resilience. The benefits of guidance and support from colleagues, and the need to nurture traits of resiliency in the self, students and co-workers, have been noted. (23)
By definition, adversity is not a positive phenomenon. However, adversity and hardship often do have some positive aspects. Resilient people are able to draw on some form of positive emotion, even in the midst of stress and hardship. (20) Optimism and the capacity to see the range of future possibilities that events carry with them are aspects of maintaining a positive outlook. (16) Resilient people are able to see the positive aspects and potential benefits of a situation, rather than being continually negative or cynical. Positive emotions and laughter are associated with beneficial physical and emotional outcomes. Positive emotions and laughter can lessen levels of adversity-related stress. (20)
Understanding emotional needs
Emotional intelligence (EI) is an important attribute of managers and leaders, and integral to resilience. EI is the ability to understand your own emotional needs, and have insight into the emotional needs of others in the workplace. (20,21) Understanding your own emotional needs and reactions gives insights into how to cope with stress and adversity, and can help develop ideas for different ways of coping in the future. (16,24) Developing insight into negative and positive emotions could be a beginning step in strengthening personal resilience. Journaling and self-reflection have been suggested as strategies for enhancing emotional insight. (24,23)
Adult learning theory identifies the importance of reflection to learning and resilience. (25,26) Reflection is a way of developing insights and understandings into experiences, and of developing knowledge that can be used in subsequent situations. In reflection, personal experience is used for thinking and learning. Journal writing can be a useful reflective strategy, (24) which I find particularly helpful in developing my own resilience. Writing about an experience gives meaning to events, (27) as better understanding and insights can be gained through the act of writing. This will be particularly significant to the new graduate nurse, and should be encouraged by all managers and leaders. It is my experience that if I am consistently negative about a person, place or thing I will benefit from writing a reflection. This act shows me ways of adopting more positive responses to particular situations, people and events. I am forced to look at the entire situation and find solutions.
Finally, personal resilience cannot be achieved without feeling connected to life, and having a balance of work and leisure. (26) The importance of some form of belief system that provides existential meaning to life has been acknowledged. Regardless of spiritual beliefs, it is important to participate in a range of healthy activities outside your professional life. (14) These activities should ideally include those that are physically, emotionally and spiritually nurturing. Maintaining life balance is important when occupied in a very demanding career such as nursing.
All too frequently, the media contributes to a negative depiction of the modern nurse, the flow-on effect of which is the subsequent oppression of nurses arising from this depiction. The inaccuracies that television dramas ascribe to nurses' work and relationships with other clinicians are pervasive and unparalleled. New graduate nurses do not want to be the type of nurse depicted in these popular television dramas, which are beamed into almost every person's home almost every night. Strong, adept nursing leadership and management will set a positive example to the new graduate, and show how to reject the nursing stereotype perpetrated by the media. Work is needed to refocus leadership and management to improve the image and public voice of the nurse.
Nursing is a profession of consequence to society and should not be demeaned or trivialised without being challenged. The development of resilience as an effective trait will benefit nurses. When leaders and managers model resilience, they allow graduate nurses to build their confidence, become secure in their professional status, and combat the negative images of nursing in the media. Let there be an end to RNs "suffering in silence", and may the roar of approbation when the profession is demeaned in any way take its place.
(1) NZNO. (2001) New Zealand Nurses Organisation Code of Ethics. Wellington: Author.
(2) Nursing Council of New Zealand. (2009) Personal correspondence with corporate facilitator Nicole Hay.
(3) Buresh, B.& Gordon, S. (2006) From silence to voice. What nurses know and must communicate to the public. (2nd ed) Cornell University Press. New York.
(4) District Health Boards New Zealand. (2009) Nurse practitioner facilitation programme, www.dhbnz.org.nz/Site/Future_Workforce/ Nursing-Midwifery/Nursing-Projects/Nurse-Practitioner/Default.aspx. Retrieved 14/10/09.
(5) Kalasch, B. (2000) The image of nursing: Evolution and revolution, www.nursing.umlch.edu/stti/news/Kalisch.html. Retrieved 20/03/2008.
(6) Roberts, S.J. (1983) Oppressed group behaviour: implications for nursing. Advances in Nursing Sciences; 5: 4, 21-30.
(7) Gordon, S. (2004) Nursing against the odds. How health core cost cutting, media stereotypes and medical hubris undermine nursing and patient care. New York. Cornell University Press.
(8) Richardson, S. (2008) It's all about making a difference. Kai Tiaki Nursing New Zealand; 14: 1, 15-16.
(9) Sullivan, E.J. & Decker, P.J. (2000) Effective leadership and management in Nursing (5th ed). New Jersey: Prentice Hall.
(10) Covey, S. (1990) Principal-centered leadership. New York: Simon and Schuster.
(11) Wandrow, M., Blank, J. & Trivas, I. (1981) My Daddy is a Nurse. Harper Collins: London.
(12) American Nurses Association (1999) Nursing sensitive quality indicators for acute care settings and safety and quality initiative. Washington: Author.
(13) Koch, M. W. & Fairly, T.M. (1993) Intergrated quality management. The key to improving nursing care quality. St Louis: Mosby.
(14) Tusaie K. & Dyer J. (2004) Resilience: a historical review of the construct. Hallslit Nursing Practice; 18: 3-10.
(15) Rutter, M. (1999) Resilience concepts and findings: implications for family therapy. Journal of Family Therapy; 21: 95-102.
(16) Bright, J. (1997) Turning the tide. London. Demos Publishers.
(17) Bonanno, G. (2004) Lass, trauma and human resilience: have we underestimated the human capacity to thrive after extremely adverse events? American Psychologist; 59: 20-28.
(18) Fredrickson, B. (2004) The broaden-and-build theory of positive emotions. Philosophical Transactions of the Royal Society London Biological Sciences; 359-1377.
(19) Jackson, D. Firtko, A. & Edenborough, M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review, Journal of Advanced Nursing; 60: 1, 1-9.
(20) Tugade M. & Fredrickson B. (2004) Resilient individuals use emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology; 86: 320-333.
(21) Daly J., Speedy S. & Jackson D. (2004) Nursing leadership. Elsevier: Australia.
(22) Freire, P. (1971) The pedagogy of the oppressed. New York. Herder & Herder.
(23) McGee E. (2000) The healing circle: resiliency in nurses. Issues in Mental Health Nursing; 27: 43-57.
(24) Giordano B. (1997) Resilience: a survival tool for the nineties. Association of Perioperative Registered Nurses Journal; 05: 1032-1036.
(25) Larson D. & Brady E. (2001) Learning stories of our own. Adult Learning; 11: 13-15.
(26) Wilson A. & Kiely R. (2002) Towards o Critical Theory of Adult Learning/Education: Transformational Theory and Beyond. Annual Meeting of the Adult Education Research Conference, Raliegh, NC.
(27) Jackson D. (2000) Understanding Women's Health Through Australian Women's Writings: A Feminist Exploration, Unpublished Doctoral Thesis. Flinders University of South Australia, Australia.
George McNally, RN, BN, was in his final semester of his BN at Northtec when he wrote this article last year. He now works as a bureau nurse at Whangarei Hospital.