The image of nursing perceived by the society in the Covid‐19 pandemic: A cross‐sectional study

Abstract

Background

Although nursing has made progress as a profession, there are still some negative myths to be dispelled.

Purpose

This descriptive, cross‐sectional study was conducted to determine the nursing image perceived by the society during the Covid‐19 pandemic.

Methods

The research population consisted of 663 people who were not in the nursing profession in Turkey. The data were collected with a sociodemographic data form that was prepared by the researchers and a questionnaire that contained questions on the image of nursing. The McNemar Test was used for statistical analysis.

Results

Individuals have positive views towards the nursing profession compared to the prepandemic period. Nursing is accepted as a profession that is well known (82.8%), respected (69.8%) and difficult working conditions (88.2%) by individuals in the society (p < .05). However, nursing profession is still perceived as “doctors' assistant” (71.5%).

Conclusion

Although nurses are more visible during the pandemic period and there are positive changes in public perception of the nursing profession, some unfortunate traditional perceptions persist.

1. INTRODUCTION

A profession's image encapsulates how that profession is perceived by other disciplines and individuals in society. ¹ Nursing image is about how nurses are perceived and reflect a professional image. ² Since perceptions of a profession contribute to its identity, one of the most important factors in development of the nursing profession is the public's perception of nursing. The public perception of nursing incorporates the convictions, opinions, and attitudes that individuals have of nurses and has always been a sociocultural issue for nursing. ³ Although nursing has made progress as a profession, there are still some negative myths that need to be dispelled. Studies showed that nursing had low professional image, with the following characteristics: predominantly female, low education and socioeconomic level, having stereotypes such as sexual objects, angels, duty‐focused, nonscientific, dependent on medical discipline and invisible. ¹ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Lopez‐Verdugo and colleagues reviewed a total of 17 articles in their systematic review from countries eight (Spain, Egypt, Argentina, Iran, Venezuela, Turkey, United Kingdom, Australia). This review revealed that the society is misinformed about the duties of nurses, based on stereotypes. ³ According to a systematic review that included one study from Poland and South Africa and two from Turkey, it is indicated that the nursing profession is perceived as an auxiliary profession and the duties and responsibilities of nurses are not understood by individuals in the society. Studies in Italy ⁹ and Jordan ¹⁰ indicate that individuals in the society have a positive attitude towards the nursing profession. The study one from Israel reported that individuals receiving nursing services had more positive attitudes towards nursing. ⁵ A study from Saudi Arabia reported positive perceptions about nursing although nearly half the participants perceived nursing as a job rather than a profession. ¹¹

Nursing image is a dynamic concept. Society's views, ideas and attitudes change over time, and with them thoughts professions, including nursing, also change. ¹² There have been changes in the nursing over time. The profession has become academic. In addition to their caregiving roles, nurses focused on academic studies and their education levels increased. Nursing gained more prestige and more respect. ¹³

Nursing image is influenced by such factors as nurses' self‐perception, service quality and nursing perception perceived by individuals in the society, and the media, which has been heavily influenced recently. ⁸ , ¹⁴ Crises experienced during epidemics affects the image of nursing. The Covid‐19 pandemic put the lives of individuals on the line and set nurses to work in harsh conditions, shaping the identity of health‐related professions. ¹⁵ During the pandemic, nurses were regarded as heroes, angels and indispensable members of the health care system. ¹⁶ In previous epidemics such as the Ebola and the Middle East Respiratory Syndrome Coronavirus (MERS‐CoV) crisis, ¹⁷ the devoted work of nurses positively influenced the public image of nursing and the fight against the Covid‐19 affected the image of nursing in the society as well. ¹⁸ During the pandemic, the media portrayed nurses as heroes, angels and told their stories of devotion in the struggle to save lives during the Covid‐19 pandemic. ¹⁹ The pandemic ofered an opportunity to consolidate confidence in the nursing profession and improve the image of nursing in society. ¹⁶ , ¹⁸ , ²⁰

Although there are studies on the image of nursing in society, there are limited studies conducted specifically during the Covid‐19 pandemic. Most of the studies on society's perception of nursing have been conducted with nurses and nursing students. ²¹ , ²² There is no study conducted on society's perception of nursing during the Covid‐19 pandemic period in Turkey.

According to the results of studies conducted before the pandemic; nurses were seen as a low‐income, and lower in rank than and subservient to doctors, and nursing was seen a menial labor. ⁶ , ²³ , ²⁴ , ²⁵ A study in Turkey revealed that nurses are seen as people who perform care services and assist physicians, but they are also evaluated as qualified and have good communication skills. ⁶ Some studies, although the image of nursing is not very good, it states that it is perceived at a moderate ²⁶ or good level. ²¹ , ²² The image of nursing held by society is at odds with the definition of nursing set forth in a law enacted in Turkey in 2011; according to this law, nursing is defined as a profession with areas of expertize. ²⁷

In the context of the Covid‐19 pandemic, the efforts of nurses in the fight against the pandemic and their positive portrayal in the media could affect their image in society. This study investigated the image of nursing perceived by society during the Covid‐19 pandemic. This study contributes to the global picture of the perception on nursing.

2. METHODS

2.1. Type of study

This study is a descriptive and cross‐sectional study executed to determine the image of nursing perceived by the society during the Covid‐19 pandemic.

2.2. Research population and sample

The population of the study consisted of individuals who were over the age of 18, who lived in Turkey, and who were not nursing professionals. The “Snowball Sampling Technique” was used in the study because of the Covid‐19 pandemic restrictions. Sample size that can be taken according to sample error margin table was used in determining the sampling size, and the minimum sampling size was determined to be 384 with a 95% Confidence Interval and 0.05 margin of error. ²⁸ A total of 663 people were contacted in the study. Data was collected with a personal information form and the Society's Perceived of Nursing Image Questionnaire (SPNIQ). The data collection forms were recorded on the Google Forms webpage. The researchers sent links to the forms to social media accounts of people who were not nurses and enabled these people to share the data collection forms with others registered to their accounts. In this way the targeted sample group was contacted. The data collection forms with the individuals registered in their own accounts. The data of the study was collected between April 10–May 15, 2021.

2.3. Data collection tools

The researchers developed the SPNIQ after a thorough review of the literature. ² , ⁶ , ¹⁶ , ²⁹ , ³⁰ , ³¹ Five expert opinions were used to evaluate the content validity and comprehensibility of the survey questions. The questionnaire was given to 20 participants who were not nurses; they determined the questions to be clear. The questionnaire included the following sections: (1) 9 statement about the image of nursing during the Covid‐19 pandemic; (2) 15 questions about society's perception of nurses and nursing profession. The section in which the answers to the questions were marked in a section divide into two columns, “before the pandemic (BP)” and “during the pandemic (DP).” Participants were asked to answer the questions by considering these two periods.

2.4. Data analysis

The 25.0 SPSS package program was used in the analysis of the data. The McNemar Test was used to compare the descriptive data of the study and the expressions of nursing perceived by the society as numbers and percentages, and to compare the perceptions before and during the COVID‐19 pandemic. Statistical tests p ≤ .05 were considered significant.

2.5. Ethical permissions

The University Non‐Interventional Research Ethics Committee granted ethical permission to conduct the study (Date:26.02.2021, Number:2021‐47). Informed Written Consent was obtained from individals participating in the research.

3. RESULTS

Table 1 presents the findings regarding the descriptive characteristics of the participants. A total of 663 people from 59 cities across Turkey participated in the study; 72.5% of them were women and 73.2% were university graduates, 56.0% were single, 62.6% had income equal to expenses, and 70.1% had a relative who was a nurse. Although 70.6% of the participants received services from a nurse before the pandemic, the rate of those who received nursing services during the pandemic was 43.4%; 66.2%. said their perceptions on nurses underwent positive changes in during the pandemic and 38.6% were open to their children becoming nurses (Table 1).

Table 1.

Distribution of individuals according to descriptive characteristics (n = 663)

Descriptive characteristics	Mean ± SD
Age (years)	31.50 ± 12.27 (Min:18 Max: 85)
	n (%)
Gender
Male	182 (27.5)
Female	481 (72.5)
Educational status
Secondary school	115 (17.3)
University	485 (73.2)
Postgraduate	63 (9.5)
Marital status
Married	292 (44.0)
Single	2371 (56.0)
Income level of family
Income less than expenses	78 (11.8)
Income equal to expenses	415 (62.6)
Income greater than expenses	170 (25.6)
Having a relative who is a nurse
Yes	465 (70.1)
No	198 (29.9)
Received nursing care before the pandemic
Yes	468 (70.6)
No	195 (29.4)
Received nursing care during the pandemic
Yes	288 (43.4)
No	375 (56.6)
Changes in perceptions on nursing in Covid‐19 pandemic
Positive changes	439 (66.2)
Negative changes	21 (3.2)
No changes	203 (30.6)
Open to their child becoming a nurse
Yes	256 (38.6)
No	218 (32.9)
Unsure	189 (28.5)

Table 2 presents study participants' perceptions during the pandemic about nurses: 92.5% of participants believed nurses fought the pandemic very well and risked their lives, 91.6% believed nurses have very difficult tasks, 82.8% believed nurses are heroes, 75.1% believed nurses became visible in the pandemic and were noticed by the society, 74.2% believed nurses were not valued as they deserved to be during the pandemic, 63.3% said that after the pandemic passes, nurses' struggle will be forgotten, 61.1% said nurses became visible and were vewed positive because of media attention and 50.7% said nurses were ostracized because of the fear of contagion.

Table 2.

Participant's perceptions about nurses during the Covid‐19 pandemic (n = 663)

Opinions	Yes (%)	No (%)
Nurses fought well against the pandemic	92.5	7.5
Nurses put their lives at risk at their work	92.5	7.5
Nurses have a very difficult job	91.6	8.4
Nurses are heroes	82.8	17.2
Nurses became visible to society during the pandemic	75.1	24.8
Nurses were not valued as they deserved to be during the pandemic	74.2	25.8
After the pandemic is over the struggle of nurses will be forgotten	63.3	36.6
Nurses became visible and were positively portrayed in the media	61.1	38.9
Nurses were ostracized because of the fear of disease transmission in the pandemic	50.7	49.3

Table 3 presents the perception of the individuals who participated in the study about the BP and DP nursing profession. The statistically significant changes (p < .05) detected in opinions of the nursing profession follows: “Nursing is a well‐known profession in the society” (BP: 66.7%–DP: 82.8%), “nursing is a respected profession in the society” (BP: 49.8%–DP: 69.8%), “nursing is a female profession” (BP: 9.6%–DP: 14.3%), “the working conditions of nurses are difficult” (BP: 83.1%–DP: 88.2%), “nursing salaries are low” (BP: 62.1%–DP: 70.2%), “nurses are smiling” (BP: 60.2%–DP: 63.3%), “nurses are obedient” (BP: 48.9%–DP: 46.2%), “nursing staffing is inadequate” (BP: 61.4%–DP: 69.4%), and “nurses are exposed to violence” (BP: 73.0%–DP: 76.0%).

Table 3.

Comparison of the BP and DP perceptions of the individuals on nursing profession (n = 663)

Perceptions	BP		DP		McNeamar test value	p Value
	Yes	No	Yes	No
Nursing is a well‐known profession in the society	66.7	33.3	82.8	17.2	82.015	p = .000
Nursing is a respected profession in society	49.8	50.1	69.8	30.2	96.265	p = .000
Nursing is a female profession	9.6	90.4	14.3	85.7	18.367	p = .000
Nursing salaries are low	62.1	37.9	70.2	29.8	6.942	p = .008
The working conditions of nurses are difficult	83.1	16.9	88.2	11.8	17.06	p = .000
Nurses are smiling	60.2	38.8	63.3	36.7	7.843	p = .005
Nurses are obedient	48.9	51.1	46.2	53.8	4.817	p = .028
The number of nurses is insufficient	61.4	38.6	69.4	30.6	33.383	p = .000
Nurses are exposed to violence	73.0	27.0	76.0	24.0	6.685	p = .010
Male nurses are essential for the status of the profession	64.0	36.0	65.6	34.4	1.887	p = .170
Nursing is a profession requiring self‐sacrifice	96.2	3.8	96.5	3.5	0.948	p = .824
Nursing requires university‐level education	88.4	11.6	89.2	10.8	0.516	p = .472
Nurses are doctor's assistants	71.6	28.4	71.5	28.5	5.256	p = .000
Nursing is an indispensable profession	80.8	19.2	83.0	17.0	3.250	p = .071
Nurses spend the most time with patients	91.9	8.1	92.9	7.1	0.465	p = .210

Abbreviations: BP, before the pandemic; DP, during the pandemic.

Statistically insignificant changes (p > .05) in opinions of the nursing profession follow: “Nursing requires university‐level education” (BP: 88.4%–DP: 89.2%), “male nurses are necessary for the status of the profession” (BP:64.0%–65.6%), “nursing is a profession requiring self‐sacrifice” (BP: 96.2%–DP: 96.5%), “nurses are asistant of doctors” (BP: 71.6%–DP: 71.5%), “nursing is an indispensable profession” (BP: 80.8%–DP: 83.0%), and “nurses spend the most time with patients” (BP: 91.9%–DP: 92.9%) (p > .05).

4. DISCUSSION

This study investigated soceity's percepton of nurses and the nursing profession during the Covid‐19 pandemic. Overall, study participants' perceptions of nurses and the nursing profession underwent positive changes during the pandemic. The of majority statements regarding the struggle of nurses during the pandemic were positive; the Covid‐19 pandemic was seen as necessitating unfamiliar working conditions for nurses all over the world and nurses were thought to have responded with superhuman effort. ³² In addition nurses were recognized as the most essential healthcare professionals, and the perceived importance of the profession increased during the pandemic. ¹⁶ , ³² , ³³ However, study participants were not inclined to encourage their children to be nurses, perhaps due to increased public awareness about the difficult working conditions of the profession during the pandemic. In a study conducted in South Africa, despite positive comments about nurses, only 43.6% of respondants would encourage their children to become nurses. ⁷ Studies conducted in different countries have also shown that people would not recommend nursing as a profession to their acquaintances. ² , ²⁹ , ³⁴ However, Swift et al. ³³ interviewed candidates who applied to nursing programs during the pandemic period in England and found that the support given by the public to nurses during the pandemic had a positive effect on the choice of the profession.

Individuals were asked to evaluate 15 views of the nursing profession pre‐Covid‐19 and during the epidemic. It was determined that there were statistically significant changes in nine of these views. According to this result; it is thought that the increase in the rate of participation in the statements that nursing is a well‐known profession, and a respected profession is reason that the society has information about the nursing profession and working conditions, depending on the news in the media. It is known that the visibility of nurses in print media and web‐based media increased during the Covid19 pandemic process. Bennet et al. ¹⁶ stated that nurses were featured in 5902 newspaper articles, 2674 web‐based publications, and 2149 news wires and press releases in the Covid‐19 pandemic between March 18 and April 18, 2020, a 300% increase compared to the same period in 2019. According to studies conducted in Turkey, positive changes likewise occurred in society's thoughts about the nursing profession. In the study conducted by Sis Çelik et al. ²⁶  while individuals in the society evaluated the image of nurses in the society as low; in the study conducted by Yılmaz et al. ³⁵  the majority of individuals in the society evaluated nursing as a respectable profession. A study in Saudi Arabia showed that though the majority of individuals surveyed stated nursing is an esteemed profession, nearly two thirds were not aware that nurses are able to make independent decisions. ¹¹ In a study in South Africa, respondents viewed nurses as extremely difficult working (80.0%), caring and understanding (78.2%). ⁷ Saidun ve Akhmetova state that while the nursing profession had a negative image in Malay in previous years, the image of the profession has developed positively and today it is seen by society as a noble profession. ³⁶ Now that the public has a better idea of nurses' work, it seems public perception is changing. ¹⁶ , ²⁴ , ³¹ , ³⁶

Our study found an increased rate of agreement with the statement “nursing is a female profession” during the pandemic. The rate of those who believe that male nurses are necessary to improve the status of the profession is also high. A recent legal regulation in Turkey (the 2007 Law Amending the Nursing Law) permitted men to join the nursing profession ²⁷ ; despite this, nursing is still seen in Turkey as a profession for woman. ³⁷ , ³⁸ Studies in different locations around the world agree that nursing is perceived as a female profession with lesser authority than doctors. ⁴ , ⁷ , ¹¹ , ³⁹ , ⁴⁰ The number of male nurses has been increasing in recent years. This may change the image of the profession. ⁴¹ , ⁴²

Our study, found a growing opinion that nurses' salaries are low, working conditions burdensome and the numbers of nurses insufficient. However, a high number of participants think that nursing is a profession that requires university‐level education and is indispensable and requires dedication. There is also an increase in the number who think that nurses are smiling. The nursing profession is perceived as a stressful, difficult, and low‐paid profession in society. ⁶ , ⁷ , ²³ , ³⁵ In one study, participants define nursing as a difficult profession that requires responsibility, and therefore think that a 4‐year undergraduate education is necessary. ³⁵

Our study results revealed positive changes in the public image of nursing during the pandemic period; however, unchanged negative perceptions remained that nurses are low‐status, physicians' assistants and subservient to doctors. Studies in different countries confirm the perception that nurses play a weak role, especially compared to the role of doctors. ¹ , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ¹¹ , ²⁴ Studies in the literature report perceptions that nursing is a predominantly female profession, with nurses identified as caregivers who assist physicians. ⁶ , ³⁷ , ⁴⁰ The studies in India and Indonesia report the overwhelming public perception of nurses is that they assist doctors in performing technical work. ¹¹ , ⁴³ A study in Saudi Arabia determined that over one‐third of respondents perceived nurses as assistants to doctos. ⁴⁴ López‐Verdugo et al.'s ³ review of research in different countries (Spain, Egypt, Argentina, Iran, Venezuela, Turkey, United Kingdom, Australia), reported that the society has general misinformation about nurses and nursing based on myths and stereotypes. It is clear that the perception that nurses are subordinate to doctors still persists and their independent authority is not recognized.

It is the responsibility of nurses to improve and refine the public perception of nursing in society. During the last 3 years, nurses have successfully performed many roles during the Covid‐19 pandemic and their visibility in the media has increased. This has positively affected the image of nursing in society and caused a shift in the professional identity of the profession. We see this change as a platform for public recognition of the profession and improvements in its status.

5. LIMITATIONS

Limitations exist to this study. First, it was conducted only with individuals living in Turkey and the study sample includes only individuals with access to the internet and who use social media. Further academic studies should be carried out with the participation of the entire adult population throughout the country or in cooperation with different countries. Second, the questionnaires used in the study pose a limitation in that they were adapted by the researchers based on the literature. It is necessary to retest the content validity and reliability of these survey questions. Third, because of the restrictions posed by the coronavirus pandemic, the data was collected online using the “snowball” method. Therefore, the number of individuals who did not agree to participate in the study was not known. For this reason, face‐to‐face collection of data in repeated studies is also important to ensure the reliability of the data.

6. CONCLUSION

The Covid‐19 pandemic raised worldwide awareness of the importance of healthcare employees, particularly nurses, and the care they give. Our study showed positive changes in Turkish society's views of the nursing profession largely due to the pandemic. Although there are positive changes in the public perception of nursing in Turkey, the profession still has not been able to shed its traditional image as low‐status and subservient to doctors. Nurses can choose to change the perception of nursing, creating a modern image of nurses as producers of scientific knowledge and independent leaders. The profession does not need to be considered an auxiliary profession in the 21st century. Written, visual, and social media must be used effectively to this end, and nurse leaders must be more visible.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Uysal N, Demirdağ H. The image of nursing perceived by the society in the Covid‐19 pandemic: a cross‐sectional study. Nurs Forum. 2022;57:1339‐1345. 10.1111/nuf.12813

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.