Image of Nursing: Influences of the Present

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Nursing image—how is it perceived?
After completing this chapter, you should be able to:
• Discuss the effect of image on the public perception of nursing.
• Describe different sociological models that characterize “professionalism.”
• Apply Pavalko’s characteristics as a framework to describe modern nursing practice.
• Identify the impact that nursing organizations have on professional practice.
• Describe the role of credentialing and certification in professional practice.
Nursing image—how is it perceived? What does it mean to be a professional nurse? How does the public view nursing? How does nursing define and view itself? What role does the public image of the nursing profession play in our current nursing climate? What do you do to further the image of a professional nurse?
Historically, nurses have struggled to define the image of nursing and the professional role of the nurse. There are many different views and opinions, but nurses are definitely gaining ground when it comes to defining the profession of nursing. The annual Gallup survey for professions noted that for honesty and ethical standards, nursing has been rated at the top of the list for the past 13 years. In 2014, 80% of the American public rate the standards held by nurses as either high or very high; this rates the nursing profession 15 percentage points above any other profession (ANA, 2014). The image of nursing is evolving and changing, with nursing being promoted and viewed as an intellectual, autonomous profession that demands a high level of commitment, focus, and a dedication to advancing education and scholarly activity.
Modern-day nursing has many dimensions, one of which includes the debate surrounding its identification as a profession. One ongoing challenge in nursing is to diligently foster and enhance the public image and the self-image of the nurse. In this chapter, the development of nursing into a profession is discussed, and the present and future dimensions of nursing’s “image” are explored. The lasting impact of the 2010 Institute of Medicine report on The Future of Nursing and other significant position statements and reports on the profession will be discussed. Historical knowledge about our “rites of passage” provides an appreciation of the path nursing has taken as a profession and what the future of nursing may hold for the recent graduate in this complex and evolving health care world.

Professional Image of Nursing

What Do We Mean by the Image of Nursing?

Santa Filomena

Lo! in that hour of misery

A lady with a lamp I see

Pass through the glimmering gloom,

And flit from room to room.

Longfellow, 1857

Nursing has been identified as an “emerging profession” for at least 150 years. The historical context of nursing’s image is often traced back to Florence Nightingale, the “founder of nursing.” Florence Nightingale is recognized as a nurse, statistician, and writer who became known for her groundbreaking work during the Crimean War. Nurse Nightingale was also called the “Lady with the Lamp,” as she was reported to have made rounds on her patients at night by the light of a lantern. International Nurse’s Day is celebrated each year on her birthday, May 12, and the Nightingale Pledge is still recited by new nursing graduates around the world, often with the accompaniment of flickering candles in symbolic lamps. Even though much has been written about Florence Nightingale’s many contributions, she is undeniably remembered as the pioneer of nursing education (Bostridge, 2008).
I attribute my success to this—I never gave or took any excuse.Florence Nightingale
Do you feel most nurses portray a professional image? If so, what qualities do they possess to project this image? If not, what is lacking?
The image of professional nursing continues to evolve and is significantly affected by the media, women’s issues and roles, and an ever-evolving high-technology health care environment. How nursing views itself in the evolution of the profession and how actively nurses are involved in the definition process will continue to determine the image and role of nursing in the future.
In a 2008 study on public perceptions of nursing and factors that influence these insights, the study determined a personal experience with nurses either as a patient or with a family member was the leading influence on perceptions of nurses and the profession of nursing (Donelan et al., 2008).
There is a new, innovative approach to recruiting and retaining more men into nursing, seeking a more gender-neutral attitude. The American Assembly of Men in Nursing (AAMN) has initiated the marketing campaign “Advancing Men in Nursing” with materials highlighting the camaraderie and opportunities available to men entering the profession. The professional, skilled, compassionate male image portrayed in posters and advertising is designed to break down the stereotypes typically associated with men in nursing (Stokowski, 2012). As more men enter the profession and there is a push to increase minorities in nursing, will the image of nursing change (Critical Thinking Box 9.1)?

icon CRITICAL THINKING BOX 9.1Think Quick!
Picture in your mind your image of a nurse—did you just think of a female, tidy hair, professional looking uniform, serviceable white shoes, stethoscope around the neck, determined look in the eyes, energetic walk, clipboard in hand? Or did you just envision a male nurse with many of those same attributes? The image of nursing is changing, and many media depictions now include men as nurses. There have always been men in nursing, but with the increasing respect for the profession, and the high touch, high technicality in the field of nursing, more men than ever are looking to become nurses. Indeed, many men who enter nursing are interested in fighting the same stereotypes that woman have battled through the years. The term “male nurse” is considered an unnecessary distinction, much like saying a “female physician”—the gender bias is simply not a critical element (Wilson, 2009). The first step in turning the tide of thought about gender in nursing is for members of the profession to alter their own perceptions.
Nurses should be thought of as autonomous and competent decision makers within their nursing practice areas. Throughout the 1990s, a nationwide advertising campaign supported by the National Commission on Nursing Implementation Project produced radio and television ads that said, “If caring were enough, anyone could be a nurse.” Nurses of America, an advocate organization sponsored by the National League for Nursing (NLN), implemented a very successful program directed toward improving the image of nursing as depicted on television, on radio, in print, and on lecture circuits. Consultants were contracted to work with executives, politicians, and celebrities to present nursing in a positive manner. This approach reinforced the image of the modern professional nurse as having critical thinking, evidence-based decision-making, and problem-solving skills.
At a nursing symposium in May 2012, it was noted that while the depiction of nurses in the media can affect how the public views nurses, it is truly up to each individual nurse to be proactive in presenting nursing as a respected profession (Muehlbauer, 2012). The American Academy of Nursing (, 2014) through the Raise the Voice campaign has brought nursing policy innovators to the forefront of health care policy debates. A concentrated effort by individuals and organizations is raising awareness of what nurses do and heightening the image and voice of nursing as a profession. As noted by Groves (2007), accurate portrayals of nurses as professional members of the health care team are rare, but it takes time to change perceptions. The continued trend of building a positive, intelligent, competent, and professional image of nursing must continue. Nurses who are new to the profession need to be aware of the extraordinary challenges and opportunities that they will face. It is equally important for nurses to improve the self-image of the professional nurse. The behaviors and ethics displayed by nurses on a day-to-day basis can do much to elevate the present and shape the future image of nursing (Cohen & Bartholomew, 2008).
Nursing associations are working together to promote a positive image and to handle nursing shortage issues. Nurses for a Healthier Tomorrow, an alliance of 43 nursing and health care organizations, has launched a national media campaign that demonstrates, through print and broadcast media, the many opportunities for the career of nursing. One tangible example of this effort is the website Sigma Theta Tau International, the international honor society for nursing, is the coordinator of Nurses for a Healthier Tomorrow. Review their website at The American Nurses Association published a flyer titled Every Patient Deserves a Nurse, along with other promotional materials for the lay public. The promotional message of these materials reinforces the positive image of nurses as patient advocates and critical resources both to patients and families, while also emphasizing the right of people to a safe health care environment.
In 2002, the Johnson & Johnson Company developed a nationwide campaign to support the nursing profession. This program, titled “The Campaign for Nursing’s Future,” was developed along with health care leaders and nursing organizations such as the National Student Nurse’s Association (NSNA), the American Nurse’s Association (ANA), the American Organization for Nurse Executives (AONE), the National League for Nursing, and Sigma Theta Tau. The goal of this program is to increase the number of young adults entering nursing through raising the visibility of nurses of varied races, gender, and roles. The website for the campaign can be found at
The negative images of nursing, those of the “naughty nurse” or the “Nurse Ratchet” that are depicted in the media, are still prevalent, but these erroneous portrayals do offer professional nurses the opportunity to educate the public about what nurses truly do. Nursing is not the only profession that struggles with a skewed media image. Some of these erroneous depictions may be related to the largely female population who seeks these professions; consider the sexual media images that are often illustrated by flight attendants, massage therapists, or secretaries. Other occupations that suffer from poor media portrayals include the “mad scientist” role (chemist or researcher), construction worker (often a sexual male image), or consider the negative images that both female and male lawyers are often faced with! Devaluation of the nursing profession by demeaning or comical images only extends the nursing shortage and further discourages talented people from entering the nursing profession. It is up to each individual to continue to display professional role modeling and provide public education on what nurses really do to empower the professional image of nursing (Cohen & Bartholomew, 2008).
How can nurses change the image of nursing? How can the image of nursing become more congruent with the actual role the nurse plays in today’s rapidly evolving health care environment? Nurses outnumber all other professions in health care. Mee (2006) suggests that nurses can promote the professional image of nursing by doing the following.

Patient Interactions

One by One. During the first 60 seconds that a patient sees the nurse, a lasting impression may be formed. Take a moment before meeting a new patient to portray confidence in your role and a respect for the patient from the beginning. Many health care institutions require nurses to wear nursing uniforms of a distinct color that separates them from nurse assistants and respiratory therapists.

Personal Interaction With the Public

Have a professional response ready in case someone asks about nursing. Present nursing’s image positively, and relate what an important role nurses have in society as health care providers. Nursing advocacy starts with you! Every professional nurse has the responsibility to educate the public about what nurses do and the amount of education and dedication it takes to be a nurse. Believe in yourself, and project the image you want the public to see (Jacobs-Summers & Jacobs-Summers, 2011).

Public Speaking and Community Activities

Consider speaking at or visiting schools on Career Day. You don’t have to be an expert at public speaking to discuss the role of the nurse with local community groups. A brief, interactive presentation at an elementary or high school can stimulate interest in nursing early—for both male and female students.

Participation in Political Activities

Increase the positive visibility of nurses through politics by becoming actively involved as a nurse lobbyist. Be aware of the current health care issues on the community, state, and national levels. Get to know the elected officials, and talk to them about the role of the nurse. This may be a valuable opportunity to present nursing in a very positive manner. Remember that most elected officials do not understand the role nurses play in health care (Mee, 2006).
The image of nursing continues to evolve as the many roles of nurses are portrayed through the media in the restructuring of health care environments and in a variety of settings, from emergency rooms to war zones. Studies continue to verify that competent nursing care affects mortality rates in critical care patients, and the future for many nursing jobs lies in the expanding role of nursing into emergency and disaster preparedness and integration of technology and informatics into practice settings (Health Resources and Services Administration [HRSA], 2010). The role and image of the nurse will continue to change as the many facets of health care delivery evolve during this century. The current nursing shortage will play a significant future part in the creation of the image and role of the nurse. How will nurses respond to these changes? How will you present yourself as a professional?

What Constitutes a Profession?

There are many ways to describe a “professional.” What meaning does the word have for you as a graduate professional nurse? Controversy about the definition of the term professional as it relates to nursing is not a new issue. Strauss (1966), a noted sociologist, found the word professional used in reference to nursing in a magazine article published in 1892 titled “Nursing, a New Profession for Women.” The nurses of the 20th and 21st centuries owe a great deal to Isabel Adams Hampton (later Isabel Hampton Robb) for her visionary focus in the late 1800s. She was an outstanding advocate for the professionalization of nursing. In the textbook Nursing Ethics (1900), she wrote:

The trained nurse, then, is no longer to be regarded as a better trained, more useful, higher class servant, but as one who has knowledge and is worthy of respect, consideration, and due recompense…. She is also essentially an instructor; part of her duties have to do with the prevention of disease and sickness, as well as the relief of suffering humanity…. These are some of the essentials in nursing by which it has become to be regarded as a profession, but there still remains much to be desired, much to work for, in order to add to its dignity and usefulness.

In Caplow’s classic work from the early 1950s, The Sociology of Work (Caplow, 1954), several steps in the process of “becoming professional” were defined further, and the value of forming an association that defined a special membership was addressed. Caplow suggested that making a name change to clarify an area of work or practice would subsequently produce a new role. With the creation of this new role, the group would then establish a code of ethics and legal components for licensure to practice and educational control of the profession (Caplow, 1954). This process of becoming professional was taking place in nursing in 1897 with the establishment of the ANA. Other aspects of professionalization were also beginning to develop. For example, the Code for Nurses was suggested as early as 1926, although it was not written or published by the ANA until the early 1950s. Revisions were made in 1956, 1960, and 1976, with changes made in 1985 that included interpretative statements. In the summer of 2001 at the ANA convention, delegates again updated the code and changed the name to the Code of Ethics for Nurses with Interpretive Statements. The American Nurses Association deemed 2015 the Year of Ethics and issued an updated Code of Ethics with Interpretive Statements found at
Almost 20 years after Caplow’s work, Pavalko (1971) described eight dimensions of a profession. Pavalko’s dimensions of a profession and their specific application to nursing are examined in more detail later in this chapter. Nursing continues to apply these dimensions to support nursing’s move away from the occupational focus to a professional focus. Is nursing a profession or semiprofession?
By responding to the questions in Critical Thinking Box 9.2 (which presents Levenstein’s model, a fourth model of professionalism), you will identify common themes in describing a profession. What are your thoughts about the nursing profession in light of these criteria?
icon CRITICAL THINKING BOX 9.2Levenstein’s Characteristics of a Profession
What do you think about …
• The element of altruism
How do you define caring in your clinical practice?
• Code of ethics
Are you familiar with the ANA Code of Ethics?
• Collaboration with groups and individuals for the benefit of the patient
What other groups do you work with in your clinical setting that affect the health needs of the patient and family?
• Colleagueship demonstrated by
An organization for licensing
• What is the role of the State Board of Nursing in your state?
A group that helps ensure quality
• Are you aware of the role of national nursing organizations that accredit nursing programs?
• There are two national nursing organizations that accredit nursing programs; do you know what they are?
Peer evaluations of practitioners
• What is the role of job evaluations in terms of professional growth?
• Accountability for conduct and responsibility for practice decisions
Who monitors professional conduct issues from a legal and ethical point of view?
Does shared governance reflect more control of one’s nursing practice?
• Strong research program
Are you aware that a national center for nursing research is now operating in Washington, DC?
Others have written about professions and their development, but these sociological models present some logical characteristics for you to use to examine professionalism. According to Henshaw, a noted nursing leader and researcher, a profession includes “self-regulation and autonomy with ultimate loyalty and accountability to the professional group” (cited in Talotta, 1990). Nursing is a dynamic profession and continues to strive to enhance a professional image—which leads us to the next question.

Is Nursing a Profession?

Eunice Cole, a past president of the ANA, described nursing as a dynamic profession that has established a code of ethics and standards of practice, education, service, and research components. The standards for both the professional and practical dimensions of nursing are continually reviewed and updated. Nurses, strong in numbers but splintered professionally in many ways, represent the largest group of health care providers in the United States.
There are approximately 2.9 million registered nurses in the workforce with an average age of all licensed RNs increasing by about 2 years for RNs, and about one-third of the current nursing workforce is older than 50. The RN supply is anticipated to grow by 952,000 full-time equivalents (FTEs)—from 2,897,000 FTEs in 2012 to 3,849,000 FTEs in 2025—a 33% national increase (U.S. Department of Health and Human Services, 2014).
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