Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession

Highlights

• •An outdated brand image projects nurses as lacking in influence and autonomy.
• •Nurses could use branding principles to develop and promote their desired image.
• •Branding is most effective when members agree on a set of shared values.
• •A strong brand message is built on “consistency of message and action over time.”
• •Research is needed which could inform an accurate brand image for nursing.

Abstract

Background

Nurses have been overlooked as autonomous healthcare providers due to an inaccurate image which projects them as caring and trusted, yet lacking in influence and autonomy. It is important for nurses to understand the image their profession wishes to convey, how the image falls short, and what can be done to improve it.

Purpose

To examine responses of Registered Nurses (n = 286) describing factors influencing nursing's inconsistent brand image.

Methods

Qualitative data were thematically coded, analyzed, and grouped into eight influencing factors.

Findings

Factors contributing to nursing's inconsistent image included: variety of education/credentials, image not a priority, lack of leadership development, lack of professionalism, portrayals in the media and online, patients’ personal experiences, treatment by other professional colleagues and gender role assumptions.

Discussion

A strong brand image could dispel outdated and inaccurate views while communicating new visionary leadership which aligns with priorities for the nursing profession.

Significance

Registered Nurses (RNs) comprise more than 50% of the global healthcare workforce and the largest sector of the healthcare workforce in the United States (American Association of Colleges of Nursing [AACN], 2019a; World Health Organization, 2018). Nurses also make up the largest component of hospital and long-term healthcare providers and remain in high demand across most healthcare settings, including public health, primary care, home care, out-patient centers, schools, academia, and healthcare research (AACN, 2019a; U.S. Bureau of Labor Statistics, 2019).

The profession of nursing contributes significant value to the healthcare industry in a manner that "distinguishes nurses from other healthcare professionals. First, nurses are educated to consider the social factors (or determinants) which influence health (e.g., income, gender, race, employment, education) making them essential advocates for connecting community resources and delivering healthcare to people where they work and live (Lathrop, 2013; Olshansky, 2017). Secondly, nurses provide healthcare from a holistic perspective, which centers on healing the whole person (mind, body, and spirit) in addition to treating and curing disease (Klebanoff, 2013; Mowdy, 2015). This inclusive approach to healthcare allows nurses to directly influence the delivery of primary, secondary, and tertiary prevention strategies to vulnerable populations at high risk for developing or worsening health problems (De Chesnay & Anderson, 2016). Finally, nurses have earned a high degree of respect from the public compared to other professions. According to a recent national poll, RNs hold their rank as the most trusted profession in the United States for the 20th year, with 85% of respondents rating honesty and ethical standards of nurses as high or very high (Reinhart, 2020).

The growing importance of nurses has led to an increased demand for their services in a variety of roles and contexts (Health Resources and Services Administration, 2014). The U.S. Bureau of Labor Statistics (2019) projects Registered Nursing will be the fastest growing of all professions in the United States, with a projected need of 371,500 new RNs by 2028. However, despite the growing need for nurses, the profession continues to battle an ever-growing shortage, largely due to the retirement of an aging workforce (more than half are over age 50), lack of nursing faculty, high job stress, and turnover (AACN, 2019b).

The Institute of Medicine (IOM) examined the role of nursing and offered recommendations for better utilization of nurses in a changing healthcare environment (Institute of Medicine, 2010). IOM recommendations include a redesign of the healthcare delivery system which allows nurses to practice at the full extent of their license and make use of their extensive education and training. Most RNs (55%) are prepared at the baccalaureate level or above making them educationally qualified to direct and deliver quality healthcare in a variety of settings, including in the community where professional collaboration and partnerships are essential (AACN, 2019a; Lundy & Janes, 2016). As such, the IOM has called for nurses to function as equal partners with physicians and other healthcare providers as a key strategy to advance quality healthcare (Institute of Medicine, 2010). When outlining their vision for an improved model of healthcare, the Robert Wood Johnson Foundation also relied heavily upon the capacity of nurses to assume leadership roles in quality improvement, increased access to care, and health promotion (RWJF, 2015).

However, the advancement of and increased reliance on nursing within the healthcare system have not translated to an updated perception of nursing in the minds of the public (Prybil, 2016; Summers & Summers, 2009). Despite their sheer number, unique value, respected reputation, patient-centered perspective, and academic/professional qualifications, nurses remain underutilized and unrecognized for their essential contributions to the healthcare system (Hoeve, Jansen & Roodbol, 2014; Prybil, Popa, Warshawsky, & Sundean, 2019). Numerous reports in the literature suggest that nurses have been overlooked as autonomous healthcare providers due to a persistently outdated and inaccurate image, often fed by media stereotypes, which project them as caring and trusted, yet lacking in influence and autonomy due to their subservient role to physicians (Cabaniss, 2011; Cohen & Bartholomew, 2009; Darbyshire, 2010; Hoeve, et al., 2014; Price & McGillis, 2014). As a result, the public, and other healthcare professionals, seem largely uninformed regarding the tenants of current nursing practice and licensure which are established and governed by the National Council of State Boards of Nursing (NCSBN, 2020) (rather than medical boards) as an assurance the principles of competent nursing practice are met and maintained (American Association of Colleges of Nursing, 2019a.

The profession of nursing has an unmet need to differentiate themselves from other healthcare professions and communicate their unique value to the public as decision-makers and leaders in the healthcare industry (Finkelman & Kenner, 2013). Differentiation and the communication of value are core components for branding of organizations or professions (Kotler, Hayes, & Bloom, 2002). Branding works by shaping the image held in the minds of others by creating positive associations between the object (e.g., an individual or organization), and aspects which enhance value (Kapferer, 2012; Kotler, et al., 2002). Branding is an intentional process which requires assessment and refinement over time. A fundamental step in improving the value and recognition of the brand may be to address the chasm between nursing's crucial role in healthcare and the stereotypical images still held by the public (Godsey, Perrott & Hayes, 2020).

This critically important topic deserves to be examined thoroughly and in an empirically sound manner. An important first step in this investigation is to assess the current state and desired future state of nursing's brand, as identified by nurses themselves, since nurses are the ones who must decide and act to achieve the image they want for their profession. Research is needed which informs professional consensus regarding the image challenges faced by nurses, while informing and defining rebranding strategies for the profession's future (Godsey, Hayes, Schertzer & Kallmeyer, 2018). Attempts to rebrand the profession must draw attention to the unique features that are attractive to stakeholders (nurses) so they can be translated strategically to the minds of consumers (the public) (Koch & Gyrd-Jones, 2019).

However, data is lacking in the empirical literature which could serve as a springboard for the creation of a consistent, accurate brand image for the nursing profession; one informed by nurses describing their profession's current image compared to the brand image they most desire. This research seeks to fill that need by investigating the factors which prevent the nursing profession from achieving their desired image, as informed by the voice of nurses themselves.

Literature Review

Branding is a marketing technique that allows organizations to create an image in the minds of consumers which conveys core values and differentiates their products and services from those of competitors (Brodie, `Whittome & Brush, 2009; De Chernatony & Segal-Horn, 2003; Kapferer, 2012). In the healthcare industry, consumers (patients), co-workers, and administrators are frequently unaware of many aspects of the nursing profession, including the prevalence of advanced degrees, the role nurses play in directing care, and the expansive job duties performed outside of what they personally observe in the healthcare setting (Buresh & Gordon, 2013). Because patients see nurses working alongside so many other healthcare professionals (such as imaging technicians, respiratory therapists and medical assistants), it can be difficult for them to discern the contribution each profession makes to their healthcare experience (Hoeve, et al., 2014).

The variety of pathways to a nursing degree also contribute to the confusion. Entry into educational programs for RNs include diploma programs, 2-year associate degrees, and 4-year baccalaureate degrees. Many nurses go much farther in their education to obtain graduate degrees (masters and doctoral) as well as specialty certifications which qualify them for advanced nursing practice (AACN, 2019a). The wide variety of entry points into the profession, range of academic degrees, and myriad of specialties may have fostered role ambiguity and promoted inconsistent or incorrect information concerning nursing's integral role in healthcare (Jacob, McKenna & D'Amore, 2017; Lovan, 2009). To address these concerns, the profession of nursing needs an effective brand image which is clearly understood by consumers, respected by peers, valued in the marketplace, and delivered consistently and seamlessly by nurses in the workplace (Godsey, et al., 2020).

However, the nursing profession has struggled to communicate a brand image that conveys its complex role in a changing healthcare landscape (Cabaniss, 2011; Rezaei-Adaryani, Salsali & Mohammadi, 2012). When an organization or profession fails to articulate its own brand image, others are in a position to fill the void with other images, which are frequently based on their own agenda (Gallo, 2018; Kotler, et al, 2002). For example, the media often portrays outdated or sensationalized images of nursing to fit the expectations held by audiences. The public, unaware of nursing's advanced degrees and technical competencies, continues to acknowledge the contributions of nurses primarily based on attributes of caring and kindness, and as subservient caretakers who take orders from physicians (Cohen, 2007).

Successful brands maintain their image by updating the message to stay current with changing realities and expectations while maintaining values core to the brand (Wee & Ming, 2003). In an effort to highlight and expand upon the essential contributions of nursing, the World Health Organization (WHO) and the International Council of Nurses designated 2020 as the International Year of the Nurse (WHO, 2020a). The focus of this initiative is to emphasize the urgent need for front line nurses who are essential to the goal of universal health coverage by 2030 due to their unique capability to address the social determinants of health, including affordable, quality, equitable care for all populations (National Academy of Medicine, 2020; WHO, 2020b). Nursing Now has also partnered with the WHO and the Institute for Healthcare Improvement to empower nurses with “a more prominent voice in health policy-making; encouraging greater investment in the nursing workforce; recruiting more nurses into leadership positions; conducting research that helps determine where nurses can have greatest impact; and sharing of best nursing practices” (WHO, 2020b). Coincidentally, the International Year of the Nurse falls unexpectedly during at a time when the novel coronavirus pandemic is currently underway. According to WHO's Director General, Dr. Tedros Adhanom Ghebreyesus “nurses are the backbone of the health system…on the frontline in the battle against COVID-19…a stark reminder of the unique role they play, and a wakeup call to ensure they get the support they need to keep the world healthy” (WHO, 2020b).

Nursing has an unprecedented opportunity to respond to the WHOs “wake up call” by developing an effective and accurate representation of nursing. However, the voice (and perspective) of nursing has largely been absent from the branding discussion. Factors which may have limited historically the visibility and influence of nursing include role confusion, lack of confidence, fear, a sense of inferiority/perception of physician authority, hierarchical structures of healthcare organizations, hospital policies, or threats of disciplinary action (Fletcher, 2007; Pike, 2001). Nurses must first understand the image their profession wishes to convey, how the image currently falls short, and what can be done to improve it (Godsey, et al., 2020). Though the concept of branding came from consumer products, it is well recognized that individuals and organizations can also use branding as a tool to promote their profession in a manner consistent with the desired image (Galloway 2004; Lair, Sullivan & Cheney, 2005). A strong brand message is built upon the marketing principle of “consistency of message and action over time” (Hayes, 2015, p 103). This approach is important because branding a service industry, such as healthcare, is best determined and represented by customer-facing staff (nurses), rather than the marketing department of a hospital (Bitner, Booms, & Mohr, 1994; Chernatony and Segal‐Horn 2003). In service industries, such as healthcare, effective branding can lead to positive outcomes related to customer satisfaction (O'Cass & Ngo, 2011), assessments of service quality (Baek & King, 2011), and trust (Kemp, Jillapalli, & Becerra, 2014), as well as improved recruitment and retention of qualified professionals (Dabirian, Kietzmann & Diba, 2017; Greenawalt, 2001). Branding is most effective when members of the organization (or profession) agree on a set of shared values and have a clear understanding o f the strategy needed to achieve and maintain them (De Chernatony & Segal-Horn, 2003). Shared values foster commitment and loyalty, a better understanding of the brand, and consistent delivery of the brand to consumers (De Chernatony & Segal-Horn, 2003).

Nurses routinely function in highly visible roles which serve to reinforce brand promises made by the healthcare organization (Wocial, Sego, Rager, Laubersheimer & Everett, 2014). The concept of branding in nursing is particularly relevant as the profession advocates for equal footing with other healthcare professions (such as medicine), pursues advanced leadership roles in healthcare policy, and seeks to recruit and retain an educated and diverse workforce (Dominiak 2004; Hoeve, et al., 2014; Parish, 2004). It would seem therefore, that communication of shared values is particularly relevant in nursing, where the profession is embodied in service to patients. Purposeful branding of the profession of nursing could keep the contributions of nursing at the forefront as their roles evolve to include issues of import in the 21st century. However, sparse academic or practice research exists which focuses on branding the nursing profession as its own distinct entity within the healthcare industry.

A strong brand image for the nursing profession could dispel outdated and inaccurate views while communicating a new vision that more closely aligns with contemporary nursing practice (Godsey, et al., 2020). Thus, it is important to investigate the gap between how nurses see themselves presently and how they would like to be seen in the future.

This research aims to advance the understanding of branding in the nursing profession while also potentially informing the development of new theories regarding the branding of service professions. A discovery-oriented theoretical framework guided this study (De Chernatony & Segal-Horn, 2003). The Theories-in-Use approach seeks to investigate marketing questions from the perspective of individuals (i.e., nurses) who are closest to the problem under investigation (i.e., nursing's brand image) (Zaltman, LeMasters, & Heffring 1982; Zeithaml et al. 2020). Nurses are the ones best positioned to understand and identify critical issues shaping their image and the future of their profession. This reality, combined with the sparse literature on branding in the nursing profession, makes the Theories-in-Use approach a good fit for this investigation. This paper explores factors contributing to nursing's inconsistent image and describes actions which could improve the brand position of the nursing profession going forward.

Methods

Sample

The sample consisted of RN respondents (n = 286) from two groups: (a) alumni of a private university in the Midwest who received a bachelor of science (BS) or master of science (MS) degree in nursing (n = 152), and (b) a national sample of nursing faculty with graduate degrees (MS or doctoral preparation) from a private Jesuit collegiate network (n = 134). Each group was purposively recruited as a result of their membership as alumni or faculty in this network.

Measures

This study draws upon narratives from prior research conducted by two of the authors (Godsey & Hayes, 2017) who also developed the Nursing Brand Image Scale (NBIS). The NBIS demonstrated good to excellent internal consistency and reliability. Principal component analysis showed no interitem correlations >0.9 or <0.1. Measures for sampling adequacy were high on the Kaiser–Meyer–Olkin, and Bartlett's test of sphericity was significant (p < .001) (Godsey, et al., 2018).

Development of NBIS

To begin the process of instrument development, three in-person and webinar focus group sessions were conducted with nurses (n = 27) who were asked to describe their perceptions of the brand image of nursing. The words and phrases from each session were combined, thematically analyzed, and coded. The resulting 42 themes were used to create a Likert style survey instrument measuring the current and most desired brand image of nursing (Godsey et al., 2018). Optional open text boxes were provided at strategic points throughout the survey to allow participants to give rationale for their answers. The NBIS was then anonymously administered to a convenience sample of consenting nursing faculty and alumni (n = 286) via a Survey Monkey link.

NBIS Quantitative Findings

In the quantitative portion of the original NBIS research, participants were also asked to select the top three words or phrases (from the list of 42 descriptors) they felt “best described” the profession of nursing. Phrases most descriptive of nursing included: Caring/compassionate (n = 102), advocates (n = 98), essential members of the healthcare team (n = 73), critical thinkers (n = 72), patient centered/focused (n = 72), and healthcare providers (n = 55). Phrases seen as least descriptive of the nursing profession included: White cap/uniform (n = 189), physician's assistant (n = 161), subservient (n = 158,) hard to identify from other healthcare workers (n = 73) and female (n = 59). Responses to the original NBIS research revealed an unanticipated finding that “powerful decision makers” (n = 38) and “autonomous” (n = 28) were also among words/phrases considered least descriptive of the nursing profession. Paradoxically, principal component analysis of the instrument also revealed “influential leaders” had the lowest mean score for the current brand image factor but highest mean score for the desired brand image factor (Godsey, et al, 2018).

NBIS Qualitative Findings

An exploratory qualitative method of open-ended questions guided participants to express perspectives and opinions in their own words. Most of the nursing sample in this study (77%) responded “no” to the question “does nursing have a consistent image?” Respondents attributed the cause of this problem to (a) nurses themselves (n = 259), (b) professional organizations (n = 172), and (c) universities/schools of nursing (n = 166). Participants in the NBIS study who indicated nursing did not have a consistent brand image were asked to explain the rationale for their answer in a narrative format (text box). The use of open-ended questions encouraged responses which were “meaningful and culturally salient to the participant, unanticipated by the researcher, and rich and explanatory in nature” (Mack, et al, 2005, p.4).

Data Analysis

Insights gained from the NBIS study prompted the current investigation into participants’ narratives concerning their frequently reported perception that nursing lacked a consistent brand image. This study used content analysis to examine those qualitative responses provided by a sample of RNs describing in their own words why they felt nursing lacks a consistent image. Content analysis is appropriate for this study given the lack of structured knowledge about branding in the nursing context (Elo & Kyngäs 2008) and because the study's purpose was to identify themes in communications from nurses about unobservable phenomena (i.e., reasons behind the inconsistent image of nursing) (Krippendorff 1980; Elo & Kyngäs 2008; Kyngäs 2020)

The data were coded for statements that offered insight into nursing's lack of consistent brand image. While the narratives expounding upon nursing's inconsistent image were completely voluntary, most (89%) of participants elected to respond and provide the rationale for their answer (suggesting a high level of interest in expressing opinions on this important topic). Most respondents contributed multiple statements or potential explanations. Patterns that emerged from the coded statements formed categorical themes. Recurring themes in the data were organized into eight aggregate factors that could be understood to affect nursing's inconsistent image (Figure 1 ). Coding, categorical groupings, and aggregated factors were reviewed and confirmed by doctoral prepared researchers (two marketing professors and one nursing professor).

Figure 1.

Themes and factors contributing to nursing's inconsistent image.

Ethical Considerations

Approval was obtained from the Institutional Review Board prior to recruitment of subjects into the NBIS study. Informed consent was obtained electronically prior to survey entry and anonymous data collection. Surveys were administered using password protected computers on a continuously monitored secure network that employed data encryption.

Findings

Characteristics of Sample

The sample was mostly female (89%), Caucasian (85%), with a graduate degree (73%). Age of participants was almost equally distributed with 49% age 50 or under and 44% over age 50 (the rest did not respond). See Table 1 for sample characteristics.

Table 1.

Characteristics of Sample (N=286)

Demographic Variable	Count	%
Gender
Female	255	89.2%
Male	8	2.8%
Did not respond	23	8.0%
Age
Under 30	51	17.8%
31–40	45	15.7%
41–50	43	15.0%
51–60	71	24.8%
Over 60	53	18.5%
Did not respond	23	8.0%
Race
Caucasian	242	84.6%
African American	6	2.1%
Hispanic	5	1.7%
Other	4	1.4%
Did not respond	29	10.1%
Education
Ph.D.	67	23.4%
DNP or DNP candidate	17	5.9%
Master's degree	127	44.4%
Bachelor's degree	50	17.5%
Associate's degree or equivalent	2	0.7%
Did not respond	23	8.0%

Sample size: n = 286.

Factors Affecting Nursing's Brand Image

Respondents identified numerous issues which they felt were responsible for nursing's inconsistent brand image. Statements were coded and categorized into themes (factors) by frequency of occurrence (Table 2 ). Use of the term “factor” is commonly used in qualitative descriptive studies to describe participant experiences of various phenomena (Kim, Sefcik, &Bradway, 2017), including those related to nursing perceptions (Lewis, et al, 2020; McDermid, Mannix, Peters, 2019; Varaei, Vaismoradi, Jasper, & Faghihzadeh, 2012).

Table 2.

Factors Contributing to Nursing's Inconsistent Image

Factor	Mentions*
Variety of education/credentials	93
Portrayals in the media and online	46
Lack of professionalism	36
Image not a priority	26
Patients’ personal experiences	19
Lack of leadership development	18
Treatment by other professional colleagues	18
Gender role assumptions	12

^⁎Tallies of respondents who mentioned each factor.

Many of the factors identified by nurses reflected a “silent voice” which is a sentiment also reported in the literature (Pike, 2001). Nurses in this study noted that practitioners, educators, administrators, and labor leaders could help shape the image portrayed by the profession in many ways, but nursing needs to take the lead and direct its own future. As one nurse stated, “Nursing as a profession has not taken command of its profession.” Each factor is described fully in the discussion that follows. The themes and factors contributing to nursing's inconsistent image are also summarized in the graphic on Figure 1.

Factor #1: Variety of Education/Credentials

The most frequently mentioned explanation for the inconsistent image of nursing among respondents was the wide variety of entry levels in the field without any one consistent educational requirement. There are multiple pathways to becoming a RN (from diploma RN programs to the associate degree in nursing and BS in nursing [BSN] degree programs). Nurses in our study identified the multitude of entry levels as confusing, and they saw the lower bar for entry (anything less than BSN) as detrimental to their profession.

• -“[W]e are such a diverse group without a specific entry level of education for our practice.”
• -“We have not identified one way to become a RN (Diploma, ASN, BSN, MSN).”
• -“[T]he lack of consistency of educational preparation for nursing has hurt us in forming a professional identity.”
• -“Education at the Associate Degree or diploma level has done a tremendous disservice to the profession!”
• -“Education for entry into practice is FAR below that of other professions. The vast majority of health care professions require at least a master's degree, if not a practice doctorate.”

Nurses felt the multiple pathways into the profession had contributed to confusion among those outside of nursing. They noted the lack of a single educational pathway (BSN) prevented their profession from possessing a consistent set of competencies necessary to function as autonomous healthcare professionals. Respondents also believe the diluted pathway prevents those with advanced degrees from practicing at the top of their license and fully experiencing the reputational boost which should be associated with their degrees. Patients and other healthcare professionals are unable to discern the advanced degrees, specialized training, or unique qualifications of the nurses they encounter (such as MS in nursing [MSN], clinical nurse specialist [CNS], advanced RN practitioner [ARNP], doctor of nursing practice [DNP], doctor of philosophy [PhD], etc.). Nurses saw this lack of recognition as a liability when trying to signal competence to others:

• -“Nurses do not have a consistent mode of entry into the profession therefore the public is uncertain of the profession's abilities.”
• -“I believe there is consistency [in the public image] in the basic nurse role but not in advanced practice. The general public is unaware and sometimes confused about the role of APNs [Advanced Practice Nurses] in the healthcare system.”
• -“The diverse array of career options and advanced degrees in nursing prevents one consistent image [from being portrayed].”

The differences in educational entry requirements were felt to impact the way nurses view their own profession. Others noted the growing presence of advanced degrees could clarify nursing's potential:

• -“All RNs should have a BSN as an entry level, period. We cannot compete on experience alone; our education is what will facilitate our movement forward.”
• -“[E]ach level has a different knowledge and skill base and view of nursing,”
• -“We lack common education, and we let physicians drive our practice.”
• -“I believe the development of the DNP as the terminal degree for nursing will facilitate a clearer image of nursing.”

Nurses also work in a variety of settings in the healthcare industry and frequently assume numerous roles depending on their specific training and job duties. As with the varied levels of education, nurses believed the differences in responsibilities and work environment made it difficult to portray a consistent image of the profession:

• -“There are so many nursing roles. Patient's and team member's experiences with nurses are quite variable.”
• -“The role of nursing varies by region and practice setting tremendously.”
• -“[D]ue to the varying degrees of nurses and the varying roles depending on what unit they work on, nurses may present different images of themselves.”

Respondents also noted the ubiquitous use of scrubs in the healthcare setting and the absence of clear name tags with title and qualifications as additional hurdles to distinguishing nurses from each other and from other healthcare workers. Scrubs were described as making it impossible for patients and other healthcare workers to denote rank or position. Participants also described the assortment of non-nursing staff who also wore scrubs, including imaging specialists, food servers, consultants, and custodians.

• -“Now it's difficult to tell the cleaning staff, nurse techs, radiology staff, etc. from the RN.”
• -“A nurse-practitioner does not benefit from being seen as a bedside RN and a CRNA [certified RN anesthetist] or a CNM [certified nurse midwife] does not benefit from being equated with a staff RN role.”

The confusion was described as growing from there, since the job duties of nurses were frequently allocated to non-nurses, such as medical assistants and un-licensed personnel. Some respondents found it difficult to create a professional image when observers are unable to discern the differences between professions or assign credit when it is due:

• -“[S]tate regulations often allow others to perform nursing tasks.”
• -“Nursing is confused!! Even ULPs [unlicensed professionals] are considered "nurses."

Factor #2: Image Not a Priority

Many respondents felt the reason nursing has an inconsistent image is because nurses had not put enough effort into creating and maintaining their image. By not prioritizing the image of their profession, nursing may have left the job to others by default. Many nurses responded that their profession simply had not put enough effort into the task of branding itself:

• -“We have not defined ourselves as a profession.”
• -“We have not articulated a consistent image, so others have developed it.”
• -“As a profession, we have not made this a priority.”
• -“We as nurses have let [the image] slide.”
• -“I think nursing does not do a good job of trying to change the current image of nursing.”
• -“The nursing profession has failed to use their voice to ensure their professional image in the health care system.”

Our respondents identified two institutions within nursing where the image development may have broken down: (a) nursing schools, and (b) professional organizations. The focus of nursing education was seen by some respondents as focusing too heavily on skill development and technical proficiency (particularly at entry levels), with little time devoted to the broader issues related to the profession. The lack of discussion on these issues with entry-level nursing students were thought to contribute to nursing's perpetual image problems:

• -“Nursing schools don't address image and role very deeply and students don't seem to consider this topic as very important.”
• -“We do not do a great job training or transforming the student's view of what they should embody as a professional nurse when they complete their program.”

Low participation in, and a lack of leadership within professional nursing organizations, such as the American Nurses Association (ANA) was also felt to contribute to nursing's inconsistent image. Ideally, professional organizations act as a voice for their members when interacting with industry partners, the media, and other parties. They could play a key role in crafting and advancing the image of the profession, as some respondents noted:

• -“While [the] ANA advocates for nursing, individually, the profession is still trying to define itself and how it represents this aspect of professionalism, education, [and] critical thinking to the overall public.”
• -“We also have very low participation in professional/advocacy organizations like the ANA, so we have not taken charge of our image in that way.”
• -“There is no solid support for nurses [developing a consistent image] from nursing schools, state nursing boards, or professional organizations.”

Factor #3: Lack of Leadership Development

Many respondents noted that a lack of leadership could be one reason nursing has an image problem. Nursing was described as a profession which lacks mentors, role models, and a clear pathway to leadership. This lack of attention to leadership was felt to be a disservice to the image of nursing, especially regarding how nurses see themselves. One key aspect of leadership is supporting and encouraging others. Some respondents felt nurses could be more consistent in their support of each other in the workplace and at nursing schools and state nursing boards.

• -“As nurses, we are more concerned with cutting each other down instead of progressing the profession. As a result, other disciplines see this and jump on it to continue to disrespect the nurse. Other healthcare disciplines will treat you how your own treat each other.”
• -“There are several "images" of nursing. Nurses could band together and create their own powerful image of nursing.”

Respondents also stated that nurses do not advocate for themselves. In their view, nurses “need to own their practice and speak up and advocate for it.” Nurses may be reluctant to “be vocal members of policy making and advocacy” due to a lack of confidence in their power as nurses. Nurses were often heard stating “I'm just a nurse.” Nurses were seen as great patient advocates, but not self-advocates or advocates for the profession.

Factor #4: Lack of Professionalism

In order to portray a consistent professional image, respondents suggest nurses should first agree on the essential role nursing performs in healthcare and society, and the core beliefs or tenets of the profession. The nursing profession was described as “disorganized” and “confused.”

• -“[W]e have not learned how to articulate (or even agree) on our core concepts and beliefs about our profession, much less communicate them to others.”
• -“[A]ll nurses do not own the same mental image of what being a nurse is or looks like.”
• -“When nursing agrees on what a nurse looks like, so too will society then agree.”
• -“If we can't agree within nursing what we do, how is anyone else supposed to figure it out?”

The role of nursing was described as changing and becoming even more varied. These changes may make it even more difficult for nursing to understand and define itself. The basis of a definition for nursing was seen to be constantly shifting, thereby requiring regular attention and input to be effectual.

• -“I think it is confusing to the public because it is confusing to nurses. We still spend most of our time with patients… Nurses also serve as mediators between all sorts of other members of the team.”
• -“Instead of making nursing its own profession, nursing attempts to try to be like other professions.”

Once a profession is defined and its core tenets agreed upon, it is up to individuals to exemplify those tenets. In any profession, the negative behaviors of some members can influence the perceptions people hold of the entire profession. This is particularly true in healthcare contexts, where patients feel vulnerable and trust is paramount. Bickering among nurses and unprofessional dress and behaviors were seen as harmful to nursing's image.

• -“[W]e have too many nurses who do not maintain professional standards in regards to professional appearance and professional behaviors.”
• -“Faculty and hospital sites do not [address] unprofessional/uncaring behaviors sufficiently.”
• -“Some nurses do it for the wrong reasons, and that is evident in their care and knowledge.”

Some respondents stated that faculty and hospital administrators did not do enough to sanction unprofessional or uncaring behaviors. This problem was linked to the lower admission standards implemented in nursing schools as a response to an increased demand for graduates. The result is the presence of “a fair amount of nurses who are in the profession for money only and do not seem to uphold good values.”

Factor #5: Portrayals in the Media and Online

Many respondents expressed concern that the image of nursing portrayed in television shows, in movies, and on the internet contributed to the profession's inconsistent image. The impact of mass media was felt to be far reaching and had amplified inaccurate perceptions:

• -“What the media portrays as a nursing image and what the actual profession or career really is are vastly different.”
• -“Sometimes the media does not depict the high skill level involved in today's health care settings.”
• -“[T]elevision comedy and dramas give an inaccurate view.”

Media portrayals were seen by many respondents as contributing to the inconsistent image and lack of understanding by the public. Portrayals of nursing and healthcare in general are highly varied, often inaccurate, and frequently focus on extreme cases.

• -“TV puts nursing in a very inconsistent light from sexy to dumb to the subservient to the professional caring educator.”
• -“Media images tend to portray extremes and uphold the myth that physicians are the smart ones that change lives.”
• -“Media portrayal is inconsistent at best, downright unprofessional and degrading at times and [the] public draws most of their values and beliefs from this source.”

One popular storytelling trope for television and film is the notion of the sexy nurse who frequently abandons the duties of the job to have a fling with a physician or patient. Our respondents felt this portrayal gives the impression that nurses are hypersexualized, unprofessional, and unable to separate their personal lives from the workplace.

• -“Media portrays both the responsibilities of our practice but also the indignity of a sexual side.”
• -“Google [the] word nurse and see how many ‘sexy nurse’ images come up.”
• -“Nurses are often portrayed at 2 extremes. Either ‘naughty night nurses’ or angels of mercy.”
• -“The media still portrays nurses as sexy subservient females in shows.”

However, not all portrayals of nurses on television shows were viewed negatively. When writers gave serious thought to character development in the nursing area, our respondents generally saw the results as acceptable. One respondent referenced a comedy series on Showtime which aired 2009-2015: “More recent images of nursing (i.e., Nurse Jackie) portray more autonomy and intelligence of nurses, yet old conceptions persist.” However, in the opinion of another respondent, one of the most popular TV shows downplays the role of nurses and still uses them only to advance romantic story lines: “Media does not portray nursing correctly. Nurses are given a very unimportant and/or sexy role, e.g.: Grey's Anatomy.” An explanation for the persistent inaccuracies may relate to how non-entertaining the reality of nursing really is, thereby requiring it to be fictionalized by the media: “The true image of nursing is boring because they are good at what they do. Therefore, it has to be mediated by nurses behaving badly.”

Factor #6: Personal Experiences

Respondents reported that patient experiences with the nursing profession frequently arose from a direct patient experience or an indirect experience through a friend or family member who was a patient. Limited personal encounters were felt to impact the public's perception of nursing and potentially lead to biased views of nursing. For example, nurses “are often being judged by people who are grieving or in a critical situation,” Our respondents noted:

• -“One's image of nursing is often affected by one's prior experiences with members of the nursing profession. This can be quite individual.”
• -“People base their image on what type of encounter they have had with a nurse.”
• -“[E]ach person has a unique experience with nurses and healthcare that shapes their perception of what the nurse does and how competent they are.”
• -“The perception of the public varies with their personal experience with nurses.”

Factor #7: Treatment by Other Professional Colleagues

The behavior and language used by hospital administrators, physicians, and the insurance industry was seen as influencing the image of nursing in a way that was a disservice to the nursing profession. For example:

• -“[R]eferring to NPs and PAs as ‘physician extenders’ is very problematic and insulting to me.”
• -“[O]ther healthcare professionals can discredit the profession with statements of s/he is “just a nurse.”
• -“Some facilities treat nurses as servants instead of professionals and the public buys into this.”
• -“Medicine, as a discipline, does its part to continue to portray the profession as dependent upon physicians or ‘lesser than’.”

Nurses in our study were concerned that physicians had been trained to see nurses as extenders, helpers, mid-level providers, or as something less than the physician themselves. This approach was believed to evolve into a larger problem if physicians expressed such attitudes in front of other healthcare professionals, or within earshot of patients.

• -“I think that physicians see nurses as hand maidens and their ‘helpers,’ instead of the independent thinkers that they are.”
• -“[D]octors don't always give us the respect that we deserve and are often threatened by just how much we do and know compared to them.”

In addition to the damage to nursing's professional image, this attitude was felt to hamper teamwork and foster rivalries between the staff, which could lead to negative patient outcomes. Physicians and other healthcare professionals “do not realize that the nurse at the bedside often guides the physician and the relationship between the MD and RN is very much collaborative,” according to one respondent. Others noted:

• -“[There needs to be respect from other health professionals…Instead of a collaborative team approach, there is competition.”
• -“We have spoken for years of interprofessional collaboration. I am here to tell you, there is very little of this going on, nurses want this, but MDs DO NOT.”

Factor #8: Gender Role Assumptions

Many respondents noted issues related to gender and gender roles or expectations, including the sexualization of female nurses in the media and online (discussed above), the traditional image of the white-capped female nurse or angel, the subservient relationship between female nurses and male physicians (contributing to issues discussed above), and other issues related to themes throughout this paper.

Another aspect of gender that was mentioned was the lack of males in the profession. One respondent observed that society (and the patient base) had been conditioned to expect female nurses in the healthcare setting, resulting in “many people [who] are uncomfortable with the idea of male nurse professionals.” A lack of male nurses could reinforce subservience assumptions about nurses, since the only relationship modeled in many workplaces is that of the female nurse taking direction from the male physician.

• -“[A]s a profession which is still female dominated we still experience inconsistencies everywhere. Nursing has done a terrible job of increasing the diversity of the profession (not enough men and minorities)”
• -“Many people still think nursing is a female profession.”

Discussion

This research investigated the factors which promote an inconsistent image of the nursing profession, which was a concern described by most (77%) of respondents in the NBIS research (Godsey & Hayes, 2017). Nurses identified common concerns which could be hampering the brand-building efforts of the profession. These concerns were coded thematically and organized into factors. RN respondents identified the following eight factors as contributing to their inconsistent brand:

• 1Variety of education/credentials
• 2Image not a priority
• 3Lack of leadership development
• 4Lack of professionalism
• 5Portrayals in the media and online
• 6Patients’ personal experiences
• 7Treatment by other professional colleagues
• 8Gender role assumptions

As noted earlier in this paper, branding is most effective when members of the organization share common values and strategies (De Chernatony & Segal-Horn, 2003). A well-maintained brand could help clarify the confusion surrounding the entry levels into nursing, the associated educational requirements, and the widely varied roles nurses fill upon graduation or certification. Topics such as role definition, core values, caring behavior, advocacy, leadership, and brand image were believed to receive little treatment in the classroom compared to technical skills. A strong brand could increase the pride nurses have in their profession and in their work.

Increased professional pride could reduce instances of uncaring and unprofessional behavior on the job, which could in turn improve work relationships, patient experiences, and health outcomes. The presence of a strong brand image might also motivate nurses to protect and maintain that image on the job and in their daily interactions with others. Nurses who are proud of their professional brand may be more likely to act as advocates of the profession, which would increase nursing's reach and resonance. A more professional approach to work could also lead to resolution of other issues noted by our study respondents, such as the lack of uniforms that distinguish nurses from ancillary staff, a lack of professional solidarity among nurses, and an unwillingness to advocate for better treatment in the workplace. Additionally, by clearly communicating the values and beliefs held by nurses, highly qualified students may view nursing as a viable career which matches their own values, prompting them to consider nursing education.

Some factors identified by this research were influenced externally, making them more difficult to address since they are not under the direct control of nurses. Respondents frequently identified portrayals of nurses in the media and online, lack of understanding of the nursing role, patients’ personal experiences, and treatment of nurses by physicians and other colleagues as challenges to their professional identity. Addressing these factors could yield immediate benefits as nursing leaders and institutions set new priorities and create new messaging, and long-term benefits once the brand's values take hold in the nursing workforce, and eventually, to those outside the profession. Another outcome of better branding could be a more positive and consistent portrayal of nurses and the nursing profession in the media and online. Too often, nursing leaves the portrayal of its image to others (e.g., news media, TV show writers, and online opinion leaders) who may reinforce outdated stereotypes of the profession.

The value of a service brand such as nursing is formed, in part, from routine interactions between frontline service employees and customers (i.e., nurses and patients) (Wallace, de Chernatony, & Buil, 2013). However, since many Americans do not engage in preventative healthcare, they may have little, if any, interaction with nurses during nonstressful times in their lives. Nurses are often on the front lines of major life trauma, such as illness, severe injury, disfigurement, death, and grief. An impression formed about nursing during a traumatic personal event is more likely to be committed to long-term memory (Shields, Sazma, McCullough, & Yonelinas, 2017) and could become an intrusive or agitating memory as it is critically re-examined following the event (Marks, Franklin, & Zoellner 2018). Thus, when asked to recall interactions with nurses, an individual may be more likely to recall a traumatic event rather than a non-emergency interaction, which further reinforces the need for a consistent brand of nursing which can be applicable in all settings and situations (even emergent ones). Some respondents in this study demonstrated frustration with public ignorance surrounding the role of nursing (which is often confused with medical assistants and other ancillary staff). Most phrased the problem as one which could be remedied through targeted education (i.e., consumer learning) as a key function in re-branding their profession.

The original NBIS research (Godsey & Hayes, 2017) revealed that nursing's most desired brand image was one of “leaders in practice, education and research.” A brand which highlights education, leadership, influence, autonomy, and opportunity in addition to attitudes of caring could enhance the appeal to those considering nursing as a profession, including minorities currently underrepresented in nursing. A focus on branding and living up to the brand promise could influence patient experiences and workplace interactions as nurses adopt an image which more closely aligns with nursing's vision of itself. A strong brand could also have an immediate impact on the public's understanding of nurses’ roles, conveying a more accurate representation of nurses as autonomous patient advocates, primary caregivers, innovative researchers, influential leaders and decision/policy makers who frequently hold advanced degrees and certifications in an array of specialties.

Limitations

This study featured qualitative survey data from practicing nurses across the nation who held college degrees (nursing alumni and nursing faculty). While these respondents contributed valuable insights into the profession of nursing, their perceptions were limited to the corners of nursing practice and education they have experienced. Given the variety of entry points into the nursing profession and the varied roles within the profession, the study of nursing's shared values and branding goals could benefit from input across all contexts and demographics.

Implications for Nursing and Future Research

This study suggests that nursing has a unique opportunity to identify the values they wish to convey (and not convey) through their brand image, and to set about purposely developing that brand. Research on branding should see new life in nursing's research priorities. Future branding research will benefit from this new context and should examine methods for building positive associations in the minds of patients, other healthcare professionals, and administrators, who could further boost nursing's level of responsibility in patient care and involvement in policy and decision making. While research on service branding can be a starting point, there are certain to be particulars of the healthcare context or unique to the nursing profession which could require fine-tuning of the branding approach.

Given the powerful influence of lived experience and the strength of memories made during the toughest of times (e.g., Shields et al, 2017), future research could offer guidance to help nurses live up to the brand promise on the job when interacting with patients and co-workers during times of high stress. It would also be useful to identify ways of reducing the incidents of unprofessional and uncaring behaviors in the workplace identified by our respondents. Addressing these problems could have a positive impact on the image of nursing held in the minds of patients, their family members, and other observers. Extant research from the fields of organizational behavior and management could prove adaptable here.

Traditional gender roles in healthcare, and society at large, are evolving. Nursing's move toward a more equitable workforce could benefit from ongoing efforts in society to promote fairness, justice, and equity for women in the workplace. Similarly, outdated gender-based stereotypes of nursing could improve if the profession can recruit and retain more men into nursing programs. However, a growing male presence could potentially lead to even more divergent images within the profession – one for female nurses and one for male nurses, if not managed as an integral part of the nursing brand. This concern was not a focus of this study but serves as a recommendation for future research involving the important role of gender as a branding strategy for the image of nursing.

As noted earlier in this paper, the 2020 International Year of the Nurse Campaign currently underway highlights the need for nurses to evolve as an influential, essential, and authoritative force for the provision of global health in the 21st Century. Unexpectedly, at the writing of this paper, nurses are also on the frontlines of the COVID-19 pandemic where their unwavering dedication, competency, and expert contributions are being recognized and lauded by the public and the media. Many respondents in this study spoke of a prevailing perception of nurses as subordinate to physicians. Perhaps the International Year of the Nurse could be a call for nurses to pursue aggressively targeted scholarship, which could identify and convey a long overdue consistent brand position that is positive, relevant, accurate, and distinctive from other professions (Godsey, et al, 2020). Methods of delivering the branded message should also be examined with an eye on consistency of message and action over time (Hayes, 2015).

A strong focus on branding could lead to an immediate impact on many of the factors believed to contribute to nursing's inconsistent image. Branding could prompt nursing institutions, professional organizations and leaders to regard the image of the profession as a high priority. Branding could guide professional organizations as they design and communicate nursing's role and core beliefs both internally to nurses themselves, and externally to healthcare administrators, physicians, and the media. Additionally, re-branding of the profession could increase the sense of unity among nurses based on common interests and professional goals. Brand positioning could address a question at the heart of nursing's identity: “Why should nurses lead and influence healthcare policy, practice, and research in the 21st Century?” The answer to “why nurses?” could lie in a marketing concept known as customer-based brand equity, or a consumer's reaction to marketing efforts of a branded product compared to the same marketing efforts for a non-branded or generic product (Keller 1993). This difference in response occurs when a consumer is familiar with the brand and holds strong and favorable associations with the brand that are unique and not found in the alternative.

Associations of nurses as influential leaders and expert healthcare providers could result in the elevation of nursing's contributions as essential to the provision of local, national and global healthcare initiatives. Overall, a focus on branding and positioning research could inform the strategy for a unified direction for the nursing profession, or as one respondent noted: “We are a huge population and can make a huge difference in improving healthcare, but we just need to get it together.” (National Council of State Boards of Nursing 2020, Robert Wood Johnson Foundation 2015, World Health Organization 2018, American Association of Colleges of Nursing 2019a, American Association of Colleges of Nursing 2019b, World Health Organization 2020b, World Health Organization 2020a, U. S. Bureau of Labor Statistics 2019, National Academy of Medicine 2020, Institute of Medicine 2010, Health Resources and Services Administration 2014, Baek and King, 2011, Bitner, Booms and Mohr, 1994, Brodie, Whittome and Brush, 2009, Buresh and Gordon, 2013, Cabaniss, 2011, Cohen, 2007, Cohen and Bartholomew, 2009, Dabirian, Kietzmann and Diba, 2017, Darbyshire, 2010, De Chernatony and Segal-Horn, 2003, De Chesnay and Anderson, 2016, Dominiak, 2004, Elo and Kyngäs, 2008, Finkelman and Kenner, 2013, Fletcher, 2007, Gallo, 2018, Galloway, 2004, Godsey and Hayes, 2017, Godsey, Hayes, Schertzer and Kallmeyer, 2018, Godsey, Perrott and Hayes, 2020, Greenawalt, 2001, Hayes, 2015, Hoeve, Jansen and Roodbol, 2014, Jacob, McKenna and D'Amore, 2017, Kapferer, 2012, Kemp, Jillapalli and Becerra, 2014, Klebanoff, 2013, Koch and Gyrd-Jones, 2019, Kotler, Hayes and Bloom, 2002, Krippendorff, 1980, Kyngäs, 2020, Lair, Sullivan and Cheney, 2005, Lathrop, 2013, Lovan, 2009, Lundy and Janes, 2016, Mack and Woodsong, 2005, Marks, Franklin and Zoellner, 2018, Mowdy, 2015, O'Cass and Ngo, 2011, Olshansky, 2017, Parish, 2004, Pike, 2001, Price and McGillis, 2014, Prybil, 2016, Prybil, Popa, Warshawsky and Sundean, 2019, Rezaei-Adaryani, Salsali and Mohammadi, 2012, Shields, Sazma, McCullough and Yonelinas, 2017, Summers and Summers, 2009, Wallace, de Chernatony and Buil, 2013, Wee and Ming, 2003, Wocial et al., 2014, Zaltman, LeMasters and Heffring, 1982, Zeithaml et al., 2020).