Nurses’ Perception about Stakeholders’ Image of a Nurse

Keywords

doctors - hospital staff - nurses - patients - perception - self-reports

Introduction

Despite the impressive evolution of the profession and the expanded role toward delivery and intensification of health care services, nurses across the globe continue to stumble through the challenges of shortage,[1] the increasing need due to retiring workforce,[2] and the retention of juvenile nurse graduates. Furthermore, the experienced nurses do not wish to advocate nursing career for the younger generation.[3] Although the societal appraisal of nurses is determined through their role performance as well as the significance of their work,[4] there is diversity in the public image about the profession and the professionals as well as concerning the knowledge about the true functions and domains of nurses’ job engagement.[5] This image perception is one of the powerful contrivances that impact nurses’ self-esteem and authority,[6] and recruitment and retention in the health industry.[7]

Literature Review

Several researchers have explored physicians’ image of a nurse,[8] [9] whereas others have assessed patients’ perception.[8] [10] Some have explored other health care workers’ image of a nurse,[10] public image of a nurse,[2] [11] [12] [13] and media image.[14] [15] [16] A few have also identified the image from nurses themselves[8] [17] as well as among nursing students.[13] [18]

A few researchers have disclosed a significant relationship between image of a nurse and job satisfaction/performance. The stereotypical, traditional public as well as the image of a nurse among nurses themselves has been identified as having a significant relationship with their job satisfaction and retention plans,[19] self-esteem, self-concept, job satisfaction, job performance,[20] turnover intentions,[21] intention to migrate,[22] and professionalization of these professionals.[23] ten Hoeve et al[24] indicated the diversity in the actual public view about nurses and the need of identifying strategies that will encourage nurses to improve their public image, which is crucial in enhancing professionalization and professional attitudes among these professionals.

Objective

Extant research related to the construct, image of a nurse and/or nursing among physicians, patients, general public, nursing students, and nurses themselves has emanated from the developed countries. There is limited exploration of this construct in the developing countries including India. Moreover, there is limited research on image of a nurse by stakeholders from the nurses’ perspective especially in the Indian setting. India is a developing nation, and the nurses from this country serve as a major segment of health care human resource for the developing countries. Also, doctors and patients are the imperative members of the health care team and other hospital personnel directly or indirectly influence nursing care services. What and how the nurses perceive what the stakeholders think about a nurse can influence the professionals’ behavior and attitude. Hence, this study tries to explore and test the difference in the stakeholders’ image of a nurse from the perspective of nurses employed in the various settings within the state. The aim of the study is to identify the difference in nurses’ perception about different stakeholders’ image of a nurse.

Methods

Study Design

An exploratory survey was used to identify the nurses’ perception about the stakeholders’ image of a nurse.

Materials

An adapted version of the Porter Nursing Image Scale[25] designed to capture nurses’ self-image as a 32-item three-dimensional bipolar semantic differential scale was used to collect data in this study. The adaptation process was based on the guidelines outlined by Van Widenfelt et al.[26] Permission was sought from the original author for use as well as for adaptation of the scale. Item reduction was performed by deleting items having a similar meaning. The tool was validated by 11 experts from the nursing and management domain. The tool was also validated by the original authors. The item content validity index was between 0.875 to 1 and scale content validity index was 0.982. Reliability test for internal consistency of the tool indicated Cronbach α value of 0.851. A unipolar five-point rating scale was finalized with 14 items on three dimensions ([Supplementary Material], available in the online version).

Population and Sample

The sample in this study was selected using the stratified proportionate random sampling technique. The population of registered nurses was stratified based on the health care sectors within the state of Goa. The accessible population of nurses employed in the government (N =1,289), private (N =338), and autonomous (N =35) considered as each strata was 1,662. The calculated sample size for the accessible population at 95% confidence level and 5% margin of error was 322 (using the table for estimating sample size for 2,000 population, sample size calculator indicated a sample size of 312, or 10% of population as a good sample size). List of nurses with a minimum of six months’ work experience was obtained from the management of each setting. Individual sampling frames were prepared, and a specific code number was assigned to each nurse for each stratum. Around 50% of the nurses, i.e., 833 (government = 645; private = 170; and autonomous = 18) were randomly selected as a proportionate study sample using the lottery method.

Ethical Considerations

Ethical approval was sought from the ethical committee in the government sector, and written permission was obtained from individual private and autonomous hospital administrative heads. Written informed consent was obtained from every respondent after due explanation and confidentiality assurance.

Data Collection

Data were collected as self-reports from registered nurses regarding their perception about doctors’ image of a nurse, patients’ image of a nurse, other hospital staffs’ image of a nurse, and self-perception about a nurse using nurses’ perception about stakeholders’ image of a nurse scale. The tool administered to 830 registered nurses was collected after a day. Due to attrition, data were obtained from 749 nurses and used for analysis in SPSS (IBM Corp.). The sample demographics are shown in [Table 1].

Table 1 Sample demographics (n = 749)

Variable	Classification	Frequency	Percentage
Abbreviations: ICU, intensive care unit; Obst-Gynae, obstetrics and gynecology.
Age (y)	20–30	375	50
	30–40	217	29
	40–50	122	16.3
	50–60	35	4.7
Marital status	Married	458	61.1
	Single	291	38.9
Qualification	GNM	422	56.3
	B. Sc. Nursing	319	42.6
	M. Sc. Nursing	8	1.1
Area of work	Medicine	150	20
	Surgery	163	21.8
	Obst-Gynae	75	10
	Pediatrics	89	11.9
	Emergency/ICU	164	21.9
	Psychiatry	25	3.3
	Community	83	11.1
Sector	Government	586	78.2
	Private	151	20.2
	Autonomous	12	1.6

Results

The data in [Table 2] tested for the mean and standard deviation (SD) indicate that the nurses’ perception about the different stakeholders’ image of a nurse was favorable but differed with respect to every stakeholder. Furthermore, the mean values indicate that the nurses themselves had the most favorable image of a nurse (mean = 58.37; SD = 6.91). They perceived that the doctors had more favorable image of a nurse (mean = 53.22; SD = 6.49) as compared with other hospital staff (mean = 53.06; SD = 6.78) and that the patient’s favored the image of a nurse the least (mean = 51.91; SD = 6.89).

Table 2 Mean and SD related to nurses’ perception about different stakeholders’ image of a nurse (n = 749)

No.	Measure	Mean	SD
Abbreviation: SD, standard deviation.
1	Nurses’ perception about doctors’ image of a nurse	53.22	6.49
2	Nurses’ perception about patients’ image of a nurse	51.92	6.89
3	Nurses’ perception about other hospital staffs’ image of a nurse	53.06	6.78
4	Nurses’ perceived image of a nurse	58.37	6.910

As data were gathered from the sample regarding four individual stakeholders, further test for within-subjects difference using the general linear model and repeated measures analysis of variance (ANOVA) in SPSS was performed to identify the difference in the nurses’ perception. This analytical technique creates the “Within-Subjects Factor,” which is considered as an independent variable from among the two or more existing variables, which then are considered as the levels of the new independent variable.[27]

Repeated Measures ANOVA

Assumptions of repeated measures ANOVA include the following:

• Independence of observations (within-subjects or repeated measures).

• Deviations from the mean of each person’s score on one measure and more than one measure for each person.

• The covariance involves deviations from the mean of each of two measures for each person.

• Homogeneity assumption known as sphericity mandates equal variances and covariance for every level of within-subjects variable.

Behavioral science data rarely meets the sphericity assumption, which can seriously influence the results. Fortunately, this problem can be dealt with by adjusting the degrees of freedom (dfs) or using multivariate tests of the within-subjects effect and test whether the ratings are equal. The sphericity assumption is tested using the Mauchly test, the Huynh–Feldt tests, and/or the Greenhouse–Geisser test.

Data in [Table 3] show that all the four tests in the multivariate analysis have the same F values and are significant (230.502; p < 0.000). However, Wilks’ lambda is a commonly considered multivariate test. The significant F (230.5; p < 0.000) indicates that there is a difference in how the construct, nurses’ perception about different stakeholders’ image of a nurse, is rated.

Table 3 Multivariate tests^a indicating the F values and level of significance

Effect		Value	F	Hypothesis df	Error df	Significance	Partial eta squared
Abbreviation: df, degree of freedom. aDesign: Intercept Within Subject Design: image bExact statistics computed using α = 0.05. Note: Design: Intercept Within-Subjects Design: image
Image	Pillai’s trace	0.481	230.502b	3.000	746.000	0.000	0.481
	Wilks’ lambda	0.519	230.502b	3.000	746.000	0.000	0.481
	Hotelling’s trace	0.927	230.502b	3.000	746.000	0.000	0.481
	Roy’s largest root	0.927	230.502b	3.000	746.000	0.000	0.481

Further, as seen in [Table 4]. Mauchly’s test for shericity is used to test the level of significance and obtain the epsilon (Greenhouse–Geisser or Huynh–Feldt). Mauchly’s test statistics is significant (W = 0.815; p < 0.01) and the epsilons (Greenhouse-Giesser = 0.872; Huynh-Feldt = 0.875), which are measures of degree of sphericity, are less than 1.0. This indicates that the assumption of sphericity is violated.

Table 4 Within-subject effects with Mauchly’s test of sphericity^a

Within-subjects effect	Mauchly’s W	Approx. chi-square	df	Significance	Epsilonb
					Greenhouse–Geisser	Huynh–Feldt	Lower bound
Abbreviation: df, degree of freedom. aDesign: Intercept Within Subject Design: image. bMay be used to adjust the degrees of freedom for the averaged tests of significance. Notes: Tests the null hypothesis so that the error covariance matrix of the orthonormalized transformed dependent variables is proportional to an identity matrix. Corrected values are displayed in [Table 6].
Image	0.815	152.439	5	0.0000	0.872	0.875	0.333

In such case, either the results of the multivariate tests or the epsilons are used to adjust the “dfs” numerator and denominator. Correction is made to reduce the dfs by multiplying them by epsilon. Greenhouse–Geisser’ test is used when Mauchly’s W is <0.75 and Huynh–Feldt’s test is used when Mauchly’s W is >0.75. The test of within-subjects effects indicates the dfs as 3 and 2,244, as shown in [Table 5].

Table 5 Within-subjects effects with dfs

Source		Type III sum of squares	df	Mean square	F	Significance	Partial eta squared
Abbreviation: df, degree of freedom. Note: Values computed using α = 0.05.
Image	Sphericity assumed	18,594.250	3	6,198.083	352.656	0.000	0.320
	Greenhouse–Geisser	18,594.250	2.615	7,110.178	352.656	0.000	0.320
	Huynh–Feldt	18,594.250	2.625	7,083.092	352.656	0.000	0.320
	Lower bound	18,594.250	1.000	18,594.25	352.656	0.000	0.320
Error (image)	Sphericity assumed	39,439.250	2244	17.575
	Greenhouse–Geisser	39,439.250	1,956.139	20.162
	Huynh–Feldt	39,439.250	1,963.620	20.085
	Lower bound	39,439.250	748.000	52.726

Since the assumption sphericity is violated in these data, and Mauchly’s W is more than 0.75, correction is made using the Huynh–Feldt epsilon (0.875), which is multiplied by 3 and 2,244, yielding dfs of 2.625 and 1963.5, respectively.

[Table 6] shows that values obtained after correcting the dfs are the same as the table values. Hence, using repeated measures ANOVA and Huynh–Feldt’s correction, the findings can be considered as indicative of the difference in the nurses’ perception about the different stakeholders’ image of a nurse with respect to doctors, patients, and other hospital staff, as well as self–perception, with F(2.625, 1963.5) = 352.656, p < 0.000, and R ² = 0.32.

Table 6 Corrected values using dfs and Huynh–Feldt’s epsilon

Image df	Huynh–Feldt df	Huynh–Feldt epsilon	Value obtained after correction
Abbreviation: df, degree of freedom.
3	2.625	0.875	0.875 × 3 = 2.625
2,244	19,63.620		0.875 × 2,244 = 1963.5

Discussion

The findings of this study indicate that there is a difference in the nurses’ perception about the stakeholders’ image of a nurse. The construct, image of a nurse, has been explored by several researchers and have reported varied findings. General public had a positive professional view of nurses.[11] However, nurses themselves did not hold positive self-image, which was consistent with public image.[20] This is further contradicted by Siebens et al[17] and Takase et al.[21] Nurses’ image differed according to the departments; department of nursing had the most positive image, followed by physical therapy, radiology, emergency medical technology, and least by clinical pathology.[28] Image of nurses was low among second- and third-year nursing students.[18] Slovenian newspapers presented a relatively positive image of nurses.[15] Nurses’ appraisal was lower among patients as well as among doctors as compared with the appraisal by nurses themselves.[8] Patients visiting acute care units of private hospitals in South Africa described a positive image of nurses.[10] [12] However, the South African newspapers presented negative images of nurses.[16] Self-perception of nurses’ image was higher than the perceived public image among nurses.[13] ten Hoeve et al[24] discussed that the actual public image of nurses is varied and incongruous.

The findings also indicate significant practice-related implications. Nurses serve as the most significant members of the multidisciplinary health care team across all health care settings; hence, identification of this construct with reference to varied stakeholders was considered important. The common understanding holds that doctors are all powerful, authoritative, and knowledgeable, but nurses’ are less professional subordinates, merely following doctors’ orders. Nursing is not even considered as a professional career. The perception of nurse image by different stakeholders is interconnected. Nurses’ perception about their image by various stakeholders influences their thought, actions, and particularly interpersonal and professional relations in the team. It is important to understand doctors’ image of a nurse because a trustworthy and respectful relationship between the nurses and doctors facilitates effective communication and promotes confidence. This further endorses efficient nursing care practices and significantly influences patient care outcomes. Patients’ as well as other hospital staffs’ image of a nurse is important as it can be a powerful tool that directly and quickly extends the nurses’ image throughout the community. This image has the potential to stimulate prospective new entrants into the profession as well as influence the recruitment, performance, and retention of these professionals. Positive stakeholders’ image in conjunction with the positive nurses’ perceived image of a nurse is associated with enhanced self-esteem, fruitful interpersonal relations among the team, and improved job satisfaction, leading to productive participation in decision-making, maintaining standards of practice, and improving patients’ satisfaction. This is a cyclic process that can prop up the image of a nurse.

Conclusion

The findings of this study indicate that although the overall perception of nurses’ about the stakeholders’ image of a nurse is favorable, there is a difference in the nurses’ perception with respect to the doctors’, patients’, and other hospital staffs’ image of a nurse, as well as self-perception. Nurses’ perceived image of a nurse was more favorable as compared with the nurses’ perception about doctors’ image of a nurse followed by nurses’ perception about other hospital staffs’ image of a nurse. The rating, though favorable, was lowest on nurses’ perception about patients’ image of a nurse. This research suggests the need for nurses to maintain favorable therapeutic team relations besides providing quality patient care services as well as management to facilitate favorable practice environment that will boost the nurses in providing enhanced care, thereby improving their image among the stakeholders in the health care system.

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