Year : 2018 | Volume
: 7 | Issue : 4 | Page : 180--185
The image of nursing as perceived by nurses: A phenomenological study
Joko Gunawan1, Yupin Aungsuroch1, Ade Sukarna2, Nazliansyah2, Ferry Efendi3,
1 Department of Nursing Administration, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand
2 Department of Adult and Community Nursing, Academy of Nursing of Belitung, Akademi Keperawatan Pemerintah Kabupaten Belitung, Bangka Belitung, Indonesia
3 Department of Community Health Nursing, Faculty of Nursing, Airlangga University, Surabaya, Indonesia
Borommaratchachonnani Srisataphat Building, Rama 1 Road, Pathumwan, Bangkok 10330
Background: Image remains crucial for nursing profession. How nurses view professional self-image has an impact on their professional self-esteem. Objectives: This study explored the image of nursing as perceived by Indonesian nurses. Methods: This was a phenomenological study with a purposeful sample of 19 clinical nurses participated in in-depth interviews. The interviews were audio-recorded, transcribed verbatim, and validated by relistening to the recording by researchers. The analysis was thematic. Results: Five themes emerged (a) Islamic culture, (b) job definition, (c) role of nurses, (d) self-confidence, and (e) relationship between multigenerations of nurses. Conclusion: This study addressed positive and negative images of nursing in Belitung, Indonesia. The findings may be used for nurse managers to improve nursing image through the improvement of nurse competence and continuing professional development.
|How to cite this article:|
Gunawan J, Aungsuroch Y, Sukarna A, Nazliansyah, Efendi F. The image of nursing as perceived by nurses: A phenomenological study.Nurs Midwifery Stud 2018;7:180-185
|How to cite this URL:|
Gunawan J, Aungsuroch Y, Sukarna A, Nazliansyah, Efendi F. The image of nursing as perceived by nurses: A phenomenological study. Nurs Midwifery Stud [serial online] 2018 [cited 2019 Aug 25 ];7:180-185
Available from: http://www.nmsjournal.com/text.asp?2018/7/4/180/240677
Nursing image is very important for nursing profession. It is the way the profession appears to others including to general public. Image of the nursing profession impacts to the recruitment of students, the view of the public, funding for nursing education and research, relationships with health-care administrators and other health-care professionals, government agencies, and legislators at all levels of government, and ultimately, the profession's self-identity. The most important is that image can influence nurses themselves, just like nurses may feel depressed or less effective if others view them negatively. Professionals can experience similar reactions if their image is not positive, which impacts everything the profession does or wishes to do.
Image is defined as a mental picture representing a real object or a more or less accurate likeness of a thing or person. How nurses view their professional self-image has an impact on professional self-esteem. How one is viewed has an impact on whether others seek that person out and how they view the effectiveness of what that person might do. Every time a nurse says to family, friends, or in public that he or she is a nurse, the nurse is representing the profession. As literature stated, “we cannot expect outsiders to be the guardians of our visibility and access to public media and health policy arenas, but we must develop the skills of presenting ourselves in and to the media, and have to take the responsibility for moving from silence to voice.”
Nursing is considered as a critical resource, which is why it is essential to know its image to contribute to consolidating its identity and consequently increase its number and place among health-care professionals and society.
In Indonesia, nursing image is likely seen to be assistants to physicians and committed to housekeeping duties, rather than devoted to caring, which is similar to Shields and Hartati said that nurses are regarded as “doctors” helpers. This image could discourage young generation to choose nursing as a career. In contrast, Indonesian nurses are also seen as knowledgeable, intelligent, and analytical. This tells that there is a gap of nursing image perceived by nurses and nonnurses.
In addition, previous studies might not represent the number of population to describe nursing image in Indonesia, as Indonesia consists of 220,004 nurses serving about 250 million of population in 17,000 Islands. Therefore, we need to explore further about nursing image, as the image may be different in each island in Indonesia. Furthermore, there is a limited number of studies related to nursing image in Indonesia which appears to two studies in 2003 and 2018.
This study aimed to explore the image of nursing perceived by Indonesian nurses. The main research question is “Are there any differences of nursing image perceived by nurses in Indonesia, especially in the south part of Indonesia?” This study remains important for the future of nursing development, particularly for the recruitment of a new generation into nursing profession in Indonesia.
Study design, setting, and participants
This was a phenomenological study to explore Indonesian nurses' perception on their professional image. The phenomenological study is congruence with the purpose of this study to gain deeper understanding of the nature of the phenomenon by viewing each piece as a whole.
There were 19 participants selected using purposive sampling to ensure that the relevant data were collected. The participants were contacted through short message service and phone call to inform them about the purpose of the study. The inclusion criteria were the nurses who had at least 2 years of clinical experiences. There was no age and gender restriction of participants in this study. This study was conducted at the General Hospital Belitung, Bangka Belitung Province, Indonesia.
Data collection procedures
Upon accepting the invitation, potential respondents were given oral and written information about the research, and after they signed a consent document, an appointment was scheduled for an interview and focus group discussion (FGD). Interviews and FGD were conducted in Bahasa Indonesia (Indonesian language) or Belitung language (local language) by principle investigators ranging from 60 to 120 min. Each interview and transcript were individually analyzed and then reviewed and discussed collaboratively by the other researchers. The interview was taken place in the meeting room in the hospital to avoid the noise and the other disturbances during interview. The interviews were audio-recorded, transcribed verbatim, and validated by relistening to the recording by researchers. The interviews were performed from July 2015 to August 2015. The participants in this study were initially asked with the open-ended questions. “How do you view the image of nurses today? What influenced how you view nursing?” and continued with the other questions until the data reached saturation when any new information was not achieved.
Data analysis and trustworthiness
Data were analyzed using interpretive phenomenology, as outlined by Van Manen, allowing flexibility in emphasizing or minimizing one step or another, depending on the emergent data, which consists of six steps, namely, (i) turning to the nature of lived experience involving formulating a research question, (ii) investigating experience using in-depth interviews for data collection, (iii) reflecting on the essential themes which characterize the phenomenon identified from interviews, (iv) describing the phenomenon in the art of writing and rewriting, (v) maintaining a strong and oriented relation to the phenomenon, and (vi) balancing the research context by considering the parts and the whole.
In this study, we read interview transcripts carefully and repeatedly for emerging themes, then using highlighting or selective approach, and finally reading holistically. In the holistic approach, we viewed the text as a whole and attempted to understand the overall meaning. We then highlighted or selected phrases and statements that seemed essential to the study. For the next step, we developed the keywords and concepts dialogue with the texts. Then, themes were interpreted from components of experience to the whole experience and back again. Finally, we analyzed every sentence and essential themes were discovered through this process. These themes were then reconstructed into a description of the perceptions of the participants, as indicated by literature. All of the themes were then translated into English. J.G provided the first translation, which was then agreed by the other researchers.
Data credibility was established by face-to-face discussion with any participants and through prolonged engagement. To ensure that no data were lost on the analysis process, peer review was done by an experienced researcher to compare and contrast on the data quality and interpretations. Dependability was achieved through a researcher audit and notes that documented all methodological issues and decisions. Although the interviewers were mostly Indonesian nurses, according to literature, bracketing was ensured by discussing among researchers about personal biases and experiences with the research topic.
The study has been reviewed and approved by the Institutional Review Board of the Government Institution of Society Protection (Approval No: 070/219.a/BKBPPB/2015). All participants in this study were recruited and informed about the aim of the study. They were assured that participation in this study was voluntary. Moreover, they were able to voluntarily withdraw from the study. The researchers guaranteed the confidentiality of their data and also ensured them that their information would be published anonymously. In the end, the researchers asked the informants to read and sign the written informed consent form. It was confirmed that all participants had obtained an appropriate consent form.
Nineteen participants were identified using purposive sampling to ensure that relevant data were collected, which consisted of 15 females (79%) and 4 males (21%). Ten (52%) of them were clinical diploma nurses and nine (48%) of them were bachelor nurses. Their age ranged between 25 and 37 years old, which was considered as generation Y (born 1977–1995) and generation X (born 1965–1976). There was no baby boomer generation (born 1946–1964) reported in this study.
Findings emerged from the data using Van Manen's thematic approach. Five themes emerged: Islamic culture, job definition, role of nurses, self-confidence, and relationship of multigeneration of nurses. Those themes are illustrated below with exemplars from the informants' stories using pseudonyms for the informants.
Majority of nurses agreed that their work was influenced by Islamic culture, which could be seen from what their wear and the way their care with patients, like ones described:
N7: “We are Muslim, so we work basically based on Islamic culture, including our appearance. We use Hijab (veil) to cover our head.” While N9 said, “We ensure that there is no pork when we provide the food for the patients and collaboration with dietician.” N11 said, “Every time we see the patients, we do not forget to say “Assalamualaikum” (peace be upon us), and we always ask the permission if male nurses want to take care female patients. However, usually male nurses take care male patients, especially in bathing the patients.”
Majority of nurses expressed themselves as someone who is always by the side of patients and always fulfills the needs of patients and their families. However, some nurses indicated that they are doctor's assistants, which only performed technical procedures such as drug administration, injections, measuring blood pressure, and temperature. Both views are explained in the following statements:
N1 said, “A nurse is someone who helps patients, and is constantly by their side.” N2 said, “Nurses are those who are always smile and answering all the needs of patients and families.” In contrast, N3 said, “A nurse is a doctor's assistant in reality although nurses think that they are in the same position with medical doctor.” But N4 said, “Because of the condition, such as the lack number of nurses with nurse-patient ratio (3:30), and a number of medical procedures that need to do, nurses have no time to work as a profession.”
Role of nurses
Majority of nurses indicated that nurses have a number of roles that are often depending on patient's needs such as a caregiver, decision-maker, communicator, advocator, and teachers. At the same time, some nurses said that nurses also do other profession's roles such as pharmacist roles. This is described in the following statement:
N5 said, “I always be a caregiver to my patients, giving health education to families, keeping the smile and advocating them.” and N7 said, “I always facilitate my patients and become a good communicator to them.” Besides, N8 said, “We are nurses having many roles, including other professions' roles like doing pharmacist's job in preparing medicine for patients, even patients often ask nurses to fix air conditioner. Additionally, hospital administrators also place nurses in every position because they think nurse can do everything.”
This study found that the majority of the nurses perceived themselves as those having good self-confidence in taking care of patients and in collaboration with other health professions. However, some nurses view them that not all nurses had a good self-confidence due to low level of education and competence. This is described in the following statement:
N19 said, “I take care of patients everyday, surely I have more confidence including collaboration with medical doctor.” In opposite that N6 said, “I personally think that I am a good nurse, I have more confidence, but sometimes I look at another nurse having no confidence and it is not good.” While N10 said, “I cannot generalize that nurse is good or bad, because some nurses may be good and some may be not. They sometimes feel shy because of their education and competence.”
Relationship between multigenerations of nurses
Some nurses mentioned that there was the gap between new nurses and senior nurses, which lead to the lack of collaboration as well as the difficulty in sharing knowledge and experiences between them.
For instance, S3 said, “I am afraid whether I need to share my knowledge or not to senior nurse. Just feeling afraid”, while S2 said, “We need our head nurse to facilitate us to communicate with all nurses. May be meeting in pre or postconference. So, we will complete each other.”
This study was conducted qualitatively to explore the perspectives of Indonesian nurses on their professional image. Five themes emerged from the data: Islamic culture, job definition, the role of nurses, self-confidence, and relationship between multigenerations of nurses.
Under “Islamic culture” theme, it is indicated that nurses have awareness in bringing the spiritual and cultural value in clinical practice, as the majority of the population in Belitung Indonesia is Muslim. Nurses at this point have to be culturally competent in providing care to Muslim patients. As literature mentioned that Muslims believe that they should meet illness and death with patience, meditation, and prayer, and it is important to discuss patients' dietary requirements including the need to avoid pork or medication that contains alcohol, and in a life-threatening emergency, there are no restrictions on the treatment that can be provided to a Muslim patient.
In “job definition” theme, there were two different perspectives perceived by nurses. Some nurses defined a nurse in a positive way as someone who always beside patients and fulfills their needs based on interpersonal skills and caring practices, rather than their technical skills. In contrast, the other nurses thought negatively about themselves as doctor's assistant, which contradicts with a study who found that nurses had a more positive image of themselves compared with how they thought the public perceived nurses. However, if nurses perceive their own prestige as low, that they are not appreciated, then they will be victims and that they are subordinate to other professions, they will act out that self-image.
Under “role of nurses” theme, findings of this study indicated that nurses had many roles. Nurses are demanded to do everything and often placed in many positions in a hospital. It seems that other professions may need to understand the role of nurses comprehensively. Besides, it is suggested that nurses need to emphasize nursing as a thinking profession and to highlight clinical knowledge and competence. The literature also suggests that nurses need to affirm their professional identity that can be demonstrated in a number of ways. Nurses need to view their work as a career rather than a job and could resurrect the title “nurse” and attach it to their last name. However, if physicians do this and nurses do not, there is an imbalance of status between the professions.
The “self-confidence” theme indicated that some nurses had more self-confidence in taking care of patients. However, some of them felt less confidence although having more experiences due to low level of education. This finding indicated that there might be a relationship between confidence and education, as a literature revealed that nurses' confidence increased with ongoing education and experience. On the other hand, in Indonesia, there are many levels of education of nurses in Indonesia including SPK (high school nurse), diploma III, diploma IV, bachelor nurse, and nurse specialist. These levels probably lead to the question of which kind of level of nurses need to be upgraded. However, to be called as a professional, nurses need to hold at least bachelor degree, as Indonesian nursing profession also mentioned that nurse who holds a bachelor degree and complete “Ners” program (1-year nursing profession program after finishing bachelor level program in nursing science) is considered as the first professional degree. Consistency in educational preparation at the baccalaureate level and a demonstrated commitment to continuing education are identified as important. It is even suggested that the Doctor of Nursing should be required for entry to practice.
The “relationship between multigenerations of nurses” theme indicates that nurse manager needs to understand how to lead a multigenerational nursing workforce because every generation has differences in attitudes, beliefs, work habits, and expectations., Head nurses need to facilitate the communication between senior and new nurses, promote, and clearly describe the job among nurses when the mixed-staff nurses work together. Nursing staff skill-mix models may need to be addressed in this situation to deliver best nursing care. The previous study showed that a mixed nurse staff model is associated with lower rates of medication errors and wound infection, and the majority of numerous research reports evidence of the link between nurse staffing and patient safety outcomes.
Based on these findings, it could be explained that a nurse in Indonesia is a person who is trained to take care of patients with highly skill and full confidence and is influenced by religious value, particularly Islamic value, to culturally understand the patients comprehensively.
In addition, Indonesian nurse is also seen as the one who respects each other, especially to physician, as everyone including nurses in the community think highly about the image of a physician. That is why physician is often treated differently, as to consider the value of respect. However, this may result in misconception between the relationship of physician and nurse, which is quite challenging to break the image of nurses, especially the image of being doctor's assistant.
Furthermore, Indonesian nurse is viewed as a person who brings the principle of seniority to bring higher status or precedence to employees in an organization for a longer period of time. However, this may lead the gap between senior nurses (those who have more experiences but having a low education) and junior nurses (those who have less experience but having a high education), particularly in the case of sharing session.
The last, Indonesian nurse is perceived as a person who can do many roles in hospitals and can be placed in any positions in hospital, which strongly influence the professional identity in the community.
Findings of this study contribute further to knowledge in understanding nursing image. However, the results may not represent the overall status of the Indonesian nursing image, so caution is needed when generalizing the results to other places. Recommendations for future study include increasing the sample size and sample representation from various settings. In addition, cross-sectional studies are also recommended to identify influencing factors of nursing image, especially in Indonesia.
This study explored the perspectives of Indonesian nurses on their professional image. The results showed that nursing image in Belitung Indonesia is spiritually and culturally influenced by the concept of religion, especially Islam, in clinical practice based on the need of patients. Indonesian nurse is likely to have more confidence in caring patients, and it is related to education. However, the image of nurses as a doctor's assistant also still exists, which might be influenced by the value of respects and seniority. Therefore, changing this image remains crucial. Nurses need to think highly as professional nurses and are encouraged to reject the positions, which are not related to nursing and health. Top managers are suggested to improve nursing image by developing nurse competence and upgrading nurse education through continuing professional and education development. In addition, the skill-mixed model needs to be addressed to bridge the gap between multigenerations of nurses in their clinical practice.
We acknowledge Faculty of Nursing, Chulalongkorn University Thailand and Indonesian Nurses Association of Belitung, Indonesia, for all valuable supports. We also are thankful for all participants who participated in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Varaei S, Vaismoradi M, Jasper M, Faghihzadeh S. Iranian nurses self-perception – Factors influencing nursing image. J Nurs Manage 2012;20:551-60.|
|2||Finkelman A. Professional nursing concepts: Competencies for quality leadership. Jones and Bartlett Learning; 2017.|
|3||Venes D. Taber's Cyclopedic Medical Dictionary. Philadelphia: FA Davis; 2017.|
|4||Hallam J. Nursing the Image: Media, Culture and Professional Identity. New York: Routledge; 2012.|
|5||Van Manen M. Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. United States: Routledge; 2016.|
|6||Sommers CL, Tarihoran DE, Sembel S, Tzeng H. Perceived images and expected roles of Indonesian nurses. Nurs Open 2018;2:1-6.|
|7||Shields L, Hartati LE. Nursing and health care in Indonesia. J Adv Nurs 2003;44:209-16.|
|8||Gunawan J, Aungsuroch Y. ASEAN mutual recognition arrangement for Indonesian nurses: Is it a promise? Int J Community Med Public Health 2017;22:77-80.|
|9||Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. Philadelphia: Lippincott Williams and Wilkins; 2010.|
|10||Gunawan J. Ensuring trustworthiness in qualitative research. Belitung Nurs J 2015;1:10-1.|
|11||Gunawan J. Generation Y nurse: What do i need in the workplace? Belitung Nurs J 2016;2:44-6.|
|12||Gunawan J. Potret Keperawatan di Belitung Indonesia: A Portrait of Nursing in Belitung Indonesia. Kendari Indonesia: YCAB Publisher; 2016.|
|13||Rassool GH. Cultural competence in nursing muslim patients. Nurs Times 2015;111:12-5.|
|14||Ford S. Patients view Smiling as “Best” Indicator of Nurse Skill; 2009. Available from: http://www.nursingtimes.net/news/hospital/patients-view-smiling-as-best-indicator-of-nurse-skill/5006094.fullarticle. [Last accessed on 2016 Jun 26].|
|15||De Vliegher K, Milisen K, Wouters R, Scheepmans K, Paquay L, Debaillie R, et al. The professional self-image of registered home nurses in flanders (Belgium): A cross-sectional questionnaire survey. Appl Nurs Res 2011;24:29-36.|
|16||Boyle DA. The invisibility of nursing: Implications from an analysis of national cancer institute-designated comprehensive cancer center web sites. Oncol Nurs Forum 2010;37:E75-83.|
|17||Buresh B, Gordon S. From Silence to Voice: What Nurses Know and Must Communicate to the Public. New York:Cornell University Press; 2013.|
|18||Destree L, Ludwig-Beymer P, Vercellino M, Rowe A. Effects of education on nurse confidence and cardiac surgical glycemic control. AACN Adv Crit Care 2013;24:362-9.|
|19||Gunawan J. Diploma nurse: A player or a spectator in ASEAN mutual recognition arrangement. Arch Med Health Sci 2016;4:157.|
|20||Black B. Professional Nursing-E-Book: Concepts and Challenges. Philadelphia: Elsevier Health Sciences; 2016.|
|21||Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. OJIN Online J Issues Nurs 2010;15:1-11.|
|22||Gunawan J, Aungsuroch Y. Managerial competence of first-line nurse managers: A concept analysis. Int J Nurs Pract 2017;23:e12502-n/a.|
|23||Duffield C, Diers D, O'Brien-Pallas L, Aisbett C, Roche M, King M, et al. Nursing staffing, nursing workload, the work environment and patient outcomes. Appl Nurs Res 2011;24:244-55.|