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 21 April 2005

Correspondence:

Miyuki Takase,

School of Nursing,

Deakin University/Cabrini Hospital,

183 Wattletree Road,

Malvern,

Victoria 3144,

Australia.

E-mail: m.takase@pgrad.unimelb.edu.au

TAKASE M., MAUDE P. & MANIAS E. (2006)TAKASE M., MAUDE P. & MANIAS E. (2006) Journal of Advanced Nursing

53(3), 333–343

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 346 Australian nurses participated in a ques-

tionnaire study in 2003. 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 self-

image relating to leadership aptitude. On the contrary, the relationship between self-

image and perception of the public image as being caring predicted job performance.

When nurses perceived their public image as caring less positively than their self-

image, 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

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 333

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 1994, Tomey et al. 1996, Rossiter et al.

1998, Hemsley-Brown & Foskett 1999, Tang et al. 1999).

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 2001). A poor public image of nursing may

affect not only nursing recruitment, but also nurses’

attitudes towards work (Takase et al. 2002). 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 investi-

gate 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 1984, Walsh & Holland

1992). 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 1984, Walsh

& Holland 1992). 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 1962, Dawis &

Lofquist 1984).

A hypothesized model illustrating the relationship between

the person–environment fit and job performance is illustrated

in Figure 1. 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 1, 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 perform-

ance shows a downwards curve, suggesting nurses’ job

performance becomes lower when they perceive a greater

image misfit (Edwards & Parry 1993).

As for the relationship between image fit and turnover

intention, the curvilinear relationship illustrated in Figure 1 is

–2·5

–1·5

–0·5

0·5

1·5

2·5

–2·5

–2–1

·5–1

–0·5 0

0·5 1

1·5 2

2·5

0

1

2

3

4

5

6

Job

perf

orm

ance

Public image (x-axis)

Self-image(y-axis)

Figure 1 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 1993). The straight line in the xy-plane illustrates the Y ¼ X

line, while the dotted line illustrates the Y ¼ �X line.

M. Takase et al.

334 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

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 2) (Edwards &

Parry 1993).

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 charac-

teristics and employees’ vocational interests (Fritzsche et al.

1999, Ton & Hansen 2001), and between employees’ work

values and organizational culture (O’Reilly et al. 1991,

Livingstone et al. 1997, Edwards 2002). 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. (2001) 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 (1992) 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

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 2001). 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 b0 þ b1(E � P) þ e ¼b0 þ b1E � b1P þ e, where Z represents a dependent vari-

able, E for an environmental factor and P for an employee’s

factor. According to Edwards (2001), 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 2003.

Participants

The study participants were a convenience sample of 943

Registered Nurses who had completed a 3 -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-

–2·5

–1·5

–0·5

0·5

1·5

2·5

–2·5

–2–1

·5–1

–0·5 0

0·5 1

1·5 2

2·5

0

1

2

3

4

5

6

Turn

over

inte

ntio

n

Public image (x-axis)

Self-image (y-axis)

Figure 2 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 1993). The straight line in the xy-plane illustrates the Y ¼ X

line, while the dotted line illustrates Y ¼ �X line.

Nursing and healthcare management and policy Impact of the perceived public image of nursing

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 335

naires were sent to a large number of nurses in order to

obtain a minimum of 300 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 self-

addressed reply-paid envelope. For the university group, we

visited classrooms with the permission of subject coordina-

tors 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 1991). The original

Porter Scale consists of 30 matched-pair, bipolar adjectives,

which are rated on a seven-point semantic differential scale.

To reduce the time needed to answer the questionnaire,

17 single/unipolar adjective items from the scale were

administered to participants. Twelve items measured leader-

ship 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

1999), 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. 1984). 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. 1984). The questionnaire was then pilot-

tested with 16 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 institu-

tions. All participants received a letter explaining the purpo-

ses 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 (2002) are as follows.

Polynomial regression analysis began with identifying the

regression equation for the hypothesized model. As shown in

Figures 1 and 2, the hypothesized models involve a curvilin-

ear 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

M. Takase et al.

336 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

OP ¼ b0 � b1ðPI � NIÞ2 þ e; ð1Þwhere organizational job performance is represented as OP,

perceived public image as PI, nurses’ self-image as NI, the

coefficients as b (b0 is a constant), and the unexplained error

as e. Expanding this equation gave the following:

OP ¼ b0 � b1PI2 þ 2b1PI � NI � b1NI2 þ e: ð2Þ

This expanded equation was compared with a general

(unconstrained) quadratic equation:

OPðor TIÞ¼ b0 þb1PIþb2NIþb3PI2 þb4PI�NIþb5NI2 þ e: ð3Þ

It was identified that the coefficients in equation 3 must

meet the following assumptions (constraints) in order to

correspond to equation 2: (1) b1 ¼ 0; (2) b2 ¼ 0; (3) b3 ¼ b5

and b3 and b5 are negative; and (4) b3 þ b4 þ b5 ¼ 0.

The equation predicting turnover intention (represented as

TI) was:

TI ¼ b0 þ b1ðPI � NIÞ2 þ e

¼ b0 þ b1PI2 � 2b1PI � NI þ b1NI2 þ e: ð4Þ

Comparing equation 4 with equation 3, the same four

assumptions in equation 2 were identified, except that b3 and

b5 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 3) was

entered for regression analysis. In this analysis, an explorat-

ory 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. PI2, PI · NI and NI2) 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 exam-

ination 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 2 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. PI3, PI2 · NI, PI · NI2, NI3) were added to the regres-

sion analysis to determine whether the relationship was truly

quadratic, but not cubic in nature. To support the hypothe-

ses, these cubic terms should be rejected.

Response surface analysis was conducted to further exam-

ine whether the curvilinear relationships identified by poly-

nomial regression analysis would fit the hypothesized model

illustrated in Figures 1 or 2. The detailed procedures of the

analysis are described by Edwards (2002) and Edwards and

Parry (1993).

Focus group

Focus group data were analysed using the framework meth-

od, which involved becoming familiar with the data through

listening to the tape and reading transcriptions, identifying a

thematic framework, indexing the transcription in accord-

ance with the thematic framework, charting the index/sub-

index, and interpreting the data (Ritchie & Spencer 1994).

Results

A total of 346 questionnaires were returned, which repre-

sented a response rate of 36Æ7%. The demographics of the

survey participants are presented in Table 1.

The reliability of the instruments, means of the variables,

and results of the t-test are presented in Table 2. Nurses rated

their overall self-image statistically significantly more posi-

tively than how they believed the public viewed them. This

difference was more prominently observed in leadership

aptitudes. As shown in Figure 3, 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 percep-

tion of the public image. In fact, respondents rated their

public image slightly more positively than how they perceived

themselves (Figure 4).

Table 3 presents the results of polynomial regression

analysis. As for leadership aptitudes, the unconstrained

monotonic models explained the statistically significant var-

iances 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 perform-

ance can be predicted by a linear relationship with their self-

image as having leadership aptitudes. Their turnover intention

can be predicted by linear relationships with both their self-

image and the perception of their public image as leaders.

Nursing and healthcare management and policy Impact of the perceived public image of nursing

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 337

With reference to caring aptitudes, the unconstrained

monotonic model explained the statistically significant vari-

ance with their turnover intention. However, the quadratic

terms did not add a statistically significant variance to the

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 relation-

ship with nurses’ caring aptitudes and their perception of the

public image of nurses as being caring. As shown in Table 3,

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 signi-

ficant. However, the coefficient on the quadratic term of

the perceived public image was insignificant, and all the

Table 1 Demographics of survey participants

Characteristic Percentage (n)

Gender

Female 92Æ7 (316)

Male 7Æ3 (25)

Work status

Full-time (‡35 hour/week) 58Æ9 (201)

Part-time (<35 hour/week) 41Æ1 (140)

Age (mean) 33Æ6 years

(range 21–68,

SDSD ¼ 9Æ43)

Currently studying or have completed postgraduate courses

Yes 67Æ9 (226)

No 32Æ1 (107)

Have a diploma 11Æ7 (39)

Have a degree 20Æ4 (68)

Clinical specialty

Critical (including intensive care unit,

emergency, cardiology, coronary care unit)

34 (117)

Medical/surgical 27Æ8 (96)

Chronic (including aged care, mental,

palliative and oncology)

19Æ4 (67)

Paediatric 5Æ8 (20)

Others 13Æ1 (44)

Clinical position

Clinical staff 90Æ4 (312)

Others (including nurse unit manager) 9Æ6 (33)

The total sample size ranges from 333 to 345 because of missing

values.

Table 2 Reliability of the instruments, the means and the results of

the t-test

Variables Reliability Mean (SDSD) t-test

Overall image

Nurses’ self-image 0Æ89 4Æ96 (0Æ51) t(343) ¼ 13Æ22

Perceived public image 0Æ91 4Æ48 (0Æ68) P < 0Æ001

Leadership aptitudes

Nurses’ self-image 0Æ87 4Æ88 (0Æ55) t(343) ¼ 16Æ46

Perceived public image 0Æ91 4Æ17 (0Æ79) P < 0Æ001*

Caring aptitudes

Nurses’ self-image 0Æ85 5Æ16 (0Æ66) t(343) ¼ �1Æ29

Perceived public image 0Æ88 5Æ22 (0Æ70) P > 0Æ05*

Organizational job

performance

0Æ81 5Æ09 (0Æ58) –

Turnover intention 0Æ79 2Æ37 (1Æ06) –

n ¼ 343 due to system missing.

*The significance level was adjusted by the sequential Bonferroni

procedure to control type I error (Holland & Copenhaver 1988).

1

1·5

2

2·5

3

3·5

4

4·5

5

5·5

6

Lead

er

Intell

igent

Logic

al

Indep

ende

nt

Profes

siona

l

Confid

ent

In co

ntrol

Compe

tent

Ration

al

Power

ful

Respo

nsibl

e

Organ

ised

Perceived public imageNurses' self-image

Figure 3 Comparison of respondents’ self-image and their perception

of the public image of them as having leadership aptitude.

1

1·5

2

2·5

3

3·5

4

4·5

5

5·5

6

War

m

Nurtur

ing

Patien

t

Compa

ssion

ate

Respe

ctful

Perceived public imageNurses' self-image

Figure 4 Comparison of nurses’ self-image and their perception of

the public image of nurses as having caring aptitude.

M. Takase et al.

338 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

coefficients on the quadratic terms had opposite signs to those

identified in equation 2. The patterns of these coefficients did

not follow the hypothesized model. In fact, the constraints

were rejected [F(4, 325) ¼ 18Æ14, P < 0Æ01] when they were

imposed on the unconstrained quadratic model. The cubic

terms were also rejected [F(4, 321) ¼ 1Æ32, P > 0Æ05]. 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 be-

tween 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’ self-

image and their perceived public image was made in a way

that the scores ranged from �2Æ5 to þ2Æ5, 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 1. Figure 5

shows that the surface along the Y ¼ X line was positively

sloped (ax ¼ 0Æ54) and its curvature is a2x ¼ �0Æ02. Yet,

response surface analysis shows that this slope and curva-

ture were not statistically significantly different from 0,

indicating that the surface along the Y ¼ X line is flat and

linear. This result supports the hypothesized model, sug-

gesting that nurses’ performance would be constant when

they perceived the image fit. In contrast, the curvature along

Y ¼ �X line is upwards curved (a2x ¼ 0Æ51, P < 0Æ05),

instead of downwards, as illustrated in Figure 1. This

upwards curvature suggests that respondents tended to

perceive their organizational job performance positively

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

Table 3 Results of polynomial regression analysis

Relationships

The first step: monotonic

model (B) The second step: unconstrained quadratic model (B) Change in R2 from

first to second

step (F-change).PI NI R2 PI NI PI2 PI · NI NI2 R2

Leadership aptitudes and

job performance

0Æ04 0Æ59** 0Æ28** 0Æ10 0Æ53** 0Æ02 �0Æ08 0Æ05 0Æ29** F(3, 326) ¼ 0Æ27

Caring aptitudes and

job performance

0Æ16** 0Æ29** 0Æ15** 0Æ30** 0Æ21 0Æ02 �0Æ26** 0Æ23** 0Æ19** F(3, 325) ¼ 4Æ63*

Leadership aptitudes and

turnover intention

�0Æ22** �0Æ33** 0Æ07** �0Æ23 0Æ36 �0Æ03 �0Æ02 0Æ02 0Æ07** F(3, 326) ¼ 0Æ07

Caring aptitudes and

turnover intention

�0Æ33** �0Æ47** 0Æ15** �0Æ46** �0Æ73** 0Æ00 0Æ20 0Æ09 0Æ16** F(3, 324) ¼ 1Æ03

PI, perceived public image; NI, nurses’ self-image.

*P < 0Æ05; **P < 0Æ01. The significance level was controlled by the sequential Bonferroni procedure.

n ¼ 330–332. 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’ self-

image and their perception of the public image of nurses. Thus, the scales range from �4Æ5 to þ1Æ5 in this analysis.

–2·5–1·5

–0·50·5

1·5

2·5

–2·5–1·5

–0·50·5

1·52·5

0

1

2

3

4

5

6

7

8

Job

perf

orm

ance

Public image: caring (x-axis) Self–image: caring (y-axis)

Figure 5 Relationship between respondents’ self-image and their

perceived public image of nurses as being caring and nurses’ organ-

izational job performance. This figure is based on the result of pol-

ynomial 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 �2Æ5 to

þ2Æ5, to make the comparison between Figures 1 and 5 easier.

Nursing and healthcare management and policy Impact of the perceived public image of nursing

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 339

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 0–2Æ5 in both nurses’ self-

image 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

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 (2000) 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 profession-

als (Lewis & Urmston 2000, Buchanan & Considine 2002).

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 2000 health-related

articles from 16 news publications (Sigma Theta Tau

International 1998).

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. 1995,

Greenwood 1999) 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

32·82·62·42·2

21·81·61·41·2

10·80·60·40·2

00·2 0·4 0·6 0·8 1 1·2

Public image: caring (x-axis)

Sel

f-im

age:

car

ing

(y-a

xis)

1·4 1·6 1·8 2 2·2 2·4 2·6 2·8 3

Figure 6 Contour plot: magnification of Figure 5 in the positive

ranges along the X and Y axes. The actual positive scores range from

0 to 2Æ5. The thick line represents the bottom line of the upwards

curvature in this range. The thick dotted line represents the Y ¼ X

line.

M. Takase et al.

340 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

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 prepar-

ing themselves for their future career (Hemsley-Brown &

Foskett 1999, Tang et al. 1999). 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 (2000) 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 rela-

tionship between them was curvilinear, although the hypo-

thesized 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 per-

formance 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

an important aspect of nursing, not only for nurses (March &

McPherson 1996, Watson et al. 1999), 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. 1998, Hemsley-Brown & Foskett

1999, Tang et al. 1999). Hospitals also use quality nursing

care in their promotional materials to attract many patients

(Powers 2001). Indeed, one of the participating hospitals

cited patients’ satisfaction with their nurses being courteous

and compassionate in their report (Barwon Health 2003).

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 stereotyp-

ical beliefs about their group. This fear causes stress, and

leads to low performance (Steele 1997). Rather than being

pressured not to reinforce a negative image of nursing, nurses

in this study may have felt pressured to confirm the well-

regarded 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 partic-

ularly true for those who rated their self-image highly, but

also rated their public image negatively. The person–envi-

ronment fit theory maintains that when individuals experi-

ence the misfit, they may reduce their job performance or be

motivated to change either themselves or the environment to

avoid the misfit (French & Kahn 1962, Dawis & Lofquist

1984). 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 suppor-

ted 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 1990, Donovan 2002).

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

Nursing and healthcare management and policy Impact of the perceived public image of nursing

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 341

seen more strongly in employees who tend to be hard-

working, self-disciplined (Simmering et al. 2003) and moti-

vated (Tatum & Nebeker 1995). 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 perform-

ance. 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.

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.

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 (2003) 2002/03 Quality of Care Annual Report.

Barwon Health, Geelong, Victoria, Australia.

Buchanan J. & Considine G. (2002) Stop Telling Us to Cope: New

South Wales Nurses Explain Why They Are Leaving the Profes-

sion. Retrieved from http://www.nswnurses.asn.au/documents/

3240/extract on 15 November 2005.

Buresh B. & Gordon S. (2000) From Silence to Voice: What Nurses

Know and Must Communicate to the Public. Canadian Nurse

Association, Ottawa.

Dawis R.V. & Lofquist L.H. (1984) A Psychological Theory of Work

Adjustment. University of Minnesota Press, Minneapolis.

DeVries S., Dunlop M., Goopy S., Moyle W. & Sutherland-Lock-

hart D. (1995) Discipline and passion: meaning, masochism and

mythology in popular medical romances. Nursing Inquiry 2, 203–

210.

Donovan J.J. (2002) Work motivation. In Handbook of Industrial,

Work and Organisational Psychology: Volume 2. Organisational

Psychology, 2nd edn (Anderson N., Ones D.S., Sinangil H.K. &

Viswesvaran C., eds), SAGE Publications, London, pp. 53–76.

Edwards J.R. (2001) Ten difference score myths. Organisational

Research Methods 4(3), 265–287.

Edwards J.R. (2002) 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. 350–400.

Edwards J.R. & Parry M.E. (1993) On the use of polynomial

regression equations as an alternative to difference scores in

organisational research. Academy of Management Journal 36(6),

1577–1613.

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.

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 perform-

ance tends to improve.

M. Takase et al.

342 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

French J.R.P. Jr & Kahn R.L. (1962) A programmatic approach to

studying the industrial environment and mental health. Journal of

Social Issues 18(3), 1–47.

Friedman I.A. & Harber B.A. (1992) Professional self-concept as a

predictor of teacher burnout. Journal of Educational Research

86(1), 28–35.

Fritzsche B.A., Powell A.B. & Hoffman R. (1999) Person–environ-

ment congruence as a predictor of customer service performance.

Journal of Vocational Behaviour 54, 59–70.

Goodman S.A. & Svyantek D.J. (1999) Person–organisation fit and

contextual performance: do shared values matter? Journal of

Vocational Behaviour 55, 254–275.

Greenwood J. (1999) ‘All Saints’ or ‘Nurse as Enquire’? An irritable

polemic. Contemporary Nurse 8(4), 128–135.

Hemsley-Brown J. & Foskett N.H. (1999) Career desirability: young

people’s perceptions of nursing as a career. Journal of Advanced

Nursing 29(6), 1342–1350.

Holland B.S. & Copenhaver M.C. (1988) Improved Bonferroni-type

multiple testing procedures. Psychological Bulletin 104(1), 145–

149.

Kernan M.C. & Lord R.G. (1990) Effects of valence, expectancies,

and goal-performance discrepancies in single and multiple goal

environments. Journal of Applied Psychology 75(2), 194–203.

Lewis M. & Urmston J. (2000) Flogging the dead horse: the myth of

nursing empowerment. Journal of Nursing Management 8, 209–

213.

Livingstone L.P., Nelson D.L. & Barr S.H. (1997) Person–environment

fit and creativity: an examination of supply-value and demand-

ability versions of fit. Journal of Management 23(2), 119–146.

March P.L. & McPherson A. (1996) The important attributes of

a nurse from the perspective of qualified and student nurses.

Journal of Advanced Nursing 24, 810–816.

Mowday R.T., Koberg C.S. & McArthur A.W. (1984) The psy-

chology of the withdrawal process: a cross-validational test of

Mobley’s intermediate linkages model of turnover in two samples.

Academy of Management Journal 27(1), 79–94.

Nurse Recruitment and Retention Committee (2001) Final Report.

Department of Human Services, Policy and Strategic Project

Division, Melbourne, Victoria.

O’Reilly C.A. III, Chatman J. & Caldwell D.F. (1991) People and

organisational culture: a profile comparison approach to assessing

person-organisation fit. Academy of Management Journal 34(3),

487–516.

Porter R.T. & Porter M.J. (1991) Career development: our profes-

sional responsibility. Journal of ProfessionalNursing7(4), 208–212.

Powers P. (2001) The image of nursing in hospital promotional

materials: a discourse analysis. Scholarly Inquiry for Nursing

Practice: An International Journal 15(2), 91–108.

Reiskin H. & Haussler S.C. (1994) Multicultural students’ percep-

tions of nursing as a career. IMAGE: Journal of Nursing Schol-

arship 26(1), 61–64.

Ritchie J. & Spencer L. (1994) Qualitative data analysis for applied

policy research. In Analysing Qualitative Data (Bryman A. &

Burgess R.G., eds.), Routledge, London, pp. 173–194.

Rossiter J.C., Bidewell J. & Chan P.T. (1998) Non-English speaking

background high school students’ attitudes towards the nursing

profession. Journal of Advanced Nursing 27, 604–613.

Sigma Theta Tau International (1998) The Woodhul Study on

Nursing and the Media: Health Care’s Invisible Partner. Centre

Nursing Press, Indianapolis, IN.

Simmering M.J., Colquitt J.A., Noe R.A. & Porter C.O.L.H. (2003)

Conscientiousness, autonomy fit, and development: a longitudinal

study. Journal of Applied Psychology 88(5), 954–963.

Steele C.M. (1997) A threat in the air. American Psychologist 52(6),

613–629.

Takase M., Kershaw E. & Burt L. (2001) Nurse–environment misfit

and nursing practice. Journal of Advanced Nursing 35(6), 819–

826.

Takase M., Kershaw E. & Burt L. (2002) Does public image of nurses

matter? Journal of Professional Nursing 18(4), 196–205.

Tang K.C., Duffield C., Chen J., Choucair S., Creegan R., Mark C. &

Lesley G. (1999) Nursing as career choice: perceptions of school

students speaking Arabic, Serbo-Croatian, Spanish, Turkish or

Vietnamese at home. Australian Health Review 22(1), 107–121.

Tatum B.C. & Nebeker D.M. (1995) Effects of system control and

feedback variability on job performance and affective reactions.

Human Performance 8(4), 297–325.

Tomey A.M., Schwier B., Marticke N. & May F. (1996) Students’

perceptions of ideal and nursing career choices. Nursing Outlook

44(1), 27–30.

Ton M.N. & Hansen J.C. (2001) Using a person–environment fit

framework to predict satisfaction and motivation in work and

martial roles. Journal of Career Assessment 9(4), 315–331.

Walsh W.B. & Holland J.L. (1992) A theory of personality types and

work environments. In Person–Environment Psychology: Models

and Perspectives (Walsh W.B., Craik K.H. & Price R.H., eds),

Lawrence Erlbaum Associates, Publishers, Hillsdale, NJ, pp. 35–

69.

Waltz C., Strickland O.L. & Lenz E.R. (1984) Measurement in

Nursing Research, 2nd edn. F.A. Davis Company, Philadelphia,

PA.

Watson R., Deary I.J. & Lea A. (1999) A longitudinal study into the

perceptions of caring and nursing among students nurses. Journal

of Advanced Nursing 29(5), 1228–1237.

Nursing and healthcare management and policy Impact of the perceived public image of nursing

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 343