Review: Nurses’ views on the impact of mass media on the public perception of nursing and nurse–service user interactions

This is a review of paper published in the Journal of Research in Nursing about Nurses’ views on the impact of mass media on the public perception of nursing and nurse–service user interactions by Louise P Hoyle, Richard G Kyle and Catherine Mahoney. Cite as: De Souza, R. (2017). Review: Nurses’ views on the impact of mass media on the public perception of nursing and nurse–service user interactions . Journal of Research in Nursing, 0(0) 1–2.

Mass media comprises the storytellers and portrayers of our social worlds (Nairn et al., 2014), and has a central role in reproducing the contradictory views held about nurses by the public. As the reviewed paper shows, media representations are far from harmless: they influence public understanding and confidence in the profession and impact on recruitment, policy and nurses’ self-image (Kalisch et al., 2007). Nurses are considered
highly trustworthy by the public due to their virtues of care and compassion. However, the dominant representations of nurses in the media are often inaccurate, erasing male nurses from the profession and downplaying the autonomous judgement of the nursing
professional. Nurses as feminised handmaidens play a subordinate support role to medical decision makers. The media nurse engages in bedside routines and repetitive tasks, and is sometimes a sex object, an angel of mercy or a battleaxe, sometimes all three. These stereotypical representations have changed over time, and sometimes nurses are depicted as strong and confident professionals (Kalisch et al., 1981; Stanley, 2008). Yet the significant professional, theoretical and scholarly innovations that have reshaped the role of nurses are largely invisible to the public (Ten Hoeve et al., 2014). In tandem with nursing’s processes of
professionalisation, austerity measures in the neoliberal health system have demanded efficiency and cost containment, while also reorienting services so they can be more clientcentred. This twin move to the proletarianisation of nursing care (through the growth of
various classes of healthcare assistants doing tasks previously performed by nurses) and democratisation of health within a technocratic, market-led and more participatory health system has profound implications for the future of nursing.

The reviewed paper is timely, given the growing focus on shared decision making and participation as an outcome of client-centredness in Western health systems. It raises questions about the customary role of nurses as gap fillers and problem solvers, who maintain the status quo on doctors’ orders. New media channels such as the Internet allow access to on-demand health information outside of authoritative channels, and new
technologies such as fitness trackers and wearables produce a wide range of personal health information. These technologies do some of the work of nursing in the sense that they put recipients at the centre of the health experience and allow health information to enhance the consumer’s knowledge of, control of and impact on their own healthcare. The role of the
nurse as a facilitator in these new flows of health information is yet to be effectively represented within the profession’s view of itself, let alone in the mass media, as this paper suggests.

The reviewed study’s findings on the aversion felt by nurse participants to informed consumers is an issue with significant ramifications. The question that remains is whether there is an opportunity for nurses to enter the public sphere in a meaningful alignment with consumer aspirations for healthcare? If healthcare is to become more participatory, equitable and consumer-driven, what transformative changes will we as nurses need to
make in our own self-identity and practice?

Kalisch BJ, Begeny S and Neumann S (2007) The image of the nurse on the internet. Nursing Outlook 55(4): 182–188.
Kalisch BJ, Kalisch PA and Scobey M (1981) Reflections on a television image: The nurses 1962–1965. Nursing & Health Care: Official Publication of the National League for Nursing 2(5): 248–255.
Nairn R, De Souza R, Barnes AM, et al. (2014) Nursing in media-saturated societies: Implications for cultural safety in nursing practice in Aotearoa New Zealand. Journal of Research in Nursing 19(6): 477–487.
Stanley DJ (2008) Celluloid angels: A research study of nurses in feature films 1900–2007. Journal of Advanced Nursing Available at: 1365-2648.2008.04793.x/full (accessed 30 September 2017).
Ten Hoeve Y, Jansen G and Roodbol P (2014) The nursing profession: Public image, self-concept and professional identity. A discussion paper. Journal of Advanced Nursing 70(2): 295–309.

Ruth De Souza on Wearable Technology

I am speaking at the WT | Wearable Technologies conference in Sydney next month. I spoke to Wearable Technologies Australia (WTA) about the future of the wearable tech industry and some of the challenges the industry is facing. Check out the  full program here.

Here’s a link to the interview we did and I’ve also reproduced it in full below.

WTA: Tell us a little bit about yourself and your journey within the wearable technology space

RDS: I am a nurse, educator and researcher by background and currently work in a unit called the Centre for Culture, Ethnicity and Health at North Richmond Community Health Centre in Melbourne. I came from Monash University to this role with an interest in translating research into practice. I was really interested in doing research in the community and being based there, so that there wasn’t such a big lag between research and knowledge implementation. Wearable tech seemed a good area to explore in a community setting where there is a high percentage of overseas-born residents (38%). Many speak a language other than English at home which has an impact on health literacy. I have been working with colleagues at the University of Melbourne and Paper Giant using “design probes” to engage women from culturally and linguistically diverse (CALD) backgrounds in discussions about health tracking and wearable health technologies in the context of pregnancy and parenting. We started with a stakeholder forum where we explored the research issues around wearable tech and cultural diversity to develop an agenda. More recently with the the University of Melbourne we have conducted a health self-tracking week where we provided daily community education sessions on a range of topics including diabetes and nutrition and self-tracking. Before the end of the year we will be following up with interviews with trackers and asking them about the barriers and enablers to self-tracking.

WTA: Wearable Tech is the next big thing now. Where do you see the industry heading in the next 5 years?

RDS:I am interested in what changes need to be made in health care systems to really maximise the benefits of Wearable Tech. What kinds of educational preparation will the future health workforce need? How will health workers need to modify their roles from being traditional gate-keepers of information in light of the democratisation of information access? What skills will they need to support patients who are activated, motivated and informed? How will health care systems need to change so they can really make the most of patient generated health data? How will workflows and practices change in order to accommodate the new models of care that are emerging with wearable tech?

WTA: According to your expertise in the wearables space which industry do you think will be impacted most by wearable technologies in the next few years

RDS: Technology is moving faster than the health care and education industries. In order to realise the benefits of advances in wearable tech, it’s going to be crucial for the health care workforce to be well prepared educationally and to develop digital literacies both at the undergraduate level and then in terms of continuing education and training. There’s going to have to be a huge shift not just in terms of knowledge and skills, but also in terms of understanding how to be more collaborative in health care.

WTA: Do you think personal IoT has a sustainable future? Will people need more than one platform to handle all their wearable devices?

RDS: I think interoperability is a big issue. Merely generating personal health data without the capacity to have it integrated into your health care means that the potential benefits may not be realised. For this our current models of care and institutional systems need to become more agile and nimble. Many health workers are sceptical about the benefits of wearable technology and concerned about who gets to benefit from the aggregation of health data. They need reassurance about the ethical treatment of data.

WTA: What do you think is the biggest challenge within the wearable technology industry?

RDS: I think the biggest challenge is how wearable technologies can work for people who are marginalised. Working in community health as a researcher I am interested in what wearable self tracking devices mean for people who don’t fit the wealthy, worried, well and white demographic, that typically wearables are marketed to. There is an urgent need to bring people and communities into processes of information handling that are more transparent and accountable. Health workers adhere to codes of conduct and have a duty of care, I’d like to see the developers of technologies engage in more careful scrutiny and have more transparency about the uses of data. I think also that if wearable tech is to be democratised and benefit everyone then communities who are wary of surveillance must have greater control of their data and personal health information.

Improving collaboration between nursing professionals and support workers in the New Zealand mental health system– A position paper

In 1998 I began teaching the first mental health support work cohorts in New Zealand at Unitec Institute of Technology. I had the privilege of working with Maori and Pacific mental health workers, peer support workers and consumer providers until 2005. I wrote this position paper for the Australian and New Zealand College of Mental Health Nurses way back in 2003. I have taken it out of the vault in case it is of use. I have listed more up to date references at the end of the document for those who might want to do some further reading.


The Mental Health Commission (1997) states that mental health is the concern of all. Support workers are a reality of today’s mental health system in New Zealand and this paper looks at their relationship with community mental health nurses. This paper is a response to the major changes in mental health care in New Zealand over the last decade, which have dramatically altered the landscape of the mental health workforce. It seems timely to look at a way forward and to develop guidelines for nurses working with support workers in the community. In this paper “support workers” include community support workers and consumers as providers and the term “nurses” refers to community mental health nurses.

No one group can meet the needs of consumers. Together these two groups can provide complimentary services to improve client care but a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. The changes in the socio-political context of mental health care in New Zealand are challenging nurses to re-define their scope of practice. These developments and their implications are summarised and options for the nursing profession are discussed and recommendations given.


Competition for funding

The creation of the Regional Health Authorities (RHA) in 1991 was part of a new system of purchasing health services which replaced Area Health Boards (Yegdich & Quinn, 1996). This new funder /purchaser /provider system encouraged competition between providers and led to many new services entering the health sector. These included non-governmental services who were now able to compete directly with Crown Health Enterprises (CHE), previously there was an obligation for boards to concentrate funding on their own services (Yegdich & Quinn, 1996). In 1996 the new coalition government initiated another review of the health system leading to funding being centralised under the Transitional Health Authority (THA). Competition for central funding begs the question of whether competing services with different philosophies and types of workers can cooperate with each other. When community support services were established in Auckland there was antagonism from nurses as these new services were seen as better resourced, with lower caseloads and were seen to be eroding the role of the professional nurse.

Culturally appropriate parallel services

The changes in funding have also lead to the development of specialised Maori and Pacific Island support work services. In Auckland, the Maori community support work (CSW) service has dramatically reduced the rate of admission and re-admission for Maori . Previous statistics had shown that Maori were entering the mental health system at the same rates as non-Maori but required longer stays and more frequent re-admissions (Te Puni Kokiri, 1993). Increased numbers of immigrants and refugees from Africa, Asia and Eastern Europe have led to the formation of specialised mental health services, for example the Refugees As Survivors (RAS) centre. However, a disadvantage of parallel services is that nurses in main stream services lose the opportunity to develop specialised skills for working with cultures other than their own.

Case management

Case management originated in the United States in the 1980’s in the context of deinstitutionalisation, normalisation and the development of community mental health centres (Sledge, Astrachan, Thompson, Rakfeldt & Leaf, 1995; Willis & Morrow, 1995). It was seen as a way of improving the connections between services and linking both clinical and rehabilitation services together to ensure that “severely mental ill” clients received adequate services (Sledge, et al. 1995). Versions of case management are used in New Zealand although little has been written about the experience locally. Universal agreement has not been achieved regarding the scope of practice of case managers and the level of education required. The assumption that nurses are the most suitable group to provide case management services is being challenged by the emergence of support work services and parallel ethnic mental health teams.

Role change

Yegdich and Quinn (1996) have observed that the role of nurses has extended with the move from institution to community. Needs of clients now include housing, income, employment and social networks. However, an audit of community services in Auckland found that the dominant activity of nurses was crisis intervention (Yegdich & Quinn, 1996). Support work services have evolved in recognition of the gaps in community care provision. This movement to the community has also resulted in an increased emphasis on tertiary prevention, rehabilitation and recovery. New postgraduate training courses in mental health nursing have been developed as a result of a growing dissatisfaction with comprehensive nurse training and what is seen as inadequate preparation for working in this area (Ministry of Health, 1996). This is also important from a case management perspective particularly as broader skills are necessary for this role, for example knowledge of community resources.

Changing relationship with consumers

The consumer movement is influencing the movement of mental health service delivery from a medical to psychosocial rehabilitation model (Worley, 1997). New opportunities have arisen for consumers to interact with policy makers, professionals and others from a position of strength. Consumer operated programmes and initiatives have been developed due to the dissatisfaction with clinical mental health services. Consumers have found consumer-staffed organisations more empathetic, tolerant and understanding because of their own struggles with psychiatric disability (Worley, 1997). Consequently, guidelines have been developed as a result of increased consumer participation in professionally run mental health agencies (Ministry of Health, 1995). This has also led to changes in relationships between consumers and professionals. There is growing recognition on the part of professionals of the value of experiential knowledge and what consumers have to offer other consumers.

Safety and extended roles

  • Assessment by a nurse is required to detect changes in the mental state of a client. Where a support worker is the predominant contact, changes may be missed particularly if they have no clinical experience or assessment skills. In an article about extended roles, Rieu (1994) stated that discussion about accountability (“professional” and “legal”) and competency is needed. Other questions that need to be addressed include:
  • What preparation and training are support workers given?
  • What supervision do they get and how are they regulated?
  • How well are they resourced and supported?
  • Is their scope of practice clearly defined?


Recognising the strengths of support workers

Support workers are seen as filling the gaps in community care, particularly in terms of work with clients with complex needs not met within the reductionist medical model (Davies, Harris, Roberts, Mannion, McCosker & Anderson, 1996). Other advantages include breaking the barrier of client-worker distance, providing a bridge between clients and mainstream staff and providing a role model for clients of similar background (Davies et al., 1996). Studies have shown that support workers are considered more effective than health professionals for several groups with varying mental health needs (Davies et al., 1996; Grant, Ernst, Streissgut, Phipps & Gendler, 1996). These include abused women, who have viewed the health system as sexist, fragmented and professionals as judgemental and insensitive (Davies et al., 1996). Other studies have shown that chronically drug-dependent women have become distrustful of “helping” agencies and in turn many professionals see these women as a hopeless population (Grant et al., 1996). They describe an advocacy model of case management using support workers, who worked intensively with women, who used drugs or alcohol heavily during their pregnancies and were alienated from community services. This alienation increased the risk of delivering children with serious medical, developmental and behavioural problems. It also prevented them from seeking assistance from agencies that were designed to help them. These ‘advocates’ were support workers experienced in social services with high-risk populations, had a variety of life experiences and came from a similar cultural background to their clients. They were seen as positive role models, providing hope and motivation. It was found after one year that clients now engaged with treatment agencies, decreased drug use, increased use of birth control and increased their involvement with supportive and skill building groups, such as parenting classes (Grant, et al., 1996).

Training and education of nurses

Nursing training must incorporate concepts such as recovery and consumer perspectives. Nurses need to be supported to work as case managers and build on their roles as more than adjuncts to the medical model. Mental health nurses working in the community must clarify their current roles and define what pathways they will follow.

Diversity in the workforce to provide culturally appropriate services

Reviews have shown that there are a paucity of culturally safe services for Maori and Pacific people (Ministry of Health, 1997). Furthermore, the provision of resources and devolution of resources have not supported other views of mental illness (Mental Health Commission, 1996). “Moving Forward” (Ministry of Health, 1997) national objectives states more trained mental health workers are needed before culturally appropriate services can be provided by mainstream and kaupapa Maori mental health services. A better partnership is needed between education and health sectors so that training can be specifically targeted to Maori. The Pacific Island objective also recommends that work be done so that mental health services become more responsive to the diverse needs of Pacific peoples. The national objectives recommend educating consumers as providers, community support workers and Maori and Pacific Island workers.

Better cooperation with ethnic support workers

In an Australian article, Fuller (1995) argued that health care practices by professionals continue to be predominantly monocultural despite recognition of the need to be responsive to the culturally diverse population. Fuller added that different ethnic groups practice illness prevention and health promotion differently. Some prefer direct, practical and immediate assistance from the Western care system rather than long term strategies. Fuller argued that nurses could not attain all the necessary cultural knowledge to provide total care to clients without a partnership with cultural intermediaries. According to Fuller, this expectation would result in lists of stereotypical traits being produced rather than an improved understanding of clients individual needs. Fuller added that the values and assumptions of primary nursing with contradictory notions of empowerment and autonomy have resulted in rigid professional boundaries which restrict multi-disciplinary team work, thereby increasing the need for an ethnic support worker.

Alternative structures and models

The Ministry of Health (1997) recommends that mental health promotion and prevention for Maori and Pacific Islanders be strengthened. They suggest using traditional (Pacific and New Zealand) structures to promote mental health including circulating Pacific language descriptions of key western mental illnesses. In addition, the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996) suggested that Maori consumers become integrated into the provider culture of mental health services, so services reflect the wealth of Maori consumer experience. This is in line with the request by Maori consumers to have more Maori community support workers, patient advocates and crisis teams. This leads on to the next area for discussion about who can best provide services for those with mental health needs. Takeuchi, Mokuau & Chun (1992) found that the establishment of parallel services improved mental health for minorities and led to an increase in their use.

Multiskilled, multidisciplinary and comprehensive

According to Øvretveit (1993), it is rare that one profession alone is able to meet the needs of a person with a social or health need. Usually the skills and knowledge of a range of specialists are beneficial and coordination is crucial to prevent costs of duplication and staff frustration. This is echoed by the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996). It suggests that the best way to deliver mental health services to consumers is by having a team of multi-skilled and multi disciplinary workers. This team would be able to address the many facets of care required by sufferers of mental illness and would include community support workers as well as Maori and Pacific Island workers. “Moving Forward’s” National objectives are to increase the Maori and Pacific Island mental health workforce. In addition, a flexible system is required where a case manager might need to spend more time with someone as the nature of mental illness changes rapidly.

A proposed model of cooperation

The mental health of consumers will be maximised if professionals and support workers are able to work in partnership and combine their skills, knowledge, life experience and expertise in a coordinated way. This would ensure that services are respectful, relevant, flexible, responsive and effective and that they are available to consumers to reduce the barriers that prevent them from achieving their full health potential. The framework for community service delivery for people with mental health problems needs to be comprehensive, health promoting and collaborative; a partnership that is committed to client empowerment and the elimination of barriers to access (Association of Ontario Health Centres, 1994).


Several recommendations are proposed:


  • Adopt protocols for networking within all services so that inter-agency cooperation is maximised and clients receive a seamless service.
  • Improve the interface between clinical, cultural and psychosocial models to increase understanding and collaboration from both perspectives.


  • Educate support workers to understand the role of the nurse but not to the extent that traditional healing structures are negated in favour of psychotherapeutic methods.
  • Formalise traditional roles into the mental health system, for example the role of Kaumatua (Street & Walsh, 1996).
  • Train nurses in cultural and psychosocial models.

Role and Scope of practice

  • Develop job descriptions for support workers in cooperation with nurses to prevent role ambiguity, promote job satisfaction and decrease discontent.
  •  Support and safeguard support workers to ensure that their role does not compromise the safety of clients and staff or the role of the nurse.
  • Use nurses appropriately and ensure that they are not substituted by support workers for fiscal or political reasons.
  • Define core competencies for support workers at a national level and ensure on-going monitoring of standards.

Alternatives to the medical model

  • Recognise that the clinical model has limitations and cannot meet the needs of all clients.
  • Increase familiarity with alternative models of mental health amongst nurses, for example recovery and cultural models.
  • Review and clarify the role of nurses working in mental health.

Cultural safety 

  • Acknowledge the importance of spiritual issues, land rights, whanau reconstruction and physical health (Street & Walsh, 1996).
  • Resource nurses appropriately for the cultural component of their work.
  • Involve nurses in developing appropriate policy and healthcare services to Maori and ethnic minorities in New Zealand (Street & Walsh, 1996).
  • Familiarise nurses with the work of ethnic mental health workers and Maori support work services.

Consumer participation/consumer focused

  • Recognise the experiential and personal knowledge of consumers.
  • Ensure that consumers are key players in planning and accountability structures which are linked to outcome measures.


This paper has shown how support workers can reach clients who are lost to or fearful of the mental health system, whether this is because of social, ethnic or cultural reasons. In an evolving mental health system moving from institutionalisation to community-based care, these new roles provide a bridge between the clinician and the consumer. No one group can meet all the needs of consumers. Support workers can widen the focus of the mental health system in a way that better meets the needs of clients in the community at large, whatever their background. Friction has existed between nurses and support workers, the former often viewing the latter as eroding their role and of being unskilled. Alternatively support workers have sometimes viewed nurses as part of a system that they see as having failed them. Support workers are seen by some as being a political solution to eroded health care funding. Although there are several issues requiring on-going discussion, not least the legal and ethical requirements for support workers and their regulation, a synergy exists between nurses and support workers and together they can provide complimentary services to improve client care. For this to be successful a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. A guiding framework of principles for working in harmony should be developed.


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Fuller, J. (1995). Challenging old notions of professionalism: how can nurses work with paraprofessional ethnic health workers? Journal of Advanced nursing, 22, 465-472.

Grant, T.M.; Ernst, C.C.; Streissgut, A.P.; Phipps, P.& Gendler, B. (1996).When case management isn’t enough: a model of paraprofessional advocacy for drug and alcohol abusing mothers. Journal of Case Management, 5, 1, , 3-11.

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