The image of the nurse on the Internet Beatrice J. Kalisch, PhD, RN, FAAN Suzanne Begeny, MS, RN Sue Neumann, MS, RNC The media image of the nurse is a source of concern and negative.2,11,21–25 Nurses are under-represented and because of its impact on: recruitment into the profes- often invisible in media portrayals of healthcare. sion; the decisions of policy makers who enact legis- This article reports the results of a study investigat- lation that defines the scope and financing of nursing ing the newest form of the mass media, the Internet. services; the use of nursing services by consumers; The Internet image of nursing has become increasingly and the self-image of the nurse. This article reports on more important in recent years because of the public’s the results of a study of the image of nursing on the Internet utilizing content analysis methodology. A total (especially young adults’ and teens’) growing use of of 144 Websites were content-analyzed in 2001 and this form of media to obtain information and learn 26 152 in 2004. Approximately 70% of the Internet sites about the world. showed nurses as intelligent and educated and 60% as respected, accountable, committed, competent, and trustworthy. Nurses were also shown as having special- BACKGROUND ized knowledge and skills in 70% (2001) and 62% (2004) Image of Nursing of the Websites. Scientific/research-oriented, compe- Although the image of nursing on the Internet had tent, sexually promiscuous, powerful, and creative/ not been previously studied, the image of nursing in innovative increased from 2001–2004 while commit- other forms of media has been the subject of a number ted, attractive/well groomed, and authoritative images of research studies over the past 2 and a half de- decreased. Doctoral-prepared nurses were evident in 2,3,19,20,27–40 19% of the Websites in 2001 and doubled in 2004. The cades. These researchers uncovered a num- results of this study suggest that there are important ber of distinct images (eg, angel of mercy, girl Friday, opportunities to use the Internet to improve the image heroine, wife/mother, battleaxe, sex object) that have 1,20,30–34,41–43 of the nurse. emerged over time. A negative image of nursing has a number of negative consequences. It impacts the quality and quan- he image of the nurse is noted as a significant tity of persons who choose nursing as a profes- problem in many countries of the world including sion.1,15,20,35,44–46 A public constantly presented with Australia,1,2 Britain,3,4 Canada,5,6 Ireland,7 Poland,8 inaccurate and negative nurse images will view a career T 9 10 11–12 Hong Kong, Taiwan, and the United States. One in nursing as undesirable. This is especially relevant to of the major influences on the image of the nurse is the the recruitment of men—in that media portrayals have mass media portrayal of the profession.18–20 What focused primarily on women3,16 and the image of a individuals see, hear, and read in the media influence male nurse is often negative.47 the image they develop of nursing. Although there have The public image of the nurse also affects decisions been a few successful efforts to reshape the media of policymakers who enact legislation that defines the image of nursing, the image is still largely inaccurate scope and financing of nursing services and allocates the scarce resources that undergird nursing prac- 19,20 Beatrice J. Kalisch is Director, Nursing Business and Health Systems tice. Consumers are also affected by the public and a Titus Distinguished Professor of Nursing at the University of image of the nurse. Since the media do not portray Michigan, School of Nursing, Ann Arbor, MI. nurses as instrumental health care providers and have Suzanne Begeny is a Research Associate and Doctoral Student at University of Michigan, School of Nursing, Ann Arbor, MI. failed to mirror the changing role of the nurse, the Sue Neumann is a Perinatal Clinical Safety Specialist, Risk Manage- public lacks awareness of the many vital services that ment at Covenant HealthCare, Saginaw, MI. nurses currently do provide. The physician continues to Reprint requests: Beatrice J. Kalisch, PhD, RN, FAAN, University of receive nearly all of the credit for any positive health Michigan, School of Nursing, 400 Ingalls Building, Room 4170, Ann 1,4,20 Arbor, MI 48109-0482. care outcomes. E-mail: [email protected] The negative image of nursing also creates problems with nurses’ self-image. While some nurses may not Nurs Outlook 2007;55:182-188. 0029-6554/07/$–see front matter consciously recognize the impact of media depictions Copyright © 2007 Mosby, Inc. All rights reserved. of their profession, on a subliminal level the impact is 2,3,20,48,49 doi:10.1016/j.outlook.2006.09.002 unmistakable. 182 V OLUME 55 ● N UMBER 4 N URSING O UTLOOK The image of the nurse on the Internet Kalisch et al The Impact of the Internet A codebook/user guide with detailed coding instruc- The introduction of Netscape’s Mosaic browser on tions was developed. The instrument was then indepen- October 13, 1994 changed the way Americans’ access dently applied by each of the 7 members of the original and gather information.26 The US Department of Com- working group to a sample of 25 nursing Websites. merce in their 2002 report, A Nation Online: How Inter-rater reliability was assessed between dyads of the Americans Are Expanding Their Use of the Internet, principal investigator with each rater and between 2 states, “Increasingly, we are a nation online.”50 The raters. Items considered confusing, ambiguous, redun- Pew Research Center (2005) confirms this growth: dant or with low inter-rater reliability were removed or “The Web has become the ‘new normal’ in the Amer- revised. Revisions were then made in the codebook. ican way of life; those who don’t go online constitute an This process was completed 5 times and resulted in a ever-shrinking minority.”26 The increase in Americans refinement of the final tool to 65 items. Before the using the Internet translates into 63% of American actual coding of Websites took place, the coders under- adults (age Ն 18) and 81% of the nation’s teenagers went training in the use of the tool until they reached a (age 12–17).26 The Pew Research Center (Trends 2005, percentage of agreement of at least 85% with the Internet) points out that many people “can scarcely principal investigator. imagine what the world was like way back when people The tool devoted to measuring 17 nurse characteris- weren’t always connected, ‘always on,’ ”26 and “the tics included: (1) intelligent, (2) respected, (3) autono- longer the Internet is around, the more people expect mous, (4) warm, kind/compassionate, (5) educated, (6) of it. Increasingly, it is seen as a utility rather than a accountable, (7) trustworthy, (8) diverse, (9) cool/ “with novelty.”26 This increase in Internet use is broad-based, it” (10) attractive/well groomed, (11) competent, (12) affecting every demographic group, regardless of in- sexually promiscuous, (13) committed, (14) creative/ come, race, gender, education, and age group.50 innovative, (15) powerful, (16) scientific and (17) authoritative. Each item was scored as present, not RESEARCH QUESTIONS present, or cannot determine. Characteristics that were The research questions for this study are: present were clearly portrayed on the Website. The ● What is the image of nursing on the Internet? characteristic was considered not present if there was ● Has the image of nursing on the Internet changed no evidence or opposite evidence of the characteristic. from 2001 to 2004? If there was a lack of sufficient information for the reviewer to evaluate the attribute, it was then marked STUDY METHOD undeterminable. A descriptive comparative research design was selected The Cronbach coefficient ␣ for the 65-item scale was to examine the image of nursing on the Internet and to .772 in 2001. Based on Nunnally et al’s (1994) criteria compare the image of nursing on the Internet in 2001 that .70 is adequate for newly developed instruments and 2004. and .80 is adequate for more developed instruments, the Internet Nursing Image Tool was considered to be Content Analysis Tool reliable.51 Before the tool was used again in 2004, the A content analysis research instrument, the Internet reliability was tested to verify that the tool was still Nursing Image Tool, was developed to systematically valid, considering the changes to Internet technology. and objectively measure the image of nursing on Again, 25 sites were tested. The Cronbach coefficient Internet Websites. An initial pool of 136 items was ␣ was .911 in 2004. To find the overall reliability of the derived on theoretical grounds from historical content tool for both years, 50 sites (25 from 2001 and 25 from analysis research conducted on the image of the nurse 2004) were tested for reliability. For both 2001 and in the mass media (ie, television, motion pictures, 2004, the Cronbach coefficient ␣ was .881. novels, newspapers and magazine articles) by Kalisch and Kalisch.20,30–34,41 These initial items were re- Sample viewed for relevance and clarity by a working group of Sample selection in both years utilized search engine 7 reviewers (nurses with a master’s or PhD degree or technology. The aim was to select sites that received the working toward a graduate degree) and reduced to a set most exposure to the public. In 2001, the sample of 93 items. This 93-item tool was then reviewed selection process involved prompting what were then item-by-item by a panel of experts (12 nurses from the top 10 search engines with the word “nursing” practice and education) to establish face validity.