Abstracts

ORIGINAL ARTICLE

Nurses' visibility according to the perceptions of the communication professionals

Ligia Fahl Kemmer^I; Maria Júlia Paes da Silva^II

^IAssistant Professor, State University of Londrina Department of Nursing. Doctoral student in Nursing at the University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, e-mail: ligia@fahl.com.br

^IIFull Professor, University of São Paulo College of Nursing, e-mail: juliaps@usp.br

ABSTRACT

This study aimed to further our understanding of the social representations of nurses and the nursing profession by communication professionals, since they are intermediates in the decoding of imaging and written representations about society. Method: this is a qualitative study, based on the social representation theory of Moscovici. Five communication professionals working on radio, television, written press, advertising and events were interviewed. Results suggest 1) ignorance about the nurse's field of work, job market and nursing profession categorization. 2) nurses' invisibility before the media and society and 3) nurse's own responsibility to obtain professional recognition and visibility. Participants in this study pointed two essential processes for building a more coherent image of nursing and nurses: 1) exposing the profession primarily before the media, which ignores its potentialities, and 2) through the media in order to reach the population in general.

Descriptors: communications media; nurse's role; communication

INTRODUCTION

The image of a professional group or a profession represented by the media is frequently understood as significant measure of the social and economic value of that group⁽¹⁾. In the last decades, international literature has shown great interest in the image of the nurse and the nursing profession in different communication means, regarding the historical, social and ethical focus and gender-related issues. This image has a meaning, expressed by social representations:

"We understand by professional image a network of social representations of Nursing which, by means of a set of concepts, affirmations and explanations, reproduces and is reproduced by ideologies originated in the daily social practices internal/external to it. The professional image leads us to professional identity itself, in its intricate network of meanings that intend to be exclusive and, therefore, inherent to that specific profession. Hence, the professional meaning consubstantiates in its own representation of professional identity"⁽²⁾.

Nursing has moved towards the construction of its body of scientific knowledge, seeking, through studies and research, its definition as science. Research and fields of action in nursing have grown substantially in more recent years, opening perspectives of knowledge in multiple directions. The social representations identified in several social segments and those transmitted by the media reflect, however, a professional with neither power, autonomy, knowledge nor voice⁽³⁾.

Research that evaluates these social representations of nursing worldwide, and more specifically in Brazil, also denounce an old fashioned and depreciating representation of the profession^(3-5). Studies performed with different population strata identified representations related to the invisibility of the nursing professional, who is characterized by performing simply technical tasks⁽⁴⁾, subordinated to the medical area⁽⁶⁾, identified as the physician's aid, and exercising a profession that suggests cheap labor⁽⁷⁾.

Reflections on the results of these studies legitimate inquiries about the influence the media exerts on collective ideas about the nurse and the nursing profession. The importance of transmitting representations - through texts or images by the media - for the perpetuation of stereotypes or the contribution of new representations stems in its pervasiveness, many times without connection to reality.

A study based on the analysis of images in newspapers, national magazines and TV programs in Brazil illustrates the way the image of the nurse is conveyed in the Brazilian media⁽³⁾. The study reveals that, in soap operas, men's magazines and newspapers, the transmitted representations are related to the morality associated with the characters embodied by nurses: the mother, the saint, the angel, the physician's shadow and the woman-object. The research also identified the character "doctor-nurse", isolated among other representations and decoded by nurses' attempt to articulate an audible vocabulary.

Inquiries aimed at analyzing the little exposition of nursing in the media, or its oftentimes misrepresentation, include the concern to better understand the view of the professional responsible for mediating between the source and the reception of information: the journalist and the marketing and advertising professional.

The feelings of communication professionals - intermediaries in the communication of news and the construction of representations - can be impregnated with preconceptions related to nursing as an undesirable profession, because it is predominantly feminine and subaltern. Thus, it is suggested that the perceptions of journalists and media producers regarding nursing and nurses⁽⁸⁾ should be further explored.

An analysis of articles published in the major São Paulo State press in 1994 was the base of a study about journalists' perception about the image of nurses and their profession⁽⁵⁾. It was revealed that, from their point of view, nurses and the nursing profession are concentrated in six categories: education and professional exercise, what the nurse does, the transgressor nurse, the victim nurse, the nurse as a person and citizen and the profession as an adjective. The study authors discuss that the perception of journalists influences the constructions of the nurse's image in society and that, although they identified care in a very solid way in the discourse they analyzed, the functions related to management, teaching and research were not explicitly mentioned at any time.

In national literature, there are few studies investigating the perceptions of communication professionals themselves about the nursing profession, which made us inquire about the social representations of nurses and nursing of some communication professionals who work in a city in the North of Paraná.

Therefore, this research aims to analyze the social representations about the nurse and the nursing profession among five professionals active in different communication areas, in a city in the north of Paraná.

JUSTIFICATION

The media have portrayed the nurse in a pejorative and subservient way. As they establish a dynamic of convergence that contributes to explain several codes that are shared, recognized and institutionalized by modern society, it can be inferred that the symbolic constructions found in the contents they transmit are not distant from other social elements' constructions. Communication professionals are intermediates in the coding of image and text representations of society. By giving some communication professionals the opportunity to voice their interpretations, we intend to further understand what representations on nurses and nursing these professionals (working in different areas of communication in the same city) share, since they are code intermediaries of imaging and text representations on society.

METHODOLOGICAL PROCESS

We decided to use a cross-sectional descriptive study with a qualitative approach. The qualitative approach is justified because it permits "incorporating the issue of meaning and intent as inherent to acts, relations and social structures. The latter are considered both in their manifestation and transformation as significant human constructions"⁽⁹⁾.

Study Participants

A convenience sample of five professionals from distinct areas of communication was selected. These professionals are considered references in Londrina, PA, Brazil, and have had some contact with the health area and health professionals in their activities.

This sample was used to obtain the view of professionals from different segments of the communication area, but working in the same city, with their life experiences, their encounters with health and illness and with the possible diversity of their representations about nursing and the nurse. Five professionals were interviewed, who work on 1) Television, 2) Radio, 3) Written press, 4) Advertising and 5) Events. All participants worked in communication, with an educational background in journalism or marketing, and their activities included production, editing or presentation of programs that, at some point, involved or approached health professionals and sectors.

Ethical Aspects

We obtained the approval of the Research Ethics Committee at the Hospital Universitário Regional in Northern Paraná and, next, the participants' written informed consent, which described the research objectives, the voluntary nature of the participation, the possibility to withdraw from the research at any time, without any loss or damage, and the researcher's commitment to preserve confidentiality.

Instrument

We used a script with identification data, such as age, gender, professional background and occupation, and guiding semistructured questions: What is your image of nursing? What is your image of the nurse? Where does this image come from? How do you perceive the image of the nurse and nursing through the media?

Access to Participants

Data were collected through semistructured interviews, in sites chosen by the participants. The researcher introduced herself, explained the research objectives, guaranteed the ethical aspects involved in the research and asked permission to use a recorder.

Discourse Analysis

The Collective Subject Discourse was used as a conceptual framework for discourse analysis. This can be described as "a legitimate way - certainly not the only one - of conceiving the Social Representations, understanding them as the expression of what a determinate population thinks or believes about a certain theme. This thinking, in turn, can be manifested, among other ways, through the set of verbal discourses issued by people from this population" ⁽⁹⁾.

The statements were first transcribed and submitted to descriptive analysis. Therefore, four methodological figures were used: anchorage, central idea, key expressions and the collective subject discourse⁽¹⁰⁾. Data were interpreted by selecting the main anchorages and/or central ideas present in each of the individual statements and in all of them together, finishing in a synthetic form, in which we sought to obtain the discursive reconstitution of the social representation of the nurse's and nursing's image.

PRESENTATION AND DISCUSSION OF THE RESULTS

The interviewees' age varied between 26 and 44 years, two were women and three men; two had a bachelor's degree in Social Communication, three had a graduate degree in Marketing and Propaganda, with eight to 23 years of experience in their respective areas.

Collective discourses were reconstituted by analyzing the individual perceptions of communication professionals about the image of the nurse and nursing. Their construction revealed some social representations that stand out. These representations cover images about nursing, reflected as: care and serenity, identifying, at the same time, that the media transmits a distorted image of the nurse; the perception of a hard and exhausting profession, struggling for insertion in the job market and the adverse conditions of this reality; the lack of knowledge about the nurse's activity areas; lack of knowledge by media professionals about professional categories (reflecting that the population, as a whole, does not recognize the nurse in an independent way either); the invisibility of the profession in terms of tasks and achievements/ the nurses' responsibility for their invisibility before the media and society.

This article, given the little space available, will focus on the discussion about 1) the lack of knowledge of activity areas, job market and professional categorization; 2) the invisibility of nursing before the media and society and 3) responsibility of the nurses themselves to get professional recognition and visibility - bearing in mind that the other representations we found support and interconnect the discussion presented below:

Llack of knowledge about activity areas, job market and professional categorization

The statements reveal lack of knowledge about the nurse's activity areas in Brazil nowadays, but point out the actual need for nursing professional activities, given the population's health conditions:

[about activity areas] I cannot affirm, I cannot say… It would be a guess, right? I figure, that, in a macro way, as the economists say, a question: is the population well attended today in health care? I can say, as a citizen, that no! So, in that sense, the nurse's activity area is very good! (…) If you ask me, I'll say, I believe that there is a good activity area, with very great potential, but it must be very difficult for the nurse to work today… like in any other profession… (IC1 DSC1)

The communication professionals perceive the job market difficulties for the nurse as inserted in a national context, in which the health care structure is still inadequate - a difficulty shared also by other not so acknowledged and valued professions.

I don't know, I don't have criteria to speak, but something tells me that the job market must be difficult to get into. I believe that you have to be very good to stand out in this area. Because today there are many technical nursing courses, right? I guess that these courses put a lot of people in the job market and sometimes, I don't know about the quality standard, if they are really prepared for practice, and due to the Brazilian health system itself, which is broke… lack of beds, materials, medication, physicians and probably nurses… and vacancies for these people to work. I see that, in all professions, there is great difficulty to ascend and occupy one's place in the job market. Many people go through this difficulty, I believe that a large part of newly graduated people and even senior nurses go through this situation. I guess that, for the common nurse, it is complicated, hospital nurse, ICU… (IC6 DSC2)

This perception about difficulties to ascend in the profession reflects impressions of a certain lack of prestige, shared by other parts of the population. As to social prestige, nursing occupied the eighth position in a study that assessed this concept among 13 university level professions ⁽¹¹⁾.

The media professionals identified their lack of knowledge about the nursing professional categorization as a mere reflex of the fact that the population, as a whole, does not recognize the nurse in a independent way either:

Why do I think everybody who attends in hospital is a nurse? Just supposing [laugh]. Are there people who attend at the hospital who are not nurses? [surprise] Really I don't know, if they had graduated or were in training or something like that… I'm only supposing [that everybody was a nurse]. We have a rough idea of the nurse and other professionals, we mix up a little, the nurse with the aid, with someone else… (IC12 DSC1)

The communication professionals appoint the lack of knowledge related to professional categorization as a great difficulty in the recognition of the profession by other elements in society.

First, the main issue is that everybody gets confused and doesn't know who's a nurse, because we think that everybody is a nurse, and they actually are not. There is the technician, the aid and the nurse. Because there is this mix-up… Common sense is that the person who goes into the hospital room is always the nurse, that there is no subdivision in the professional category. Now I separate them. I know that there are professionals of technical level and there are professionals of university level, whom I think are called standard nurses; I cannot say that for sure. My family, for instance, my closest friends and even the community, people do not say: Look, she is a nurse technician… No, [they say] it was the nurse who took care or it was the nurse who did not take care of me. As an opinion maker in the communication area I can tell you, without any doubt, I believe this confusion that I used to make is kind of common. (IC15 DSC2)

We agree with the reflection that, to occupy spaces and be acknowledged as one of the essential health professions, a political agenda of the class should include the several aspects that constitute a profession, that is, specific knowledge, exclusive job market, form of organization and clarification about the nursing team hierarchy ⁽¹²⁾.

The invisibility of nursing before the media and society

Regarding how they perceive the representation of nurses by the media, the perceptions are in line with studies that, among the representations, identified the nurse figure as a professional described as "the doctor's shadow"⁽³⁾, and often in a stereotyped way:

[the media portray the nurse] As a doctor's aid. Communication means approach the nurse and nursing in general, making the same mistake as common sense does… Because I don't know exactly what a nurse does…I don't know until now. I guess that the press and communication media in general also make this confusion, because you don't need higher education to be a technician or an aid. So the guy [communication professional] wants that nurse, with that little thing stuffing one's head with a thing that nobody wears… but the guy suddenly wants that [to use in advertising]. (IC15 DSC1)

Amidst perceptions of a suffered and depreciated profession and the non-identification of the class hierarchy, the surprise, in personal encounters with nurses, of finding out that (s)he can be a referral professional of reference in health knowledge areas:

I am going to tell you about a specific situation of one occasion when I went to do an article and then I found out that the main authority in breastfeeding here in the city was a nurse, not a doctor. It was really funny because, on that occasion, I worked for the paper and the article was specifically about breastfeeding and, obviously, I went to pediatricians, gynecologists first. Then they said: no, here in this city the person who knows more about breastfeeding is a nurse, she was a consultant for that determinate hospital at that time. I worked there a few years with campaigns suggested by nursing professionals who administer, or coordinate a human milk bank at the university. It was very remarkable for me, an important moment. We had professionals [nurses] with a lot of experience, people with a doctoral degree in this area, who worked to recover that old culture that maternal milk means health for the child and that this means health!! …It was exactly because of that [that I have this image of competence about the nurse].

At the same time, the communication professionals in this study appoint that this competence is not socialized with the rest of population and warn that the nursing profession is almost anonymous and invisible to the communication media in relation to any highlights in their tasks and achievements.

I perceive that I haven't seen anything [in the communication media], like, it seems that the profession is kind of anonymous, the profession you see in the newspapers are doctors, physiotherapists… The media highlights the profession very little. It distinguishes technology, medical advances, research. It gives a lot of attention to the health crisis. My memory is not very good, but I can't remember any interview with a nurse. I can recall something of a TV commercial, for instance, that has a nurse attending an old lady in hospital. But see, it is a commercial about a health insurance plan, of the elite. Actually, we, as opinion makers, there is no work, not that I recall at least, a more mass thing that can really change the image (of nursing). At the start of the interview, I said, as an opinion maker in the communication area, that I could say beyond doubt that this is the image people have of the nurse and of nursing. I see that people, because of an actual lack of information, I guess that this common sense exists because people are badly informed. I recall some outdoor propaganda of some professions, but I don't recall of any of nurse. It is a pity because we don't read anything about it (IC15 DSC2)

Responsibility of the nurse (him)herself for professional recognition and visibility

In view of this anonymity, they consider it is relevant to stress the role nursing professionals themselves have in a clear dissemination about nursing, its potentialities and tasks.

Who is guilty for us not having clear information about nursing, what nursing is, that it is specialized work? I, who am from the media? Or you who are from nursing? [pause and smile]. Who is wrong? The institutions that do not inform correctly how things work? There is a lacks of communication. The professional needs to be a little creative too, because if he keeps on waiting for others to organize, who will organize it? Will the hospitals' owners organize things? But I also think that the fault lies in the professional organization, because something must be done through an association, something to lapidate this image. There must be a direct mechanism and talk directly with these people and explain to them, you know… like… a directed communication, a folder, or a site, for example… (IC16 DSC1)

A journalist who has been dedicated to writing about nursing and nurses, warns about the fact that nursing professionals have contributed to their invisibility before the media because they do not take a stand, even when there is something important to be communicated⁽¹³⁾.

For the nursing profession to be identified, the need is discussed to construct a history through relevant and serious work, including the identification of the professional based on his/her activity in practice:

The newer professions [such as nursing] will have to make their history. How is this history constructed? With serious work, with originality, with discoveries relevant to society, with that. I think that the category itself or healthcare professionals are responsible [for correcting the image]. When you arrive at a healthcare unit, the receptionist does not say: You are going to be attended by a nursing technician… (s)he says: The nurse will measure your blood pressure… and it is not the nurse… we know it is not… So, on one hand, I guess this image is created and crystallized because of the professionals themselves. (IC16 DSC3)

The professional image of nursing that is transmitted by the media has been responsible for perpetuate outdated stereotypes, but without valuing the media's role in our construction of something that is nothing more than a reflex of reality⁽¹⁾. Thus, the discussion includes inquiries about the extent to which the nurses themselves are responsible when they do not take a stand, neither to correct the distorted images nor for the visibility of the roles they have performed in health care.

This positioning definitely begins in professional practice, in the way we think about ourselves, developing professional competence, and also through a position towards the clients, the family and towards other health professionals; through collaborative development with communication and public relations professionals; comprehension of the media's role and active exposition in communication means⁽¹⁴⁾.

As a strategy to construct a more coherent image, the research participants acknowledge that the profession is primarily exposed towards the media themselves, which do not know about its potentialities:

Maybe what is missing is contact with a leadership, inside the category, to establish this communication with us, because we can disseminate this. All hospitals have press assistants, public relations that send material to us [the media] and there is no release talking about the nursing sector. What they do send are releases about the installment of machines, that some doctor concluded his doctoral program, has put I don't know what, don't know where, with honor, but there is nothing specific [from nursing]. I guess that not even the internal press, which could collaborate a lot in this sense, has this concept established. This internal dissemination that sends material to mass communication means, does not say anything about it [nursing] (IC16 DSC4)

In the second place, an exposition through the media to reach the whole population as essential processes to transmit a more coherent image of the nurse and nursing:

Going to the press, I don't see any other way, I don't see any other way. If a nurse makes a wonderful discovery, and keeps it to himself/herself? Nobody finds out about it. How many voluntary services are done, how many histories does the nurse participate in? Then, if you only disseminate what went wrong, maybe there are a lot of things that went right, maybe one thing depended on the professional, but it will pass unnoticed. I guess that something could be done in this sense, but I think that it normally is not communicated, I may be wrong, I haven't seen it at least. So, as a communicator, I see that, if there existed a concern, I guess there would have to be a press service in this sense. I think that the [nursing] associations should also collaborate with the dissemination… If we don't disseminate, nobody will find out…!! (IC16 DSC2)

This statement is in accordance with a reality identified in a study funded by the International Honor Society of Nursing, called the "Woodhull Study about Nursing and Media: the invisible partner in health care". The authors analyzed twenty thousand articles published in magazines and newspapers selected in the United States, identifying that nurses were mentioned in only 4% of the articles related to heath, while physicians were present in 43%⁽¹⁵⁾. Recommendations to give more visibility to the nursing role include the need for professionals to position themselves strategically towards the communication means and also to educate the journalists themselves about nursing^(13-15).

If it does not appears in the press... [the fact does not exist]…the press is so strong that it changes opinions!! The news serves to construct and to deconstruct also, both things. Because you cannot make the public opinion if don't use mass communication means… As soon as you go to the TV, to a network and talk to millions of people simultaneously, you build an image and this image can sometimes be deconstructed, although this requires time. You have to provoke, including the image. The written press has its value, but the visual press has a much bigger value (IC16 DSC5)

The emphasis on the role of the visual image may lead to important reflections to nursing, since pejorative visual images about nurses are relatively common in TV programs and magazines. The question is that visual images often go beyond the critical sense of who sees them, even if they have no reference in reality, as a contemporary philosopher puts it⁽¹⁶⁾: " One can also think that images do not possess identity to circulate in the sphere of communication networks. They do not pass through customs and do not need to present a passport to enter territories, like people. Physical barriers do not exist for images; once they have reached a centrifugal speed, they do not have any reference in reality".

They emphasize the importance of using multiple communication media: internet, television, internal news, written press, to achieve greater visibility of nursing:

I think that, anyway, the media add up, so, if you explore the internet, and could make this available with continuous input and also use press services to inform the rest of the press, and one thing leads to the other. Have you imagined, a really well done site, with several kinds of information, it would help a lot, so some more notes that would slowly be issued, even very small, everything forms opinion, everything, everything, social column… It is very important to say that university professor x defended a dissertation about I don't know what… this has that meaning. We see it in the newspaper! Things that happen. Today we have seen other professionals being exposed by the media and then you [can be seen] as well. (IC16 DSC6)

CONCLUSIONS

These communication professionals' statements point to relevant issues in the exercise and teaching of a nursing that aims to break with old paradigms of subordination and invisibility. Although they recognize us as important pieces in a health care process, the communication professionals seem to ask for more information, more visibility and more voice regarding our role in health care.

The importance of this positioning and exposition is not restricted to the acknowledgement of the profession and its professionals. The most important inquiry about our invisibility is that is diminishes our ability to change the directions of health care⁽¹⁷⁾. This reflection is necessary at a moment when nurses have performed such relevant activities inside the Single Health System, in Brazil, ranging from planning processes to their execution and evaluation.

In this study, the communication professionals appoint strategies and formulate important considerations for a positioning of voice and visibility based on practical situations, through joint work in the media and through the media, aiming to reach the public in general.

It seems urgent and challenging at the same time for these reflections to find echo in our actions, so that we no longer are the "eternally invisible partners" in health care.

Recebido em: 15.2.2006

Aprovado em: 25.9.2006

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