Impact of the perceived public image of nursing on nurses work behaviour

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1 NURSING AND HEALTHCARE MANAGEMENT AND POLICY Impact of the perceived public image of nursing on nurses work behaviour Miyuki Takase PhD RN Research Fellow, School of Nursing, Deakin University/Cabrini Hospital, Victoria, Australia Phillip Maude PhD RN Senior Lecturer, School of Nursing, The University of Melbourne, Victoria, Australia Elizabeth Manias PhD RN Associate Professor, School of Nursing, The University of Melbourne, Victoria, Australia Accepted for publication April 5 Correspondence: Miyuki Takase, School of Nursing, Deakin University/Cabrini Hospital, 8 Wattletree Road, Malvern, Victoria 44, Australia. m.takase@pgrad.unimelb.edu.au TAKASE M., MAUDE P. & MANIAS E. (6) Journal of Advanced Nursing 5(), 4 Impact of the perceived public image of nursing on nurses work behaviour Aim. This paper reports a study comparing nurses perceptions of their public image with their self-image, and examining how the relationship between their perceived public image and self-image was associated with their job performance and turnover intentions. Background. The stereotypical public image of nursing is a major concern to nurses. However, it is relatively unknown how this image affects nurses. A few studies have investigated how nurses interpretations of their public image affect their self-image and work behaviour. Methods. A convenience sample of 46 Australian nurses participated in a questionnaire study in. The results were analysed by t-test, polynomial regression and response surface analysis. Six participants from the survey participated in a focus group to provide further interpretation of the findings. Results. Nurses rated their aptitude for leadership more positively than they thought the public viewed them. In contrast, nurses rated their image as being caring less negatively than their perceived public image. Job performance was predicted by selfimage relating to leadership aptitude. On the contrary, the relationship between selfimage and perception of the public image as being caring predicted job performance. When nurses perceived their public image as caring less positively than their selfimage, their job performance tended to improve. As for turnover intention, both self-image and perceived public images of having an aptitude for leadership and being caring were negatively related to intention to quit the job. Conclusion. To enhance nurses job performance and reduce their turnover intentions, it is important to improve both the public image and self-image of nurses. Keywords: nurse, nursing, nursing image, organizational behaviour of nurses, person environment fit, professional development Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

2 M. Takase et al. Introduction Nursing is a profession that has long been troubled with its public image. The public has a stereotypical view of nursing, in which nurses may be regarded as less intelligent than doctors, dependent on doctors, powerless and underpaid (Reiskin & Haussler 994, Tomey et al. 996, Rossiter et al. 998, Hemsley-Brown & Foskett 999, Tang et al. 999). This view, however, may not be an accurate portrayal. While there have been many studies on the public image of nurses, there is a lack of research on how nurses actually perceive their public image. There is also a lack of knowledge of how nurses interpret their public image based on their self-image, and how this interpretation affects their work behaviour. This lack of knowledge arises because the public image of nursing is often discussed in the context of recruitment (for example, Nurse Recruitment and Retention Committee ). A poor public image of nursing may affect not only nursing recruitment, but also nurses attitudes towards work (Takase et al. ). The aims of this study were to explore how nurses perceive their public image, to compare this with their self-image, and to examine how this relationship affected their job performance and intention to leave their jobs (hereafter referred to as turnover intention). Theoretical framework The person environment fit theory was adopted to investigate these relationships The person environment fit refers to a perceived compatibility between employees characteristics and those of the work environment, or between employees occupational needs and organizational capability to reinforce those needs (Dawis & Lofquist 984, Walsh & Holland 99). The theory contends that when employees perceive a fit between the person and environment, they tend to manifest favourable occupational behaviours, such as increased job performance and job satisfaction, and low intention to leave their job (Dawis & Lofquist 984, Walsh & Holland 99). When they perceive a misfit (i.e. incompatibility between their characteristics and those of the environment/job), employees experience frustration and dissatisfaction with their job. To reduce the burden, employees attempt to maintain the person environment fit by adjusting their characteristics to the environment or by attempting to modify their environment. The ultimate solution to avoiding this burden is to leave an organization or an occupation and to look for a more compatible environment or job (French & Kahn 96, Dawis & Lofquist 984). A hypothesized model illustrating the relationship between the person environment fit and job performance is illustrated in Figure. In this figure, the score of the perceived public image (i.e. the environmental factor) is described along the x- axis, that of nurses self-image (i.e. the personal factor) along the y-axis, and that of job performance along the z-axis. The larger scores along the x-, y-, and z-axes indicate positive responses to perceived public image, nurses self-image and job performance. The fit between the perceived public image and nurses self-image (hereafter referred to as the image fit) is represented by the Y ¼ X line, which is illustrated by the straight line in the xy-plane. Along the Y ¼ X line, the scores of the perceived public image correspond to those of nurses self-image. As depicted in Figure, when nurses perceive the image fit, their job performance is constantly high. The image misfit is illustrated along the Y ¼ X line, which is illustrated by the dotted line in the xy-plane, and where the scores of the perceived public image contradict the nurses self-image. The misfit along the Y ¼ X line is viewed as a continuum in which the midpoint of the line represents the image fit, whereas both ends of the line represent the extreme misfit. Along the Y ¼ X line, the surface illustrating job performance shows a downwards curve, suggesting nurses job performance becomes lower when they perceive a greater image misfit (Edwards & Parry 99). As for the relationship between image fit and turnover intention, the curvilinear relationship illustrated in Figure is Job performance Self-image(y-axis) Public image (x-axis) Figure A hypothesized model illustrates the three-dimensional relationship between nurses self-image, the perception of their public image and their job performance (based on the work of Edwards & Parry 99). The straight line in the xy-plane illustrates the Y ¼ X line, while the dotted line illustrates the Y ¼ X line. 4 Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

3 Nursing and healthcare management and policy Impact of the perceived public image of nursing Turnover intention Self-image (y-axis) 5 inverse; that is, the surface is an upward curved along Y ¼ X line, indicating that the misfit contributes to an increased turnover intention of nurses (Figure ) (Edwards & Parry 99). Various dimensions of person environment relationships and their effects on employees work behaviours have been investigated in the fields of psychology and organizational studies. Examples include relationships between job characteristics and employees vocational interests (Fritzsche et al. 999, Ton & Hansen ), and between employees work values and organizational culture (O Reilly et al. 99, Livingstone et al. 997, Edwards ). However, few studies have investigated the relationship between employees professional self-image and how they are perceived by others in their environment. Takase et al. () compared nurses self-image with nurses perception of the public image, and found that nurses had a significantly more positive self-image compared with how they perceived their public image. The results also showed that the image misfit was negatively associated with nurses job satisfaction and job performance. Friedman and Harber (99) tested the impact of the image fit on teacher burnout and found a negative association. While these studies inform the impact of the image fit on nurses job performance and turnover intention, their findings are susceptible to methodological limitations. This is because the investigators used the absolute difference score between Public image (x-axis) Figure A hypothesized model illustrates the three-dimensional relationship between nurses self-image, the perception of their public image and their turnover intentions (based on the work of Edwards & Parry 99). The straight line in the xy-plane illustrates the Y ¼ X line, while the dotted line illustrates Y ¼ X line. self-image and the image perceived by others to represent the degree of the image fit. The use of the difference score has been criticized for two reasons (Edwards ). First, the difference score obscures the individual effects of personal and environmental factors as they are hidden in the single index. Secondly, there is a problem relating to the equation used to produce the difference score. A simple algebraic difference score is expressed as Z ¼ b þ b (E P) þ e ¼ b þ b E b P þ e, where Z represents a dependent variable, E for an environmental factor and P for an employee s factor. According to Edwards (), the use of a single index of the person environment fit assumes untested assumptions, such as that the coefficient on E must be equal in magnitude to that on P with an opposite sign. An absolute difference score involves more complex assumptions. The present study addressed these methodological concerns by adopting more sophisticated procedures in order to examine the effect of the image (mis)fit on nurses job performance and turnover intention. The study Aim The aim of the study was to answer the following research questions: How do nurses perceive their public image compared with their self-image? How does the image (mis)fit affect nurses work behaviour? The hypotheses tested were: The image fit is positively related to increased job performance of nurses. The image fit is positively related to low turnover intention of nurses. Design A correlational design was adopted, using questionnaires and a focus group. The data were collected in. Participants The study participants were a convenience sample of 94 Registered Nurses who had completed a -year nursing diploma or degree programme and were working in a variety of clinical settings. These nurses were from a metropolitan public hospital, a rural public hospital, or were studying as postregistration students at a university in Victoria, Australia. For the hospitals, questionnaires were distributed by nurse unit managers at the request of the researchers. Question- Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd 5

4 M. Takase et al. naires were sent to a large number of nurses in order to obtain a minimum of respondents, with which it is sufficient to conduct factor analysis and to maintain an adequate statistical power to detect 5% increase of variances in regression analysis. Completed questionnaires were returned using a selfaddressed reply-paid envelope. For the university group, we visited classrooms with the permission of subject coordinators and distributed questionnaires to students. Students were given the opportunity to complete the questionnaires in the classroom or at home. To seek focus group participants, fliers were sent to hospital nurses and university student nurses. In addition, face-to-face recruitment of hospital nurses was conducted by visiting each ward. A total of six nurses who had participated in the previous survey took part in the focus group. Data collection Questionnaire Nurses self-image and their perception of the public image of nurses were measured using a shortened version of the Porter Nursing Image Scale (Porter & Porter 99). The original Porter Scale consists of matched-pair, bipolar adjectives, which are rated on a seven-point semantic differential scale. To reduce the time needed to answer the questionnaire, 7 single/unipolar adjective items from the scale were administered to participants. Twelve items measured leadership aptitudes, and five measured caring aptitudes. These items were rated on a forced-choice six-point Likert scale, with higher scores indicating positive images. Job performance was measured using four items derived from the Task Performance Scale (Goodman & Svyantek 999), with minor rewording made. The original Task Performance Scale consisted of nine items, measured on a seven-point Likert scale. However, we used a forced-choice six-point Likert scale. High scores indicate a positive evaluation of organizational job performance based on organizational objectives. Turnover intention was assessed initially using five items based on the three-item Withdrawal Cognitions Scale, which measures turnover cognition in three factors (i.e. thinking of quitting, searching for a job, and intention to quit; Mowday et al. 984). This original three-item scale was reworded to measure two different reasons for nurses turnover: leaving the current organization to look for a new nursing job (three items) and leaving the nursing profession itself (two items). These items were also rated on a six-point Likert scale, with a high score indicating high turnover intention. Focus group A schedule of open-ended questions was used to explore the selective findings of the survey study. The focus group session was audio-recorded and transcribed verbatim. Validity and reliability To establish the validity of the modified instruments, the following steps were taken. Prior to administration of the questionnaire to participants, the questionnaire was reviewed by a panel of nursing experts using the Index of Content Validity to establish the relevance of the instruments to the study (Waltz et al. 984). The questionnaire was then pilottested with 6 postregistration students. After administering the instruments, a factor analysis was conducted to establish construct validity. The reliability of the modified instruments was assessed with Cronbach s alpha. The rigour of data collection in the focus group was maintained by checking the researcher s understandings with the participants at the end of each question. As a means of checking that the content of the data accurately reflected participants views, they were asked to review the focus group transcription. Except for minor editorial changes, they made no alterations to this. The data analysis was conducted by the first author and was re-validated by the second author. Ethical considerations Ethics approval was obtained from all participating institutions. All participants received a letter explaining the purposes and procedures of the study. Consent to participate was assumed by return of the questionnaire. Written informed consent was obtained from the focus group participants. Data analysis Correlational study A paired t-test was used to compare nurses self-image and their perception of the public image. The hypotheses were tested using polynomial regression and response surface analysis. The procedures of polynomial regression analysis described by Edwards () are as follows. Polynomial regression analysis began with identifying the regression equation for the hypothesized model. As shown in Figures and, the hypothesized models involve a curvilinear relationship, with a greater discrepancy between nurses self-image and the perceived public image contributing to reduced job performance and increased turnover intention. Thus, the equation to predict nurses organizational job performance was 6 Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

5 Nursing and healthcare management and policy OP ¼ b b ðpi NIÞ þ e; ðþ where organizational job performance is represented as OP, perceived public image as PI, nurses self-image as NI, the coefficients as b (b is a constant), and the unexplained error as e. Expanding this equation gave the following: OP ¼ b b PI þ b PI NI b NI þ e: This expanded equation was compared with a general (unconstrained) quadratic equation: OPðor TIÞ ¼ b þ b PI þ b NI þ b PI þ b 4 PI NI þ b 5 NI þ e: It was identified that the coefficients in equation must meet the following assumptions (constraints) in order to correspond to equation : () b ¼ ; () b ¼ ; () b ¼ b 5 and b and b 5 are negative; and (4) b þ b 4 þ b 5 ¼. The equation predicting turnover intention (represented as TI) was: TI ¼ b þ b ðpi NIÞ þ e ¼ b þ b PI b PI NI þ b NI þ e: Comparing equation 4 with equation, the same four assumptions in equation were identified, except that b and b 5 are positive. In order to examine whether the relationship between nurses self-image, their perception of the public image and their work behaviour would support the hypotheses, the unconstrained quadratic equation (i.e. equation ) was entered for regression analysis. In this analysis, an exploratory procedure was used because this helps to identify an appropriate model to explain nurses work behaviour beyond the hypothesis testing. Thus, the monotonic terms of PI and NI were entered together first into regression. Then, the quadratic terms of PI and NI (i.e. PI,PI NI and NI ) were added as a set. If the relationship is curvilinear, there should be a statistically significant increase in the variance when the quadratic terms are added to the regression analysis. When a statistically significant increase was identified, visual examination of the coefficients was made to see whether the appropriate coefficients were statistically significant and if they were in the hypothesized directions, as shown in equation or 4. This visual examination was followed by a statistical examination of the four identified assumptions by imposing them on the unconstrained regression equation. For the hypothesized model to be satisfied, these constraints should not be rejected. Finally, the cubic terms of PI and NI (i.e. PI,PI NI, PI NI,NI ) were added to the regression analysis to determine whether the relationship was truly ðþ ðþ ð4þ quadratic, but not cubic in nature. To support the hypotheses, these cubic terms should be rejected. Response surface analysis was conducted to further examine whether the curvilinear relationships identified by polynomial regression analysis would fit the hypothesized model illustrated in Figures or. The detailed procedures of the analysis are described by Edwards () and Edwards and Parry (99). Focus group Focus group data were analysed using the framework method, which involved becoming familiar with the data through listening to the tape and reading transcriptions, identifying a thematic framework, indexing the transcription in accordance with the thematic framework, charting the index/subindex, and interpreting the data (Ritchie & Spencer 994). Results Impact of the perceived public image of nursing A total of 46 questionnaires were returned, which represented a response rate of 6Æ7%. The demographics of the survey participants are presented in Table. The reliability of the instruments, means of the variables, and results of the t-test are presented in Table. Nurses rated their overall self-image statistically significantly more positively than how they believed the public viewed them. This difference was more prominently observed in leadership aptitudes. As shown in Figure, nurses rated their self-image as being leaders much higher than the perceived public image. They also rated themselves as more independent, intelligent, professional, and logical than their perceived public image. With reference to the image of nursing as being powerful, nurses rated their self-image and the public image as low. In contrast, there was no statistically significant difference between nurses self-image as being caring and their perception of the public image. In fact, respondents rated their public image slightly more positively than how they perceived themselves (Figure 4). Table presents the results of polynomial regression analysis. As for leadership aptitudes, the unconstrained monotonic models explained the statistically significant variances with both nurses organizational job performance and turnover intention. When the quadratic terms were added to both models; however, they did not increase the explained variances, thus rejecting the hypothesized curvilinear models. These results suggest that nurses organizational job performance can be predicted by a linear relationship with their selfimage as having leadership aptitudes. Their turnover intention can be predicted by linear relationships with both their selfimage and the perception of their public image as leaders. Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd 7

6 M. Takase et al. Table Demographics of survey participants Characteristic Percentage (n) Gender Female 9Æ7 (6) Male 7Æ (5) Work status Full-time ( 5 hour/week) 58Æ9 () Part-time (<5 hour/week) 4Æ (4) Age (mean) Æ6 years (range 68, SD ¼ 9Æ4) Currently studying or have completed postgraduate courses Yes 67Æ9 (6) No Æ (7) Have a diploma Æ7 (9) Have a degree Æ4 (68) Clinical specialty Critical (including intensive care unit, 4 (7) emergency, cardiology, coronary care unit) Medical/surgical 7Æ8 (96) Chronic (including aged care, mental, 9Æ4 (67) palliative and oncology) Paediatric 5Æ8 () Others Æ (44) Clinical position Clinical staff 9Æ4 () Others (including nurse unit manager) 9Æ6 () The total sample size ranges from to 45 because of missing values. Table Reliability of the instruments, the means and the results of the t-test Variables Reliability Mean (SD) t-test Overall image Nurses self-image Æ89 4Æ96 (Æ5) t(4) ¼ Æ Perceived public image Æ9 4Æ48 (Æ68) P < Æ Leadership aptitudes Nurses self-image Æ87 4Æ88 (Æ55) t(4) ¼ 6Æ46 Perceived public image Æ9 4Æ7 (Æ79) P < Æ* Caring aptitudes Nurses self-image Æ85 5Æ6 (Æ66) t(4) ¼ Æ9 Perceived public image Æ88 5Æ (Æ7) P > Æ5* Organizational job Æ8 5Æ9 (Æ58) performance Turnover intention Æ79 Æ7 (Æ6) n ¼ 4 due to system missing. *The significance level was adjusted by the sequential Bonferroni procedure to control type I error (Holland & Copenhaver 988). With reference to caring aptitudes, the unconstrained monotonic model explained the statistically significant variance with their turnover intention. However, the quadratic terms did not add a statistically significant variance to the Leader Perceived public image Nurses' self-image Intelligent Logical Independent Professional Confident In control Competent Rational Powerful Responsible Organised Figure Comparison of respondents self-image and their perception of the public image of them as having leadership aptitude Warm Perceived public image Nurses' self-image Nurturing Patient Compassionate Respectful Figure 4 Comparison of nurses self-image and their perception of the public image of nurses as having caring aptitude. model. These results suggest that the relationship between nurses turnover intention, their self-image and the perceived public image is linear with nurses self-image and public image individually explaining nurses turnover intention. On the contrary, the results indicate that nurses organizational job performance is better explained by a curvilinear relationship with nurses caring aptitudes and their perception of the public image of nurses as being caring. As shown in Table, the quadratic terms of caring aptitudes added a statistically significant variance to the monotonic model. The coefficients on the perceived public image, interaction between the perceived public image and nurses self-image, and higher order term of the nurses self-image were statistically significant. However, the coefficient on the quadratic term of the perceived public image was insignificant, and all the 8 Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

7 Nursing and healthcare management and policy Impact of the perceived public image of nursing Table Results of polynomial regression analysis Relationships The first step: monotonic model (B) The second step: unconstrained quadratic model (B) PI NI R PI NI PI PI NI NI R Change in R from first to second step (F-change). Leadership aptitudes and job performance Caring aptitudes and job performance Leadership aptitudes and turnover intention Caring aptitudes and turnover intention Æ4 Æ59** Æ8** Æ Æ5** Æ Æ8 Æ5 Æ9** F(, 6) ¼ Æ7 Æ6** Æ9** Æ5** Æ** Æ Æ Æ6** Æ** Æ9** F(, 5) ¼ 4Æ6* Æ** Æ** Æ7** Æ Æ6 Æ Æ Æ Æ7** F(, 6) ¼ Æ7 Æ** Æ47** Æ5** Æ46** Æ7** Æ Æ Æ9 Æ6** F(, 4) ¼ Æ PI, perceived public image; NI, nurses self-image. *P < Æ5; **P < Æ. The significance level was controlled by the sequential Bonferroni procedure. n ¼. In this analysis, outliers were screened out to improve the accuracy of the prediction. Data transformation to reduce the outliers was not favoured. This was because the regression equation involved higher order and interaction terms. Thus, data transformation would make the interpretation of the findings difficult. Deleting outliers reduces the generalizability of study findings. However, it should be noted that the overall findings without outliers were consistent with those with all the cases included. Constant is omitted in this table. Prior to the analysis, a linear data transformation was made to reduce multicolinearity by subtracting 4Æ5 from the scores of both nurses selfimage and their perception of the public image of nurses. Thus, the scales range from 4Æ5 toþæ5 in this analysis. coefficients on the quadratic terms had opposite signs to those identified in equation. The patterns of these coefficients did not follow the hypothesized model. In fact, the constraints were rejected [F(4, 5) ¼ 8Æ4, P < Æ] when they were imposed on the unconstrained quadratic model. The cubic terms were also rejected [F(4, ) ¼ Æ, P > Æ5]. This led to the conclusion that the relationship was quadratic, but it did not support the hypothesized model. Figure 5 shows the three-dimensional relationship between nurses self-image and the perceived public image of being caring, and organizational job performance. In this figure, a linear transformation of the scores for nurses selfimage and their perceived public image was made in a way that the scores ranged from Æ5 toþæ5, with higher scores indicating more positive images. This transformation makes it easier to compare the results of response surface analysis with the hypothesized model illustrated in Figure. Figure 5 shows that the surface along the Y ¼ X line was positively sloped (a x ¼ Æ54) and its curvature is a x ¼ Æ. Yet, response surface analysis shows that this slope and curvature were not statistically significantly different from, indicating that the surface along the Y ¼ X line is flat and linear. This result supports the hypothesized model, suggesting that nurses performance would be constant when they perceived the image fit. In contrast, the curvature along Y ¼ X line is upwards curved (a x ¼ Æ5, P < Æ5), instead of downwards, as illustrated in Figure. This upwards curvature suggests that respondents tended to perceive their organizational job performance positively Job performance 5 5 Public image: caring (x-axis) when they perceived either a more positive or a negative public image of themselves as being caring compared with their self-image. In reality, approximately 95% rated both 5 5 Self image: caring (y-axis) Figure 5 Relationship between respondents self-image and their perceived public image of nurses as being caring and nurses organizational job performance. This figure is based on the result of polynomial regression analysis. However, the result of polynomial regression analysis was linearly transformed in a way that the scales for the public image and self-image of nurses range from Æ5 to þæ5, to make the comparison between Figures and 5 easier Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd 9

8 M. Takase et al. Self-image: caring (y-axis) their self-image and their public image above the midpoint of the scales. Only a few rated either their self-image or their public image negatively. Figure 6 displays the magnification of the contour plot of Figure 5 in the positive ranges of Æ5 in both nurses selfimage and the perceived public image. The thick line represents the bottom line of the upwards curvature in this surface. As shown in the figure, this bottom line is slightly rotated off the Y ¼ X line. This finding indicates that when respondents perceived themselves as being caring and perceived their public image even more positively than their self-image, they tended to evaluate their performance slightly lower than other nurses, who also had a positive self-image, but perceived their public image slightly more negatively than how they saw themselves. Discussion Study limitations Public image: caring (x-axis) Figure 6 Contour plot: magnification of Figure 5 in the positive ranges along the X and Y axes. The actual positive scores range from toæ5. The thick line represents the bottom line of the upwards curvature in this range. The thick dotted line represents the Y ¼ X line. A cautious interpretation is necessary for the findings on nurses job performance because job performance was rated by respondents whose self-evaluation may be different from the evaluation they might receive from their supervisors. A limited sample representation resulting from the low response rate also requires the careful application of the study findings because there is the possibility of bias in the results. In addition, small variances explained in regression analysis suggest room for improvement in the models. Nurses perceptions of their public image and self-image The results showed that overall nurses perceived themselves statistically significantly more positively than how they perceived the public viewed them. The factor level analysis revealed that, in particular, nurses perceived their self-image as leaders was not congruent with how they perceived the public viewed them. On the contrary, nurses view of their public image as being caring was in accordance with how they viewed themselves. These results illustrate the public s tendency to view nurses as one-dimensional. That is, nurses were viewed as feminine and caring professionals, but they were not recognized as leaders or professionals who were independent in their practice. The focus group participants also said that the public had a fuzzy image of nurses, and generally agreed that the public viewed them as being caring. However, participants also considered that the public had a lack of recognition and knowledge about nursing roles: They [the public] don t necessarily have an appreciation for what we actually do for patients I just don t necessarily think people do really know what we do. Buresh and Gordon () also agree that the public lack understanding of what nurses do at work, although they hold nursing in the highest regard. This lack of understanding of nursing roles may partly be a result of their expansion into other healthcare fields, which has blurred professional boundaries between nursing and other healthcare professionals (Lewis & Urmston, Buchanan & Considine ). In addition to the changing roles of nursing, the fuzzy image of nursing held by the public is also a result of nurses invisibility in the media. Indeed, an extensive review of the US media coverage on healthcare revealed that nurses were cited only 4% of the time in the over health-related articles from 6 news publications (Sigma Theta Tau International 998). As a consequence of the public s lack of understanding about the nature of current nursing work, there is still some adherence to the old image of nursing. It is apparent that fictional portrayals of nurses as being doctors handmaidens and angelic in the entertainment media (DeVries et al. 995, Greenwood 999) are reinforcing the traditional images of nurses. That the public is being caught up with the old image of nursing was also a concern in the focus group: The public s overall view of the nursing role is sitting by the bedside, holding the patient s hand, getting a glass of water. While the results suggest that nurses perceived a lack of understanding from the public, their own perception of their public image is moderately positive. This positive perception 4 Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

9 Nursing and healthcare management and policy may illustrate that the public image of nurses has been improving, partly as a result of the advancement of nursing towards professionalization; for example, transfer of nursing education from hospitals to universities is recognized by the public, particularly by high school students who are preparing themselves for their future career (Hemsley-Brown & Foskett 999, Tang et al. 999). The public image of nurses can also be improved by interactions with them. By being cared for by nurses during hospitalization, the public can learn what nurses do in their daily practice and develop a more accurate image of them: Once patients or visitors have some interaction with the RN they get to know them and respect them for their knowledge. However, Buresh and Gordon () assert that individual experiences with nursing care do not automatically translate into the public s understanding of nursing. This may be a reason why nurses still perceive an image misfit. Impact of image fit on nurses work behaviour The impact of the relationship between nurses self-image and their perceived public image was diverse. As was the case with the image of nurses as being leaders, nurses self-image had a positive effect on their organizational job performance, while the perceived public image did not have any effect. This is because nurses motivation to maintain a high standard of nursing practice guides their performance. A focus group participant stated: I don t think on a day-to-day basis about what the public out there think of me, I just have my own professional standards and I work according to those. Indeed, maintaining a high standard of patient-focused practice was a theme that was frequently identified in the focus group, and which characterized nurses professional orientation. Nurses self-image and their perception of the public image of them as being caring interacted with one another to predict nurses organizational job performance. Moreover, the relationship between them was curvilinear, although the hypothesized model was not supported. The results showed that the majority of nurses rated positively their self-image and the public image of them as being caring. Among those, nurses who perceived their public image more positively than their self-image tended to perceive their organizational job performance slightly more negatively than those who saw their self-image more positively than their public image. This phenomenon may result from the public s high expectation of nurses as being caring. The literature suggests that caring is Impact of the perceived public image of nursing an important aspect of nursing, not only for nurses (March & McPherson 996, Watson et al. 999), but also for the public and for organizational structures. Studies show that the public views caring as the primary and highly regarded role of nursing (Rossiter et al. 998, Hemsley-Brown & Foskett 999, Tang et al. 999). Hospitals also use quality nursing care in their promotional materials to attract many patients (Powers ). Indeed, one of the participating hospitals cited patients satisfaction with their nurses being courteous and compassionate in their report (Barwon Health ). Thus, nurses perception of themselves as not meeting the public s expectations may have led them to evaluate their job performance negatively. A high social expectation of nursing care may also have caused stress/pressure on nurses that resulted in actual low performance. This pressure may be characterized as the opposite of the stereotype threat. The stereotype threat is the fear individuals feel that their performances may happen to confirm the negative stereotypical beliefs about their group. This fear causes stress, and leads to low performance (Steele 997). Rather than being pressured not to reinforce a negative image of nursing, nurses in this study may have felt pressured to confirm the wellregarded public image of nurses as being caring and what hospitals advertise in regard to nursing care. Although maintaining a high standard of care is the focus of nurses, the pressure to be even more caring than how they feel they already are might have created stress and resulted in a reduction in job performance. On the contrary, nurses who rated their self-image of being caring more positively than their public image, tended to perceive their performance positively. This view is particularly true for those who rated their self-image highly, but also rated their public image negatively. The person environment fit theory maintains that when individuals experience the misfit, they may reduce their job performance or be motivated to change either themselves or the environment to avoid the misfit (French & Kahn 96, Dawis & Lofquist 984). In the present study, the results illustrated nurses motivation to change their public image by displaying excellent performance rather than reducing their performance or changing their self-image. Individuals efforts to achieve their goals by exhibiting better performance are also supported in other literature; for example, the Goal-Setting Theory and Control Theory maintain that a discrepancy between the goal and its achievement by individuals creates self-correcting motivation that subsequently enhances their job performance (Kernan & Lord 99, Donovan ). Nurses motivation to change the public image is further precipitated by their professional orientation. The literature suggests that the motivation to change their environment is Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd 4

10 M. Takase et al. What is already known about this topic A stereotypical public image of nurses exists in many countries. The public image of nursing affects nursing recruitment. Cultivating nurses self-image as being caring further helps them to cope with the potential pressure from the public s high expectation of nursing care. The nursing profession needs to improve its public image if the self-image of nurses is to advance and turnover problems are to be resolved. What this paper adds It is important to consider nurses self-image and their perceived public image in relation to their intention to leave their jobs and their overall job performance. Nurses regard their self-image as leaders much higher than their perceived public image. When nurses perceive their public image as being caring less positively than their self-image, their job performance tends to improve. seen more strongly in employees who tend to be hardworking, self-disciplined (Simmering et al. ) and motivated (Tatum & Nebeker 995). Considering that nurses see themselves as professionals and value a high standard of care, it is likely that nurses professional orientation motivates them to improve their public image through better performance. In fact, changing the public image was a theme identified in the focus group: If there is a perception from a patient that they don t care too much about what we re doing, it probably only stimulates me to work harder [and] to demonstrate the wealth of things that we actually do for them. While a negative perception of the public images of nurses had either no or a positive effect on nurses organizational job performance, the results suggested that it could lead to increased turnover intention. This may be because changing the public image of nursing is a stressful process. Therefore, it may cause frustration and job dissatisfaction among nurses, and may eventually wear down their motivation to change their public image and maintain a high standard of care, leading to a greater intention to quit their jobs. Conclusion Lack of understanding of nursing as a profession by the general public is a common phenomenon that contributes to nurses turnover intention. Thus, it is important to improve the public image of nurses in order to mitigate the current nursing shortage. The results also emphasize the importance of reinforcing nurses professional value of maintaining high standard care, which sustains their job performance. Acknowledgements The authors would like to thank Associate Professor Ian Gordon from the Statistical Consulting Centre at the University of Melbourne and the Distinguished Professor of Management, Jeffry R. Edwards from the University of North Carolina for the statistical advice. However, responsibility for how their advice was used in this paper rests with the authors. Author contributions MT was responsible for the study conception and design, data analysis, drafting of the manuscript and obtaining funding. MT, PM and EM critically revised the paper. PM and EM supervised. MT and PM collected data. References Barwon Health () / Quality of Care Annual Report. Barwon Health, Geelong, Victoria, Australia. Buchanan J. & Considine G. () Stop Telling Us to Cope: New South Wales Nurses Explain Why They Are Leaving the Profession. Retrieved from 4/extract on 5 November 5. Buresh B. & Gordon S. () From Silence to Voice: What Nurses Know and Must Communicate to the Public. Canadian Nurse Association, Ottawa. Dawis R.V. & Lofquist L.H. (984) A Psychological Theory of Work Adjustment. University of Minnesota Press, Minneapolis. DeVries S., Dunlop M., Goopy S., Moyle W. & Sutherland-Lockhart D. (995) Discipline and passion: meaning, masochism and mythology in popular medical romances. Nursing Inquiry,. Donovan J.J. () Work motivation. In Handbook of Industrial, Work and Organisational Psychology: Volume. Organisational Psychology, nd edn (Anderson N., Ones D.S., Sinangil H.K. & Viswesvaran C., eds), SAGE Publications, London, pp Edwards J.R. () Ten difference score myths. Organisational Research Methods 4(), Edwards J.R. () Alternatives to difference scores: polynomial regression analysis and response surface methodology. In Advances in Measurements and Data Analysis (Drasgow F. & Schmitt N.W., eds), Jossey-Bass, San Francisco, CA, pp Edwards J.R. & Parry M.E. (99) On the use of polynomial regression equations as an alternative to difference scores in organisational research. Academy of Management Journal 6(6), Ó 6 The Authors. Journal compilation Ó 6 Blackwell Publishing Ltd

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