Introduction

Nursing as a profession has developed considerably over time (Walter 2013). However, media representations have historically failed to illustrate this (Summers and Summers 2015). Inaccurate portrayals have potential damaging implications on societal perception, professional identity and nurses’ status (Kalisch and Kalisch 1987; Hallam 2000; Summers and Summers 2015). This paper seeks to explore discourse around this slow evolution in UK media representation.

This work is particularly important amid a difficult time for nursing. Regular reports highlight staff shortages; Britain’s exit from the European Union means uncertainty for the status of European nurses; student bursaries have been cut; nurses are retiring early; newly qualified nurses are leaving for other professions (Ulmer 2000; Finlayson et al. 2002; Seago et al. 2006; Sephel 2011; Monaghan 2015; Simpkin and Mossialos 2017). Nursing’s image elicits public expectation regarding how nurses treat them (Summers and Summers 2015). Researching the image of nursing is important because if representation does not match self-image, it can negatively affect how nurses think and work (Takase, Maude, and Manias 2006). Grasping why and how nursing’s image has developed enables exploration of nursing’s societal status, as media representation is a political tool affecting policy making, recruitment efforts and funding (Darbyshire 2014, Summers and Summers 2015). By analysing representation, this research argues that improved public image could mend professional identity, influence public policy, increase public trust in nursing, and improve recruitment and multidisciplinary relationships (Cohen and Bartholomew 2009, Summers and Summers 2015).

Background

‘To know the past is to understand the present and to have hope for changing the future’ (Hudson-Jones 1988, 21). The analysis of nurse-related stereotyping in the media has a long history. Media coverage glorifies nursing’s past which hinders contemporary nurses regarding poor public opinion and government policy, as image affects debate regarding future organisation of nursing (Hallam 2000; Gillett 2014; The Press Association 2014). Using Richard Dyer’s (2013) work on representation, this section clarifies why representation is significant by exploring one particular stereotype which arguably influenced current images.

Representation re-presents the real world through platforms such as film or television, ‘it is not directly reality itself’ (Dyer 2013, 2). Media constructs one version of reality which is ‘partial, selective, incomplete and from a point of view’ and extremely influential regarding reinforcing social norms and values (3). This is achieved by content creators portraying images determining or reiterating what is acceptable using recognisable ‘symbols’ (Bandura 2001); for example, stereotypical symbols of female nurses assisting male doctors (Summers and Summers 2015). Reality is more complex than representation is able to capture, therefore media makes subjects easier to engage with (Dyer 2013). Accurate representation is important as social statements are conveyed in media content. Dyer (2013) argues image analysis must consider how phenomena are embedded in broader networks. Bandura (2001) claims: ‘a vast amount of information about human values, styles of thinking and behaviour patterns is gained from the extensive modelling in the symbolic environment of the mass media’ (271). Dyer (2013) and Bandura (2001) echo a critical realist framework as representation cannot be explored as stand alone. Excluding wider context behind representation limits deliberation into purposes and influences of representation to enable real-world depth of understanding of subjects (Pawson 2006). Representation is vital in regards to real-world consequences for people concerning how they are treated and how it may restrict or delimit what people and their roles are within society (Dyer 2013). Inaccurate representation leads to potential ill-treatment or poor sentiments towards nurses from patients, other professionals and society (Summers and Summers 2015). Moreover, Hallam (2000) argues that representation affects self-identity and occupational pride. Additionally, negative connotations may deter those considering nursing careers (Brodie et al. 2004).

Kalisch and Kalisch (1987) outline ‘when lay people are asked to evaluate the role of nurses in healthcare, they usually rely on information acquired from mass media’ (1). Media portrayals impact even contemporary media-aware audiences’ perception (Heilemann 2012; Hart 2013; Summers and Summers 2015). Repeated images foster ‘visual-shortcuts’ which audiences understand instantly (Lippmann 1956). Although this implies audiences’ passivity in accepting what they consume is accurately depicting nursing, Takase, Maude, and Manias (2002) argue ‘the public continues to perceive nurses in a stereotypical manner, and there has been little improvement over time’ (196). Girvin and Hutchinson (2016) state out-dated, limiting images remain. Exploration into stereotypes enables understanding of contemporary representation (Darbyshire 2014).

Kalisch and Kalisch (1987) argue that nursing has matured regarding education, technological understanding and autonomous decision-making, which was previously exclusively the realm of doctors. However, nurses remain ill-represented by outdated ideals (Gillett 2014; Girvin and Hutchinson 2016). Some major well-documented mass media nurse representations are ‘Angel of Mercy,’ ‘Girl Friday,’ ‘Heroine,’ ‘Wife/Mother’ and ‘Sex Object’ (Kalisch and Kalisch 1987). The ‘Sex Object’ depiction was ‘sensual, romantic, hedonistic, frivolous, irresponsible and promiscuous,’ existing for male doctors and patients’ pleasure (17). Nursing involves intimate provision of care; negative connotations sexualise nursing as a ‘metaphor for sex’ (Fagin 2000). Due to touching strangers’ bodies, nurses are considered willing sexual partners, but unlike sex workers, they are perceived as safe because “quality” is inferred in clean, crisp uniforms (32). Medically focused Carry On… films and the theme of nursing in pornographic films has historically reduced nurses’ singular role as sex objects (Kalisch and Kalisch 1987). Carry On Nurse, the biggest British film of 1959, was successful in America and Europe (Bright 1997, 27). The medical Carry On… films also include Carry On Doctor (1967) and Carry On Matron (1972). Kalisch and Kalisch (1987) argue that in these portrayals, sex linked patients, doctors and nurses rather than illness. Nurses were exaggerated forms of beauty, availability and idiocy than previous stereotypes. Barbara Windsor’s portrayal of a pretty, foolish, young, blonde nurse reflected societal ideals (Kalisch and Kalisch 1987). In contrast to this was the ‘battle-axe’ stereotype: the strict, uncompromising and authoritative matron (Muff 1988). This depiction undermines women, suggesting incompetence regarding authority, becoming hardened and creating misery for all (ibid.). However, Matron shifts to ‘jealous, love-sick fool’ from Carry On Nurse to Carry On Matron (Kalisch and Kalisch 1987). This contrast arguably traps all nurse representation in the Carry On’s universe as sex-obsessed and receptive when pursued by male patients and doctors.

Conversely, Bright (1997) states: ‘Carry On painted a portrait of the way the nation, apparently at ease with itself, looked in the later middle decades of the century. As such it is arguably an important historical work, although it is important to keep in mind that it was devised as entertainment’ (27). Bright’s argument pertaining to sexual suggestion and innuendo being integral to Carry On’s comedic formula is relevant, but places nurses in demeaning positions in society, possibly reflecting historic social structures. In the scheme of nursing’s arduous history with establishing the profession and being taken seriously, it could be contended that medical Carry Ons hindered nursing’s image (Ehrenreich and English 2010). Furthermore, it has been pointed out that ‘these fleeting images rarely elicit prolonged contemplation or critical analysis’ (Kalisch and Kalisch 1987, ix), suggesting viewers’ poor knowledge of stylistic genre conventions.

The sex object stereotype extends to detrimental pornographic imagery via ‘sexploitation’ films entering popular culture (Soothill, Henry and Kendrick 1992). Pornographic films such as Deep Throat (1972), an X-rated pornography film, contributed to overt sexual depictions of nurses serving doctors’ and male patients’ sexual needs (Kalisch and Kalisch 1987). As Thorpe (2016) suggests, pornography is the ‘reduction of a human being to an object of the gaze, action, and power of another, encodes and solidifies the social structures of hierarchy and domination in which it is embedded’ (153). Although pornography does not intend realism, nurse sexualisation is damaging. Kalisch and Kalisch (1987) state: ‘the quality and quantity of mass communication pertaining to nursing strongly influences the course of the nursing profession, by shaping the nature of nursing’s relationship with the public it serves’ (193). Pornography is highly accessible and conveys detrimental messages about nursing. These hypersexual images have infiltrated popular culture with ‘the pop-punk band blink-182 [‘s use of] a photo of a porn star as a naughty nurse’ (Summers and Summers 2015) (Appendix 1). Similarly, ‘sexy nurse’ Halloween costumes are popular (Stange, Oyster and Sloan 2013). Huston (2014) highlights that in reviewing nurse images on Google, countless ‘young women dressed in cleavage-baring uniforms, and wearing fishnet stockings, high heels and garter belts’ appear (334). A ‘poll by Budget Van Insurance found 54% of British men had sexual fantasies about nurses,’ over any other profession, emphasising how ingrained this negative image is within society (Summers 2010, 1). Summers and Summers (2015) link this with men desiring perceived low-status submissiveness associated with nursing. Bronner, Peretz and Ehrenfeld (2003) state sexual harassment is a long standing problem for nurses. Approximately 25% of nursing staff experience sexual harassment worldwide with the rate being highest in English speaking countries which are linguistically and culturally similar, including England, Scotland and Ireland (Spector, Zhou and Che 2014). It has been suggested that a ‘sex object’ image affects nurse-patient relationships, possibly encouraging or permitting a culture surrounding tolerance of sexual harassment (Madison and Minichiello 2000).

Huston (2014) adds that male nurses are represented as ‘gay, effeminate and sexually predatory’ (333). Male nurse stereotypes are usually negative, which Huston (2014) argues is problematic regarding recruitment, such as men portrayed as less caring and compassionate, possibly linking to nursing’s construction around women’s “intrinsic” caring ability (Huston 2014). Furthermore, male nurses’ portrayal as overly sexual has real-world implications, as it potentially means concern about how caring actions are interpreted (ibid.). Another detrimental depiction is male nurses failing to follow a career in medicine, the “appropriate” healthcare role, thus being represented as a ‘non-achiever’ (ibid.). The evolution and representation of nursing has not always correlated and real-world consequences are apparent (Summers and Summers 2015). Perpetuating stereotypes is negligent, and continued inaccurate, negative representation produces problematic expectations (Muff 1988). The remainder of this paper aims to explore contemporary representation, having set the scene with the well-documented historical views.

Aim

To explore whether the discourse outlined above regarding nursing’s known media stereotypes and female-dominated status affects contemporary media representation.

Objectives

  1. 1.

    To explore links between female media representation generally possibly affecting nurse representation.

  2. 2.

    To use Laura Mulvey’s theoretical framework of the ‘Male-Gaze’ to situate analysis of UK media content to understand if issues debated in existing literature are observable in UK texts.

  3. 3.

    To determine whether recommendations may be made using findings of this research for incorporation into nursing practice.

Methodology

A critical realist lens was employed in this research to enable exploration of why something exists, in this case, why nurse representation exists in its current form (Bhaskar 1998; Archer 1995; Sayer 2000; Pawson 2006; Bhaskar 2008). Critical realism relates to cause and structure of why something exists. It provides strategy for synthesising research and picks apart mechanisms of complicated workings or failings of something (Pawson and Tilley 1997), for example, why representation may or may not work in favour of nursing. This approach is beneficial over a systematic review which may seek to establish effectiveness of clinical nursing interventions within ‘closed systems’ (Pawson 2006). This work instead investigates, applies and critically analyses theories from various platforms such as media studies, psychology and sociology. This forms a greater understanding of social influences of phenomena (Grant and Booth 2009; Edgley et al. 2014). A critical realist review means findings can be placed within social realist context because the essence of critical realist reviews allows greater freedom regarding exploration (Pawson 2006), enabling new findings to direct this research in ways which may have been overlooked had a more structured methodology been selected (Edgley et al. 2014).

Critical reviews explore existing literature to synthesise aspects from various disciplines relating to social occurrences linking with healthcare to develop innovative concepts within real-world contexts, potentially allowing practical applicability of results (Edgley et al. 2014; Grant and Booth 2009). Merging concepts from many fields of study that may not ordinarily link directly with healthcare, is helpful in allowing sociology and psychology as ‘outside’ interpretations of nursing to provide better understanding of what influences representation. These theoretical fields emerge as important to explore following an initial review undertaken surrounding existing knowledge about nurses’ representation, as described in the background section.

Another positive aspect of a critical review approach is the enablement of flexible structure (Edgley et al. 2014). Empirical studies have restrictive formal methods to follow, for example, the requirement of an initial definitive question with intentions of concluding with an answer (ibid.). However, critical reviews may produce models, hypotheses or innovative illuminations on existing theories (Grant and Booth 2009). This, therefore, means literature on conducting critical reviews are guides, not rigorous rules. This was advantageous as it allowed the research to follow new logical sources, enabling a natural progression of selection and analysis of texts and for knowledge to emerge as it stands leading to possible resolutions or ways forward (Grant and Booth 2009; Edgley et al. 2014).

A perceived disadvantage of critical reviews is the prospect of taking stances in debates, guiding readers through certain viewpoints with justification which can be problematic and incite bias (Grant and Booth 2009). Being a nurse or a feminist, for example, may sway research in certain directions. However, by acknowledging this and looking at concepts from opposing angles, partiality was minimised. and, as Skeggs (1997) argues, it is difficult not to be influenced by individual held values regarding theoretical research because interests will direct exploration.

Text selection

Critical reviews have no strict inclusion or exclusion criteria (Edgley et al. 2014). This is beneficial as research and findings produced unconventional texts that may not have been considered with no focus on one platform alone, permitting lateral and creative thought (ibid.). This meant there was no exclusion of schools of thought that could provide inventive contributions (Pawson and Tilley 1997). To prevent digression, Bryman (2014) suggests an initial literature search strategy, which enables theorisation and refinement of the aims of this research. This change inevitably occurs with this theory-based research and complied with critical reviews’ “non-structure.” Fraenkel and Wallen (2006) suggest source-searching after generating relevant terms. Therefore, ‘nurse,’ ‘nursing,’ ‘representation,’ ‘portrayal,’ ‘image,’ ‘media’ and ‘feminism’ were input into The University of Nottingham library catalogue search engine. Databases such as Science Direct, Web of Science, SAGE Journals and Elsevier’s Scopus were utilised as they provided valuable, peer-reviewed articles from nursing, social sciences and arts and humanities, all of which intertwine regarding this project. Grey literature was also explored, as non-academic sources encouraged realism (Edgley et al. 2014).

Several main sources foregrounded this research including Kalisch and Kalisch (1987) and Summers and Summers (2015), which highlighted how the issues Kalisch and Kalisch (1987) outlined continue to exist in contemporary media. Hallam (2000) was also a foregrounding text, exploring UK portrayals. Each laid a foundation regarding this project’s legitimacy, emphasising that nurse representation is highly researched and debated. The core theoretical framework used to interpret and synthesise views on nurse representation in the media is Laura Mulvey’s (1975) ‘Male-Gaze’ in the findings sections. It is important to state this work understands ‘image of nursing’ to also mean ‘representation.’ Additionally, ‘media’ is a broad term, reaching from film and television to static media. This is because when looking at preliminary readings from different areas of study such as sociology, psychology or media studies, different terms were used to discuss the same topic.

Media ‘texts’ encompass products, such as films, to be analysed or ‘read’ (Long and Wall 2014). Selecting contemporary UK media texts allows current issues to be explored and contrasted with media sources discussed in existing literature. This means appreciation of significant changes in representation, public perception and professional identity that exist, with greater applicability of findings to UK practice. Three photographs that were widely circulated and critiqued on the social media platform Twitter for sexist connotations were considered important to analyse within Laura Mulvey’s feminist theoretical framework the ‘Male-Gaze’ (Thompson 2010; Girvin 2017; Ford 2017a; Ford 2017b). To explore changes within contemporary nurse representation, texts such as 24 Hours in A&E (2011) and ‘This Is Nursing’ posters were selected (Ford 2012a; Ford 2012b).

Analysis

The application of three main lenses – ‘historical’ for the background section, foregrounding research, and ‘feminist’ and ‘psychosociological’ for analysis – allowed scope to interpret nurses’ media representation from varied perspectives. These lenses support a critical realist analysis, placing understanding of public perception of nurses within the ‘real world’ (Pawson 2006). These arenas do not exist in a vacuum, and although the lenses will be explored individually, they overlap to influence representation and interpretation (Pawson 2006). Therefore, this method of analysis provides understandings of nurse representation in theoretical and realist contexts (ibid.). As a large proportion of the nursing workforce is female, a feminist lens using Mulvey’s ‘Male-Gaze’ (1975) framework was pivotal to explore how this fact potentially influences representation, together with audience interpretation. The psychosocial lens employed used Bandura’s (2001) work ‘Social Cognitive Theory of Mass Communication’ to understand how mass communication affects public perception. Audiences have varying interpretations of the world; therefore it was important to consider how individuals and society both influence representation and, vice versa, to decipher ways in which representation has the potential to benefit nursing and society. Summative media content analysis was also employed in the findings section to engage with media texts, creating a structured process of qualitative analysis allowing for interpretation of underlying contexts (Hsieh and Shannon 2005).

Findings

The nurse and the media

‘An important element within this wider discourse is the fact that the vast majority of nurses are women or, more specifically nursing is seen as a female occupation. Hence, the way in which nurses are represented has common ground with the way that women are represented within the media in general’ (Soothill, Henry and Kendrick 1992,17). This section considers importance of ‘common ground’ of female and nurse representation. Three advertisements which faced backlash for sexism are analyzed using Laura Mulvey’s (1975) theoretical feminist framework: the ‘Male-Gaze.’ This questions whether and how sexist nurse stereotypes remain; if this filtered into the framing of these campaigns; and whether intersectionality, inclusivity and accurate representation of contemporary nurses is present.

Gender vs. the Media

Awareness has increased regarding female presence lacking in creative industries (Carter, Steiner and McLaughlin 2014). The industry’s gender imbalance arguably links with bias content distributed in mass media (Thornham 2007). Matos (2017) suggests ‘the connection between inequality in our society and gender representations in the media, are as relevant today as they were 20 years ago’ (46). Ceulemans and Fauconnier (1979) argues women’s representations ‘emphasize the dual image of women as decorative object and as the home and marriage-oriented passive person, secondary to and dependent on men’ (26-7). This echoes stereotypes outlined, except ‘women’ replaces ‘nurse,’ demonstrating ‘common ground’ in representation. Thus, potentially supporting image problems stemming from nursing as female-dominated, making it a target for a male-dominated media industry where women face poor representation generally. Thio and Taylor (2012) state ‘women are still too often depicted as sex objects, even when they are successful professionals’ (80). This emphasises contemporary issues of stereotypes irrespective of women’s independence and professional success (Gill 2007; Thio and Taylor 2012). Representation remains saturated with ‘inaccurate stereotypes that damage women’s self-perceptions and limit their social roles’ (Thornham 2007, 23). Tuchman offers practical responses to stereotypes’ continuation. Women account for a minority of executives in media organisations, media content distorts real-world female status, harmful role-models impede female accomplishment and encourage both genders to define women as sex objects, wives or mothers (1979). Ross and Padovani (2017) argue media-related careers are easier for women; however, positions of power remain male-dominated. The UK Media Reform Coalition (UKMRC) argue a lack of pluralism in media ownership. There are ‘3 companies in control of 71% of national newspaper circulation and 5 companies in command of 81% of local newspaper titles,’ all are male-owned (Ramsay 2019). Arguably, the danger of concentrated male ownership is over-representation of viewpoints favoured by dominant media owners (Doyle 2002; Byerly 2013; Joseph 2013). Therefore, male-dominated media may contribute to slow changes in accurate nurse representation.

Media content analysis: bus advertisement and recruitment campaigns

Mass media plays an influential role within society (Bandura 2001). Content creators convey messages; however, persistent, unchanged images within mass media influences audiences’ perceptions of subjects (ibid.).

Consequences of poor female representation and nurse stereotypes are arguably evident in a bus advertisement with a nurse as prominent focus, and two recruitment campaigns. Mulvey’s framework, which focused on framing of women in cinema, is applied here. The ‘Gaze’ is how audiences view characters, and ‘Male-Gaze’ specifically is audiences made to view characters from heterosexual male perspectives, which relegate women to ‘object’ (Mulvey 1975), for example, a focus on female’s anatomy such as curves or revealing clothing. Sexual imbalance within society and ‘pleasure in looking’ is separated into active/male and passive/female (806-808). Mulvey suggests: ‘The determining male gaze projects its phantasy onto the female figure which is styled accordingly. In their traditional exhibitionist role, women are simultaneously looked at and displayed, with their appearance coded for strong visual and erotic impact’ (62).

This notion is applied to Worcester Royal Hospital’s hopper bus advertisement (Thompson 2010a) (Appendix 4). The advertising company, with no affiliation with the NHS Trust, presented an attention-grabbing depiction of a nurse in a PVC uniform coded to appease a ‘male-gaze.’ The contours of her body, the cut of the dress accentuating her breasts, and the text, “Ooooh Matron,” support this. The ‘sex object’ stereotype is evident as this is Kenneth Williams’ character’s catchphrase in medical Carry Ons when responding to matron’s sexual innuendos, emphasising how entrenched this image is. Furthermore, the PVC uniform has associations with ‘naughty-nurse’ Halloween costumes and pornographic images. This has overtones of sexual fetishism and visual desire (Shelton 1995; Mulvey 2013). As this stereotypical image is well-established, it is questionable whether this was the interpretation before placing the image on the bus. However, it highlights that stereotypical representation continues and is argued to demean and devalue nursing’s image (Thompson 2010b).

Two recruitment examples are arguably more detrimental to nursing’s image as the NHS Trusts co-created them to circulate to prospective nurses and social media audiences. The first image tweeted by Wrighton, Wigan and Leigh NHS Foundation Trust shows four smiling, young female nurses behind another lying on a hospital trolley with her legs kicking in the air (Wigan Hospitals 2017) (Appendix 5). This faced backlash on social media with claims it aligns with stereotypical views of nursing as playful and sexy (Ford 2017a). The Trust responded apologetically although not comprehending concerns raised, they suggested it aimed to show nursing’s ‘softer/fun’ side (Ford 2017a). Subsequently, further questions arose on social media regarding whether this approach would be taken showing the ‘fun side’ of being a doctor (Ford 2017a). Supporting Mulvey’s argument of female’s constructed image for male preferences, Girvin (2017) states that in this advert, nurses are ‘characterised as sexual playthings, beautiful, young and sexy, defying danger to find romance.’ The nurse on the trolley is framed in a manner inappropriate for the role, not in a position exuding professionalism.

The second recruitment campaign was a joint effort by a professional marketing company and Hull and East Yorkshire Hospitals NHS Trust (The Times 2017; Ford 2017b) (Appendix 6). Featuring two young, blonde, female nurses, the text utilises romance to sell nursing (The Times 2017). The statement’s implication of conventionally attractive young nurses as love interests for men links with Mulvey’s (1975) framework due to undertones regarding the nurse’s purpose of being ‘looked at.’ Both posters received significant criticism with social media users labelling them as sexist and worn out (The Times 2017; Girvin 2017). This suggests nursing is still perceived via a lens of femininity perpetuating the sex object stereotype. Girvin argues defamation has been part of nursing’s history and the ‘sex object’ image is ‘culturally ingrained’ (2017).

The posters potentially play on stereotypes that imply nurses are objects for men to lust over, using the technique of subversion of expectation, as the concluding sentences on both posters highlight the skills and knowledge required (Connell 2011). However, this could be refuted as there is scope for disregarding significance of nurses not being love interests if people are unaware of inaccurate stereotypes (The Times 2017). Additionally, no other graduate profession is recruited in this manner (ibid.). The posters serve as reminders that stereotypes and expectations of nurses exist via sexualisation of women the workplace. Girvin argues the posters ‘demonstrate how deeply seated these damaging stereotypes are, how normalised in some thinking, how unrecognised as offensive, even when tongue-in-cheek’ (2017).

A further issue is the lack of inclusivity in these advertisements. Intersectionality aims to broaden the feminist agenda to be more inclusive of more than ‘white feminism’ (Crenshaw 1989), considering the oppression of people of colour or with disabilities and self-definition of gender for true equality. However, the diverse nursing workforce is not represented in either recruitment effort. They assume an all-female, all-white nursing identity. Additionally, with ethnic minority groups concentrated in the healthcare sector than all other industries, these campaigns are poor reflections and do not align with statistics (Yar, Dix and Bajekal 2006).

Male-dominated media creating images for male preferences contributes to preserving female and nurse stereotypes (Thio and Taylor 2012) as nursing is female-dominated, this larger target for male-dominated media has damaging real-world impacts as stereotypical representations shape beliefs of nurses, causing problems regarding poor professional identity (Hallam 2000). Improved male nurse representation could mean better recruitment to ease shortages, as male nurses make up 11% on the Nursing and Midwifery Council register in the UK (NMC 2016). Moreover, historical sexist representation evidently have contemporary consequences (Thompson 2010a; Wigan Hospital 2017). Nurses arguably continue to be constructed for male viewing pleasure and relegated to the position of (white, able-bodied) sex objects. The reality of large numbers of ethnic minorities working within the NHS are not reflected. Misrepresentation is ‘one of nursing’s biggest issues professionally and it is deeply troubling that employers should exploit this as a recruitment tactic’ (Girvin 2017). The backlash and calls for change on social media may suggest positive shifts due to recognition and criticism of narrow, sexist and stereotypical representation.

Is there really a problem with nursing’s image in the UK?

The Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010) stated that nursing’s image is outdated and campaigns must launch encouraging fresh narratives of highly-educated, talented and independent professionals to inspire nurses and new recruits. It states emphasis must be on career opportunities and updating nurses’ image to raise public awareness of what nursing entails. The Willis Commission suggested targeting nurse education, to encourage improved ‘dialogue with the media’ in promoting greater awareness of contemporary nursing (Willis 2012, 32).

Dean (2014) outlines a commission that may be considered controversial. The Lancet aimed to explore nursing’s image, alongside education, organisation and practice. Chair Robert Watson stated a two-year timeframe for the project to tackle poor perceptions of UK nursing, compared with countries such as America or Australia, where nursing ranks highly (first in America for fifteen years consecutively) as most trustworthy profession (Dean 2014; Norman 2016). UK nursing never previously ranked, regularly featuring in ‘negative media stories’ (Dean 2014). Previous initiatives were labelled failures regarding public perception, thus this commission aimed for measurable change (ibid.). Although the RCN’s Head of Nursing endorsed this, the announcement was criticised (ibid.). Editor-in-Chief of the British Journal of Nursing Ian Peate (2015) states the commission hinders nursing’s image by reinforcing that poor image exists, instead of encouraging improvement. Peate argues the commission should aim to emphasise nurses’ ‘competent and outstanding work’; saturation of positive exposure of the profession may therefore be beneficial. The Lancet, a medical journal, investigating the phenomenon implies nursing bodies are unable to govern their own profession as ‘naughty nursing can’t be managed by the nurses, so the doctors have to take it over’, therefore the announcement is ‘patronising’ (429). Essentially, the commission could be viewed as reinforcing historical hierarchical stereotypes that nurses are subordinate to doctors.

Since The Lancet Commission’s announcement, no published report is available. However, nursing was listed, for the first time, as ‘UK’s most trustworthy profession’ by an Ipsos MORI survey in 2016 (Munn 2016). This possibly suggests the commission’s disbandment as it may have been deemed unnecessary. Media texts such as the medical-documentary ‘24 Hours in A&E’ (2011), representing a busy accident and emergency department may have contributed to the profession being listed. Now in its 13th series, ratings average around two million viewers per episode; this highlights its popularity (Broadcasters’ Audience Research Board 2017). This television programme adopts a ‘fly on the wall’ format with camera access over 24-h in King’s College and St George’s Hospitals. It alternates between observing and interviewing healthcare professionals, patients and relatives to gain greater perspectives of what occurs. Moreover, the RCN commissioned advertisements on buses throughout the UK highlighting skills required for a challenging, rewarding role (Appendix 2 and 3). Educating audiences on realistic roles, responsibilities and demands on nurses, possibly helped to eliminate dated nursing images by showcasing contemporary reality.

Girvin (2017) links the fact that nursing was listed as most trustworthy profession with respect for stereotypical nurse images of ‘selfless young women, cheerful, hardworking and overworked’ rather than public comprehension of varying roles and impacts of their work. Chief Nursing Officer for England, Jane Cummings, wishes to continue investigating nursing’s image and to increase public understanding, highlighting expertise and compassion required, by demonstrating positive work (Jones-Berry 2017). Cummings’ goal supports Bandura’s notion of continual positive imagery in the media encouraging improved public perceptions. Repeated images eventually normalise subjects to influence societal values and actions (Bandura 2001).

How do we solve a problem like nursing’s image?

‘The media play a central role in informing the public about what happens in the world, particularly in those areas in which audiences do not possess direct knowledge or experience’ (Happer and Philo 2013, 321). These findings can add value to the current debates around the image of nursing and how new media may be used in favour of the profession. Media representation has shown to have real-world consequences regarding public perceptions and professional identity. Nursing’s previous media stereotypes, its female status impacting media images and the influence that mass media has regarding ingraining certain depictions have all been presented as contributing factors affecting public opinion and action. To improve image, a ‘long-term, strategic solution is required that focuses on public engagement and interaction with the profession’ (Girvin and Hutchinson 2016, 994). Social media may be a valuable ‘change agent’ for combating stereotypes (Silva and Freischlag 2017). In today’s rapidly changing methods of media consumption, instant communication may prove prosperous for self-representation as nurses themselves could emphasise their work accurately. This could challenge negative stereotypes and mean intersectionality is represented to reflect the dynamic and multicultural nursing profession. It is argued that ‘social media is sparking vital conversations that are challenging sociocultural constructs, evolving historical concepts, and influencing change’ (1354).

Keeping Silva and Freischlag’s (2017) argument in mind, nursing may benefit from utilising a ‘monologue to a dialogue’ approach that social media facilitates (McNab 2009, 556). This supports Girvin’s (2016) hope of better engagement and interaction with the public regarding what nursing entails. A recent example highlighting McNab’s (2009) notion of instant open conversation via social media is doctors refuting claims of ‘Monday to Friday culture in parts of the NHS’ with hashtag “#iminworkjeremy” directed at Health Secretary Jeremy Hunt’s claim that doctors do not work weekends (BBC 2015; Knapton 2015). Therefore, this technique of rapidly reaching the public could be implemented, as many have argued: nurses are responsible to think critically and make criticisms clear via providing accurate depictions of work they do to counter media inaccuracies (Cohen and Bartholomew 2009; Cabaniss 2011; Muehlbauer 2012; McAllister et al. 2014; Summers and Summers 2015). Given the regulator’s guidance on using social media responsibly, further research may be required concerning how the profession currently uses it and how this could be improved with media training (NMC 2015; Muehlbauer 2012). However, regarding the findings of the importance of representation and the consequences for nurses, self-representing using new media such as Twitter may provide an opportunity to reach broader audiences to improve outdated ‘public perception of nursing rooted in nostalgia, fiction and fantasy … not fit for the 21st century’ (Girvin 2015, 3342).

Concluding points

‘The image of nursing is socially and culturally constructed, and accurate portrayals of nurses and their roles are necessary in all media’ (Carroll and Rosa 2016, 141). This work explored nursing’s media stereotypes, providing broader understanding of why nursing may be represented within contemporary media in its current form with hints of sexist, outdated images continuing to exist. It has shown how representation is important as it has real-world negative and positive effects on public perception and professional identity. Additionally, there are implications of nursing being a female-dominated profession represented by a male-dominated media industry that is historically slow in changing nursing’s image in line with reality. Therefore, it is important for the nursing profession itself to act, and perhaps view social media as a tool for improvement in a society where technology allows for instant and open communication with the public it cares for in the work place. Utilising this platform may prove helpful to improve the issue via self-representation. A campaign for the public understanding of nursing is urgent.