Nurse Education Today 32 (2012) e49–e53
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Nurse Education Today journal homepage: www.elsevier.com/nedt
The image of nursing as perceived by nurses Lorraine Emeghebo ⁎ Molloy College, Nursing Division, 1000 Hempstead Ave., Rockville Center, NY 11571, United States
a r t i c l e
i n f o
Article history: Accepted 18 October 2011 Keywords: Professional image Perceptions Senior nurses New nurses Student nurses
s u m m a r y Purpose: To explore the image of nursing as perceived by nurses. Background: Nurses' image has always been a concern among those in the profession. The decision to enter nursing, to remain in nursing, to promote nursing, and to further a career in nursing may be the result of nurses' perception of the image of the profession. No recent studies have been done on how nurses perceive the profession Methods: A purposeful sample of 13 participants ranging in experience from senior student nurses to Registered Nurses with over 21 years of experience in direct patient care, participated in in-depth interviews. For this descriptive exploratory design, qualitative data were collected and analyzed. Findings: Three broad categories that were signiﬁcant in how nurses perceive the profession emerged: a) role of nurses, b) nursing knowledge, and c) attitude of nurses. Those about to enter the profession have a positive image of nursing based on their roles and their nursing knowledge. Attitude of nurses signiﬁcantly inﬂuenced participants' perceptions of nursing's professional image. As they progress through their career, nurses have negative perceptions of the profession, inﬂuenced by working environment and interactions with others in the health care arena. Conclusion: Overall, nurses working in hospitals have negative perceptions of the profession; nurses working in maternal–child health have positive perceptions; nurses' perceptions of nurses working in areas different from theirs are negative; nurses perceive senior nurses in a negative light and senior nurses have negative perceptions of new nurses. © 2011 Elsevier Ltd. All rights reserved.
Introduction Nurses' image has always been a concern for those in the profession. The decision to enter nursing, to remain in nursing and to promote nursing, may be the result of nurses' perception of the image of the profession. The current nursing shortage in the United States is attributed, in part, to nurses leaving the profession. (United States Bureau of Labor Statistics, 2009). Takase et al. (2006) concluded that nurses' image was negatively related to intention to quit the job. A study conducted by Price Waterhouse Cooper (2007) reported about a 52% turnover rate for new RNs within the ﬁrst two years of employment. Nursing is predominantly a female profession, yet only one-half as many women select nursing as a career as compared to 25 years ago (Buerhaus, 2000). Sochalski's (2002) study found that male nurses are leaving nursing at twice the rate of female nurses. Kimball and O'Neil (2001) reported that one factor that contributes to the nursing shortage is general dissatisfaction of nurses with their professional image of nursing. This study explored the image of nursing using Boulding's (1956) theory of image as a framework. Boulding theorized that image is
based on what a person believes is true, and is inﬂuenced by incoming messages and how those messages are interpreted. Messages that nurses receive about the profession may perhaps inﬂuence their image of the profession. The image of nursing as perceived by nurses and by the public, affects recruitment of new nurses and retention of experienced nurses (Buerhaus et al., 2005). In one survey of Registered Nurses, 36% of nurses said that they would not recommend nursing as a career option for young people (AMN Healthcare Inc, 2010). In fact, Baumann et al. (2004) reported that 25% of nurses would “actively discourage someone from going into nursing” (p. 13). The issue of nursing's image is so signiﬁcant that since 2002, Johnson and Johnson has been funding a campaign to improve the nursing shortage by improving nurses' image (Discover Nursing, 2003) This strategy has not been effective for the long term as evidenced by the recurrent cycle of nursing shortages. One reason may be that those efforts have focused on the public's image of nursing instead of nurses' image of the profession. Studies about nursing image have mainly focused on the public's image of nursing. There are no recent studies on the image of nursing from nurses' perspective. Methods
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0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.10.015
This qualitative study explored nurses' perceptions about their professional image from just prior to entering the profession and at
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various phases of their career. Columbia University Institutional Review Board approved the study. A sample of 13 participants included eight Registered Nurses (RN) and ﬁve student nurses (SRN). SRN's were included to obtain baseline information on nurses' image just as they are about to enter the profession. RNs were staff nurses who gave direct patient care and who were working in various acute care institutions in the New York metropolitan area. In order to explore image perceptions of nurses over time, a purposeful sample of two nurses from each of the following phases of experience: one to four years, ﬁve to ten years, 11 to 20 years, and upwards of 20 years was chosen. SRNs included a purposeful sample of students in their ﬁnal semester in a generic Baccalaureate Nursing program in the New York area. Participants were informed of the purpose of the study, written consent was obtained, and conﬁdentiality was assured prior to the start of each interview. Interviews took place in a private setting chosen by participants and they were informed that they could withdraw at any time. Data collection involved use of semistructured interviews. SRNs were initially asked the open-ended question, “What is your image of nursing?” Other probing questions to SRNs included: “What prompted you to choose nursing as a career?” “What inﬂuenced how you view nursing today?” RN interviews began with the open ended statement, “Tell me about how you perceive the nursing profession today.” As the interviews evolved, other probing questions included: “Describe your image of nursing when you graduated from nursing school.” “How has your image of nursing changed since you entered the profession?” Interviews were recorded and questions were narrowed based on the data obtained. Interviews lasted from one hour to 90 min. After one hour, permission was requested to continue the interview until questions that were integral to the study were answered. Additionally, two SRNs and four RNs were interviewed. However, those additional participants added no new information, achieving saturation. Data were analyzed and transcribed within a few days after the interviews. Information obtained was used to direct future questions when that became necessary. Data analysis consisted of organization and coding of data, sorting into categories and identifying themes. Analysis of data revealed themes that reﬂected similarities and differences about nurses' image among SRNs and practicing RNs. Themes and categories were examined against the research questions and interpreted to see if they ﬁt with the perceptions of the participants. Credibility was established by taking all data back to participants to verify that perceptions of the subjects were accurately captured. No revisions were needed. An experienced nurse researcher conducted an independent external audit of data by reading the transcripts, checking them against themes and categories, and conﬁrming support of categories and themes. Results
Table 1 Themes and categories of nurses' image of nursing. Themes
Task oriented Paperwork Other's image about nursing Patient advocate Time constraints Educational preparation Fear of failure Self-conﬁdence Clinical expertise Length of time in practice Support Preceptor's attitude Respect Teamwork Commitment Compassion
Role of nurses
Attitude of nurses
attributed to nurses' roles included task-oriented chores as bathing, cleaning, and medicating patients. One SRN explained that she knew nurses “… helped people, but I wasn't exactly sure how… I had a vague idea that it meant medications, needles and white hats.” Other's image of nursing had an impact on SRNs' images of nursing. They expressed how they were often forced to defend their choice of nursing as a career. One student talked about family members who, “…look down on me…” when he went into nursing and accused him of, “…taking the easy way out.” SRN participants indicated that they believed that paperwork required of nurses prevented them from administering compassionate care. One student noted too much documentation makes “…nurses…too busy to be nice…” RN participants described frustrations of heavy workload demands, especially required paperwork, that prevented them from performing roles for which they were educated. As one new RN echoed “…nurses are not able to care for the patient the way they want…” Collaborating with other members of the health profession provided evidence to RN participants on how their work was valued by others and inﬂuenced participants' images of the profession. As one experienced RN voiced, “We're still seen as the doctors' handmaiden…we wait for them to give us orders even though we know what to do.” Most nurses valued their nursing role as patient advocates. One RN with 20 years experience described one of her roles as an ICU nurse: …if a person needs a bed-bath to make them comfortable, and you ought to do what has to be done for them and feel the rewards that you have eased their suffering somewhat, no matter how small…it's a whole process…a lot of it is touching and turning and being with the patient.
Categories that emerged identiﬁed the image of nursing as perceived by RNs and SRNs from just prior to commencing their career to their current stage of experience. SRNs responses reﬂected a retrospective perception of their image of nursing during nursing school, as well as their current image of nursing as they are about to begin their career. RN interviews provided data related to nurses' image during the course of their career. Themes that were closely related were classiﬁed into three broad categories that reﬂected study participants images of nursing. They were: role of the nurse, nursing knowledge, and attitude of nurses (See Table 1).
The theme of time constraints was consistent. One RN with nine years experience stated that she “…could barely, in the hours that I was there, get everything that I had to do, done.” In this study, nurses who are about to begin their career, have a positive image of the role of nurses, and as they progress through their career, they have mostly negative perceptions of their nursing roles. These perceptions are inﬂuenced by how others perceived nurses' roles and by how RNs perceived their ability to provide compassionate, safe care. Boulding (1956) stated that people form their images from behaviors observed and values internalized.
Role of the Nurse
The category identiﬁed as “role of the nurse” include data that described the work that nurses are expected to perform in the hospital, the actual work of nurses, and how nurses' work is perceived by nurses and by others. Prior to nursing school, activities that SRNs
Nursing education was a major factor in SRN's image of the profession. They perceived nursing as a respected occupation, though not a highly educated one. This, combined with their pre-nursing school image of nursing as task-oriented, convinced them that they would
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be able to complete their nursing education effortlessly. Once they began nursing school, students repeatedly expressed surprise and pride at the scope of their educational preparation. As one SRN noted, “It's very highly educated…I didn't know that before I got into nursing school.” SRNs reported that unrealistic clinical educational preparation provoked themes of fear of failure and lack of self-conﬁdence as they are about to become nurses. One SRN echoed their fears as she stated, “I'm scared…I have to know so much and I'll have so much responsibility…I know I'm not prepared for all this.” SRNs expressed hope that as they progress through their nursing career, they will be supported by their colleagues. RN participants described pride and satisfaction with their knowledge and clinical expertise. As one senior RN articulated, “Nurses are multitalented…you hear nurses telling doctors…let's try this and you do that.” However, they also expressed disappointment at what they perceived as disregard and lack of respect for their knowledge, experience, and skills. Experienced RN participants questioned the depth and scope of educational preparation of new nurses. They saw new nurses as not interested in learning from experienced nurses. As one senior RN stated: “…the younger ones…look at monitors not patients…they have an attitude. …they think it's a good way…to get a good salary.” Two experienced RN participants admitted that as long as their patient's health was not compromised, they would leave new nurses to struggle. All study participants saw most senior nurses as not willing to assist and mentor newer nurses. RN participants agreed that they have a positive image of nursing based on their knowledge and expertise. However, the disregard by those who did not value their educational preparation negatively inﬂuenced how they sometimes perceived their professional image. Boulding (1956) stated that individuals internalize values, which inﬂuence their value image. Attitude of Nurses A major category that evolved from this study was the attitude of nurses. SRNs formed their images during clinical rotations as they observed nurses in practice. These SRNs reported that many nurses did not promote the profession. As one student stated, “A lot of nurses … always try to talk me out of it.” SRNs frequently compared differences in attitudes based on length of time in practice. One student stated: “The young nurses really try hard…the ones who have been nurses for a few years…do their job but don't put in any of the little extras…” Another theme that nurses do not support other nurses was also consistent. One student observed, “Nurses do not support the new nurses….they are mean and nasty…” New RNs expressed frustration at the lack of support from senior nurses. One neophyte nurse admitted to wanting to quit because “…it seems that I have to do everything that the others don't want to do…sometimes I feel so overwhelmed that I don't know how long I could keep doing this.” One the other hand, one senior RN expressed that, “You could tell the difference with the older nurses; they are much more serious” Many senior nurses stated that because of the attitude of newer nurses, they do not intervene to help them as much as they should. One RN with over 20 years of experience echoed what the others expressed, “I think you need to step in when you need to…but you need to let them drown a little bit…” Younger RN participants perceived this as a lack of support by older nurses. Experienced RN participants expressed frustration at what they perceived as new nurses' lack of commitment and lack of desire to learn. Both new and experienced RNs in this study described experienced nurse colleagues by the adage “nurses eat their young.” Most RNs in this study stated that, for the most part, they felt they were not supported by other nurses. Only one RN, who worked in the maternal–child unit, described feeling supported when she ﬁrst
entered the profession. She had 3 years of experience and emphasized that her nurse manager assisted her to seek out those who nurture, so that “…the implementing is so much easier to implement.” However, most RNs expressed frustration that nurse managers' lack of support for staff nurses made them entertain thoughts of leaving the profession. RN participants perceived that nurse managers' main concern was for the organization at the expense of nurses and quality patient care. All RNs in this study attributed their experiences as new nurses to their preceptor's attitude. All but one RN admitted that their preceptors were not nurturing. The new nurse working in maternal–child unit stated that her preceptor was supportive and nurturing. One RN with 11 years of experience echoed what most of the others stated, that because of her preceptor's attitude “…there were times I just wanted to walk away and leave.” Another RN with six years experience described her experiences at the start of her career, “I felt like I was thrown to the wolves, and I didn't have support…” Still another senior RN put it this way, “I think they eat their own…they'll just leave you out there to hang.” RNs in this study judged nurses in other areas as doing less than nurses in their area. This lack of respect was illustrated as one senior RN participant, who worked in ICU, described her image of nurses who work in the clinic: “They ask them to open their mouth, to stand on a scale, to take their blood pressure…” The RN with three years of experience, who works in obstetrics declared, “The nurses in med–surge area…they do what they have to do, nothing else, the meds, the documentation, they don't even do a full assessment… then they sit at the nurses' station and talk.” All RNs in this study accused nurses working in other nursing units as portraying a negative image, which inﬂuence their image of the profession. Newer RN participants complained that senior nurses lacked compassion, and senior RN participants criticized newer nurses as not committed and having an attitude. Neither group felt that the other group respected them, creating a sense of lack of teamwork among senior and junior nurses. Study participants images of nursing were described in terms of nurses' interactions with each other and with their patients. According to Boulding (1956) an often repeated message has the capacity to inﬂuence a person's image.
Discussion and Implications Students in this study began their nursing education during the time when television advertisements extolled the complex roles of the profession by depicting nurses as expert clinicians who provide care for patients of all ages and in all stages of illness. Results of this study show that in spite of this campaign, today's nursing students begin their nursing education with a stereotypical, inaccurate image of nursing. Findings from this study also suggest that many of those who enter the nursing profession do not initially aspire to be nurses, and only consider the ﬁeld of nursing when they are not doing well in another major in college. Their decision to become nurses is based on the notion that nursing is a respectable though not a highly educated career. This supports previous studies that concluded that the public has vague notions of what nurses do (Takase et al., 2006). This ﬁnding is perhaps a reﬂection of the ineffectiveness of the image campaign, on college-bound students, on the role of nurses and depth of knowledge that nursing requires. Data show that graduating SRNs' perceptions of the image of nursing, come from evaluating what they learned in school, as the role of nurses, against the standards displayed by nurses in practice. Positive nursing role-models reinforced nursing students' beliefs that nursing is a distinguished profession. In addition, their nursing school experience appears to offset any negative images of nursing. As they progress through nursing school, SRNs' images of nursing evolve from an image of basic role functioning, to one of more complex role performance by the time they
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graduate, reinforcing a positive image of the profession at the time of entry into the profession. This study suggests that nurses begin their career with a generally positive image of nursing. Study participants blame other nurses for the perceived decline in nursing image. However, ﬁndings from a landmark study by Maxﬁeld et al. (2005) found that of 53% of nurses and other health care providers who were concerned about peer's incompetence, only 12% of nurses, discussed these concerns when the peer was a nurse. Results from this study indicate that RNs believe that nursing has deteriorated because other nurses do not portray professional values. It is likely that nurses fail to see similar traits within themselves that they identify in other nurses, such as when their own standards of practice may have dipped below professional levels. RN participants complain that they do not perceive that their work is valued by others. Nurses who feel devalued, may manifest their frustrations by not acknowledging the worth of the profession. None of the RNs in this study was willing to promote nursing, and in fact, all participants reported that nurses generally discourage potential nurses from pursuing nursing as a career. Experienced nurses have a wealth of knowledge to share with new nurses and new nurses count on guidance from experienced nurses. Kilstoff and Rochester (2004) reported that new graduate nurses lack self-conﬁdence about their ability to meet performance expectations as RNs. Experienced RNs in this study admitted that they are not inclined to offer assistance to new nurses. This has some important implications in that new nurses may feel intimidated by their senior colleagues and may be reluctant to seek their help. Senior nurses likely perceive this reluctance as “having an attitude” and so ignore these neophyte nurses, reinforcing their low professional self-worth. In their study, Rowe and Sherlock (2005) found that RNs reported that the most frequent source of abuse was nurses, and staff nurses were reported to be the most frequent nursing source. RNs do not appear to understand the work of their colleagues. All RN participants made disparaging remarks about the work of nurses in other clinical areas. When nurses do not respect their nursing colleagues' knowledge and skills, it is unlikely that other health professionals will. Lack of respect for their professional contributions can lead to poor professional self-image among nurses. This has been such a cause for concern that Standard 5 of the American Association of Critical Care Nurses (2005) to promote a healthy work environment, states that nurses must recognize each other for the value each brings to the organization. Evidence from this study shows that nurses' images of the profession are signiﬁcantly inﬂuenced during orientation. Most RN participants reported negative experiences with nurse preceptors that led to thoughts of leaving the profession. Too often, nurses are chosen to precept new nurses solely because of their clinical skills or seniority. Preceptors, who believe that their role is more of an evaluative process in preparing the neophyte nurse to practice independently as soon as possible, may not place importance on guidance and support. Benner (1984) cautioned that new nurses have difﬁculties bridging the gap from classrooms to the realities of patient care. This judgmental approach not only intimidates new nurses, but also inﬂuences their image of nursing negatively, at the beginning of their career. Most RNs in this study perceived new nurses as uncommitted, and they admit that they discourage individuals from choosing nursing as a career unless they feel that they have a “calling.” Individuals in the 20 and 30 age bracket, look to balance work and outside interests (Boychuk-Duchscher and Cowin, 2004) and may be judged as not having a “calling.” There are intelligent, caring individuals who do not aspire to become nurses solely because they do not know exactly what nurses do. There are also those who look for career choices that provide adequate compensation as well as workplace satisfaction before they make a commitment to invest in any career. Those seemingly unlikely candidates need to be encouraged and nurtured into the profession. This can only serve to enhance the image of nursing.
All RNs in this study perceived senior nurses as exercising power over new nurses by withholding support, allowing them to ﬂounder, and generally ignoring them. This passive aggressive form of tyranny likely intimidates and decreases the self-conﬁdence of new nurses. The National Sample Survey of Registered Nurses (2006) reported that the average age of RNs is rising while the RN population under 30 is falling. This suggests that the majority of nurses working in hospitals are likely to be older. Analysis of the data reveals that behaviors of senior nurses did indeed have an effect on the images that study participants have of the profession. The following recommendations to improve the image of nursing are offered to nurse managers, and educators: • Programs that provide a venue whereby new and experienced nurses can share new knowledge and innovations in their areas to foster respect for nurses in all ﬁelds. • Preceptor training programs for nurses who have characteristics that reﬂect a passion for nursing, commitment to nursing, and compassion for patients. • Supplementing meaningful clinical experiences for students that afford them a real sense of the challenges of day-to-day work of nurses, which may not always appear obvious to them. • Collaborative activities that include quality externship experiences before students graduate, and arranging with nurse managers for nursing students to attend and contribute at staff meetings on topics such as qualities they would like to see in RNs as this may stimulate nurses to reﬂect on their own behaviors.
Limitations An important limitation of this study is the small number of participants studied. Future studies with larger samples should explore: new graduate nurses and experienced nurses' perceptions of each other's roles and responsibilities; nurse satisfaction in relation to nursing image on medical–surgical units; relationship of years of experience and nurse's perceived image; and preceptors' role in inﬂuencing the image of nursing among new nurses. It is recommended that further research should include longitudinal mixed method approach for more objectivity of ﬁndings across time and for generalization of ﬁndings. This should be supported by qualitative rationale to the studies. References American Association of Critical Care Nurses, 2005. AACN standards for establishing and sustaining healthy work environment. A journey to excellence. American Journal of Critical Care 14, 187–197. AMN Healthcare Inc, 2010. 2010 Survey of Registered Nurses: Job Satisfaction and Career Plans. Retrieved March 1, 2011 from http://www.amnhealthcare.com/pdf/ 10_NurseSurveyWeb.pdf. Baumann, A., Blythe, J., Kolotylo, C., Underwood, J., 2004. The International Nursing Labour Market Report. The Nursing Sector Study Corporation, Ottawa ON. Benner, P., 1984. Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA. Boulding, K.E., 1956. The Image. The University of Michigan Press, Ann Arbor. Boychuk-Duchscher, J., Cowin, L., 2004. Multigenerational nurses in the workplace. Journal of Nursing Administration 34 (11), 493–501. Buerhaus, P., 2000. Implications of an aging, registered nurse workforce. Journal of the American Medical Association 283 (22), 2948–2954. Buerhaus, P., Donelan, K., Norman, L., Dittus, R., 2005. Nursing students perceptions of a career in nursing and impact of a national campaign designed to attract people into the profession of nursing. Journal of Professional Nursing 21 (2), 75–83. Discover Nursing, 2003. Campaign for Nursing's Future. Retrieved June 2011 from www.jnj.com/connect/caring/patientstories/preparing-nurses-for-the-future. Kilstoff, K.K., Rochester, S.F., 2004. Hitting the ﬂoor running: transitional experiences of graduates previously trained as enrolled nurses. Australian Journal of Advanced Nursing 22 (1), 13–17. Kimball, B., O'Neil, E., 2001. The evolution of a crisis: nursing in America. Policy, politics, & nursing practice. Nursing Practice 2 (3), 180–186. Maxﬁeld, D., Gremmy, J., McMillan, R., Patterson, R., Switzer, A., 2005. Silence Kills: The Seven Crucial Conversations for Healthcare. Retrieved September 29, 2011 from: http://www.silenttreatmentstudy.com/silencekills/SilenceKills.pdf.
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