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DISCUSSION PAPER

The nursing profession: public image, self-concept and professional

identity. A discussion paper

Yvonne ten Hoeve, Gerard Jansen & Petrie Roodbol

Accepted for publication 27 April 2013

Correspondence to Y. ten Hoeve:

e-mail: [email protected]

Yvonne ten Hoeve MA

Researcher, PhD Candidate

School of Nursing & Health,

University Medical Center, Groningen,

The Netherlands

Gerard Jansen PhD

Senior Lecturer Master of Advanced

Nursing Practice

School of Nursing, Hanze University of

Applied Sciences, Groningen,

The Netherlands

Petrie Roodbol PhD RN

Professor of Nursing Science

School of Nursing & Health,

University Medical Center, Groningen,

The Netherlands

T E N H O E V E Y . , J A N S E N G . & R O O D B O L P . ( 2 0 1 4 ) The nursing profession:

public image, self-concept and professional identity. A discussion paper. Journal

of Advanced Nursing 70(2), 295–309. doi: 10.1111/jan.12177

Abstract Aim. To discuss the actual public image of nurses and other factors that influence

the development of nurses’ self-concept and professional identity.

Background. Nurses have become healthcare professionals in their own right

who possess a great deal of knowledge. However, the public does not always

value the skills and competences nurses have acquired through education and

innovation.

Design. Discussion paper.

Data sources. We identified 1216 relevant studies by searching MEDLINE,

CINAHL and PsycINFO databases in the period 1997–2010. Finally, 18 studies

met our inclusion criteria.

Discussion. The included studies show that the actual public image of nursing is

diverse and incongruous. This image is partly self-created by nurses due to their

invisibility and their lack of public discourse. Nurses derive their self-concept and

professional identity from their public image, work environment, work values,

education and traditional social and cultural values.

Implications for nursing. Nurses should work harder to communicate their

professionalism to the public. Social media like the Internet and YouTube can be

used to show the public what they really do.

Conclusion. To improve their public image and to obtain a stronger position in

healthcare organizations, nurses need to increase their visibility. This could be

realized by ongoing education and a challenging work environment that

encourages nurses to stand up for themselves. Furthermore, nurses should make

better use of strategic positions, such as case manager, nurse educator or clinical

nurse specialist and use their professionalism to show the public what their work

really entails.

Keywords: job performance, literature review, nurses, perception, professional

identity, public image, self-concept

Introduction

The professionalization of nurses through education and

innovation has proven to be the focus of one of the most

significant and ongoing discussions in the history of nursing.

Worldwide, nurses have developed themselves into profes-

sionals with a great deal of knowledge, as witnessed by the

development of nursing protocols and guidelines. Despite

these developments towards professionalization, previous

studies on this subject have shown that nurses are not given

due recognition for the skills they have by the majority of

the public. The essence of nursing is not always clear and

nurses still suffer from (gender) stereotypes (Bridges 1990,

Hallam 1998, Warner et al. 1998). A stereotype can be

defined as ‘a cognitive representation or impression of a

social group that people form by associating particular char-

acteristics and emotions with the group’ (Smith & Mackie

2007). Bridges (1990) identified 34 different stereotypes of

nurses, most of which have negative connotations. Bridges’

study also showed that the media often depict nurses work-

ing at the patient’s bedside and performing repetitive and

routine tasks, mostly as the doctor’s handmaiden (Bridges

1990). Other studies indicate that the portrayal of nurses in

the media might give a clue as to how their public image is

perceived (Kalisch & Kalisch 1983, Warner et al. 1998,

Gordon 2005). These studies show that the public image of

nurses does not always match their professional image;

nurses are not depicted as autonomous professionals and the

public is not aware that nowadays nursing is to a great

extent a theory-based and scholarly profession (Dominiak

2004). The nursing discipline has undergone tremendous

developments over the last 30 years of the 20th century and

in the first decade of the 21st century, in particular, with

respect to professionalization. The professionalization of

nursing is closely intertwined with a focus on the develop-

ment of nursing theory (Meleis 1997), nursing research and

nursing practice, which ideally are interrelated. Research

can validate theory, which then may change nursing practice

(Donahue1998). Nightingale and Henderson have been

visible forces for nursing across boundaries, in respectively

the 19th and the 20th century. Moreover, the nursing

profession has developed numerous types of education

programmes in the last decades, which resulted in a variety

of nursing levels, like bachelor, master and doctoral degrees.

Even the most respected news media sources belittle nursing,

so readers do not get a sense that nurses are educated life-

saving professionals (Summers & Summers 2009).

Although the phenomenon of nursing and its characteris-

tics are carefully considered, this has not yet resulted in a

public image that recognizes the scientific and professional

development of the nursing profession. The aim of this

paper is to discuss the current state of affairs regarding the

public image of nurses worldwide and to analyse the poten-

tial influence of this image on the development of nurses’

self-concept and professional identity. A search of the litera-

ture is performed and recent publications on these themes

are brought together to broaden this discussion.

Background

Although Florence Nightingale saw nursing as an indepen-

dent profession that was not subordinate but equal to the

medical profession (Nightingale 1969), for a long time nurs-

ing was seen as inseparable from the medical profession. The

medical (male) dominance strongly influenced the role devel-

opment, the image and the position of nurses (Hallam 2000,

Gordon 2005, Fletcher 2006). Previous studies on this

subject show that nurses have always been strongly aware of

their subordination to the medical profession and are still

experiencing high levels of dissatisfaction with their profes-

sional status. Twaddle and Hessler (1987) investigated how

the domination of nursing by others originated. They found

that in the Western civilization, domination began in the

early 1900s, when medicine became a dominant force and

care of the sick became institutionalized. The study of Walby

et al. (1994) shows that the nursing and medical professions

in Western Europe have a complicated relationship, which

amongst others is mediated by hierarchy and subordination.

The workplace studies of Adamson et al. (1995) and Aiken

and Sloane (1997) demonstrated how the impact of medical

dominance on autonomy and job satisfaction of nurses led

to decreased patient outcomes. Adamson et al. (1995) exam-

ined the influence of perceived medical dominance on the

workplace satisfaction of Australian and British nurses. The

results of their study show that medical dominance is an

obstacle to the workplace satisfaction of both Australian

and British nurses, who experienced a high degree of dissat-

isfaction with their professional status. Historically, nurses

deferred to physicians, for reasons that include the disparity

of power between the genders (Summers & Summers 2009).

However, understanding nursing and the development of

nursing and medicine cannot be separated from understand-

ing the societal context, as Kalisch and Kalisch (1995) dem-

onstrate in their study on American nursing.

The traditional role and image of nurses can be seen as

the expressions of an oppressed group. The dominance of

the oppressor, in this case the physician, marginalizes the

oppressed group and may lead to the development of low

self-concept, which can in turn lead to negative self-presen-

tation (Fletcher 2006, 2007). Self-concept is closely related

Y. ten Hoeve et al.

to professional self-concept, which is a prerequisite for the

vocational and academic development of the identity of a

profession (Arthur 1995, Arthur & Randle 2007).

The idea of being subordinated to the medical profession

is not the only factor that influences the self-concept and

professional identity of nurses. Other determinants include

work environment, work values, education and culture.

Professional identity and self-concept can undergo changes

due to interactions with colleagues, other healthcare profes-

sionals and patients. Work environment and work values

can also play a role in this respect (Mills & Blaesing 2000,

Ewens 2003, Allen 2004). Education and the acquisition of

knowledge are likely to have an impact on nurses’ job

satisfaction and self-concept (Arthur 1992, Pask 2003).

Furthermore, international differences in traditional cultural

and social values need to be taken into account when

measuring nurses’ professional identity and self-concept

(Fealy 2004, Thupayagale-Tshweneagae & Dithole 2007).

There is a strong need for a discussion on the image, the

self-concept and the professional identity of nurses in a

global context. The outcomes of such a discussion can help

nurses develop strategies to achieve a public image that

reflects their scholarship and professionalism. This paper

looks at the characteristics of the international development

of these important issues.

Data sources

Search methods

A literature search was performed using the databases

MEDLINE, CINAHL and PsycINFO. The search strategy

aimed to retrieve suitable studies published between 1997

and 2010. The search terms used were nurses, nurse*, per-

ception, public image, professional image, stereotyp*, self

concept, power, public opinion and social identification.

Original research was included if it was published in Eng-

lish and available as a full-text article. The research design

of the studies had to be clear, with sample, instrument(s)

and statistical method explicitly described.

Search outcome

The first search resulted in 1216 citations. After screening

these on title, 287 abstracts were included for further

assessment. The first author assessed the abstracts on their

relevance for the purpose of the study, which resulted in

58 articles. These were reviewed by all authors and finally

18 articles were included in this discussion paper. Rele-

vant studies included studies that examined the role of

the public image of the nursing profession, studies that

analysed the way nurses develop their self-concept and

professional identity or studies that looked at the influence

of the public image on nurses’ self-concept and profes-

sional identity. Figure 1 shows a flow chart of the

selection process.

The included studies were heterogeneous with respect to

design, sample and setting. The samples vary from 1957

RNs to five communication professionals. The settings were

a university nursing school, the clinical setting of a hospital

or a variety of settings. The included studies were

conducted in Australia (3), Brazil (3), Sweden (3), USA (3),

Taiwan (2), Hong Kong (1), Israel (1), Japan (1) and

Norway (1).

Studies excluded, after abstract analysis

(n = 229)

Studies retrieved for more detailed evaluation

(n = 58)

Potentially relevant studies identified and screened for retrieval

(n = 1216)

Studies retrieved for evaluation (n = 287)

Studies excluded, after title analysis

(n = 929)

Studies excluded, after full text analysis

(n = 40)

Studies included in the literature review

(n = 18) Figure 1 Flow chart of study selection process.

JAN: DISCUSSION PAPER Public image and professional identity of nurses

Data abstraction and synthesis

A keyword analysis was performed based on the concepts

of public image, professional identity and self-concept.

Next, a content analysis of the included studies was

conducted to systematically identify the main characteristics

of the studies on the basis of the terms public image, self-

concept and professional identity. Extracted data included

author(s), year and country of publication, study design,

quality of the study, sample, instrument(s), data analysis,

aim of the study, outcomes on public image, outcomes on

self-concept and professional identity and comments. The

main characteristics of the 18 included studies are presented

in Table 1.

Subsequently, the articles were judged on their substan-

tive concepts to identify the main themes. Five main themes

were identified: (1) work environment and work values; (2)

education and career choice; (3) traditional values, culture

and gender; (4) caring; and (5) identity and performance.

The themes and related studies are presented in Table 2.

Discussion

Nurses’ depiction in the media

The image of nursing is determined by how nurses them-

selves and others (the public) perceive nursing. Earlier

studies have indicated that the public image of nurses

often differs from nurses’ own image of nursing. This

public image is predominantly based on misconceptions

and stereotypes, which find their origins in distorted

images of nurses in the media. The media plays a part in

perpetuating the stereotype of the nurse as angels of

mercy, the doctor’s handmaiden, battleaxe and sexy nurse

(Bridges 1990, Hallam 1998, Gordon & Nelson 2005).

Due to such images, the public views nurses as feminine

and caring, but not necessarily as autonomous healthcare

providers (Takase et al. 2006, Kemmer & Silva 2007).

Kalisch and Kalisch (1981, 1982a,b,c, 1983) have con-

ducted extensive research on the image of nursing in the

media (newspapers, TV, films, novels). They identified six

images of nurses corresponding to six different periods:

(1) Angel of Mercy (1854–1919); (2) Girl Friday (1920–

1929); (3) Heroine (1930–1945); (4) Mother (1946–

1965); (5) Sex Object (1960–1982); and (6) Careerist

(1983–Present). The presence of these stereotypical images

is confirmed by Gordon (2005), who analysed the image

of nurses in advertising campaigns and found that even

though much has changed for women in the 20th cen-

tury, images of nurses still rely on images of angels.

Nurses are generally prized for their virtues, not their

knowledge. In contrast, the study of Stanley (2008), who

analysed the image of nurses in feature films made in the

Western world, shows a more nuanced picture. Stanley

(2008) examined 36,000 feature film synopses and found

that while early films portrayed nurses as self-sacrificial

heroines, sex objects and romantics, more recent films

portray nurses as strong and self-confident professionals.

A recent study of Kelly et al. (2012) discussed how

nurses and nursing identities are constructed in video

clips on YouTube. Three nursing identity types could be

found as follows: the nurse as ‘a skilled knower and

doer’, the nurse as ‘a sexual plaything’ and the nurse as

‘a witless incompetent individual’. Although the results of

these studies show a rather heterogeneous picture of the

image of nursing, the stereotypical images of nurses nev-

ertheless remain persistent.

We have identified several aspects of these stereotypical

images in the studies discussed in this paper and, as can be

expected from the outcomes of previous studies, the results

show that the actual public image of nursing is diverse and

incongruous and tends to be influenced by nursing stereo-

types ( €Ohl�en & Segesten 1998, Takase et al. 2002). With

respect to male nurses, men were either portrayed as the

second sex in nursing care (Dahlborg-Lyckhage & Pilham-

mar-Anderson 2009), or as nurses with different work

patterns who are not influenced by marriage (Liu 2010). €Ohl�en and Segesten (1998) demonstrate that male nurses

experience uncertainty from other people meeting a male

nurse as a result of stereotyped images.

The media’s projection of images of nurses, in ways that

neglect the official requirements of the profession, also has

an impact on the view of the public on nursing (Takase

et al. 2001, Dahlborg-Lyckhage & Pilhammar-Anderson

2009). Nurses seem to be viewed as feminine and caring,

not as autonomous healthcare providers (Takase et al.

2006, Kemmer & Silva 2007). Moreover, nursing is seen

as a profession with limited career opportunities (Huffstu-

tler et al. 1998, Ben Natan & Becker 2010). Donelan

et al. (2008) report more positive findings. They demon-

strate that the nursing profession is highly respected by

the American public, but nevertheless, the authors con-

clude that a nursing shortage persists in the USA. The

study of Kalisch et al. (2007) also shows that nurses are

seen as qualified, skilled and respectable professionals. The

limitation is that, in their study, Professional Nursing

Organizations and job sites are populating nursing on the

internet. From the results of the studies, we may carefully

conclude that the image of nurses in the media does not

(yet) meet the professional image of nursing.

Y. ten Hoeve et al.

T a b le

1 C h a ra ct er is ti cs

o f th e in cl u d ed

st u d ie s.

R ef er en ce

S tu d y d es ig n

S a m p le /i n st ru m en t

D a ta

a n a ly si s

A im

P u b li c im

a g e

C o m m en ts

P u b li c Im

a g e

B en

N a ta n a n d

B ec k er

(2 0 1 0 )

Q u a n ti ta ti v e

m et h o d s

D es cr ip ti v e su rv ey

3 0 9 a d u lt s 1 8 – 5 0 y ea rs

M cC

a b e q u es ti o n n a ir e

D es cr ip ti v e st a ti st ic s,

in fe re n ti a l st a ti st ic s; t- te st s

p a ra m et ri c te st s; S p ea rm

a n

co rr el a ti o n

T o cl a ri fy

fa ct o rs

th a t

in fl u en ce

th e ch o ic e o f id ea l

ca re er s a n d n u rs in g ca re er s

a m o n g th e g en er a l

p o p u la ti o n

T h e p u b li c h a s a m a jo r m is p er ce p ti o n o f

n u rs es ’ w o rk . C a re er s in

n u rs in g a re

p er ce iv ed

a s te d io u s a n d la ck in g ch a ll en g es ,

cr ea ti v it y , re sp o n si b il it y , h ig h w a g es , st a tu s

a n d co m fo rt a b le

w o rk in g co n d it io n s

N u rs in g sc h o o ls n ee d to

p ro m o te

th e

n u rs in g p ro fe ss io n a m o n g th e p u b li c.

L ec tu re s b y n u rs es

a re

v er y si g n ifi ca n t.

R es ea rc h is

n ec es sa ry

to ex a m in e w h y

p eo p le

w h o a re

in tr in si ca ll y m o ti v a te d

to ch o o se

a ca re -g iv in g p ro fe ss io n d o

n o t ch o o se

a ca re er

in n u rs in g .

D a h lb o rg -L y ck h a g e

a n d P il h a m m a r-

A n d er so n (2 0 0 9 )

Q u a li ta ti v e d es ig n

D is co u rs es

fr o m

1 9 9 9 – 2 0 0 3

D o cu m en ts , re p o rt s,

C a m p a ig n s, T V

se ri es

D is co u rs e a n d co n te n t

a n a ly si s

T o ex p li ca te

th e p re d o m in a n t

d is co u rs e in

th e fi el d o f

S w ed is h n u rs in g

T h e m ed ia

p la y a m a jo r ro le

in d is se m in a ti n g

p re v a il in g co n ce p ti o n s a n d co n v en ti o n s

p er ta in in g to

th e n u rs in g p ro fe ss io n . T h e

m ed ia

p re se n t n u rs in g in

w a y s th a t n eg le ct

th e o ffi ci a l re q u ir em

en ts

o f th e p ro fe ss io n

H ea lt h ca re

se em

s to

b e m o re

h ea v il y

in fl u en ce d b y th e m ed ia

th a n b y th e

o ffi ci a l re q u ir em

en ts

o f n u rs in g .

T h er ef o re , th e p u b li c co u ld

re ce iv e lo w

ex p ec ta ti o n s o f th e co m p et en ce s o f

n u rs in g

D e A ra u jo

S a rt o ri o

a n d P a v o n e

Z o b o li (2 0 1 0 )

Q u a li ta ti v e st u d y

w it h in

th e sc o p e

o f d es cr ip ti v e

et h ic s

1 8 n u rs e te a ch er s

S em

i- st ru ct u re d a n d

u n st ru ct u re d in te rv ie w s

H er m en eu ti c- d ia le ct ic

m et h o d

T o id en ti fy

th e et h ic a l im

a g e

o f n u rs in g

F iv e d is ti n ct iv e p er sp ec ti v es

o f a n et h ic a l n u rs e

em er g ed

a s fo ll o w s:

g o o d n u rs es

fu lfi l th ei r

d u ti es

co rr ec tl y ; g o o d n u rs es

a re

p ro a ct iv e

p a ti en t a d v o ca te s; g o o d n u rs es

a re

p re p a re d

a n d a v a il a b le

to w el co m e o th er s a s p er so n s;

g o o d n u rs es

a re

ta le n te d , co m p et en t a n d

ca rr y o u t p ro fe ss io n a l d u ti es

ex ce ll en tl y ; g o o d

n u rs es

co m b in e a u th o ri ty

a n d p o w er

sh a ri n g

in p a ti en t ca re

S o m e p er sp ec ti v es

p o in te d to

tr a it s fr o m

th e p a st . T h is ca u se d so m e co n ce rn ,

b ec a u se

st u d en ts

sh o u ld

n o t st a rt

th ei r

ca re er s w it h th e sh a d o w s o f h is to ri ca l

h u rt s.

F a cu lt y sh o u ld

m a k e th e te a ch in g

a n d w o rk

o f n u rs in g h ea lt h ie r

D o n el a n et

a l.

(2 0 0 8 )

Q u a li ta ti v e

d is p ro p o rt io n a te

st ra ti fi ed

sa m p li n g

d es ig n

1 6 0 4 re sp o n d en ts

a g e 1 8 a n d

o ld er

S u rv ey : C o m p u te r- A ss is te d

T el ep h o n e In te rv ie w in g

S tr a ti fi ca ti o n sc h em

e a n d

sa m p le

b a la n ci n g

T o ex a m in e th e in fl u en ce

o f

so ci et a l d em

o g ra p h ic s,

p er ce p ti o n s o f th e n u rs in g

sh o rt a g e a n d m ed ia

in fl u en ce s o n p er ce p ti o n s o f

n u rs in g ca re er s

Im a g es

o f n u rs es

a re

p a rt ly

sh a p ed

b y p er so n a l

ex p er ie n ce

w it h n u rs es , b u t a ls o b y ex p o su re

in th e m ed ia

(T V , n ew

s) . T h is

ex p o su re

m o re

h el p fu l th a n h a rm

fu l

T h e n u rs in g p ro fe ss io n is

h ig h ly

re sp ec te d .

N ev er th el es s,

a sh o rt a g e o f n u rs es

p er si st s. Im

p le m en ti n g a w o rk fo rc e

st ra te g y is es se n ti a l to

u n d er st a n d a n d

m a in ta in

th e p u b li c’ s su p p o rt

fo r th e

n u rs in g p ro fe ss io n

H u ff st u tl er

et a l.

(1 9 9 8 )

Q u a li ta ti v e su rv ey

8 3 1 in te rv ie w s w it h n o n -

n u rs in g u n iv er si ty

st u d en ts ,

p ro fe ss io n a l p er so n s, o th er

n o n -n u rs in g in d iv id u a ls

In te rv ie w s w it h th re e o p en -

en d ed

q u es ti o n s

S ec o n d a ry

a n a ly si s te ch n iq u e

T o ev a lu a te

th e p er ce p ti o n s o f

n u rs in g ’s im

a g e b y n o n -

n u rs in g u n iv er si ty

st u d en ts ,

p ro fe ss io n a ls , a n d o th er

n o n -n u rs in g in d iv id u a ls

S tu d en t o p in io n s o f n u rs in g w er e si g n ifi ca n tl y

a ff ec te d b y p a re n ts , fr ie n d s a n d g u id a n ce

co u n se ll o rs . T h e m ea n in g a n d p ra ct ic e o f

n u rs in g ca re

is n o t en ti re ly

u n d er st o o d b y th e

v a ri o u s in d iv id u a ls w h o w er e in te rv ie w ed

N u rs es

n ee d to

b e a g en ts

o f ch a n g e a n d

ed u ca te

th e p u b li c a b o u t th e m a n y

d if fe re n t p o ss ib il it ie s a v a il a b le

in b a si c

n u rs in g a n d a d v a n ce d p ra ct ic e

p re p a ra ti o n

JAN: DISCUSSION PAPER Public image and professional identity of nurses

T a b le

1 (C

o n ti n u ed ).

R ef er en ce

S tu d y d es ig n

S a m p le /i n st ru m en t

D a ta

a n a ly si s

A im

P u b li c im

a g e

C o m m en ts

K a li sc h et

a l.

(2 0 0 7 )

Q u a n ti ta ti v e

d es cr ip ti v e

co m p a ra ti v e

d es ig n

N u rs in g w eb si te s

1 4 4 in

2 0 0 1

1 5 2 in

2 0 0 4

In te rn et

N u rs in g Im

a g e T o o l

D es cr ip ti v e st a ti st ic s; P ea rs o n

X 2 te st s; n o n -p a ra m et ri c

te st s, in te rr a te r re li a b il it y

T o a n a ly se

th e im

a g e o f

n u rs in g o n th e In te rn et

a n d

to re se a rc h w h et h er

th is

im a g e u n d er w en t ch a n g es

fr o m

2 0 0 1 – 2 0 0 4

O n e o f th e m a jo r in fl u en ce s o n th e im

a g e o f

n u rs es

is th e la rg el y in a cc u ra te

a n d n eg a ti v e

p o rt ra y a l o f th e n u rs in g p ro fe ss io n . T h is

im a g e h a s a n im

p a ct

o n th e q u a li ty

a n d

q u a n ti ty

o f th e w o rk

p er fo rm

T h is st u d y re v ea ls a re la ti v el y p o si ti v e

im a g e o f n u rs in g o n th e in te rn et .

U n fo rt u n a te ly , a d o w n w a rd

tr en d in

th e

d ep ic ti o n o f n u rs e ch a ra ct er is ti cs

ev id en t. T h e In te rn et

o ff er s n u rs es

th e

o p p o rt u n it y to

d em

o n st ra te

th e b es t

a sp ec ts

o f th ei r p ro fe ss io n

K em

m er

a n d S il v a

(2 0 0 7 )

Q u a li ta ti v e cr o ss -

se ct io n a l

d es cr ip ti v e st u d y

5 C o m m u n ic a ti o n

p ro fe ss io n a ls

S em

i- st ru ct u re d in te rv ie w s

C o ll ec ti v e su b je ct

d is co u rs e

D es cr ip ti v e a n a ly si s

T o fu rt h er

th e u n d er st a n d in g

o f th e so ci a l re p re se n ta ti o n s

o f n u rs es

a n d th e n u rs in g

p ro fe ss io n b y co m m u n i-

ca ti o n p ro fe ss io n a ls

T h e m ed ia

tr a n sm

it a d is to rt ed

im a g e

o f n u rs es . N u rs es

a re

d ep ic te d a s th e

d o ct o r’ s sh a d o w

a n d n o t a s p ro fe ss io n a ls

T o g iv e m o re

v is ib il it y to

th e n u rs in g ro le

p ro fe ss io n a ls n ee d to

p o si ti o n th em

se lv es

st ra te g ic a ll y a n d to

ed u ca te

th e p u b li c

o n n u rs in g (T V , in te rn et , n ew

s, p re ss ).

In v is ib il it y d im

in is h es

n u rs es ’ a b il it y to

ch a n g e th e d ir ec ti o n s o f h ea lt h ca re

S el f- c o n c e p t a n d p ro fe ss io n a l id e n ti ty

A rt h u r et

a l. (1 9 9 9 )

Q u a n ti ta ti v e d es ig n

1 9 5 7 R N s fr o m

1 1 co u n tr ie s

Q u es ti o n n a ir es : P S C N I; T IQ

;

T IS Q ; C A Q

C o rr el a ti o n a n d re li a b il it y

a n a ly si s;

A N O V A

T o co m p a re

th e ca ri n g

a tt ri b u te s o f R N s fr o m

el ev en

d if fe re n t co u n tr ie s

w it h th ei r v ie w s o f

th em

se lv es

a n d th ei r

p er ce p ti o n s o f te ch n o lo g ic a l

in fl u en ce s o n th ei r p ra ct ic e.

P a rt ic ip a n ts

v a lu ed

p ro fe ss io n a l in te ra ct io n

w it h co ll ea g u es

a n d b el ie v ed

in th ei r sk il ls

a n d fl ex ib il it y a s n u rs es . T h ey

fe lt re sp ec te d

b y o th er

p ro fe ss io n a ls , b u t w er e le ss

co n v in ce d th a t th ei r ca re er

w a s g o in g in

th e

d ir ec ti o n th ey

h a d en v is io n ed

b ef o re

st a rt in g

N u rs es

w o rl d w id e h a v e m u ch

in co m m o n ,

b u t st il l re ta in

in d iv id u a l cu lt u ra l

fe a tu re s re la te d to

ca ri n g a n d th ei r

p ra ct ic e a s n u rs es . F u tu re

st u d ie s a re

re co m m en d ed

to ex a m in e,

re sp ec t,

p re se rv e a n d n u rt u re

th es e u n iq u e

ch a ra ct er is ti cs

F a g er b er g a n d

K ih lg re n (2 0 0 1 )

Q u a li ta ti v e

lo n g it u d in a l st u d y

2 7 n u rs in g st u d en ts

1 9 n u rs es

In te rv ie w s a n d d ia ri es

P h en o m en o lo g ic a l

h er m en eu ti cs

T o u n d er st a n d h o w

n u rs es

ex p er ie n ce

th e m ea n in g o f

th ei r id en ti ty

a s n u rs es , a s

st u d en ts

a n d tw

o y ea rs

a ft er

g ra d u a ti o n

T h e co n te x t in

w h ic h n u rs es

w o rk

is v er y

im p o rt a n t fo r th e d ev el o p m en t o f th ei r

id en ti ty , sk il ls a n d ex p er ti se

a s n u rs es . A ll

n u rs es

n a rr a te d th ei r st o ri es

fr o m

o n e

d o m in a n t p er sp ec ti v e,

w h ic h is

u n d er st o o d a s

th ei r p ro fe ss io n a l id en ti ty

P a rt ic ip a n ts

d id

n o t sh if t th ei r d o m in a n t

p er sp ec ti v e o v er

ti m e.

It m a y b e

u n d er st o o d a s th e n u rs es ’ li fe

p a ra d ig m

F a g er m o en

(1 9 9 7 )

M ix ed

M et h o d

S u rv ey

+ fo cu s

g ro u p s

7 6 7 n u rs es

+ 6 n u rs es

Q u es ti o n n a ir es

+ in te rv ie w s

H er m en eu ti ca l a n a ly si s

T o id en ti fy

th e v a lu es

u n d er ly in g n u rs es ’

p ro fe ss io n a l id en ti ty

a s

ex p re ss ed

b y w h a t is

m ea n in g fu l in

n u rs es ’ w o rk

W o rk in g a s n u rs es

m a in ta in s a n d en h a n ce s

th ei r se lf -c o n ce p t b o th

a s n u rs es

a n d a s

p er so n s. T h e v a lu e o f a lt ru is m

o r ca re

fo r th e

p a ti en ts ’ h ea lt h a n d w el l- b ei n g a p p ea re d to

b e a n o v er ri d in g v a lu e;

a m o ra l p o in t o f v ie w

o n w h ic h th ey

b a se d th ei r p ra ct ic e

S h o rt a g e o f p er so n n el

a n d ti m e w er e

p er ce iv ed

to a ff ec t th e o p p o rt u n it ie s fo r

p ro v id in g q u a li ty

n u rs in g ca re , w h ic h in

tu rn

w a s ex p er ie n ce d a s a st ra in

a n d fo r

so m e cr ea te d a fe el in g o f m ea n in g le ss n es s

G re g g a n d

M a g il v y (2 0 0 1 )

G ro u n d ed

th eo ry

D es ig n

1 8 n u rs es

In te rv ie w s

O b se rv a ti o n s

T h eo re ti ca l m em

o s

C o n st a n t co m p a ra ti v e

a n a ly si s

T o ex p lo re

th e p ro ce ss

o f

es ta b li sh in g th e p ro fe ss io n a l

id en ti ty

o f Ja p a n es e n u rs es

N u rs es ’ w o rk

co n tr ib u te s to

th ei r p ro fe ss io n a l

g ro w th

a n d sa ti sf a ct io n . P a rt ic ip a n ts

id en ti fi ed

th em

se lv es

a s n u rs es

th ro u g h

in te g ra ti n g a n u rs e in to

se lf . T h e fi n d in g s

a ck n o w le d g e th e in se p a ra b il it y o f

id en ti fi ca ti o n w it h n u rs in g a n d co m m it m en t

to n u rs in g

N u rs es

a s ed u ca to rs

a n d ro le

m o d el s a re

es se n ti a l to

th e p ro ce ss

o f es ta b li sh in g a

p ro fe ss io n a l id en ti ty

Y. ten Hoeve et al.

R ef er en ce

S tu d y

d es ig n

S a m p le /i n st ru m en t D a ta

a n a ly si s

A im

P u b li c im

a g e

S el f- co n ce p t P ro fe ss io n a l id en ti ty

C o m m en ts

P u b li c im

a g e,

se lf -c o n c e p t a n d p ro fe ss io n a l id e n ti ty

D eM

ei s et

a l.

(2 0 0 7 )

Q u a li ta ti v e

st u d ie s

2 7 n u rs in g p ro fe ss io n a ls

In te rv ie w s

C o n te n t a n a ly si s

In te rp re ta ti v e

p h en o m en o lo g ic a l

a n a ly si s (I P A )

T o p re se n t n a rr a ti v es

o f

p ro fe ss io n a l id en ti ty

a m o n g

n u rs es

in B ra zi l a n d se a rc h

fo r m ea n in g s o f ca re

a n d

th ei r p la ce

in n u rs in g

a ct iv it ie s

N u rs in g is

st il l in fl u en ce d b y

tr a d it io n a l v a lu es . N u rs in g is

se en

a s a p ro fe ss io n o f lo w

so ci a l st a tu s a n d a s a d o m es ti c

a ct iv it y th a t d o es

n o t re q u ir e

q u a li fi ca ti o n s

N u rs es

p o ss es

a lo w

p ro fe ss io n a l

se lf -e st ee m , ca u se d b y a

n eg a ti v e p u b li c im

a g e

W it h th e p ro ce ss

o f in cr ea si n g

p ro fe ss io n a li za ti o n , n u rs es

a cq u ir e h ig h er

a ca d em

q u a li fi ca ti o n s a n d te ch n ic a l

k n o w le d g e,

b u t ca re

d el eg a te d to

so ci a ll y le ss -

v a lu ed

p ro fe ss io n a ls

L iu

(2 0 1 0 )

Q u a li ta ti v e

st u d y

2 0 n u rs es

W eb -b a se d o n li n e fo ru m

o p en -e n d ed

q u es ti o n s

T h em

a ti c a n a ly si s

T o ex p lo re

n u rs es ’ p er ce p ti o n s

o f th ei r w o rk

ro le

o n th e

b a si s o f th e p er sp ec ti v es

o f

C h in es e g en d er

ro le s a n d

cu lt u re

In C h in es e cu lt u re , th e

tr a d it io n a l g en d er

ro le s h a v e a

st ro n g in fl u en ce

o n th e p u b li c

im a g e o f p h y si ci a n s a n d

n u rs es . N u rs in g is

st il l se en

a s

a fe m in in e,

ca ri n g o cc u p a ti o n ,

w it h lo w

p ro fe ss io n a l st a tu s

a n d su b o rd in a te

to p h y si ci a n s

N u rs es ’ p er ce p ti o n s o f th ei r ro le

a n d w o rk

en v ir o n m en t a re

st ro n g ly

in fl u en ce d b y cu lt u re

a n d g en d er

st er eo ty p es

A m o re

g en d er -s en si ti v e w o rk

en v ir o n m en t in

h ea lt h ca re

is re co m m en d ed . N u rs es

co u ld

co n tr ib u te

b y a sk in g

th e g o v er n m en t to

im p le m en t g en d er

eq u a li ty

ed u ca ti o n p ro g ra m m es

€ O h l� e n a n d

S eg es te n

(1 9 9 8 )

Q u a li ta ti v e

S u rv ey

8 R N s

S em

i- st ru ct u re d

in te rv ie w s

C o n ce p t a n a ly si s

T o h ig h li g h t th e co n ce p t o f

p ro fe ss io n a l id en ti ty

o f

n u rs es

to p ro m o te

th eo re ti ca l cl a ri ty

a n d

ex a m in e im

p li ca ti o n s fo r

n u rs in g p ra ct ic e

N u rs es

a re

p a rt

o f a so ci a l

st ru g g le

fo r p o w er

w h er e

id ea s a re

cr ea te d th ro u g h

g en d er

se g re g a ti o n . T h e

st er eo ty p ic a l im

a g e o f th e

n u rs e in

th e m ed ia

is a n

ex p re ss io n o f th is st ru g g le

P ro fe ss io n a l id en ti ty

is d ev el o p ed

th ro u g h in te ra ct io n w it h o th er

n u rs es

a n d h a s a st ro n g im

p a ct

o n n u rs es ’ se lf -e st ee m

a n d

em p o w er m en t. T h e p ro fe ss io n a l

se lf -i m a g e o f th e n u rs e is a ls o

b a se d o n th e id ea s o f p eo p le , in

g en er a l, re g a rd in g n u rs es

P ro fe ss io n a l p er so n a l

d ev el o p m en t a n d g ro w th

o f

n u rs es

sh o u ld

b e m a d e

p o ss ib le

th ro u g h th e

d ev el o p m en t o f p er so n a l

se lf -c a re

sk il ls a n d in cr ea se d

p o ss ib il it ie s fo r n u rs es

fo r

sh a ri n g ex p er ie n ce s w it h

o th er

n u rs es

in a n a rr a ti v e

a n d re fl ec ti v e w a y

T a k a se

et a l.

(2 0 0 1 )

Q u a n ti ta ti v e

d es cr ip ti v e

co rr el a ti o n a l

d es ig n

8 0 R N s

IW S ; P N IS ;

S ix -D

im en si o n S ca le

o f

N u rs in g P er fo rm

a n ce

D es c.

st a ti st ic s; P ea rs o n ;

C ro h n b a ch

a co ef fi ci en t

T o in v es ti g a te

n u rs es ’

re sp o n se s to

th e im

a g e

d is cr ep a n cy

b et w ee n th e

p u b li c a n d n u rs es

a n d it s

re la ti o n sh ip

w it h th ei r se lf -

co n ce p t, jo b sa ti sf a ct io n a n d

p er fo rm

a n ce

T h e m ed ia

p ro je ct

d is to rt ed

im a g es

o f n u rs in g . T h e

p u b li c’ s p er ce p ti o n o f th e

n u rs in g p ro fe ss io n te n d s to

b e

in fl u en ce d b y th es e n u rs in g

st er eo ty p es

N u rs es

p er ce iv e th ei r p u b li c

im a g e m o re

n eg a ti v el y

co m p a re d w it h h o w

th ey

se e

th em

se lv es , w h ic h ca u se s im

a g e

d is cr ep a n cy . T h is

ca n le a d to

jo b d is sa ti sf a ct io n a n d lo w

jo b

p er fo rm

a n ce s

T h e d ev el o p m en t o f

co u n te ra ct iv e m ea su re s to

p u b li c st er eo ty p es

co u ld

le a d

to im

p ro v em

en t o f n u rs in g

p ra ct ic e,

w h ic h ca n ch a n g e

th e p u b li c’ s a tt it u d e to w a rd s

n u rs in g

T a b le

1 (C

o n ti n u ed ).

JAN: DISCUSSION PAPER Public image and professional identity of nurses

T a b le

1 (C

o n ti n u ed ).

R ef er en ce

S tu d y

d es ig n

S a m p le /i n st ru m en t D a ta

a n a ly si s

A im

P u b li c im

a g e

S el f- co n ce p t P ro fe ss io n a l id en ti ty

C o m m en ts

T a k a se

et a l.

(2 0 0 2 )

Q u a n ti ta ti v e

D es cr ip ti v e

C o rr el a ti o n a l

st u d y

8 0 R N s

P N IS ; S el f- es te em

sc a le ;

IW S ; S ix

D im

. S ca le

o f

N u rs . P er fo rm

a n ce ;

D es cr . S ta t;

C ro h n b a ch ; A N O V A ;

P ea rs o n

T o id en ti fy

th e re la ti o n sh ip s

b et w ee n n u rs es ’ p er ce p ti o n

o f co m m o n p u b li c

st er eo ty p es

o f th ei r

p ro fe ss io n , n u rs es ’ se lf -

co n ce p t, se lf -e st ee m , jo b

sa ti sf a ct io n a n d jo b

p er fo rm

a n ce

T h e p u b li c st il l h a s a

st er eo ty p ic a l im

a g e o f n u rs es ,

w h ic h in fl u en ce s th e

d ev el o p m en t o f n u rs es ’

se lf -c o n ce p t

N u rs es

w h o p er ce iv e th ei r p u b li c

im a g e m o re

n eg a ti v el y te n d to

re p o rt

a m o re

n eg a ti v e se lf -

co n ce p t. T h e g re a te r th e se lf -

co n ce p t, o r jo b sa ti sf a ct io n , th e

g re a te r th e p er fo rm

a n ce

a n d th e

en g a g em

en t in

a n d in te ra ct io n

w it h so ci et y a n d o th er

h ea lt h ca re

m em

b er s

N u rs es

n ee d to

d ev el o p th e

n ec es sa ry

p re v en ti v e

m ea su re s to

co u n te ra ct

th e

m u lt if a ri o u s ef fe ct s o f n u rs e

st er eo ty p in g

T a k a se

et a l.

(2 0 0 6 )

M ix ed

M et h o d

C o rr el a ti o n a l

d es ig n

3 4 6 n u rs es

+ 6 in

fo cu s

g ro u p s

P N IS ; T a sk

P er f. S ca le ;

P a ir ed

t- te st ; re g re ss io n

T o ex a m in e h o w

th e

re la ti o n sh ip

b et w ee n n u rs es ’

p er ce iv ed

p u b li c im

a g e a n d

se lf -i m a g e is a ss o ci a te d w it h

th ei r jo b p er fo rm

a n ce

a n d

tu rn o v er

in te n ti o n s

T h e p u b li c te n d s to

v ie w

n u rs es

a s fe m in in e a n d ca ri n g

p ro fe ss io n a ls , n o t a s le a d er s

o r in d ep en d en t p ro fe ss io n a ls .

T h is im

a g e is a ls o a re su lt o f

n u rs es ’ in v is ib il it y in

th e

m ed ia

N u rs es

p er ce iv e a la ck

o f

u n d er st a n d in g fr o m

th e p u b li c.

T h e re la ti o n sh ip

b et w ee n se lf -

im a g e a n d p er ce p ti o n o f th e

p u b li c im

a g e a s b ei n g ca ri n g

p re d ic ts

jo b p er fo rm

a n ce

T h e n u rs in g p ro fe ss io n n ee d s

to im

p ro v e it s p u b li c im

a g e

a n d it s se lf -i m a g e to

so lv e

tu rn o v er

p ro b le m s a n d to

re so lv e th e cu rr en t n u rs in g

sh o rt a g e

T ze n g (2 0 0 6 )

Q u a n ti ta ti v e

st u d y

C ro ss -s ec ti o n a l

d es ig n

4 8 8 p a rt ic ip a n ts

(s tu d en ts , st a ff

a n d

fa cu lt y m em

b er s)

N u rs in g Im

a g e

Q u es ti o n n a ir e

D es cr ip ti v e a n d o rd in a l

L o g is ti c re g re ss io n

a n a ly si s

T o in v es ti g a te

th e p er ce iv ed

im a g es

a n d ex p ec te d im

a g es

o f T a iw

a n es e n u rs es

N u rs es

a re

fr eq u en tl y p o rt ra y ed

in p ri m e ti m e si tc o m s a n d

d ra m a s a s su b se rv ie n t, in ep t

a n d in si g n ifi ca n t. T h e p u b li c

p er ce p ti o n o f n u rs in g d o es

n o t

m a tc h th e p er ce p ti o n o f

n u rs es

th em

se lv es

T h e in co rr ec t p o rt ra y a l o f n u rs es

is p a rt ia ll y re sp o n si b le

fo r

p u b li c p er ce p ti o n s o f n u rs in g

a n d fo r h o w

n u rs es

p er ce iv e

a n d u se

p o w er . T h e p u b li c

im a g e o f n u rs es

is a m ir ro r o f

n u rs es ’ p er ce p ti o n s o f se lf

N u rs es

sh o u ld

d o m o re

im p ro v e th ei r im

a g e.

If th ey

h a v e a n eg a ti v e im

a g e o f

th em

se lv es , th e im

a g e th ey

p ro je ct

to th e p u b li c is

eq u a ll y n eg a ti v e

Y. ten Hoeve et al.

Defining image, self-image, self-concept and

professional identity

In the included studies, the concepts image, self-image, self-

concept and identity were used incongruously, even by the

same author in the same study, thus making it difficult to

come to a uniform definition. Self-image and self-concept,

for instance, were used interchangeably, as were profes-

sional image and professional identity. For the sake of clar-

ity, this paper restricts its focus to the terms self-concept

and professional identity and uses the definition of Tajfel

and Turner (1986) on self-concept, in general, which reads

as follows: ‘the way we think about ourselves’. With respect

to the self-concept of nurses, in specific, we rely on the defi-

nition of Takase et al.: ‘nurses’ self-concept can be defined

as information and beliefs that nurses have about their

roles, values and behaviours’ (Takase et al. 2002, p. 197).

The Social Identity Theory of Tajfel and Turner (1986)

argues that the self-concept of an individual or a group

(e.g. nurses) is derived from the perceived image of the

group by society. When you assume that society thinks well

of you, it will boost your self-concept and vice versa. Self-

concept (the way we think about ourselves) can be used as

an umbrella term, with self-image (the way we see our-

selves), self-esteem (the way we feel about ourselves) and

self-presentation (the way we present ourselves to others) as

underlying concepts (Tajfel & Turner 1986). We chose to

use the concept of self-concept throughout this paper

because it applies mostly to the professional self (the profes-

sion), rather than to the psychological self (the person).

Therefore, it can be linked to professional identity. Nurses’

professional identity is defined as ‘the values and beliefs

held by nurses that guide her/his thinking, actions and

interactions with the patient’ (Fagermoen 1997). The

included studies show that professional identity can be

reflected in the nurse’s professional self-concept, which is

also based on the general public opinion on nurses ( €Ohl�en

& Segesten 1998, DeMeis et al. 2007). Congruence exists

between the public image and nurses’ self-concept: nurses

who perceive their public image to be negative are likely to

develop low self-concept ( €Ohl�en & Segesten 1998, Gregg

& Magilvy 2001, Takase et al. 2002). In turn, nurses’

negative self-concept and presentation influence the public’s

opinion (Tzeng 2006).

Work environment and work values

In 7 studies, work environment and work values were men-

tioned as factors of influence on nurses’ professional iden-

tity. Nurses learn from their work experiences and

professional interaction with colleagues, in particular, is

highly valued. In the study of Arthur et al. (1999), the pro-

fessional self-concept, technological influences and caring

attributes of 1957 Registered Nurses in 11 countries were

examined. They found that the sample as a whole valued

professional interaction with colleagues and believed in the

skills of nurses. This view is shared by Gregg and Magilvy

(2001), who also found that nurses learn from their work

experiences. Through interaction with other nurses, they

learn things about nursing and about themselves and work-

ing as a nurse may also contribute to their personal growth

and self-concept (Gregg & Magilvy 2001). The Swedish

nurses in the study of €Ohl�en and Segesten (1998) mentioned

that they develop their professional identity through inter-

action with other nurses and by sharing their experiences in

a narrative and reflective way. Takase et al. (2001) found

Table 2 Themes and related studies.

Themes identified in

the included studies Related studies

Work environment Arthur et al. (1999), De Araujo Sartorio and Pavone Zoboli (2010), Fagerberg and Kihlgren (2001),

Fagermoen (1997), Gregg and Magilvy (2001), €Ohl�en and Segesten (1998), Takase et al. (2001)

Education & career

choice

Ben Natan and Becker (2010), Dahlborg-Lyckhage and Pilhammar-Anderson (2009), De Araujo Sartorio and Pavone

Zoboli (2010), DeMeis et al. (2007), Donelan et al. (2008), Fagerberg and Kihlgren (2001), Gregg and

Magilvy (2001), Huffstutler et al. (1998), Kalisch et al. (2007), Liu (2010)

Traditional values,

culture & gender

Dahlborg-Lyckhage and Pilhammar-Anderson (2009), De Araujo Sartorio and Pavone Zoboli (2010),

DeMeis et al. (2007), Huffstutler et al. (1998), Kemmer and Silva (2007), Liu (2010), €Ohl�en and Segesten (1998),

Takase et al. (2001)

Caring Arthur et al. (1999), Ben Natan and Becker (2010), Dahlborg-Lyckhage and Pilhammar-Anderson (2009),

DeMeis et al. (2007), Donelan et al. (2008), Fagerberg and Kihlgren (2001), Fagermoen (1997), Huffstutler et al.

(1998), Liu (2010), €Ohl�en and Segesten (1998), Takase et al. (2006)

Identity &

performance

Ben Natan and Becker (2010), Donelan et al. (2008), Huffstutler et al. (1998), Kalisch et al. (2007), Kemmer and

Silva (2007), Liu (2010), Takase et al. (2002, 2006), Tzeng (2006)

JAN: DISCUSSION PAPER Public image and professional identity of nurses

that the participants in their study evaluated their perfor-

mance as nurses positively and that this positive self-con-

cept is related to the professional socialization process.

Nurses develop a professional identity through the skills,

knowledge and values inherent in their profession. The

study of Fagermoen (1997) showed that working as nurses

maintains and enhances their self-concept, both as nurses

and as persons.

Education and career choice

Next to work environment, education and the presence of

preceptors also contribute to nurses’ job satisfaction and

self-concept. The nurses in the study of Fagerberg and

Kihlgren (2001) mention that the influence of preceptors

during education and in the work was very important. This

view was shared by the participants in Gregg and Magilvy

(2001) study on nurses in Japan. Some participants consid-

ered their (basic) nursing training to be low-level education,

but most participants felt they had gained positive influ-

ences from their education, including continuing education

after becoming a nurse. In contrast, De Araujo Sartorio and

Pavone Zoboli (2010) found that the nurse teachers in their

study seemed to be driven by historical scars that still influ-

ence their focus on the actual role of nurses and which in

turn might have detrimental effects on the teaching and

work of nurses.

Although nurses see themselves as well-trained profes-

sionals, the public still sees nursing as a low-status profes-

sion that is subordinate to the work of physicians, does not

require any academic qualifications and lacks professional

autonomy. The public is oblivious to the different levels of

education and professionalism involved in nursing (DeMeis

et al. 2007, Dahlborg-Lyckhage & Pilhammar-Anderson

2009, Liu 2010). The study of Huffstutler et al. (1998)

shows that even though many of the respondents believe

that education is important for becoming a nurse, the

majority does not have a clear conception of the meaning

and practice of the nursing profession. In a study on Israeli

nurses, Ben Natan and Becker (2010) found a positive

correlation between the image of nursing and the decision

of students to choose a nursing career. They discovered that

the more positive the image of nursing, the higher the

chance that students would opt for a nursing career. Their

findings also revealed that nursing is seen as a profession

that has limited career opportunities and that the character-

istics of nursing are incompatible with the characteristics of

an ideal career.

However, these results contrast with the findings of Don-

elan et al. (2008), who performed a national survey of the

public’s opinion of nursing and a national survey of Regis-

tered Nurses in the USA on their own opinion of nursing.

Donelan et al. (2008) found that the public was more posi-

tive about a career in nursing than the nurses themselves.

The qualifications the public named most frequently with

respect to nursing included ‘highly knowledgeable, quali-

fied, skilled’. Kalisch et al. (2007) share this view as a result

of their study on the image of nurses on the Internet. With

respect to education, nurses are described as being knowl-

edgeable and skilled and more nurses who hold a doctoral

degree are mentioned than in the past. However, we must

keep in mind that these results are biased by the fact that

the subjects were Professional Nursing Organizations, job

sites and resource/Website directories.

Traditional values, culture and gender

The nursing profession continues to suffer from the influ-

ence of traditional values and cultural and social norms

with respect to gender and professional status. €Ohl�en and

Segesten (1998) found that a stereotypical image of nurses

is an expression of the tradition of viewing nursing as a

part of the female sphere of the family. As a result, nurses

are struggling for power in a gender-segregated society. In

Brazil, for instance, nursing is still seen as a female and

domestic vocation related to the social universe of the

‘house’. Nursing remains a predominantly feminine and

domestic activity that has a low social status and is discred-

ited by society. People look at the doctor who gets all the

credits (DeMeis et al. 2007, Kemmer & Silva 2007). The

online forum used by Liu (2010) to explore nurses’ percep-

tions of their work role on the basis of Chinese cultural

and gender roles shows similar results. Participants

mentioned that they would not encourage their children,

especially their sons, to become nurses. The author argues

that one of the main underlying reasons for this negative

view of nursing is to be found in the traditional norms and

values in Chinese culture. The Chinese caring system, where

persons with lower status should care for those with higher

status, qualifies nurses as caregivers with low professional

status and as subordinates to physicians. Nursing is still

seen as a feminine, caring sub-professional occupation

rather than a profession (Liu 2010). The study of Dahl-

borg-Lyckhage and Pilhammar-Anderson (2009) on pre-

dominant discourses in Swedish nursing shows that the

image of nurses in gendered discourse has been mainly

negative. Nursing was, and sometimes still is, portrayed as

a female profession, with nurses playing supporting roles to

physicians and occupying a subordinate position with

regard to decision-making and delegating tasks. These

Y. ten Hoeve et al.

studies show that the public in various countries has a

strong tendency to regard nurses as ‘subordinate to doctors’

(Huffstutler et al. 1998, Takase et al. 2001, De Araujo

Sartorio & Pavone Zoboli 2010) or as ‘the doctors shadow’

(Kemmer & Silva 2007). €Ohl�en and Segesten (1998), how-

ever, believe that awareness of this process may create

opportunities for nurses to develop professionally.

Caring

Caring was the most commonly identified factor of influ-

ence on the development of nurses’ self-concept and profes-

sional identity (mentioned in 11 studies). The nursing

profession is strongly associated with caring, both by the

public and by nurses themselves. However, a discrepancy

exists in the interpretation of the concept of caring. The

studies show that nurses consider caring to be part of their

professional identity, whereas the public associates caring

with feminine qualities and unprofessionalism. Today’s

nurses try to gain recognition for the importance of caring

in a society where caring is undervalued ( €Ohl�en & Segesten

1998). Nurses are viewed by the public as feminine and

caring professionals, but they are not recognized as leaders

or independent healthcare professionals (Takase et al.

2006). The results of the study of Huffstutler et al. (1998)

indicate that nursing is seen as the profession most closely

associated with caring. Despite the technological develop-

ments in health care, nurses are considered to be caring

persons and thus the most important requirement for

becoming a nurse is to be able to care for others.

With regard to nurses themselves, the extensive study of

Arthur et al. (1999) showed that nurses in all 11 countries

believe in a confidential relationship between nurses and

their patients based on truthfulness and respect. Despite

their individual cultural features, nurses across the world

do have much in common when it comes to caring and

their practice. Nurses believe that the primary responsibility

of nurses is to perform nursing care for patients and to

ensure their patients’ well-being (Fagerberg & Kihlgren

2001, Dahlborg-Lyckhage & Pilhammar-Anderson 2009).

Fagermoen (1997) shows that for most of the nurses in her

study, the value of care for the patients’ health and well-

being appears to be an overriding value, on which they base

their practice. Positive correlations have also been found

between choosing nursing as a career and intrinsic factors,

such as caring for others, helping others and feeling respon-

sible for others (Ben Natan & Becker 2010). In contrast,

the study of DeMeis et al. (2007) showed that nurses them-

selves may also consider caring to be an unprofessional

activity. The respondents state that when nurses reach

higher professional standards, patient care is delegated to a

socially less-valued professional category that requires

lower academic qualifications.

Identity and performance

Nine studies mentioned the poor communication of nurses

with the public and the invisibility of nurses in the media. A

common theme in these studies is that nurses should do their

best to improve the negative image of their profession,

whereby keeping the goal to recruit new students in mind.

The studies emphasize the shortage of nurses, which is partly

caused by nurses themselves, who do too little to recommend

their careers to others (Takase et al. 2006, Donelan et al.

2008). Nurses need to counteract the effects of nurse stereo-

typing and improve the public image of their profession. A

stereotypical public image is also partially responsible for the

way nurses perceive and use power. Nurses need power to

improve their visibility (Takase et al. 2002, Tzeng 2006).

According to Kemmer and Silva (2007), nursing professionals

have partly inflicted their invisibility in the media on them-

selves. As long as nurses do not feel responsible for the

distorted images of the roles they have performed and are still

performing in health care and as long as they do not take a

stand to correct these images, their invisibility will continue.

Nurses need to raise public awareness about the various roles

and opportunities both basic and advanced nursing practice

have to offer. To give more visibility to the nursing role, a

strategy needs to be developed, which will use the (social)

media (Internet, TV, internal news, press) to inform the

public (Kalisch et al. 2007, Kemmer & Silva 2007).

Implications for nurses

Around the world, nursing baccalaureate, master and

doctoral degree programmes prepare nurses for a variety of

nursing roles. Nurses are educated to develop nursing theo-

ries and conceptual models, conduct nursing research and

test nursing theories (Meleis 1997). As a result, nursing is

becoming more scholarly. The public needs to become

aware that nursing research exists and that it is important

to patient health. This awareness, in turn, will have a posi-

tive effect on the public image of nursing and will empower

nurses.

This paper, however, shows that the public is not always

aware of the qualifications nurses need for their profession.

The public image of nursing is, to a large extent, affected by

the invisibility of nurses and the way they present

themselves. Ineffective communication skills influence the

public perception of nurses. Nurses should work harder to

JAN: DISCUSSION PAPER Public image and professional identity of nurses

communicate their professionalism to the public and they

need to make clear what they really do. As nurses see caring

for patients as a core value in nursing practice, it is impor-

tant to demonstrate to the public that this entails more than

just sitting by the patient’s bedside, as portrayals of nurses in

the media would sometimes lead the public to believe.

Nurses could use discourse and new (social) media to present

their profession to the public (Kalisch et al. 2007,

Ben Natan & Becker 2010).

Recommendations

We argued in this paper that, to become more visible inside

and outside healthcare organizations, nurses should present

themselves more clearly to the public. This could be

achieved by pursuing higher education and by working in a

challenging work environment that offers nurses the oppor-

tunity to break away from the daily routine and that

challenges them to deepen and broaden their knowledge

and skills. Job rotation, gaining professional autonomy,

opportunities for interprofessional learning and peer consul-

tation could help nurses to become more visible within their

organization and on a macro level, within society. Nurses

could, for example, create a more challenging work envi-

ronment by embracing a more active attitude that includes

participation in representative bodies and unions. Interac-

tion with other nurses and working as a nurse may contrib-

ute to the development of their self-concept and identity as

a nurse. Out of their professional identity, nurses can also

adopt and develop new leadership roles. Nursing research

can be helpful to further the profession and research

outcomes could be used to improve the development of

professional identity. Another strategy that could help

nurses is to participate in the development of cross-national

knowledge about nursing practice. It would be very inter-

esting to examine in which countries nurses are ‘doing well’

in respect to public image and consequently represent their

professionalism in the eyes of society.

Conclusion

This discussion paper gives an overview of the current

state of affairs with regard to public image, self-concept

and professional identity of nurses. The findings show a

rather diverse picture of the actual view of the public on

the nursing profession. The heterogeneity of setting, sam-

ple and population of the studies makes it quite difficult

to explain these differences. Furthermore, traditional

cultural and social values determine the way the public

perceives the nursing profession. The self-concept of nurses

and their professional identity are determined by many

factors, including public image, work environment, work

values, education and culture. Virginia Henderson (1978)

already stated that ‘nurses self-image is often at odds with

the public’s image and what nurses do is at odds with

what nurses and the public think they should do’. A nega-

tive public image may challenge nurses to look for success-

ful strategies to improve their self-concept and to show

their invaluable contribution to the healthcare system. One

of the strategies is to promote nursing by giving lectures

to spread information on the profession. As educators and

role models, they can establish a professional nurse

identity. Professional development of nurses could also be

realized by sharing their work experiences with other

What is already known about the topic

• The professionalization of nurses and the public image of the nursing profession is the subject of ongoing

international debates.

• A negative public image has a negative impact on nurses’ self-concept and the development of their pro-

fessional identity.

• The professional aspects of the work nurses perform remain invisible in the media, partly as a result of the

dominant position of the medical profession.

What this paper adds

• A discussion of the influence of the public image on the self-concept and the professional identity of nurses

in an era of nurse professionalization.

• An analysis of other factors that influence the self-con- cept of nurses, such as work environment, work val-

ues, education and traditional social and cultural

values.

• A discussion of the relationship between public image and nurses’ self-concept, professional identity and

work performance.

Implications for practice and/or policy

• Nurses should work harder to communicate both their professionalism and their contribution to the health-

care system to the public.

• To be given due recognition, nurses could profit from using social media, such as the Internet and YouTube.

• In the curriculum of nursing schools, more attention should be given to performance and empowerment of

nurses.

Y. ten Hoeve et al.

nurses. In addition, nurses should make better use of

strategic positions, such as case manager, nurse educator

or clinical nurse specialist to show what their work as

healthcare professionals entails. The public should be able

to identify with nurses and the work they do. In the

media, nurses are hardly seen as professional advisors or

experts. A convincing number of nurses is needed to

change the public opinion. Kalisch and Kalisch (1983)

state that nurses can intervene in four steps: (1) getting

organized; (2) monitoring the media; (3) reacting to the

media; and (4) fostering an improved image. Unless nurses

themselves establish a public image and professional iden-

tity that recognizes the value of their professional and edu-

cational development, the problem of a ‘fuzzy’ and

inaccurate image will continue to exist.

Acknowledgements

We would like to thank Sonja Hintzen of the University

Medical Center Groningen for her constructive advice and

editing services.

Funding

The authors received no external funding or grant to under-

take this research.

Conflict of interest

The authors declare that there is no conflict of interest.

Author contributions

YH and PR were responsible for the study conception and

design; YH performed the data collection; YH and PR per-

formed the data analysis; YH, PR and GJ were responsible

for the drafting of the manuscript.

All authors have agreed on the final version and meet at

least one of the following criteria (recommended by the

ICMJE: http://www.icmje.org/ethical_1author.html):

● substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

● drafting the article or revising it critically for important

intellectual content.

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JAN: DISCUSSION PAPER Public image and professional identity of nurses