1. Nursing Image in the 21st Century
Randy E. Gross MS, RN, NP, CNS
WHNP-BC, ACNS-BC, AOCNP®, AOCNS®
Nurse Practitioner & Clinical Nurse Specialist
Gynecologic Medical Oncology Service
Memorial Sloan Kettering Cancer Center
New York, New York
Candidate – PhD in Nursing Science Program
CUNY Graduate Center

2. Objectives: Describe the history of nursing’s image
Present the contributing factors to nursing image
Discuss the relevant research on nursing image
List evidence-based approaches to improve nursing image
Move towards discussion on nursing image in 21st century
Objectives:

3. Recognize this image?

4. Bravery, resourcefulness, and esprit de corps
Military nurses paralleled and equaled film depictions of soldiers in combat
This was the largest, strongest, and most positive depiction of nursing in the 20th century
(Kalisch, 1981)
So Proudly, We Hail (1943)

5. A Brief History of Nursing
In distant past, nursing care was free and provided by nuns and/or priests or by families in the home
In the 19th century, nursing image had devolved to the Dickensian version of nurses as “camp followers” & hospitals were places people only went to die
Then Florence Nightingale stepped in…
Diploma programs evolved  the definition of professional nursing
Slaves, servants, or saints?
(Kalisch & Kalisch, 1975)
Or were nurses the heroines depicted in novels of the 1950s-1970s?
A Brief History of Nursing

6. Mid 20th Century Nursing Image

7. Mid 20th Century Nursing Image

8. Mid 20th Century Nursing Image
“It was as close to a harem as an American male can get- and get he did!”
Mid 20th Century Nursing Image

9. Nursing Image at End of the 20th century
1970s & 1980s: changes in nursing as profession
Diploma  college educated
Defined knowledge base and language
Nursing theories
Code of Ethics
Primary nursing  model of care delivery
Shedding of the cap
1990s: decade of cost-containment
Healthcare moved to ambulatory & community
Nursing was largest & most costly department
Dismantling of nursing power  “code green”
(Weinberg, 2003)
Nursing Image at End of the 20th century

10. Nursing Image as a Concept
Invisibility versus
Stereotypes
Nursing’s history
Attire/uniforms
Nurses’ self image & self-concept
Gender issues
Public’s exposure
versus
non-exposure
Media Imagery
Identification with professionalism
Nursing Image as a Concept
(Adapted from: Rezai-Adaryani, Salsali & Mohammadi, 2012)

11. Invisibility versus Stereotypes
Rooted in history as nuns caring for the sick Say Little Do Much
Absence of or a lack of recognition of nursing contributions or presence
Couching the description of nursing work in charitable, devotional, or altruistic terms
Continued downplaying of nursing knowledge & skill with emphasis on virtue and ethics
(Boyle, 2010; Buresh & Gordon, 2013; Hannah & Kennedy, 2011; Nelson, 2011)
Stereotypes
Beliefs, usually oversimplified or generalized ideas, associated with members of a given group and are simple solutions to complex social relationships
Activated or available in conscious or unconscious memory
Stereotyping is both a social cognitive and a neurobiological process
In nursing, not a new phenomena 15th & 16th women healers…
(Bean et al 2013; Ehrenreich & English, 2010; Fagin, 2015; Fiske, 1998; McDonald, 1990; Quadflieg et al, 2011)
Invisibility versus Stereotypes

12. Assistant Professor of Illustration, Kent State University
Female Nurse Stereotypes
Nurse Stereotypes
(Darbyshire & Gordon, 2005; Jinks & Bradley, 2004; Muff, 1982; Summers & Summers, 2014)
Commissioned images from: Christopher Darling MA
Assistant Professor of Illustration, Kent State University

13. Assistant Professor of Illustration, Kent State University
Male Nurse Stereotypes
Nurse Stereotypes
(Burton & Misener, 2007)
Commissioned images from: Christopher Darling MA
Assistant Professor of Illustration, Kent State University

14. Exposure versus Non-exposure to Nursing
89.2% (452) of non-nursing college students were not interested in the nursing profession, and in 75.9% (388) of them information regarding nursing was incorrect
(Dante, Rizzi, Ianderca & Palese, 2012)
71.7% (503) of high school students would never consider nursing as a career choice.
(Nelson & Jones, 2012)
Exposure
Major reasons for choosing a career in nursing included:
selecting a “caring” career
prior work experiences
friend & family influences
observing nurses in action
(Beck, 2000; Mooney, Glacken & O’Brien, 2008; McLauglin, Moutray & Moore, 2010)
A paradox exists where nurses describe themselves as angels or sweet, kind people thus ensuring public to trust them which makes nurses feel good thus reinforcing the stereotypical description/behaviors virtue script.
(Nelson, 2011)
Exposure versus Non-exposure to Nursing

15. Media Imagery  films, books, TV, advertisements, cards, pornography, internet
A five year review of UK press looking for sexual stereotyping of professions:
The ‘naughty nurse’ far outweighed any other profession (medicine, law, pharmacy, nutrition, social work, or police).
The only other profession that came close to ‘naughty’, ‘sexy’, ‘saucy’, or ‘kinky’ identification was British actresses in tabloid media.
National press was far more likely to use sexual stereotypes to describe nurses.
Local press was more focused on caring, trustworthiness, duty, and accomplishments of nursing.
(Ferns & Chojnacka, 2005)
A content analysis comparison study of 144 websites between 2001 & 2004 demonstrated:
70% of sites showed nurses as intelligent and educated in 2001 but decreased to 62% in 2004
The images of the nurse as research-oriented, competent, powerful, creative & innovative, and sexually promiscuous increased from 2001 to 2004
(Kalisch, Begeny & Neumann, 2007)
A descriptive study exploring the inclusion of oncology nursing in NCI-designated comprehensive cancer centers websites:
2 of 40 CCC revealed broad representation (met all 4 categories) of oncology nursing
63% had no or minimal mention of oncology nursing on their websites
(Boyle, 2010)
A critical discourse analysis content study was conducted on 10 You Tube videos examining the construction of nurse identity and image revealing 3 distinct types: 1) the skilled doer and knower, 2) the sexual plaything, and 3) witless incompetent
(Kelly, Fealy & Watson, 2011)
A qualitative study explored images of men in nursing on television:
Five American TV programs from 2007 to 2010 were explored for content: Grey’s Anatomy, Hawthorne, Mercy, Nurse Jackie, & Private Practice
Portrayals consisted of explicit and implicit stereotypes regarding career choice, masculinity, & sexuality.
Men who were nurses were reduced to background prop, spokesperson for the minority, or comedic foil.
These programs exposed stereotypes while simultaneously implicitly reinforcing them.
(Weaver, Ferguson, Wilbourn & Salamonson, 2013)
Boyle inclusion criteria: 1) recognition, 2) citations, descriptions, recognition of contributions, 3) dedicated web page, 4) acknowledge of CNO
Media Imagery

16. Gender Issues & Nursing
Nursing has repeatedly been perceived and cited as “womans’ work”
(Seago, Spetz, Alvarado, Keane & Grumbach, 2006; Summers & Summers, 2014)
A qualitative study of 16 Canadian nurses who were men described:
Job dissatisfaction was related to work stress, lack of full time opportunities, and gender based stereotypes.
All 16 men disliked the term “male nurse”.
Recruitment strategies should begin at an earlier age to ameliorate persistent stereotypes.
All the men noted that providing care and being able to make a difference outweighed the negatives and fueled their desire to stay in the nursing profession.
(Rajacich, Kane, D., Williston & Cameron, 2013)
Gender was seen as a predictive factor in completion of nursing education in sample of 384 UK students:
males more likely to withdraw
stereotypes & gendering of profession were highly correlated as factors
females also disliked gendered nurse stereotypes.
(McLauglin, Muldoon & Moutray, 2010)
Nursing image in students qualitative interviews with 10 male and 10 female Turkish baccalaureate students:
males saw nursing as more gendered than female students
(Karabacak, Usluosy, Alpar & Bahcecik, 2012)
Gender Issues & Nursing

17. Somewhere in Memorial Hospital….
Theme #1- Being a nurse
Families led the path to nursing
Gaining and demonstrating knowledge
Stressful, but rewarding
Teamwork and support to do the job
Theme #2- Male and female perspectives of working together
A calm, cohesive milieu
Males: negotiating intimate care & lifting help
Theme #3- Stereotypes in nursing
The stereotypes of angel & handmaiden persisted in the minds of the nurses and patients, as did the gender stereotyping of nursing
Social media and television still have an impact on nurse image and stereotyping
Somewhere in Memorial Hospital….

18. Nurse Clothing & Uniforms
A modern version of a traditional nurse’s uniform is acceptable to most patients and this was a lower priority than the provision of help, information, and advice.
(Rowland, 1993)
The older the age of the patient, the greater preference for the nurse uniform to be white; however, uniform preference was not related to perception of nurse image or professionalism.
(Albert, Wocial, Meyer et al, 2008)
Nursing uniforms should be perceived by patients as professional and approachable; however, different preferences existed among generations: seniors, baby-boomers, gen X, and millenials.
(Skorupski & Rea, 2006)
Patients’ preferences for nurse uniforms included: 1) clean, 2) fit appropriately, and 3) some sense of personal style. Patients overall high ratings for nurse image and professionalism were not associated with uniform choice.
(Clavelle, Goodwin & Tivis, 2013)
Cartoon images on uniforms are perceived as unprofessional, except for nurses working in pediatrics.
(Buresh & Gordon, 2013; Darbyshire & Gordon, 2005; Summers & Summers, 2014)
Nurse Clothing & Uniforms

19. Nurse Clothing & Uniforms

20. Nurse Self-Image & Collective Professional Identity
(except 2001) Gallup Poll saw nurses as #1 most trusted healthcare professional
(Gallup.com, 2015)
Public image of nursing is intertwined with nurse’s own professional image, which creates boundaries that confine & construct the image of nursing. As a profession, nurses don’t have a positive image of themselves.
(Fletcher, 2007)
Nurses’ expectations and perceptions of nursing as inferior and/or subordinate are shaped by stereotypical and hierarchal images existent in cultural representations of nursing and medicine.
(Price & McGillis Hall, 2013)
Nursing image is diverse & incongruous, partly self-created by nurses due to invisibility and lack of public discourse. Nurse self image is derived from their public image, work environment & values, education, and social & cultural values.
(ten Hoeve, Jansen & Roodbol, 2013)
Nursing image in nurses qualitative interviews with 13 practicing nurses (new to 21 years of experience)
newer were more enthusiastic & had more positive attitude
experienced were more negative due to work environment and work interactions.
(Emeghebo, 2013)
Nurse Self-Image & Collective Professional Identity

21. Nursing Image as a Concept
Invisibility versus
Stereotypes
Nursing’s history
Attire/uniforms
Nurses’ self image & self-concept
Gender issues
Public’s exposure
versus
non-exposure
Media Imagery
Identification with professionalism
Nursing Image as a Concept
(Adapted from: Rezai-Adaryani, Salsali & Mohammadi, 2012)

22. (Adapted from: Rezai-Adaryani, Salsali & Mohammadi, 2012)
Resource allocation departmental & institutional budgets to federal allocations
Pay & compensation
Staffing, recruitment, retention, and workforce shortage
Interdisciplinary relationships
Nurse workload & performance  safety, quality, missed care, failure to rescue
Incivility, bullying, workplace violence  lateral and/or horizontal
Job dissatisfaction
Moral distress, moral injury, and burnout
Public trust
Consequences
(Adapted from: Rezai-Adaryani, Salsali & Mohammadi, 2012)

23. 21st Century Representations of Nursing Image
Holmes, V.C. (2012). An analysis of Richard Prince's “Lake Resort Nurse”: using an image to expose and critically reflect on stereotypes in nursing. Journal of Professional Nursing, 28(6),

24. Improving Nursing Image
Abandon the virtue script of nursing
Eschew the child-like & unprofessional descriptions of nursing and such associations to nursing
Emphasize the critical importance of the evidence supporting the importance of nursing care to saving lives
Challenge the invisibility of nursing in healthcare’s fabric
Emphasize the intellectual and scientific challenges inherent in a career in nursing, but don’t forget the warmth and compassion necessary to be a nurse
Be aware of the the image of nursing projected individually AND collectively and take responsibility to communicate a professional and knowledgeable description of being a nurse and nursing
Improving Nursing Image

25. Improving Nursing Image
Answering the phone: “Memorial 23, this is Nurse Randy Gross.”
Patient: “I like Mary Sue, she is such a nice nurse.” Nurse Leader: “Thank you for the compliment. Mary Sue is indeed an excellent nurse, both warm & competent, but like all our nurses she is also a healthcare professional with a bachelor’s degree in nursing.”
Attending MD: “I would like to introduce our new fellow, Dr. John Smith.” Nurse Leader: “And I would like to introduce some of our nurses- Charge Nurse Sarah Jones, Nurse Frank Washington, Nurse Mary Sue Black, and Nurse Jack James.” Fellow: “Please call me John.” Nurses: “You can call me Sarah.” “and you can call me Frank.” “I’m Mary Sue.” “Jack.”
Nurse introducing self to patient on first visit to institution: “Good morning, I am Nurse Glenda Valdez, and I am the nurse who works with Dr. Smith’s patients.”
Patient: “Dear, you are such a lovely nurse, where did you train?” Nurse: “I have a Bachelor’s Degree from Hunter College, a Masters Degree from NYU, and I am working on my Doctor of Nursing Practice degree at Stonybrook University.”
Challenge #1…develop your own introduction as to how you introduce yourself to patients in your practice arena. Practice it over and over again, until it is rote in your mind.
Improving Nursing Image

26. Improving Nursing Image

27. Improving Nursing’s Image
1) Every nurse present’s him or herself with a full name and title
2) Every nurse has a business card for presentation on first introduction
3) Nursing education curriculum have a thread of professional presentation from #1 & #2 throughout educational process
4) Nursing education departments develop and provide professional presentation workshops as part of mandatory training
5) Individual nurses highlight their accomplishments and be proud to promote themselves
Colloquially and professionally
Appropriate use of social media
6) Nursing departments of every healthcare institution partner with media relations departments in hospitals
Improving Nursing’s Image

28. Improving Nursing’s Image
Display your full name with credentials and title
Highest degree earned
Licensures
Professional certifications
State or federal certifications
For example…
Sarah Forbes BSN, RN, OCN®
Clinical Nurse IV, GI Chemotherapy
Happy Healthy Hospital, Springfield MA
John Williams PhD, MBA, RN, FNP-BC
Nurse Leader & Nurse Practitioner, Ambulatory Services
Care for All Community Clinic, Mobile AL
Mary Major DNP, RN, CNS, AOCNS®
Clinical Nurse Specialist, Medical Oncology Division
Cure for Cancer Center, San Francisco CA
Improving Nursing’s Image

29. Remember the Evidence Exists…

30. Remember the Evidence Exists…
In hospitals with high patient-to-nurse ratios, surgical patients experience higher 30 day mortality & failure to rescue rates with higher nurse job dissatisfaction and job burnout.
Aiken, Clarke, Sloane, et al (2002) JAMA
In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, patients experienced lower mortality and failure to rescue rates.
Aiken, Clarke, Cheung et al (2003) JAMA
Higher nurse staffing protected patients from poor outcomes: mortality from CHF, failure to rescue, infections, mortality from sepsis, decubitis ulcer, and prolonged length of stay.
Blegan, Goode, Spetz et al (2011) Medical Care
Patients in hospitals with better critical care environments & higher proportions of critical care nurses with baccalaureate degrees experienced significantly lower odds of death in the ICUs.
Kelly, Kutney-Lee, McHugh et al (2014) Critical Care Medicine
Although the positive effect of increasing percentages of BSN degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.
Aiken, Cimotti, Sloane et al, (2012) Journal of Nursing Administration
Remember the Evidence Exists…

31. A Very Good Example…

32. Develop your own 45 second elevator speech that describes you as a professional nurse-one with a career that requires intellect, compassion, and education.
Practice it over and over again, until it is rote in your mind.
Challenge #2

33. Evidence-based Imagery: Be A Nurse

34. Recommended Readings (Buresh & Gordon 2013, 3rd Edition)
(Summers & Summers 2014, 2nd Edition)
Recommended Readings

35. On the Internet….

36. December 2015
In the media….

37. 21st Century Thought on Nursing Image
“Nursing is still not widely understood as a profession of life-saving, college-educated health professionals.” (2015)
Claire Fagin PhD, RN, FAAN
Dean Emerita, University of Pennsylvania School of Nursing
Interim President, University Of Pennsylvania
21st Century Thought on Nursing Image

38. Directions for Future Research
What are considered positive perceptions of nursing image in US are needed.
How do we best counter negative perceptions of nursing’s image?
Perceptions of nursing image in students of all ages needs further investigation.
school age
middle school
high school
college
Further investigation is needed on the impact of nursing’s image on:
career choice & recruitment
job satisfaction & retention
Specific studies exploring patient perceptions of nursing image are needed.
The link between nursing image and patient outcomes needs exploration.
Directions for Future Research

39. 21st Century Thought on Nursing Image
Challenge #1…develop your own introduction as to how you introduce yourself to patients in your practice arena.
Practice it over and over again, until it is rote in your mind.
Challenge #2 …develop your own 45 second elevator speech that describes you as a professional nurse- one with a career that requires intellect, compassion, and education.
21st Century Thought on Nursing Image

40. Albert, N. M. , Wocial, L. , Meyer, K. H. , Na, J. & Trochelman, K
Albert, N.M., Wocial, L., Meyer, K.H., Na, J. & Trochelman, K. (2008). Impact of nurses’ uniforms on patient and family perceptions of nurse professionalism. Applied Nursing Research, 21,
Bean, M.G., Stone, J., Moskowitz, G.B., Badger, T.A. & Focella, E.S. (2013). Evidence of nonconcious stereotyping of Hispanic patients by nursing and medical students. Nursing Research, 62(5),
Beck, C.T. (2000). The experience of choosing nursing as a career. Journal of Nursing Education, 39(7),
Buresh, B. & Gordon, S. (2013). From silence to voice: what nurses know and must communicate to the public. (3rd Ed.), Ithaca, New York: Cornell University Press
Boyle, D. (2010). The invisibility of nursing: implications from an analysis of NCI-designated comprehensive cancer web sites. Oncology Nursing Forum, 37(2), E75-E83.
Burton, D.A. & Misener, T.A. (2007). Are you man enough to be a nurse? Challenging male nurse media portrayals and stereotypes. In C. O’Lynn & R. Tranberger (Eds.) Men in Nursing: History, Challenges, and Opportunities (pp ). New York: Springer Publishing
Clavelle, J., Goodwin, M. & Tivis, L.J. (2013). Nursing professional attire: probing patient preferences to inform implementation. Journal of Nursing Administration, 43(3),
Dante, A., Rizzi, L., Ianderca, B. & Palese, A. (2012). Why do university student not choose a nursing degree at matriculation? An Italian cross-sectional study. International Nursing Review, 60,
Darbyshire, P. & Gordon, S. (2005). Exploring popular images and representations of nurses and nursing. In J. Daly, S. Speedy, D. Jackson, V. Lambert & C. Lambert (Eds). Professional Nursing: Concepts, Issues & Challenges. New York: Springer Publishing.
Ehrenreich, B. & English, D. (2010). Witches, midwives, and nurses: a history of women healers. (2nd Edition). New York: The Feminist Press.
Emeghebo, L. (2013). The image of nursing as perceived by nurses. Nurse Education Today, 32,
Fagin, C. (2015). Celebrate nurses day by strengthening the profession [A short message from ANA Hall of Fame Inductee Claire M. Fagin]. Retrieved from:
Ferns, T. & Chojnacka, I. (2005). Angels and swingers, matrons and sinners: nursing stereotypes. British Journal of Nursing, 14,
Fletcher, K. (2007). Image: changing how women nurses think about themselves. Literature review. Journal of Advanced Nursing, 58(3),
Fiske, S. (1998). Stereotyping, predjudice, and discrimination. In G. Lindzey, D. Gilbert, & S. Fiske (Eds.) The handbook of social psychology. New York: McGraw-Hill
Hannah, K.J. & Kennedy, M.A.J. (2011). Chap. 22: Invisibility to visibility: capturing essential nursing information. In Ball et al (Eds.) Nursing Informatics: Where Technology & Caring Meet (4th Ed.), New York: Springer Publishing, pp
Jinks, A.M. & Bradley, E. (2004). Angel, handmaiden, battleaxe, or whore? A study which examines changes in newly recruited student nurses’ attitudes to gender and nursing stereotypes. Nurse Education Today, 24,
Karabacak, U., Usluosy, E., Alpar, S.E. & Bahcecik, N. (2012). Image of nursing held by nursing students according to gender: a qualitative study. International Journal of Nursing Practice, 18,
McDonald, D.D. (1990). Implicit gender stereotyping by nurses. Unpublished doctoral dissertation. UMI PUZ
McLaughlin, K., Moutray, M. & Moore, C. (2010). Career motivation in nursing students and the perceived influence of significant others. Journal of Advanced Nursing, 66(2),
Mooney, M., Glacken, M. & O’Brien, F. (2008). Choosing nursing as a career: a qualitative study. Nurse Education Today, 28(2),
Nelson, G.R. & Jones, M.C. (2012). What predicts the selection of nursing as a career choice in 5th & 6th year school students? Nurse Education Today, 32,
Nelson, S. (2001). Say little do much: nursing, nuns, and hospitals in the nineteenth century. Philadelphia: University of Pennsylvania Press
Nelson, S. (2011). The image of nurses: the historical origins of invisibility in nursing. Texto Contexto Enferm, 20(2),
Price, S.L. & McGillis Hall, L. (2013). The history of nurse imagery and the implications for recruitment: a discussion paper. Journal of Advanced Nursing, DOI: /jan.12289
Rajacich, D., Kane, D., Williston, C. & Cameron, S. (2013). If they call you a nurse, it is always “male nurse”: experiences of men in the nursing profession. Nursing Forum, 48(1),
Rezai-Adaryani, M., Salsali, M. & Mohammadi, E. (2012). Nursing image: an evolutionary concept analysis. Contemporary Nurse, 43(1),
Seago, J.A., Spetz, J., Alvarado, A., Keane, D. & Grumbach, K. (2006). The nursing shortage: is it really about image? Journal of Healthcare Management, 51(2),
Skorupski, V.J. & Rea, R.E. (2006). Patients’ perceptions of today’s nursing attire: exploring dual images. Journal of Nursing Administration, 36(9),
Summers, S. & Summers, H.J. (2014). Saving lives: why the media’s portrayal of nurses puts us all at risk. 2nd Edition. New York: Kaplan Publishing
ten Hoeve, Y., Jansen, G. & Roodbol, P. (2013). The nursing profession: public image, self-concept and professional identity. A discussion paper. Journal of Advanced Nursing, DOI: /jan
Weaver, R., Ferguson, C., Wilbourn, M. & Salamonson, Y. (2013). Men in nursing on television: exposing and reinforcing stereotypes. Journal of Advanced Nursing, DOI: 10:1111/jan.12244
Weinberg, D.B. (2003). Code green: money driven hospitals and the dismantling of nursing. New York: Cornell University press.
REFERENCES

41. “Were there none who were discontented with what they have, the world would never reach anything better.”
Florence Nightingale
Final thought…

42. Thoughts on 21st Century Nursing Image
Nursing’s image is neither about the individual nurse or the profession as a whole…
Thoughts on 21st Century Nursing Image