Nursing knowledge patterns : nurses ’ image and role in society perceived by students

Rev Bras Enferm. 2020;73(4): e20180959 http://dx.doi.org/10.1590/0034-7167-2018-0959 7 of ABSTRACT Objectives: to understand high school students’ perception about the nurse’s image and role in society, from nursing knowledge patterns. Methods: phenomenographic qualitative study, developed between October 2017 and January 2018, in a public university in the countryside of the state of São Paulo, with eight Interdisciplinary Higher Education Program (Programa de Formação Interdisciplinar Superior) students. The findings were collected through semi-structured interviews and analyzed by the phenomenography framework, supported by rereading nursing knowledge patterns. Results: two categories emerged: Perception of nurses’ image, which contemplates their positive and negative characteristics, attributes and place where they operate; and Nurses’ role in society, in which their work is compared with physicians’. Final Considerations: despite their essential role in care, subordination to medical knowledge and lack of knowledge of nurses’ functions still reflect their image. Descriptors: Nursing; Social Perception; Nurse’s Role; Students; Qualitative Research.


INTRODUCTION
Professional image is a social representation established by a set of concepts and refers us to occupational identity (1) . It has direct relationships with power, status, and autonomy, and what they think about a profession is as important as what the professional really is (2) . Although their role is indispensable in health care, studies show that nurses' image perceived by society is fraught with stereotypes, being little recognized as to their role (3)(4)(5)(6)(7) . Since public opinion can determine the norms and structures of society, such stereotypes can negatively influence their professional practice (3) .
Stereotypes attribute to nurses such as physician's assistant, lack of social life, "angel" and prostitute figures are closely related to the profession's history (3) . Factors that contribute to the maintenance of these stereotypes include female condition, presence of hierarchy between physicians and nurses, misrepresentation in the media, and lack of marketing by nurses (3,8) . The mistaken assumption that nursing has no scientific knowledge, the hands-on feature attributed to care and lack of knowledge of the different degrees of nursing staff training and their fields of activity also contribute to nurses' image devaluation (3,7) . One of the possible strategies to overcome this setting is nurses' personal marketing to improve their visibility to society (8)(9) .
Public opinion and stereotypes attributed to a profession can interfere with the choice of young people. The current setting points to a multiplicity of higher education courses that influence this dilemma, not only by their belief and identification with a profession, but also by opinions of family members, labor market and their social ascension. This implies decision-making that can lead to conflicts in choosing the course (10) .
High school graduates are about to decide on a professional career, with nursing being one of the possibilities. It is important to know their perceptions about nurses, as stereotypes attributed to them can interfere with the choice of profession. The question of this study is: what is nurses' image perceived by these students?
In the understanding of the nurse's image, investment in scientific foundation's consolidation of care can impact the way society perceives nursing (11) . Carper understood that it was necessary to differentiate the area's specific knowledge and to establish the profession as a science. Carper formulated four knowledge patterns: empirical, treated as nursing science; esthetic, which is the art of nursing; personal knowledge, genuine relationship with people; and ethical, which is the moral component (12)(13) .
There is a fifth pattern, the sociopolitical (14)(15) , which allows the broadening of nurses' gaze beyond their relationship with patients. This pattern places nurses in a broad context in which nursing and health care are inserted (14)(15) . These patterns, when incorporated by nurses in their care practice, portray a body of knowledge specific to the area, establishing nursing as a science (12)(13) .
This study is justified by the need to broaden the understanding of school students' perception about nurses' image and role in society. This is a relevant theme, since the world setting points to increased training of these professionals in order to meet the population's health needs. Thus, high school students' perception assessment regarding nurses' image and role in society can be meaningful (16) .

OBJECTIVES
To understand high school students' perception about nurses' image and role in society, from nursing knowledge patterns.

Ethical aspects
The study was approved by the Research Ethics Committee of the College of Medical Sciences of UNICAMP, under Opinion 2,302,571, pursuant to Resolution 466/12 (17) . Collection of findings was started after signing the Free and Informed Consent Term. Anonymity of participants was guaranteed by using the letter E instead of their names, in chronological order of the interviews.

Theoretical-methodological framework and type of study
This is a qualitative and phenomenographic study that seeks to explore the way people live and understand the same phenomenon (18) . Phenomenography is content oriented and is more concerned with the collective sense than with individual experiences, seeking to know how each one develops to relate to the world around them (18) . It is important in nursing research because it can describe how a professional group's role is viewed (18) . This article used the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the methodology.

Study setting
The study was conducted at a public university in the countryside of the state of São Paulo, in the city of Campinas. Interdisciplinary Higher Education Program (ProFIS -Programa de Formação Interdisciplinar Superior), started in 2011, is a course for high school graduates from public schools in Campinas. At the end, they can enter, without the entrance exam, an undergraduate course. Therefore, they must necessarily choose an academic career to follow.

Source of findings
Research participants were studying at ProFIS. The inclusion criterion was being enrolled in ProFIS, aged 18 years or older. Non-ProFIS students under 18 were excluded.

Collection and organization of data
Semi-structured interviews took place from October 2017 to January 2018, with eight ProFIS students composed of the following questions: "Have you or anyone you know ever been taken care of by a nurse? Tell me how this experience went" and "What image do you have of the nurse?". Interviews characterize the main source for the collection of findings, allowing to explore the experience of each participant on the studied phenomenon (19) . Interviews were recorded and later transcribed literally, respecting information reliability. Network sampling was used to approach participants, where one indicates the other (20) . Collection of findings ended when the phenomenon was unveiled to the researcher and the objective of the study was answered (21) .
of Nursing knowledge patterns: nurses' image and role in society perceived by students Pierrotti VW, Guirardello EB, Toledo VP.

Analysis of findings
Statements analysis followed the steps: literal transcription of interviews, reduction of findings, verification of different phenomena and their understanding through the way people experience and understand them (18) . As a theoretical framework to support the analysis of findings, a rereading of knowledge patterns that permeate nursing care was used. It is possible to articulate with the participants' ways of seeing, living and understanding, regarding their understanding of the body of knowledge specific to the profession (12)(13)18) .
Two categories emerged from this movement: Perception of nurses' image and Nurse's role in society.

Perception of nurses' image
Study participants attributed positive personal characteristics to nurses such as caring, careful, responsible, patient, and dedicated to the profession. Another finding was that nurses should be able to deal with people who do not collaborate with treatment and with the high demand for work in services in which they work. They should know the right dosage of each medication, be preventive and meticulous as they can cause errors during care and even lead patients to death. Nurses' image was also associated with some negative characteristics, such as disloyalty, maltreatment, arrogance, bravery and lack of attention, which implies that the patient avoids verbal contact with them.
We know that there are many nurses who are disloyal, who treat the patient badly. (E2) [...] but there were also some who were very arrogant and we avoided talking, because they were kind of angry, didn't pay you much attention. (E5) Nurses' image perception was also related to their areas of activity, being present in all levels of health care, including health centers referred to hospitals. They are seen as responsible for managing the care unit. At the hospital level, operating rooms, emergency room and those specialized in women's health care were mentioned. They also reported the possibility of nurses being hired to provide home care, participate in academic activities and work in clinics, although their image is predominantly associated with the hospital environment. Participants pointed to social networks as an important tool to positively disseminate the image of the nurse, making it possible to suppress the propagation of stigmas, giving visibility through the report and sharing of texts by professionals and students about their work.

Nurses' role in society
Regarding nurses' role in society, interviewees considered them as physicians' assistants and that they, in turn, have greater prestige. Physicians do not stay with the patient 24 hours a day, while nurses are practically taking care of him. Thus, because they are more present, they are considered the professional who has the vision of patient care, as well as have a greater coexistence with him. Another perception pointed out that the physician is distant from the patient, which makes the nurse closer as she tries to know him better and is interested in his needs. Thus, not only does she have a more humane look at care, she also remains and relates more to the person being cared for. [ The professional choice between nursing and medicine also emerged in interviewees' speeches. They pointed out that, in hospital, physicians and nurses are kind of the same, being physicians more prestigious. However, they emphasize that they are happy if they choose nursing, because they consider it a health profession.
You're in the hospital, it's more or less the same, and although the physician is more prestigious, if I go to nursing, I'll be there in the health area. I will feel equally happy, since they are different professions, right? (E6)

DISCUSSION
There was support in rereading the aforementioned five patterns of nursing knowledge (12)(13)(14)(15) . Although all patterns were present in the interviews, some were predominant.
In the first category, understood by nurses' image perception, positive characteristics were attributed to them. The personal pattern of nursing knowledge, despite being the most difficult to incorporate into professional experience, is present in the interviewees' statements, as nurses establish a genuine and authentic relationship with patients (12)(13) . This interpersonal relationship occurs between the self, that is, as the nurse sees herself, and also between the patient who becomes the relationship's main figure, no longer seen as an object (12)(13) . Interviewees then identified, in their relationship with nurses, their positive characteristics, which eventually reflect this pattern of knowledge. The esthetic pattern also corroborates this view, since nurses must be able to fully understand patients and be able to experience their perspective through empathy (12)(13) .
In the view of interviewees, being able to diagnose and assess patients' needs, there is the incorporation of empirical knowledge by nurses. These actions denote that there is scientific knowledge of the profession evidenced by citation of some of the nursing process stages (13,22) . The esthetic experience is also present, as there is responsibility for all patient care, allowing the performance of transformative acts that bring knowledge of experiences to which the art of nursing is directed (12)(13) .
Respondents realized that nurses must know how to handle the high demand for services and be careful not to cause errors during care. It is emphasized again that empirical knowledge is present in their actions, as nurses must be guided by the use of rationality and the theoretical framework provided by science (12)(13) .
The esthetic standard says about nurses' ability to use their creativity to do what is most satisfying and effective to care for patients at a given time, such as when they are overwhelmed (12)(13) . This work overload may be related to the occurrence of errors in care, also reflecting on the ethical pattern, since there is a code of professional ethics that supports their actions (13,23) .

Nursing knowledge patterns: nurses' image and role in society perceived by students
Pierrotti VW, Guirardello EB, Toledo VP.
Negative attributes given to nurses have implications for the ethical foundation of their actions. One of their responsibilities, according to the Nursing Code of Ethics, is the obligation to provide safe care, free from risks or damage (24) . Nurses have a moral commitment to patients. They are constantly making choices that involve fundamental issues between right and wrong but not necessarily covered by the Code of Professional Ethics, which corroborates the ethical pattern (12,25) . To be achieved, this pattern requires an interpersonal involvement of nurses with patients, in order to initiate positive habituation, that is, their ability to learn from some experience and always be open to new learning in their daily lives (12)(13) .
Regarding image, interviewees associated nurses' practice areas according to their experience and reports of their relatives when they served different health services. This aspect may highlight the political pattern that mentions the broad context in which nursing and health care are inserted, although the image is predominantly hospital (15) .
Activities given to nurses are related to direct patient care, as they administer medications, vaccines, and are responsible for hygiene, food, and wound care. There is an empirical knowledge for its fulfillment, because care is based on a theoretical framework (12)(13)25) . The nursing team is subdivided into three categories: nurse, nursing technician, and nursing assistant, each with specific attributions (26) . Nurses' functions were associated with those performed by other nursing professionals, in contrast to the routines in nursing services. Although supervised, direct patient care is mostly performed by technicians and assistants. There is a lack of knowledge of nurses administrative, managerial and supervisory functions, associating them only to the fulfillment of technical activities and direct patient care (6) .
Regarding nurses' image disseminated by the media, the presence of the esthetic pattern is evidenced as a way to "intrainhabit" the other through the empathy shown to be concerned with patients and interested in meeting their demands (12)(13)25) . The personal pattern allows the establishment of an authentic and unique nurse-patient interpersonal relationship (12)(13)25) .
Social networks were identified as an important tool to positively promote nurses' image. Socio-political knowledge is integrated here with the responsibility of nursing to use the media to improve its participation in public spaces, enabling greater professional autonomy and visibility (14)(15) .
In the category referring to "Nurses' role in society", participants compared nurses' work with physicians' , and their presence 24 hours a day, characterizing a profession based on the permanence and not the visit. As nurses have more experience, they relate more to patients than physicians do, having a more human contact with him. Nurses, having the vision of patient care, must be guided not only by empirical knowledge, based on evidence, but also on esthetics, as it is a singular and subjective expression of possibilities that becomes visible in the action of caring (12)(13) . They should also be aware of the difficult choices that arise during care and involve the concepts of what is good, what should be desired or what is right for each person, as they seek to know patients to try to understand their needs (12)(13)25) .
It was also evident that nurses are seen as physicians' assistant who are most prestigious by society. The influence of medical knowledge is predominant in nurses history, inferring that they should be subordinate to the physician (27) . One of the contributions to the assumption of this inferiority is that physicians are responsible for diagnosis and treatment decisions for each patient and, without it, there would be no patient or nursing interventions to be performed (27) . Therefore, they are seen as continuing physicians' work and assisting them when necessary. However, despite the belief of their submission to physicians, nurses occupy an essential role in the articulation between nursing and health workers, being independent to perform the nursing process (22,27) . To overcome this paradigm, it is important that nurses incorporate socio-political knowledge in search of greater autonomy and visibility (14)(15) . In addition to teaching and research, it is necessary to consider the political organization of the profession as a way to achieve social representation (28) .
The professional choice between nursing and medicine also emerged in interviewees' statements. Often, nursing is the second option in relation to professional choice in response to the frustration of something not done: the dream of studying medicine. Professional identity construction of nursing is important. That should be carried out through the incorporation of socio-political knowledge by nurses. Thus, students would identify with the profession and it would be recognized by society in a coherent way and could become the first option in the entrance exam (10) .

Study limitations
Nurses' image perception was understood from a group of students inserted in a professional undergraduate program. There is a discipline in this program that provides insight into the different undergraduate courses that the university offers, including nursing, and may have influenced the image these students have about the profession. Other young people who do not have this experience in their education could present a different view of nurses' image, although the phenomenographic study considers experiences of each subject as unique.

Contributions to nursing
The research contributes to the identification of nurses' image and role in society perceived by students who are about to choose a professional career, and may reflect on the way their image is perceived in society. As studies on the subject are developed and participants recognize the importance of nurses' role in population health care, it is possible to promote their coherent image, especially if linked to the media to have greater social reach about their role. In education, the study may encourage future research on the recognition of nurses' image and role by students entering the course and how this changes during graduation.
Search for scientific deepening in nursing also positively corroborates nurse autonomy and can, besides contributing to the scientific production of health knowledge, bring more visibility to them.

FINAL CONSIDERATIONS
Phenomenography use made it possible to understand nurses' image and role in society perceived by high school students, discussed according to nursing knowledge patterns.
Interviewees associated with the nurse positive characteristics, such as caring, careful, patient and dedicated to the profession. Nurses are essential in health services, are responsible for all care and can diagnose and follow the individual's needs. The empirical pattern stands out, since it denotes nursing's scientific knowledge. However, they attributed negative characteristics such as bravery, maltreatment, and inattention, evidencing the ethical pattern, because nurses are responsible for harmful actions to the patient. There is lack of knowledge of their managerial and administrative functions, being associated with the fulfillment of direct patient care. They pointed to the use of social networks as an important tool to promote profession visibility.
There was a perception that nurses are present 24 hours a day and have more experience with patients than physicians do. This denotes the esthetic pattern due to the singular expression of possibilities in care. There is a predominance of nurses' image of subordination to physicians, because they are more socially prestigious, with nurses being their assistants.
It is important to conduct other studies that address profession visibility and how its image is perceived by different groups in society, considering the lack of research on this theme.