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 © 2013 John Wiley & Sons Ltd 295 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 ha ...

1. 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

2. 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

3. 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.

4. 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
© 2013 John Wiley & Sons Ltd 295
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.

5. 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

6. 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

7. 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-

8. 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

9. 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

10. 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
296 © 2013 John Wiley & Sons Ltd
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

11. 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

12. 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

13. 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

14. (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.
© 2013 John Wiley & Sons Ltd 297
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

15. 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-

16. 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–

17. 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

18. 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.

19. 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

20. conclude that the image of nurses in the media does not
(yet) meet the professional image of nursing.
298 © 2013 John Wiley & Sons Ltd
Y. ten Hoeve et al.
T
a
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27. o
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28. ca
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29. ti
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31. la
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32. ,
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33. h
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34. p
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35. h
is
n
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36. y
m
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ch
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re
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37. o
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a
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in
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.
D
a
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lb
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38. a
m
m
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A
n
d
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so
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(2
0
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)
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39. es
fr
o
m
1
9
9
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0
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D
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m
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ts
,
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s,
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n

40. s,
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se
ri
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D
is
co
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rs
e
a
n
d
co
n
te
n
t
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s
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41. te
th
e
p
re
d
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m
in
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n
t
d
is
co
u
rs
e
in
th
e
fi
el
d
o
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S
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is
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n

42. u
rs
in
g
T
h
e
m
ed
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p
la
y
a
m
a
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r
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le
in
d
is
se
m
in
a
ti
n
g
p
re

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. re
is
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

75. 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

76. 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

77. 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

78. 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

79. 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

80. 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

81. 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

82. 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

83. 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

84. 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

85. 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

86. 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

87. 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

88. 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

89. 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

90. 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

91. 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

92. © 2013 John Wiley & Sons Ltd 299
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

93. 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

94. 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

95. 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

96. 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

97. 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

98. 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

99. 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

100. 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

101. 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

102. 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

103. .
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

104. a
n
ti
ty
o
f
th
e
w
o
rk
p
er
fo
rm
ed
T
h
is
st
u
d
y
re
v
ea
ls
a
re
la
ti
v

105. 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

106. 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

107. ct
er
is
ti
cs
is
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

108. 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

109. 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
-

110. 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

111. 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

112. 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

113. 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

114. 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

115. 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

116. 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

117. 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

118. 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

119. 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

120. 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

121. 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

122. 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

123. 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
;

124. 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

125. 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

126. 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

127. 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

128. 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

129. 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

130. 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
,

131. 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

132. 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

133. 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

134. 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

135. 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,

136. 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

137. 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

138. 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

139. 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

140. 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

141. 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

142. 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

143. 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

144. 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

145. 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

146. 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

147. 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

148. 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

149. 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

150. 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

151. 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

152. 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

153. ’
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

154. 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

155. 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

156. 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

157. 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

158. 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

159. 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

160. 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

161. 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

162. 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

163. 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

164. 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

165. 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

166. 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

167. 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

168. 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

169. 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

170. 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

171. 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
300 © 2013 John Wiley & Sons Ltd

172. 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

173. 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

174. 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

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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

176. 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

177. 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

178. 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

179. 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

180. 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

181. 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

182. 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

183. 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

184. 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

185. 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

186. a
li
za
ti
o
n
,
n
u
rs
es
a
cq
u
ir
e
h
ig
h
er
a
ca
d
em
ic
q
u
a
li
fi
ca
ti

187. 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
is
d
el
eg
a
te
d

188. 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

189. 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

190. 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

191. 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

192. 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

193. 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

194. 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

195. 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

196. 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

197. 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

198. 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

199. 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

200. 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

201. 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

202. 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

203. 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

204. 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

205. 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

206. 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

207. 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

208. 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

209. 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

210. 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

211. 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

212. 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

213. 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

214. 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

215. 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

216. 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

217. 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

218. 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

219. 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

220. 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

221. 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

222. 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

223. 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

224. 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
-

225. 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

226. 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

227. 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

228. 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

229. 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

230. 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

231. 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

232. 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

233. 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

234. 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

235. T
a
b
le
1
(C
o
n
ti
n
u
ed
).
© 2013 John Wiley & Sons Ltd 301
JAN: DISCUSSION PAPER Public image and professional
identity of nurses
T
a
b
le
1
(C
o
n
ti
n
u

236. 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

237. 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

238. 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

239. 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
;

240. 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

241. 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

242. 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

243. 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

244. 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

245. 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

246. 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
’

247. 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

248. 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
-

249. 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
,

250. 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

251. 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

252. 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

253. 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

254. 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

255. 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

256. 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

257. 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

258. 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

259. 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

260. 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

261. ,
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

262. 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

263. 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

264. 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

265. 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

266. 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

267. 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

268. 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

269. (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

270. 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

271. 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

272. 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

273. 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

274. 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

275. 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

276. 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

277. 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

278. 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

279. 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

280. 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

281. 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
to
im

282. 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

283. 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

284. y
n
eg
a
ti
v
e
302 © 2013 John Wiley & Sons Ltd
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

285. 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).

286. 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

287. 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

288. 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),

289. 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)
© 2013 John Wiley & Sons Ltd 303
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

290. 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.

291. 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

292. 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

293. 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

294. 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
304 © 2013 John Wiley & Sons Ltd

295. 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

296. 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 technologic al 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

297. 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

298. 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 counterac t 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

299. 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.

300. 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
© 2013 John Wiley & Sons Ltd 305
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,

301. 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

302. 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

303. 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

304. 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-

305. 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.
306 © 2013 John Wiley & Sons Ltd
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

306. 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

307. 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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308 © 2013 John Wiley & Sons Ltd
Y. ten Hoeve et al.
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© 2013 John Wiley & Sons Ltd 309
JAN: DISCUSSION PAPER Public image and professional
identity of nurses
CHART FOR PROBLEM 1

319. 180 © 2018 Nursing and Midwifery Studies | Published by
Wolters Kluwer - Medknow
Background: Image remains crucial for nursing
profession. How nurses
view professional self‑ image has an impact on
their professional self‑ esteem.
Objectives: This study explored the image of
nursing as perceived by Indonesian
nurses. Methods: This was a phenomenological study
with a purposeful sample
of 19 clinical nurses participated in in‑ depth
interviews. The interviews were
audio‑ recorded, transcribed verbatim, and validated by
relistening to the recording
by researchers. The analysis was thematic. Results:
Five themes emerged (a)
Islamic culture, (b) job definition, (c) role of
nurses, (d) self‑ confidence, and (e)
relationship between multigenerations of nurses.
Conclusion: This study addressed
positive and negative images of nursing in
Belitung, Indonesia. The findings may
be used for nurse managers to improve nursing
image through the improvement of
nurse competence and continuing professional
development.
Keywords: Auditory perception, Humans, Indonesia,
Self‑ concept,
Nurse administrators

320. The Image of Nursing as Perceived by Nurses: A
Phenomenological
Study
Joko Gunawan, Yupin Aungsuroch, Ade Sukarna1,
Nazliansyah1, Ferry Efendi2
Access this article online
Quick Response Code:
Website:
www.nmsjournal.com
DOI:
10.4103/nms.nms_24_18
family, friends, or in public that he or she is
a nurse, the
nurse is representing the profession. As
literature stated,
“we cannot expect outsiders to be the guardians of
our
visibility and access to public media and health
policy
arenas, but we must develop the skills of
presenting
ourselves in and to the media, and have to
take the
responsibility for moving from silence to voice.”[5]
Nursing is considered as a critical resource,
which is
why it is essential to know its image to
contribute to
consolidating its identity and consequently increase
its
number and place among health‑ care

321. professionals and
society.[1]
In Indonesia, nursing image is likely seen to
be
assistants to physicians and committed to
housekeeping
duties, rather than devoted to caring,[6] which is
similar
to Shields and Hartati[7] said that nurses are
regarded as
“doctors” helpers. This image could discourage
young
generation to choose nursing as a career. In
contrast,
Original Article
Introduction
Nursing image is very important for nursing
profession. It is the way the profession
appears to
others including to general public. Image of
the nursing
profession impacts to the recruitment of
students, the
view of the public, funding for nursing education
and
research, relationships with health‑ care administrators
and other health‑ care professionals, government
agencies, and legislators at all levels of
government,
and ultimately, the profession’s self‑ identity.[1]
The
most important is that image can influence nurses

322. themselves, just like nurses may feel depressed or
less
effective if others view them negatively.
Professionals
can experience similar reactions if their image
is not
positive, which impacts everything the profession
does
or wishes to do.[2]
Image is defined as a mental picture
representing a real
object or a more or less accurate likeness of a
thing or
person.[3] How nurses view their professional self‑ image
has an impact on professional self‑ esteem.[3]
How one
is viewed has an impact on whether others
seek that
person out and how they view the effectiveness of
what that person might do.[4] Every time a
nurse says to
Department of Nursing
Administration, Faculty of
Nursing, Chulalongkorn
University, Bangkok,
Thailand, 1Department of
Adult and Community
Nursing, Academy of Nursing
of Belitung, Akademi
Keperawatan Pemerintah
Kabupaten Belitung, Bangka

323. Belitung, 2Department of
Community Health Nursing,
Faculty of Nursing, Airlangga
University, Surabaya,
Indonesia
A
bs
tr
ac
t
Address for correspondence: Assoc. Prof. Dr. Yupin
Aungsuroch,
Borommaratchachonnani Srisataphat Building,
Rama 1 Road, Pathumwan, Bangkok 10330, Thailand.
E‑ mail: [email protected]
This is an open access journal, and articles are distributed under
the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License,
which allows others to
remix, tweak, and build upon the work non-commercially, as
long as appropriate credit is
given and the new creations are licensed under the identical
terms.
For reprints contact: [email protected]
How to cite this article: Gunawan J, Aungsuroch Y, Sukarna A,
Nazliansyah,
Efendi F. The image of nursing as perceived by nurses:
A phenomenological
study. Nurs Midwifery Stud 2018;7:180-5.
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324. 181Nursing and Midwifery Studies ¦ Volume XX ¦ Issue XX ¦
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Gunawan, et al.: Nursing image as perceived by nurses
181Nursing and Midwifery Studies ¦ Volume 7 ¦ Issue 4 ¦
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Indonesian nurses are also seen as knowledgeable,
intelligent, and analytical.[6] This tells that there is a
gap
of nursing image perceived by nurses and
nonnurses.
In addition, previous studies might not represent
the
number of population to describe nursing image
in
Indonesia, as Indonesia consists of 220,004
nurses
serving about 250 million of population in
17,000
Islands.[8] Therefore, we need to explore
further about
nursing image, as the image may be different in
each
island in Indonesia. Furthermore, there is a
limited
number of studies related to nursing image in
Indonesia
which appears to two studies in 2003[7] and
2018.[6]

325. Objectives
This study aimed to explore the image of
nursing
perceived by Indonesian nurses. The main
research
question is “Are there any differences of nursing
image
perceived by nurses in Indonesia, especially in
the south
part of Indonesia?” This study remains important
for
the future of nursing development, particularly
for the
recruitment of a new generation into nursing
profession
in Indonesia.
Methods
Study design, setting, and participants
This was a phenomenological study to explore
Indonesian nurses’ perception on their
professional
image. The phenomenological study is congruence
with
the purpose of this study to gain deeper
understanding
of the nature of the phenomenon by viewing
each piece
as a whole.[5]
There were 19 participants selected using
purposive
sampling to ensure that the relevant data were
collected.
The participants were contacted through short

326. message
service and phone call to inform them about
the purpose
of the study. The inclusion criteria were the nurses
who
had at least 2 years of clinical experiences.
There was
no age and gender restriction of participants in
this
study. This study was conducted at the General
Hospital
Belitung, Bangka Belitung Province, Indonesia.
Data collection procedures
Upon accepting the invitation, potential respondents
were given oral and written information about
the
research, and after they signed a consent
document,
an appointment was scheduled for an interview
and
focus group discussion (FGD). Interviews
and FGD
were conducted in Bahasa Indonesia (Indonesian
language) or Belitung language (local language)
by
principle investigators ranging from 60 to 120
min.
Each interview and transcript were individually analyzed
and then reviewed and discussed collaboratively by the
other researchers. The interview was taken place in
the
meeting room in the hospital to avoid the

327. noise and
the other disturbances during interview. The
interviews
were audio‑ recorded, transcribed verbatim, and
validated
by relistening to the recording by researchers.
The
interviews were performed from July 2015
to August
2015. The participants in this study were
initially asked
with the open‑ ended questions. “How do you
view the
image of nurses today? What influenced
how you view
nursing?” and continued with the other questions
until
the data reached saturation when any new
information
was not achieved.
Data analysis and trustworthiness
Data were analyzed using interpretive
phenomenology,
as outlined by Van Manen,[5] allowing flexibility
in emphasizing or minimizing one step or
another,
depending on the emergent data, which consists of
six steps, namely, (i) turning to the nature of
lived
experience involving formulating a research
question, (ii)
investigating experience using in‑ depth interviews
for

328. data collection, (iii) reflecting on the essential
themes
which characterize the phenomenon identified
from
interviews, (iv) describing the phenomenon in
the art
of writing and rewriting, (v) maintaining a
strong and
oriented relation to the phenomenon, and (vi)
balancing
the research context by considering the parts
and the
whole.
In this study, we read interview transcripts
carefully and
repeatedly for emerging themes, then using
highlighting
or selective approach, and finally reading
holistically.
In the holistic approach, we viewed the text as a
whole
and attempted to understand the overall
meaning. We
then highlighted or selected phrases and statements
that
seemed essential to the study. For the next step,
we
developed the keywords and concepts dialogue with the
texts. Then, themes were interpreted from
components
of experience to the whole experience and
back again.
Finally, we analyzed every sentence and essential
themes
were discovered through this process. These themes

329. were
then reconstructed into a description of the
perceptions
of the participants, as indicated by literature.[9]
All of the
themes were then translated into English. J.G
provided
the first translation, which was then agreed by
the other
researchers.
Data credibility was established by face‑ to‑ face
discussion with any participants and through
prolonged
engagement. To ensure that no data were lost
on
the analysis process, peer review was done by
an
experienced researcher to compare and contrast
on the
data quality and interpretations. Dependability was
achieved through a researcher audit and notes
that
documented all methodological issues and
decisions.
Although the interviewers were mostly Indonesian
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330. Gunawan, et al.: Nursing image as perceived by nurses
182 Nursing and Midwifery Studies ¦ Volume 7 ¦ Issue 4 ¦
October-December 2018
nurses, according to literature,[10] bracketing was
ensured
by discussing among researchers about
personal biases
and experiences with the research topic.
Ethical consideration
The study has been reviewed and approved by
the Institutional Review Board of the Government
Institution of Society Protection (Approval
No:
070/219.a/BKBPPB/2015). All participants in this
study
were recruited and informed about the aim of the
study.
They were assured that participation in this study
was
voluntary. Moreover, they were able to voluntarily
withdraw from the study. The researchers guaranteed
the
confidentiality of their data and also ensured them
that
their information would be published
anonymously. In
the end, the researchers asked the informants to
read and
sign the written informed consent form. It was
confirmed
that all participants had obtained an appropriate

331. consent
form.
Results
Nineteen participants were identified using
purposive
sampling to ensure that relevant data were
collected,
which consisted of 15 females (79%) and 4
males (21%).
Ten (52%) of them were clinical diploma
nurses
and nine (48%) of them were bachelor nurses.
Their
age ranged between 25 and 37 years old, which
was
considered as generation Y (born 1977–1995)
and
generation X (born 1965–1976).[11] There
was no baby
boomer generation (born 1946–1964) reported in
this
study.
Findings emerged from the data using Van
Manen’s
thematic approach. Five themes emerged: Islamic
culture, job definition, role of nurses,
self‑ confidence,
and relationship of multigeneration of nurses.
Those
themes are illustrated below with exemplars
from the
informants’ stories using pseudonyms for the
informants.

332. Islamic culture
Majority of nurses agreed that their work was
influenced
by Islamic culture, which could be seen from
what their
wear and the way their care with patients, like ones
described:
N7: “We are Muslim, so we work basically based
on
Islamic culture, including our appearance. We use
Hijab (veil) to cover our head.” While
N9 said, “We
ensure that there is no pork when we provide
the food
for the patients and collaboration with dietician.”
N11
said, “Every time we see the patients, we do not
forget
to say “Assalamualaikum” (peace be upon us),
and we
always ask the permission if male nurses
want to take
care female patients. However, usually male nurses
take
care male patients, especially in bathing the patients.”
Job definition
Majority of nurses expressed themselves as
someone
who is always by the side of patients and always
fulfills
the needs of patients and their families. However,
some
nurses indicated that they are doctor’s assistants, which

333. only performed technical procedures such as
drug
administration, injections, measuring blood pressure,
and
temperature. Both views are explained in the
following
statements:
N1 said, “A nurse is someone who helps
patients, and
is constantly by their side.” N2 said, “Nurses are
those
who are always smile and answering all the
needs of
patients and families.” In contrast, N3 said, “A nurse
is
a doctor’s assistant in reality although nurses
think that
they are in the same position with medical doctor.”
But
N4 said, “Because of the condition, such as
the lack
number of nurses with nurse‑ patient ratio (3:30),
and a
number of medical procedures that need to
do, nurses
have no time to work as a profession.”
Role of nurses
Majority of nurses indicated that nurses have a
number
of roles that are often depending on
patient’s needs
such as a caregiver, decision‑ maker,
communicator,

334. advocator, and teachers. At the same time, some nurses
said that nurses also do other profession’s roles
such
as pharmacist roles. This is described in the
following
statement:
N5 said, “I always be a caregiver to my
patients, giving
health education to families, keeping the smile
and
advocating them.” and N7 said, “I always
facilitate my
patients and become a good communicator to
them.”
Besides, N8 said, “We are nurses having many
roles,
including other professions’ roles like doing pharmacist’s
job in preparing medicine for patients, even
patients
often ask nurses to fix air conditioner.
Additionally,
hospital administrators also place nurses in every
position because they think nurse can do everything.”
Self‑ confidence
This study found that the majority of the nurses
perceived
themselves as those having good
self‑ confidence in
taking care of patients and in collaboration with
other
health professions. However, some nurses view

335. them
that not all nurses had a good self‑ confidence
due to low
level of education and competence. This is described in
the following statement:
N19 said, “I take care of patients everyday, surely I
have
more confidence including collaboration with medical
doctor.” In opposite that N6 said, “I personally
think
that I am a good nurse, I have more
confidence, but
sometimes I look at another nurse having no
confidence
and it is not good.” While N10 said, “I cannot
generalize
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183Nursing and Midwifery Studies ¦ Volume 7 ¦ Issue 4 ¦
October-December 2018
that nurse is good or bad, because some nurses
may be
good and some may be not. They sometimes
feel shy

336. because of their education and competence.”
Relationship between multigenerations of nurses
Some nurses mentioned that there was the gap
between
new nurses and senior nurses, which lead to
the lack
of collaboration as well as the difficulty in
sharing
knowledge and experiences between them.
For instance, S3 said, “I am afraid whether I
need to
share my knowledge or not to senior nurse.
Just feeling
afraid”, while S2 said, “We need our head
nurse to
facilitate us to communicate with all nurses. May
be
meeting in pre or postconference. So, we will
complete
each other.”
Discussion
This study was conducted qualitatively to
explore the
perspectives of Indonesian nurses on their
professional
image. Five themes emerged from the data:
Islamic
culture, job definition, the role of nurses,
self‑ confidence,
and relationship between multigenerations of nurses.
Under “Islamic culture” theme, it is indicated
that nurses

337. have awareness in bringing the spiritual and cultural
value
in clinical practice, as the majority of the
population in
Belitung Indonesia is Muslim.[12] Nurses at
this point
have to be culturally competent in providing
care to
Muslim patients. As literature mentioned that
Muslims
believe that they should meet illness and death
with
patience, meditation, and prayer, and it is
important to
discuss patients’ dietary requirements including the
need
to avoid pork or medication that contains
alcohol, and in
a life‑ threatening emergency, there are no
restrictions on
the treatment that can be provided to a Muslim
patient.[13]
In “job definition” theme, there were two
different
perspectives perceived by nurses. Some nurses
defined a
nurse in a positive way as someone who always
beside
patients and fulfills their needs based on
interpersonal
skills and caring practices, rather than their
technical
skills.[14] In contrast, the other nurses thought
negatively
about themselves as doctor’s assistant, which

338. contradicts
with a study who found that nurses had a
more positive
image of themselves compared with how they
thought
the public perceived nurses.[2] However, if
nurses
perceive their own prestige as low, that they are
not
appreciated, then they will be victims and that they
are
subordinate to other professions, they will act
out that
self‑ image.[15]
Under “role of nurses” theme, findings of
this study
indicated that nurses had many roles. Nurses
are
demanded to do everything and often placed in
many positions in a hospital. It seems that
other
professions may need to understand the role of
nurses
comprehensively. Besides, it is suggested that
nurses
need to emphasize nursing as a thinking
profession[16]
and to highlight clinical knowledge and
competence.[17]
The literature also suggests that nurses need to
affirm
their professional identity that can be demonstrated
in a number of ways. Nurses need to