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Nurse identity: reality and media portrayal
  1. Rebecca Garcia1,
  2. Irtiza Qureshi2
  1. 1 Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, Buckinghamshire, UK
  2. 2 School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
  1. Correspondence to Dr Rebecca Garcia, Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes MK7 6AA, Buckinghamshire, UK; Rebecca.Garcia{at}open.ac.uk

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Introduction

The WHO, the International Council of Nurses and Nursing Now, had planned to raise the global public profile of nursing in 2020 as a consequence of Florence Nightingales 200th anniversary. However, with the unexpected arrival of the coronavirus pandemic in late 2019, nurses and the nursing profession found themselves having unexpected media attention. The degree and type of media attention that nursing achieved during this time were never anticipated. This article considers the reality of nursing, both the role and profession in the UK in 2021 compared with the public perception and temporal media portrayal.

Stereotypes of nursing

The media mediates public perception(s) through imagery and messaging. However, with reduced public understanding of healthcare services, inadequate understanding of healthcare professional roles and responsibilities, and reduced health literacy in the general population,1 there is ample opportunity for misinformation and psychological bias (such as confirmation bias or stereotyping) to operate in the mainstream discourse dictating and perpetuating a false image of nursing.2 Given that nursing is the largest global occupation of predominately female employees3 and the National Health Service (NHS) is the largest employer in Europe, qualified nurses in the UK make up 26% of the total NHS workforce.4 The consequences of nursing having a poor public image subsequently impact the profession being undervalued, with poor recruitment, retention and indirectly influence patient healthcare.4

Since the 1970s, nursing had forwarded Advanced Clinical Practice and specialist roles.5 Conversely, for decades, the media has portrayed nurses as predominantly subservient to doctors and referred to nurses as the doctor’s ‘handmaiden’ and not as independent practitioners. The idea of nursing subservience is rooted in a gross misunderstanding of the nurse’s role,6 7 with outdated patriarchal and gendered ideas around male-doctor dominance and female subservience.8 9 From the outsider and non-informed perspective, the media used negative stereotyped images to influence public perception.10 11 For example, often images of nurses have been highly sexualised (eg, female) or nurses portrayed as angel figures.7 Moreover, typically, the imagery of nurses depicts a white female and vocational workforce, with few male nurses12 or images of people from ethnic minority backgrounds.7

Gender issues in nursing and the media: disavowed, demonised and degraded

A commissioned report by the Royal College of Nursing (RCN) in 2020 showed that nursing is predominately a female profession and suggested that there are interrelated complexities behind this, coinciding with the formalisation of the nursing profession, for instance with regulation, a code of ethics and the requirement to achieve a qualification through agreed education standards.12 Moreover, socially constructed images of nursing suggest that medicine is work for men, but medicine means nursing for women. The fact that the nursing workforce contains more women is a result of, and contributor to, the ongoing deterrence of men entering the nursing profession. However, the historical facts around the number, and contribution, of men in nursing are often ignored when contemporary images of nursing are constructed.12 13

Interestingly, some of the earliest documents relating to the nursing profession demonstrate the critical role that men played as nurses throughout history.14 15 For example, the first nurses in the world were neither women nor white, but were men attending nursing schools in India in about 250 BC.16 Later, the Roman military nurses (known as Nosocomi) developed fundamental nursing practices around health and hygiene on the battlefield.16 17 Further examples were seen in Egypt, throughout Turkey and then Europe, whereby the Parabolani Brotherhood continued the tradition of men caring for the sick through the third century AD.18 In the sixth century, St. Benedict founded the Benedictine nursing order, with St. Alexis18 and in the middle ages St John of God’s Knights Hospitallers, the Teutonic Knights, the Knights of St. Lazarus and the Hospital Brothers of St. Anthony all of which were men, continued to provide nursing-related services.19

However, with the dissolution of the monasteries during the 16th and 17th centuries, the records of male nurses become scarcer.20 Various civil and international wars throughout the centuries then saw significant numbers of men taking up nursing roles on battlefields across the world.18 21 For instance, in 1859, Jean Henry Dunant provided nursing care after the Battle of Solferino, founding the International Red Cross and the Geneva Convention, following which he was awarded the first Nobel Peace Prize in 1901.22

Unfortunately, not only are men like those mentioned above, never acknowledge or mentioned in contemporary constructions of nurse identity in the media, any consideration of men that does occur is often negative and problematic. Much like the hyper-sexualisation of female nurses in mainstream media, men are also subjected to similar biased lenses. The consequential perceptions following these biased constructions can result in complex and problematic phenomena such as the perceived sexualisation of a male nurse’s touch, whereas the same is not perceived as the case for male doctors.23

This sexualisation of men in nursing has other negative consequences. For example, research into Western media representations of nursing and the nursing discourse highlights a tradition of portraying male nurses as murderers, incompetent or framing their sexuality as problematic.24 25 Meadus26 also identified common media misrepresentations of male nurses as gay or effeminate and framing this as negative. Furthermore, following research into medicalised television programmes, it was found that three subcategories of implicit and explicit negative messages were being sent out around male nurses—those being: questioning of their choice of profession, their sexuality and their masculinity.27

Turning our attention to women in nursing, it was with the help of Florence Nightingale (1820–1910) during the Crimean war (1854–1856) that nursing became a viable occupation for women since Florence was herself from an upper-class family and practising her Christian religion. It was at this time that nurses began to be represented as angels, with a female image being used to tend to male soldiers’ wounds and care needs, which was widely acceptable to the British public at that time.28 During the first world war, propaganda and media images were used showing predominately female nurses which depicted gentle angel figures whereas the reality was starkly different with both male and female nurses tending to the sick and wounded and by 1970, it was widely believed that nursing was a female profession. However, this was untrue, and men were typically found in psychiatric nursing positions. Moreover, early in the 20th century, there was little formal psychiatric training provided and as such psychiatric (male) nurses were not recognised as being highly qualified as general nurses and therefore were perceived to be of a lower status.28

Ethnic minority nurses and the media: whitewashing the truth

The reality of the nursing workforce in the UK is far more diverse and complex than the simplified image of nurses typically constructed in the media. Nursing in the UK is in crisis; chronically understaffed and reporting 43 590 vacancies.29 Consequently, the UK Government continues to place nursing on the Shortage Occupations List. These nursing shortages have meant that there have been recurrent nursing recruitment drives from overseas.30–33 This has added both more minority ethnic people and more men to the workforce. At its peak, this approach accounted for more than 80 000 overseas nurses being added to the UK nursing register between 1997 and 2004.34

More recent research confirms that people from minority ethnic backgrounds are significantly more likely to be nurses, midwives and health visitors compared with their equivalent proportional representation in the UK population.35 Indeed in 2019, figures show that in England, 20% of nurses were from a minority ethnic background and this proportion has been steadily growing since 2016 (while the headcount of white counterparts has decreased).35 This 20% figure of ethnic minority staff equates in real terms to almost 72 000 nurses, midwives and healthcare workers. Indeed, research carried out by the RCN in 2018 showed that London’s NHS region employed more nurses from minority ethnic backgrounds (27982) than white nurses (24847) (https://www.rcn.org.uk/news-and-events/news/rcn-london-research-into-bame-numbers).

It is undeniable that people from minority ethnic backgrounds have been making invaluable contributions to nursing in the UK for generations. Nurses like Mary Seacole, Dame Elizabeth Anionwu, Professor Justus Akinsanya, Dame Donna Kinair, Professor Laura Serrant and Professor Calvin Morely are just some of many eminent nurses in the profession. However, their critical contributions have been largely invisible within the mainstream construction of nurse identity in the media in the UK.

Furthermore, within the current image and discourse in nursing, not only have minority ethnic people and men been excluded or marginalised, men from minority ethnic backgrounds have been particularly invisible.36 For instance, recent investigations into the experiences of minority ethnic male nurses emphasise the views of these nurses feeling twice invisible as they are neither white nor women.36 While research has begun into the male under-representation in nursing, cross reference these investigations with male ethnicity is even rarer.37 This is a historical problem; for example, Burns38 charted the structural exclusion of acknowledging a black and male nursing workforce in South Africa, finding that public health authorities consistently failed to publicise or celebrate the (black) male contingent of the national nursing workforce.

Deprofessionalising nursing in the media: a profession not a vocation

Nursing is often invisible in the press unless there are media messages that are extreme or sensationalist, such as the recent coronavirus pandemic, and then the portrayals are rarely positive. For example, nurses under scrutiny or police investigation always attract the media’s attention (eg, Beverly Allit, Lucy Letby and Benjamin Green). This then further contributes to the publics ‘problem’ perception of nursing.39 Another example was seen during the pandemic, whereby the media constantly cited nurses as ‘heros’40; however, while the hero label may have been ascribed due to the professionalism and maturity to which the nursing profession responded to the pandemic, the ideas of heroism have inadvertently furthered negative stereotypes around nurses being female and perpetuated disempowerment.41

The public relies on media messages (or personal experiences) or to inform their perceptions of nursing.10 However, personal experience is limited to the episode of care and may have been subject to bias by preconceived ideas around nursing, or a misunderstanding of jobs roles in the clinical areas, given that the public will not be aware of the allocation and role depiction seen in the varied uniforms in the hospital/clinical areas.7 Consequently, patients often report having spoken to ‘the nurse’ when in fact they were dealing with an unqualified assistant.7

The public perception and paucity of understanding of nursing, coupled with a lack of appreciation of the scientific nature of nursing conflicts with the autonomous, highly qualified, and skilled, evidence-based practitioners that nurses are. The gendered and negative nursing stereotypes (ie, angels and sexualised) of nursing perpetuate the poor public understanding of the nurse’s true role and levels of responsibility.

A report commissioned by the RCN (2020) evaluated how gendered construction(s) around nursing continues to suppress pay and equity comparable with other healthcare professions.12 Moreover, the notion that nursing is ‘vocational’ further exacerbates the lack of professional recognition of highly skilled professionals and devalues their worth.12 The juxtaposition between the scientific and evidence-based foundation in nursing contrasts with explicit skills-based and practical knowledge (seen in some nursing procedures) and tacit knowledge such as emotional intelligence and experiential and reflexive learning.12

This conflict then contributes to perceptions of higher status given to scientific knowledge-based disciplines (for instance, doctors) and lower status awarded to practical knowledge (eg, caring roles), thus perpetuating constructions of nursing being of low(er) status than other healthcare disciplines. Clayton-Hathway et al 12 argue that while images of nursing remain associated with practical knowledge and not scientific evidence-based knowledge, nursing would continue to be undervalued.

This view of nursing as a vocation is historic and based on perceiving nursing, not as a profession but an ‘act’ and this act is seen as inherently feminine and linked to motherhood and obedience (linked to schemas around doctors being male and ideas of patriarchy).9 42 Lundmark 43 points out that mainstream thinkers began to refute nursing as a vocation, due to the misrepresentation of nursing associated with feminisation and gender-biased roles such as motherhood. Attributes such as kindness, compassion and trustworthiness were desired from nurses44 and these concepts further developed into altruism, nurturing, caring roles and as nurses being service-givers which has compounded the exploitation of nursing even more.8 43 Furthermore, ten Hoeve et al 45 argue that this traditional role of nurses and nursing is the ‘expression of an oppressed group’ which brings to the current discussion ideas of power imbalance and inequity as often seen in female-dominated or gendered roles. Clayton-Hathaway et al 12 further suggest that the female role of caring is the reward and is used as a justification for lower wages.

These ideas of altruism and caring have rigidly remained in the media profile of nurses and the public perception of nursing today, despite nurses being degree trained and highly technically skilled practitioners. Since the emergence of modern-day nursing as a profession in the late 20th century, there has been an ongoing debate on whether nursing should be a vocation or a contract. The view of nursing as a contract considers the technical and scientific aspects of nursing currently being emphasised, consistent with a positivist epistemological approach and recognises the rights and duties of each contracted party.43 This contrasts with the altruistic perspective of nursing as a vocation, whereby altruism has outdated, and unhelpful roots associated with early religious constructions of nursing.43 44 The emphasis on technical aspects of nursing includes the raising of educational standards for nurses, as seen in the current requirement for registered nurses to have a minimum BSc/BA degree in the UK and the regulation of qualified nurses (as in the requirement for registration with the NMC in the UK).28

Mainstream nursing organisations such as the RCN have lobbied to raise the profile and stature of nursing as a contract. They have argued that seeing nursing as a vocation is to the detriment of the profession as it is perceived to have less professionalism, less credibility and of a lower status within society.42 However, specific changes to the NHS such as the introduction of an internal market have been seen to further diminish the role of nursing in the UK.46 47 Here, nurses were increasingly seen as (cheap) ancillary support to doctors in the context of needing to provide more healthcare services but at less cost. Consequently, nurses are seen as a cheaper option of staffing solutions needed to cover clinical areas and direct patient care, while doctors did the ‘important work of providing medical care’.46 Unfortunately, the media have clung to the perspective on nursing as a vocation as demonstrated through contemporary reporting during the COVID-19 pandemic. For example, journalists have consistently interviewed physicians more frequently than nurses, reinforcing ideas about hierarchy and nurse media reports were limited to operationalisation issues, such as the impact of the shortage of personal protective equipment.48

Next steps

Nurses need to be proactively involved in raising their professional profile and reducing the invisibility and misinformation that surrounds the facts of the nursing profession. This means that the nurses’ voice and accurate representation need to be integral to future workforce planning, education, research, policy and healthcare agendas at government and strategic levels. One example was the Nursing Now campaign, which promoted The Nightingale Challenge to eligible nurses, to champion influential leadership stimulating changes in policy, research and practice. Creating an inclusive curriculum for nurse education and actively debating and forwarding the professional image of nursing will facilitate change from new registrants.

However, more needs to be done to actively address the outdated stereotyped and misrepresented images of nursing that have persisted in the mainstream media and which have continued to hamper the progression of the nursing profession, in becoming an attractive and valued career option for both men and people from ethnic minority backgrounds. Nursing needs to become valued by the media and the public, recognised as the keystone to effective healthcare provision and person-centred patient care and receive the remuneration deserved.49 For instance, nurses are pivotal to the delivery of the Sustainable Development Goals (SDG), therefore recognising the central role that nurses have in delivering prevention and care strategies in health for individuals, their families and populations which are essential for the success of the SDG.49

As was suggested by Kay and Norman,50 nursing needs to both educate and work alongside mainstream media to reinvent the image of nurses to portray accurate and positive accounts of what nursing entails. Using platforms such as YouTube and social media helping to reach younger audiences and presenting nursing as an attractive career option. Indeed, following the coronavirus pandemic, in 2021 the Universities and Colleges Admission Service (UCAS) reported a 32% increase in the number of applications for undergraduate nursing degree’s, with an increase of 26% from male applicants, and 15% increase from applicants in ethnic minority groups, demonstrating a positive impact of media attention on nursing and healthcare during the pandemic.

In 2018, Lord Crisp and Baroness Watkins suggested several useful strategies to increase the public profile of nurses/nursing, including;

  1. Making nursing central to health policy in every country and raising the profile of the nurse profession.

  2. Increase recruitment of nurses in education and training.

  3. Develop nurse leadership skills.

  4. Enable nurses to work to their potential.

  5. Obtain evaluations on the impact of nursing on access, cost and quality.

  6. Develop nursing to have a triple impact on health, gender equality and economies.

In conclusion, current media images and public perceptions of nursing are outdated and have contributed to perpetuating many of the erroneous social constructions in and of nursing. These ideas have inadvertently contributed to disempowerment and devaluing the profession. After the unforeseen media attention during the pandemic, nursing has an opportunity to embrace strategies to challenge misperceptions and increase the public and professional profile of nurses.

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References

Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.