Jacqueline Bloomfield
RN, CM, Dip App.Sci (Nur), BN, Grad Cert Onc Nur, Grad Dip Midwifery, MN, MCN
(NSW).
The way in which the public perceives nursing significantly influences nurse’s role performance, job satisfaction and occupational expectations. The public image of Australian nursing has been subject to a plethora of influencing factors since health-care services were first established in this country over two centuries ago, Since its colonial origins, when considered an occupation suitable only for the socially outcast, nursing has evolved through decades of changes and reform. From a position of significant oppression and medical subservience, generations of Australian nurses have fought for public recognition in terms of identity, respect and role acknowledgement. The paper briefly explores the public image of Australian nursing from a historical perspective and discuss some of the factors that have influenced the way in which the public perceives the roles and responsibilities of the nurse.
Introduction
There is little doubt that nursing in Australia has undergone significant changes since its early colonial origins over two years ago when caring for the sick was widely considered to be a task suitable only of those of criminal and social disrepute (Schultz, 1991) Since these early beginnings, Australian nursing has progressed gradually through what can be considered a social, educational, technological, political and professional revolution. Modern nursing represents this progression, and as a result, the role of the contemporary nurse has expanded considerably from what was once traditionally the fulfillment of predominantly domestic duties performed at the instruction of the doctor.
While it is relatively simple to evaluate the progression of Australian nursing in terms of emerging roles and responsibilities, it is not so easy to define if and how the public image of nursing has changed over time. ‘Image’ as defined in the Oxford Large Print dictionary (Hawkings, 1990, p.402) is a "general impression of a person, firm or product as perceived by the public". It is acknowledged that reshaping an existing image is both a long and arduous process (Kalisch & Kalisch, 1987) and that several factors contribute to shaping an image.
Recent changes in nursing practice and the ways in which nurses are educated may have contributed to nurses gaining increased autonomy, accountability and expanded role responsibilities, but it could be argued that these changes have contributed very little to upgrading the traditionally subservient and domestically oriented public image of nursing (Dahl, 1992). Contemporary nursing is a unique occupation encompassing not only a highly specialised body of knowledge, but also the utilisation of complex technology, acquired skills and immeasurable actions (Kalisch & Kalisch, 1987). These aspects of nursing, however, are frequently overlooked or misunderstood by a large proportion of the general public and it can be said that inaccurate and often negative nursing stereotypes have significantly contributed to distorted public images of nurses. It is pertinent to question whether the public has moved past the traditional image of nursing, which portrays nurses as passive, unintelligent, highly dependent medical handmaidens (Kaler, Levy & Schall, 1989). It is the aim of this paper to discuss this very relevant issue.
The Early Settlement
When examining the origins of nursing in Australia and its early public image, it is useful to consider the early settlement of Sydney when the majority of health-care givers came from convict backgrounds. As the needs of the hospitals were widely considered to be a very low priority in the overall scheme of colonial development, few provisions were made by the governing authorities to allocate resources for the sick and infirm (Cushing, 1997). As a result, convicts who were considered the least able for more useful work, such as building or agriculture, were allocated to care for the sick. Schultz (1991) reports that magistrates when sentencing convicts, often sent them to work in the hospital as punishment for their crimes. Nursing was therefore widely considered to be a role suitable only for those of social and moral disrepute. Such low public recognition may have had a significant and long lasting influence on the ongoing struggle by contemporary nurses to gain professional respect and acknowledgement both within the health care system and the wider community.
As the convicts of the lowest class were selected to work in the hospitals, it is of little surprise that standards of care relected the capabilities of the carers. Nurses often came on duty intoxicated and the basic nursing care of patients was frequently overlooked. It was not uncommon for patients to lie unwashed in dirty beds for weeks and the presence of vemin, and inadequate sanitation combined with a disregard for compassion and empathy on behalf of the caregivers, characterised the poor nursing standards of this time (Cushing, 1993). This period in Australian nursing history is widely referred to as the "Dark Age of Nursing", a term which effectively reflects the negative image with which nurses were tainted (Schultz, 1991, Cushing, 1993).
The Need for Change
In 1868 the arrival of Lucy Osburn, a Nightingale protégé, to Sydney marked the beginning of significant nursing reform. In response to the ongoing problems and the appalling low standards of nursing that existed within the Sydney Infirmary, Florence Nightingale’s assistance was sought to improve the inadequate system of nursing. During the period, Florence Nightingale was universally recognised for the contributions to the reformation of nursing in Britain and her views in all matters relating to nursing, health, hospitals and public welfare were widely sought from all corners of the globe (Brodsky, 1968).
Advances in medical knowledge and technology had also begun to effect nursing practice. The discoveries of anaesthetics, disease pathophysiology, and the benefits of aeseptic technique had led the medical authorities to demand improvements in nursing in order to improve patient outcomes and survival rates (Keneley, 1988). As a result, Miss Lucy Osburn was appointed Lady Superintendent of the Sydney Infirmary and set out to reform nursing within the hospital based on Nightingale values. It was hoped that these changes would set a precedent for the improvement of nursing and its public image within other hospitals throughout Australia.
During her five years as Lady Superintendent at the Sydney Infirmary, Osburn’s most significant achievement was not just a significant improvement in standards o f nursing care, but her remarkable positive influence on how the public perceived nurses and their work. Lucy Osburn introduced the wearing of uniforms and adherence to strict hygiene standards for nurses, and also set the initial foundations for formal nurse training, incorporating formal lectures and teaching sessions into the daily hospital routine (Brodsky, 1968).
Once training for nurses become formally established within New South Wales at he time of the opening of the Prince Alfred Hospital in 1882 (Forsyth, 1994), the image of nursing had begun to truly move in a positive direction. From this time, nursing was widely considered to be a respected and admirable vocation which had become increasingly popular among all classes of women. As demand for trained staff to implement new treatments grew, women began to view nursing as a viable alternative to traditional employment options such as domestic duties, factory work or home duties. As a result, nursing was now perceived as an occupation that was respected and no longer reserved exclusively for the socially undesirable.
Nursing as a career also began to capture the imagination of the general public. Romantic and heroic images of nurses became popular and the portrayal of the nurse as a saintly angel dressed in white attracted many aspiring nurses. Keneley (1988) suggests that it is one of history’s greatest paradoxes that despite the poor and extremely harsh working conditions, nursing remained one of the most popular female occupations well into the twentieth century.
Nursing as a Vocation
Once reform had been established and implemented into the hospitals, little occurred to fundamentally change nursing during the next several decades. By the early 1960’s, the pattern of nursing in New South Wales was well established. Nursing was firmly based on the elements of obedience, service and hard work and these principles were strongly enforced within a rigid hierachial structure headed by the often formidable hospital matron. The system of training had changed minimally since the beginning of the century and was still largely based on intrinsic Nightingale values which promoted obedience to doctors, discipline, self-control and strong work principles (Holten, 1984). The position of the nurse, in the public eye, although respected, remained subservient to the medical profession and was still primarily associated with domestic duties.
The religious images historically linked with nursing persisted well into the twentieth century and the occupation was promoted in many spheres as a vocation. Women who became nurses were widely thought as of being different to other working women and were perceived as possessing unique and special qualities. Strong emphasis was placed on the personal attributes of what was considered essential to be an "ideal" nurse. These trials included selflessness, obedience, kindness, devotion and dignity (Bridges, 1990). These ideas appeared in newspapers and journals and were strongly used to promote the virtues of nursing as an occupation to potential recruites (Kalisch & Klaisch, 1989).
The requirement for trainee nurses to live in hospital accommodation also contributed to nurses being publically viewed as a vocation during the years between 1900-1960. ‘Living in’ was historically regarded as an essential component of nurse training as it was thought that this would ensure the installation of the morals, manners and behaviours that Florence Nightingale regarded as basic qualities of a good nurse. The Nurses’ Home was treated as an integral part of the interdisciplinary structure of the hospital and its occupants were required to adhere to strict rules and regulations (Russell, 1990). Such requirements further perpetuated the cloistered and semi-religious image of nursing which had captured the public imagination.
The life of a nurse working during the 1950’s and 1960’s was not an easy one. In addition to the oppressively rigid hierachial system in which hospitals operated, the work was often long and gruelling and wages and conditions poor. Nursing retained the characteristics of obedience and conformity, and the entrenched hospital hierarchy subordinated the junior nurses to the seniors, resulting in very limited job satisfaction and high attrition rates (Russell, 1990). It was not uncommon for trainee nurses to work in excess of a sixty hour week, yet the weekly wage of a fully qualified registered nurse was within the same range as that of an untrained shop assistant (Russell, 1990).
Despite such conditions, many nurses felt that the low pay and long hours testified to a nurse’s vocation and devotion to her patients (Dickenson, 1993). The portrayal of nursing as a vocation led the general public to believe that the satisfaction of being a nurse had to be earned and that the poor working conditions were justified in return for being privileged enough to minister to the sick (Strachan, 1996).
Nursing as Women’s Work
As it was not until the early 1970’s that men were accepted for general nurse training in New South Wales (Staunton, 1997), nursing as an occupation has had to deal with gender-specific inequality for a long time. Nursing was established in Australia during a period of male dominance, patriachialism and female subservience when a women’s social position in relation to men was replicated by nurses’ subordinate position in relation to doctors. Nursing was fundamentally regarded as "women’s work" leading to a perception of nurses as "ideal women" and doctors as "ideal men". The development of nursing as an exclusively female occupation has therefore had major ramifications for its status and public image. Unlike the male oriented medical profession, whose work was highly visible, widely recognised and thus renumerated accordingly, there was widespread failure of people to distinguish between the skilled and unique work of nurses and the traditional tasks required of them. To this extent, the role of the nurse was often simply seen as that of wife and mother transplanted out of the home and into the hospital environment (Stephenson, 1970). This long standing attitude of inequality assisted in fostering a climate of poor self-esteem among nurses, and a lack of belief in the value of the nursing role and its importance in the delivery of effective health care by members of the general public.
Changing Times
From the early 1960’s, many Australian nurses became increasingly dissatisfied with prevailing wages and conditions. This was clearly demonstrated by an ever increasing display and attitude of militancy concerning industrial issues. In 1966 a series of mass meetings were held at major venues throughout the state in protest of wages, working conditions and cuts to health care funding (Russell, 1990). This marked a prelude to further protests that began to erupt around the country in years to follow and which culminated in an agreement by nurses to delete the long standing no-strike clause from the constitution of the Royal Australian Nurses Federation in 1985 (Pittman, 1985). During the 1960’s, 1970’s and 1980’s, nurses unions became stronger, larger and were more vocal as they continued to lobby the government for improved wages and conditions. Although there is little relevant literature available, it is apparent that the general public at this time, largely sympathised with nurses and their struggle for increased wages and improved conditions (McCoppin & Gardner, 1994; Dickenson, 1993). Popular women’s magazines highlighted nursing’s plight in feature articles and several leading medical experts expressed opinions publically regarding their considerable concern at the poor state of Australian nursing.
The Rise of Feminism
Feminist theory and ideology began to merge into Australian society during the 1960’s with the growth of the Women’s Liberation Movement. The establishment of the feminist movement in Australia had the effect of offering women a new awareness regarding their place in society. Until the rise of the Women’s Liberation Movement, most women were socialised into viewing marriage, and child-rearing as a full-time and life-long job (Stephenson, 1970). As opportunities within employment and education opened up for women, this widestanding belief was not only challenged but also widely discounted. Female school leavers now had the opportunity to look well beyond the scope of what was once considered the only suitable female occupations. If girls possessed the ability, desire and means, they could now enter traditionally male dominated occupations such as science, law, engineering or medicine. No longer did nursing publically hold the distinct recognition as being one of the few acceptable and attainable career options for females.
Societal Changes
Social norms were also challenged during the 1960’s and 1970’s, and it is interesting to consider the effect these changes had on nursing’s public image. During these decades divorce rates increased, marriage rates fell, reliable birth control methods became widely available and women began to delay motherhood in favour of their careers.
Employment for married women outside the home also gained societal acceptability as increasing numbers of women took outside jobs (Stephenson, 1970). As nursing shortages rose, married women and mature women were encouraged to enter nursing as students, or to return to nursing as their children reached school age. Males also began to be accepted into general nurse training programs during the 1970’s. Russell (1988) reports that these events had the unprecented effect of relaxing some of the strict rules and regulations that had traditionally surrounded nursing. Living-in requirements began to be eased in many major training hospitals and it can be said that the public perception of nursing changed as its traditional, cloistered and semi-religious image began to gradually erode.
Technological Revolution and Educational Reform
The late 1970’s and 1980’s heralded an era of rapid technological development, which strongly influenced nursing and its public image. As science and medical technology advanced rapidly, members of the medical profession became more involved with the complexities of disease diagnosis and treatment (Russell, 1990; Foley, 1984). The role of the general nurse became more complex as nurses began to assume a greater responsibility for new technological procedures that doctors no longer had time for or which they no longer considered appropriate to their level of education, expertise or status (Chinn &Wheeler, 1985). As nursing roles and responsibilities became more complex, the attitudes of nurses changed and many began to realise that the time had come for them to improve their self-image and professional status.
Foley (1984) reports that at this time, nursing leaders began to formulate theories of nursing and to build up a body of knowledge specific to nursing. Nursing research was initiated and nursing journals increased in number and circulation. Nursing leaders realised that as long as student nurses were employed by hospitals, they would continue to be seen as little more than workers obligated to fulfil the service needs of the hospitals to the detriment of their own learning needs. The move to introduce college-based nurse education was therefore initiated. After what can be considered a long and arduous battle, educational reform was finally achieved in 1983 with the announcement by the New South Wales State government that all pre-registration nursing programs would be transferred to the tertiary sector from the beginning of 1985. Other states followed this lead.
A new era had begun. Yet despite these developments the public image of nursing was slow to change and distorted nursing stereotypes continued to dominate the public mind. Although nurses recognised their changing image and move towards professional status, the general public continued to view nurses, to some extent, as subservient and powerless medical handmaidens.
Media Images
It is widely acknowledged that stereotypes of the nurse are portrayed to the public through books, television, advertising, film and even greeting cards (Green, Taylor, Walkey & McCormick, 1988). Throughout these forms of media, the image of the nurse has historically been glamorised, satirised, ridiculed, degraded and trivialised. Rarely, in the past, has the media in their fictional form, set out to recreate reality and to portray nurses as they really are, although it muse be realised that there is no single image of nursing which reflects reality. Frequent misrepresentations of nurses on television can have serious consequences not only for nurses, in that their work if often unfairly underestimated, but also for patients who may gain unrealistic expectations from watching television’s portrayal of nursing.
Australian television programs featuring nurses have evolved significantly during the past two decades and there has been a considerable alteration in the way in which nurses have been portrayed. From 1970’s soap opera, "The Young Doctors", which effectively reinforced the traditional stereotyped images of the nurse as a sex symbol, battle axe and doctors handmaiden to "A Country Practice" which made some serious attempts to overcome conventional stereotypes by utilising role reversal through the portrayal of several heterosexual male nurses and female doctors, the image of nurses on television has progressed.
The latest Australian program "All Saints" can be considered revolutionary as it effectively portrays the work of nurses as highly skilled and of considerable importance to patient care. Unlike previous television nurse images, no longer are the nurses represented as being subservient, unthinking handmaidens. Instead they portrayed as being an integral part of the health care team, making autonomous and rational nursing decisions. As it has been acknowledged that the way in which nurses are portrayed in the media has vital implications for the status of nursing within society (Kalisch & Kalisch, 1993), it is reassuring that traditional nursing stereotypes are now being replaced with a more true to life image.
Conclusion
Despite a gradual evolution in their roles and responsibilities, nurses have for many years been publically identified by traditional roles, dedication, oppression and harsh working conditions. Distorted images of the nurse have also long been perpetualised through public imagination and by the media through the reinforcement of unrealistic fantasies and negative stereotypes. It has been shown that not only are such stereotypes effective in portraying to the public an unrealistic image of nurses but they also function to undermine the diverse complexity of the nurses role.
As we enter a new millennium and age of technological advancement and highly specialised and sophisticated health-care, it can be said that the demands of the public as consumers of health-care render the traditional image of the nurse as not only outdated but also potentially harmful. As contemporary nurses increasingly recognise their unique skills and valuable contribution to healthcare, they will continue to embrace education and professional strategies in order to improve their public image. As a result, it can be said that nursing has at last moved from its traditional position of dependence and oppression to one of greater autonomy and respect. Perhaps it can now be said that the traditional public image of nursing is finally being eroded and slowly replaced with a more realistic and accurate one that truly reflects the unique and valuable work of nurses.
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