Implications of the visibility of professional nursing practices

Abstracts

A construção da imagem da Enfermagem é permeada por aspectos históricos, socioeconômicos e culturais. Ao explorar esta temática, objetivou-se conhecer a percepção dos enfermeiros acerca da visibilidade do cotidiano de trabalho da equipe de enfermagem. Pesquisa qualitativa do tipo exploratória, com 30 enfermeiros de um hospital universitário do sul do país. Os dados foram coletados, de julho a outubro de 2012, através de entrevista semi-estruturada e submetidos à análise textual discursiva. Os resultados apontam que a visibilidade da Enfermagem está relacionada à trajetória histórica da profissão, à falta de reconhecimento da cientificidade da Enfermagem, à veiculação errônea na mídia, aos comportamentos inadequados perante a equipe e, ainda, à sobrecarga de trabalho. Assim, a desmistificação da imagem da profissão inclui uma busca de maior visibilidade midiática, realização de marketing pessoal, comportamento adequado perante a equipe de saúde e demonstração de autonomia profissional, desafios estes que deverão ser superados pela Enfermagem.

Enfermagem; História da enfermagem; Autoimagem

ORIGINAL ARTICLE

Implications of the visibility of professional nursing practices

Implicaciones de la visibilidad de la enfermería en el ejercicio profesional

Liziani Iturriet Avila^I; Rosemary Silva da Silveira^II; Valéria Lerch Lunardi^III; Geani Farias Machado Fernandes^IV; Joel Rolim Mancia^V; Juliana Teixeira da Silveira^VI

^IFederal University of Rio Grande. Nurse, PhD candidate. Member of the Core Studies and Research in Nursing/Health (NEPES). Rio Grande – RS – Brazil.

^IIFederal University of Rio Grande. Nurse, PhD. Nursing Graduate School professor, and post-graduation professor at Federal University of Rio Grande – (PPGEnf FURG). NEPES's member. Rio Grande – RS – Brazil.

^IIIFederal University of Rio Grande. Nurse, PhD. Nursing post-graduation professor at Federal University of Rio Grande – (PPGEnf FURG). Research productivity fellowship / CNPq, NEPES's Leader. Rio Grande – RS – Brazil.

^IVFederal University of Rio Grande. Nurse, PhD. Nursing Graduate School professor, and post-graduation professor at Federal University of Rio Grande – (PPGEnf FURG). NEPES's member. Rio Grande – RS – Brazil.

^VFederal Board of Nursing – COFEN. Nurse, PhD. Civil servant in Porto Alegre. Research Group on the History of Nursing Knowledge and Health (GEHCES) member. Porto Alegre – RS – Brazil.

^VIFederal University of Rio Grande. Nurse, master science. NEPES's member. Rio Grande – RS – Brazil.

Author's address

ABSTRACT

Nursing construction image is permeated by historical, socioeconomic and cultural aspects. This theme aims to understand the perception of nurses regarding the visibility of nursing staff's daily work. This qualitative research is exploratory, with 30 nurses at a university hospital in southern Brazil. The data was collected from July to October 2012, through semi-structured interviews and submitted for a discursive textual analysis. The results show that nursing visibility is related to a professional historical trajectory, to an absence of recognition of the scientific aspect of Nursing, to erroneous placement in the media, to improper behavior towards the staff and also to work overload. Thus, the demystification of nursing's image includes greater media visibility, conducting personnel marketing, appropriate behavior in front of health staff and professional demonstrations of autonomy, challenges that must be overcome by nursing.

Descriptors: Nursing. History of nursing. Self Concept.

RESUMEN

La construcción de la imagen de la Enfermería está permeada por aspectos históricos, socioeconómicos y culturales. Al explorar este tema, hubo como objetivo conocer la percepción de los enfermeros acerca de la visibilidad de la labor diaria del equipo de Enfermería. Investigación cualitativa del tipo exploratoria, con 30 enfermeros de un hospital universitario del sur del país. Los datos fueron recolectados entre julio y octubre de 2012, a través de entrevistas semiestructuradas y sometidas al análisis textual discursivo. Los resultados muestran que la visibilidad de la Enfermería está relacionada a la trayectoria histórica de la profesión, la falta de reconocimiento de la cientificidad de la Enfermería, la colocación errónea en los medios de comunicación, el comportamiento inadecuado frente al equipo y también a la sobrecarga de trabajo. Así, la desmitificación de la imagen de la Enfermería, incluye una búsqueda de más visibilidad en los medios de comunicación, realización de marketing personal, comportamiento adecuado frente al equipo de salud y demostración de autonomía profesional, desafíos estos que deberán ser superados por la Enfermería.

Descriptores: Enfermería. Historia de la enfermería. Autoimagen.

INTRODUCTION

The construction of the Nursing image is permeated by historical, socioeconomic and cultural aspects. In exploring the theme of the nursing image and its stereotypes, some important factors in the history of the profession, which stay alive at a detriment to technologic and scientific evolution, were identified. These factors can be seen through the persistent image of professional submission to the other members of the healthcare staff, and the erroneous image of charitable service⁽¹⁾.

The population, in general, seems unaware of the importance of Nursing, not valuing it as a profession that is fundamental to health care. It also seems, in society and the media, that the image of subservience in nurse and nursing, in particular, to the other professionals in the health area, especially to the medical professional, is predominant⁽²⁾.

The present image of Nursing has a direct relationship with its historically religious trajectory of submission and silence. In addition the idea of religion, the media portrays an erroneous image of being a nurse, conveying someone of a fragile and gentle character, associated with subservience, and not one that corresponds to the professional reality of Nursing. ^(2-3).

It is possible that the interpretations related to the image of Nursing could be due to the lack of knowledge in regards to the importance of the profession. It seems necessary to discuss the professional image in order to contribute to the identity of the professional, and these discussions may raise the importance of the profession, providing a vision of the importance of nurses as part of the healthcare team.⁽⁴⁾.

It is believed that the lack of knowledge and lack of appreciation for Nursing by other professionals in the healthcare field, also contribute to the low visibility of the group, causing the workers to suffer, creating difficulty in their relationships with the multi-professional team and in exercising their autonomy, which may reinforce the lower visibility of the profession, in a successive sequence of difficulties in every day work ⁽³⁾.

Thus, we ask: what is the perception of nurses in regards to the possible implications of the visibility of Nursing in every day work? This research question brings us to the reflection about the way society, healthcare workers, and in particular, the nurses, see the Nursing profession. Its goal: to understand the perception of nurses in regards to the visibility of the Nursing staff's every day work.

METHODOLOGY

This study was developed through exploratory qualitative research, and it took place at a University Hospital in the south of Brazil, which provides care exclusively for people who use the Public Health System (Sistema Única de Saúde). Fifty-nine nurses from different shifts (morning, afternoon, night 1 and night 2) were invited to participate in this study, those that worked 30 hours per week. Workers that were on health or maternity leave were excluded from this study.

The number of participants was defined through a process of adhesion of the participants to the research, following the saturation criteria of the data. Of the 59 nurses invited, two professionals were on maternity leave, twenty-three did not want to participate in the study and four were not interviewed, for being contrary to the saturation of the data⁽⁵⁾. What was found, through continuous analysis of the data and perception, was that little information or no new information was found, ending the collection of data ⁽⁵⁾. Thus, a group that totaled 29 people was excluded from the study.

Acting nurses from the Medical Clinic, Pediatric Clinic, Obstetric Center, Inpatient Obstetric Clinic, Surgical Clinic, Emergency Care Service, Intensive Care Unit (Neonatal e General), Supplies and Sterilization Center, Surgical Center and the Orthopedic Trauma Regional Center, participated in this study.

All the participants gave Informed Consent, thus guaranteeing their privacy, the anonymity of the information and asking for authorization to disclosure the results. With the participants' authorization and their signature of the Informed Consent Agreement, the collection of data began, and continued from July to October 2012 using a semi-structured interview technique. ⁽⁵⁾

The nurses were interviewed, individually, and they were encouraged, through open-ended questions, to give their perception in regards to Nursing recognition and about the visibility of Nursing in their every day work. The following questions served as a guide in the interview process: How do you perceive the visibility of the profession and of nurses in particular? How do you perceive the recognition of the practice of Nursing in the work context? Which factors make your work as a nurse invisible and devalued? How do the current historical transformations in the practice of Nursing impact the visibility of the professional in this area? How do you perceive the image that the media reproduces and that society has about the Nursing profession? How does the visibility of the nurse, as a professional, impact professional practice? Which strategies could be used to support the visibility of Nursing and appreciation of the professional nurse, in particular?

The approval of the FURG Research Ethics Committee in the Healthcare Area (Comitê de Ética em Pesquisa na Área da Saúde) – (CEPAS), was obtained through opinion 51/2012.

The data was submitted to a discursive textual analysis in which it was organized in four steps: disassembly of the written material, which happened due to the involvement and permeation with the 30 transcribed interviews, creating the units of meaning, which were defined and focused on the research objective; establishing relationships, using a categorization process, approaching the similarities of the units; reception of a new emerging and a self organized process, in which descriptions and interpretations of meanings constructed from the corpus, expressing new understandings about the phenomenon being investigated. In the last few phases, an intuition process happened, establishing an active learning process that resulted in the construction of main points related to the visibility of Nursing, which brings implications to the every day work of the nurse⁽⁶⁾.

RESULTS

From an analysis of the discussions, two categories emerged, the first was about the factors that could compromise the visibility of Nursing and the second pointed to the implications of the visibility of Nursing in every day work.

Factors that could compromise the visibility of Nursing

One of the factors mentioned by the participants, related to the visibility of Nursing, was the lack of knowledge and the technical ability of the workers in the Nursing Department in performing the following procedures:

A lack of knowledge devalues the profession (E3).

A nurse may know the theory, but if he or she does not know how to do the procedures he or she will have difficulties in the work market and this will devalue the job of the nurses (E9).

A professional that knows where to work [...], having knowledge, will be respected [...] losing professional value due to the lack of knowledge, wanting to impose oneself through yelling or acting out will not help the professional, he or she needs to show his or her work through knowledge (E10).

Knowledge, interest, and responsibility have to guide what the nurse does, if these are not present he or she will be devalued, invisible (E15).

Through the testimonials, it was possible to understand the inadequate behaviors of the nurses and this could be contributing to compromising their professional image:

People misbehave, they behave in a way that has nothing to do with their job [...]there is not respect, for example: at four o'clock in the morning, in the Nursing Department, everybody was laughing and the patients wanted to sleep, the nurse too (E3).

What makes nurses more invisible and devalued is people's lack of commitment; they do not do what they are supposed to do (E4).

Another aspect that compromises the Nursing image is the work overload, this makes errors more frequent and work less possible:

The work overload brings invisibility [...] the nurse is in charge of up to three units [...] there is no time to provide quality assistance, evolving Nursing; there is not work record, causing them to lose value and become invisible (E2).

We have one nurse for 50 patients [...] it is not possible to register our work, for this reason it is not seen (E13).

We are suffocated with administrative issues, bureaucracy, so overloaded that it makes it impossible for people to realize what we do. (E1).

The lack of professional acknowledgment of nurses seems to influence their insatisfaction with the work they do and the quality of nursing assistance:

When your job is not recognized [...] it is reflected in what I do, because I feel more frustrated, dreaming about the acknowledgment that I do not have, I do my work with less motivation (E13).

After you have a voice you cannot give up [...]there is a big responsibility [...] from the professional point of view it transforms us [...]it starts to improve the quality of our work; if you are invisible, they do not know who you are, and why are you going to fight for the quality of your work? (E11).

The minimum that people expect is recognition [...] to have good social visibility, recognition is the best thing we can have, it nourishes us [...] we get motivated [...] if the profession was valued the individual would have more pride in saying that he or she is a nurse [...] respect feeds people and stimulates them [...] the way people see me, makes me take my profession more seriously (E25).

The implications of the visibility of nursing in every day work

The Nursing image stays rooted in its historical path, with deep marks still present today in every day work, associated with the difficulties that Nursing has with being recognized as a profession that underlies its actions with knowledge:

I believe that the image has a historical influence, [...] as a result of humility, with some kind of fear of standing up as a professional [...] we are a little bit submissive (E5).

Nurses are not prostitutes, they are not nuns, nor are they healers, they are graduated professionals with a theoretical-practical base, and fighting against the pre conceived image is very complicated, so we live through fights daily (E30).

One of the participants manifests his resentment of the idea that charity and submission permeate the Nursing image, emphasizing the importance of visualizing the nurse as a person with his or her own professional training and not only as someone that had a gift:

Being a profession that has a basically female origin, one of submission and charity [...] we have to do things with love and with a gift [...] and that's not what it is! I do not have to work for free, this devalues the professional [...] people work for the money and because they like it (E4).

The participants stress that the media emphasizes a negative stereotype of the image of nurses, and that the patients believe what is in the media, influencing the credibility of the profession:

People are very uncultured [...] if one person makes a mistake giving medication [...] the image of Nursing throughout the country falls, because it falls in the media, and this turns into a religion, so the patients say: 'because you give us the wrong medication we almost die,' but nobody sees that it was one person out of millions (E12).

The media portrays the female nurse with a beautiful and sexy body, underdressed and with an syringe in her hands [...] the nurse is always involved in some kind of crime [...] she is limited [...] a doctor has a firm character, good-looking and smart and the nurse is always subservient, beautiful and hot, and her image is very degraded [...] these images make the patient believe that we are not competent, and that we are going to make mistakes (E23).

The testimonies of the nurses, the medical hegemony, and the appreciation of medicine at the expense of Nursing makes its image and visibility fragile, compromising the establishment of the link to the patient:

Nursing has to build a link to the patient in order to have credibility, while the medical professional does not care who the patient is [...] the doctor says two or three words and that is it, due to the fact that he or she is a doctor [...]visibility influences the day to day of the profession (E1).

The question of the subordination to the doctor is still present [...]a nurse is still seen as someone who follows the orders in the eyes of society [...]our relatives think that we are doctors' assistants (E11).

The majority of people still see nurses as a subordinate or a secretary, society does not know what a nurse does (E13).

The negative reflections on the Nursing image and its visibility could be related to the lack of knowledge in regards to the attributes of nurses by other health professionals:

There is a lack of acknowledgement by other professionals that think they are better than the nurses [...] there are some things that we need to request authorization for, they think that they own the patients; it is like we are their servants (E8).

A good nurse is someone who does a little bit of everything, not necessary perform his or her own work, but someone who always does everything [...] there is a distortion of what really is a nurse's job [...] we work so hard that we do not have time to think, and we do many things that are beyond our job duties(E1).

Besides the lack of professional recognition and ignorance about the attributes of the different workers, the nurse does not market himself or herself, intensifying the lack of visibility of the importance of his or her work:

They do not know who the nurse is [...] Some say: 'study a little bit more and you can become a doctor', they do not have any idea of a nurse's role [...] this could be because of a lack of positioning from the nurse (E16).

Actual Nursing behaves in an invisible way, it does not talk about its knowledge, it does not guide the patient [...] it does not stand out, it does not educate people about its functions, and, it does not make itself present (E1).

We always see co-workers talking bad about the other shift staff, or the other co-workers [...] the disunity of some co-workers devalues the job (E14).

DISCUSSION

The negative reflections of the nurse's image is related to the lack of knowledge regarding the nurse's attributes, by other health professionals, who lack clarity in relation to the differences established by the nurses, assistants, Nursing technicians. The lack of knowledge in regards to the work that nurses perform could be perpetuating the old sphere of operation, restricting the nurse to discussions limited only to his or her category, staying this way, the richness of the nurse's many visions about the practice of healthcare remaining unknown.

A nurse's lack of specific knowledge was one of the main points made by the research subjects, which goes hand on hand with the conclusion of the literature, showing that the nurse is a victim of social preconceptions. Many mentioned that to be recognized professionally, one needs to be technically competent and apply his or her specific scientific knowledge to the area⁽⁷⁾.

On the other hand, it is not only knowledge that promotes visibility of what a nurse does, but also the way he or she acts, by being ethical, you can be sure that you will face a series of social prejudices that involve Nursing. Thus, a nurse needs to gain the respect of other health professionals, demonstrating knowledge and seriousness ⁽⁷⁾.

Our findings indicate that the overload of work plays an important role in determining the visibility of the nurse, leading to more frequent errors. Also, the low pay could make the nurse need to find a second job; this alone could result in more mistakes and in the non fulfillment of his or her obligations, damaging, even more, his or her image and the quality of assistance provided ⁽⁸⁾.

When the worker is acknowledged and has social prestige he or she can develop as a professional. He or she is happier at work, and can identify with his or her place of work. The acknowledgment of Nursing as a profession, and the social prestige could make nurses feel happier and more satisfied with their job duties. This satisfaction could motivate nurses to develop their patient care with increased quality⁽⁹⁾.

Achieving the recognition and the professional visibility, the nurse could be fundamental in building knowledge and technical ability so that the nurse can better develop what he or she does. Some qualities are present in the nurse's actions, such as initiative and safety. These are qualities that can promote visibility in front of the healthcare staff and the patients. It was possible to find out that Nursing, in some way, is acknowledged and admired for its charitable character. Nursing professionals seem to keep the myth of vocational donation alive as an alternative to guaranteeing some sort of social prestige.

From the nurses' testimonies, it was possible to notice that some stereotypes present in the image of nursing are rooted in the historical path of the profession, such as: humility, charity, religion, prostitution, silence, and submission. Historically, humility was an essential virtue that needed to be developed by the religious caregivers and silence was an instrument of their virtue. They did not talk about their personal and professional qualities because they practiced humility and altruism. ⁽¹⁰⁾.

From the testimonies, the nurses feel that their profession is not limited to the practice of Nursing as a gift or a professional calling, but as a practice that permeates the fields of knowledge, where they can practice their autonomy, earn their wages and interact in a critical and reflexive way while they work⁽⁷⁾.

In analyzing Nursing as a professional occupation, the lack of social acknowledgement of the profession is visible, and this weakens the visibility of Nursing. Therefore, there is a need for social acknowledgment of Nursing and of the nurse, in particular, as a professional that has his or her own education, his or her own space and scientific knowledge, which are the foundation of who he or she is. ⁽¹¹⁾.

It is visible, through the findings, that, in general, the media makes the profession visible, reinforcing a negative stereotype of the nurse's image, and this distorted vision may influence the credibility of the professional with the population. Researchers advise that Nursing and the nurses use their voices, warning that many nurses contribute to the invisibility of the profession in the media because they do not stand up, and do not speak out. Therefore, stressing the need for nurses to stand up and to contribute in a positive way to professional visibility, as well as how nurses should take steps to stand up to the means of communication⁽¹²⁾.

It has been noticed that the visibility of the image of the nurse is associated with the other health professionals' lack of knowledge in regards to his or her attributes, and also to the difficulty that the nurse has in marketing himself or herself. The personal marketing is less used in Nursing because it has many challenges represented by the professional history. It is hard to break the link with silence and simply make his or her qualities stand out, because of this it is very common that nurses do not know how to show their own virtues, which makes the profession less visible socially. Therefore, personal marketing is a skill that needs to be developed as an instrument that makes the visibility and the acknowledgment of the professional nurse viable ⁽¹³⁾.

The utilization of the means of mass communication could be an important tool for building a stronger professional identify, on the other hand, if Nursing can bring an image of better professional credibility to the public, it could feasibly create a positive image of the nurse in a social context. The development of personal marketing abilities is essential, in order for the profession to attain "appreciation of the nurse by the institutions, by the government and by society." Thus, Nursing would become a recognized profession ⁽¹⁴⁾.

It was possible to notice that one of the things that weakens the image and credibility of the nurse from the patients' perspective is related to medical hegemony and the valorization of medicine at the detriment of Nursing. Perhaps medical hegemony is related to the biomedical model of health care and common sense. Valuing the healing actions minimizes the value of the work that nurses perform, which focus on the promotion of the health. In this context, the contributions that Nursing offers, support medical practices, constituting a complementary work, being erroneously acknowledged by the society ⁽¹⁵⁾.

Moreover, the medical hegemony could distort the way the health professionals and patients see the nurse. They can portray the nurse as someone who lacks the necessary knowledge in the therapeutic area, which is not true. Thereby, the establishment of bonds with the patient could be damaged by the false image of submission and empiricism still present in Nursing. Because the care process "should be established from a relationship of trust," the patient needs to believe in the professional nurse, he or she needs to know that the nurse possesses the necessary knowledge for health care ^(3,16:326).

One limitation found in the study refers to the dimension of the problem analyzed, because the visibility of Nursing and the professional image could evoke an in-depth investigation. It is worth noting that this study was performed in one hospital in the country, thus, the reality portrayed in the research is singular because it seeks the perception of the experiences that each individual assigns to his or her every day work. However, it is believed that the reality studied in this research may portray, although with singularity, the visibility of the professional nurse.

CONCLUSION

The results showed that the visibility of the Nursing is related to the historical path of the profession, the lack of acknowledgement of Nursing as a scientific profession, the erroneous bond of its image with the media, the lack of marketing by nurses, an inadequate position in front of the group, as well as the overload of work.

In a work context, the visibility of Nursing may generate negative implications for the nurse, expressed through dissatisfaction, and lack of motivation, which could compromise the quality of care. The commitment of the visibility and the lack of acknowledgement in the profession by the other healthcare staff could inhibit the establishment of trusting bonds, affecting the effectiveness of care.

In addition the historical path that the profession has taken, negative stereotypes instilled about Nursing also relate to the actions of the nurse, in the work context, the dissatisfaction, the submission and obedience to the other health professionals, the execution of the practice without reflection and clinic knowledge, corroborating with the intensification of the uncertainty of the importance of the nurse's job, for the healthcare staff, the patients and society in general.

Despite the changes that Nursing has taken on the professional path and the constant attempts to gain professional visibility, we can see that the way the nurse behaves in his or her work environment, his or her competency, knowledge, personal marketing and professional commitment to the practice of Nursing could transform Nursing's social image.

Through this study, it was possible to give some important advice for demystifying nursing, achieving, therefore, more professional visibility: seek better media visibility; the personal marketing of nursing and, in particular, by the nurse; the pursuit of acknowledgment through adequate behaviors in front of the healthcare staff; fighting to have better working hours, avoiding the work overload and its negative consequences, and demonstration of knowledge and professional autonomy.

This research is important, because the findings could aid in the reflection of the nurse in regards to his or her practice, and this will encourage the search for appreciation of the profession. Demystifying the image of Nursing is a challenge that needs to be taken on by nurses in a way to overcome the invisibility.

Given the importance of this study, it is proposed that more research through studies needs to be done in order to reveal other experiences and realities lived by nurses throughout the country, in search for results that could lead to other findings about the visibility of Nursing.

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Publication Dates

• Publication in this collection
  02 Dec 2013
• Date of issue
  Sept 2013

History

• Received
  17 Mar 2013
• Accepted
  03 Sept 2013