Image Counts— Greeting Cards Mail It in When It Comes to Accurately Portraying Nurses

By Linda S. Smith, RN, MS, DSN, and her senior nursing students, Oregon Health and Science University,
Klamath Falls Campus
October 01, 2003

Patient Dave Jackson* was in the hospital for three days following a car accident. Dave, 28 and single, had many friends stop in and leave him get-well cards as reminders of their hospital visits. When I entered Dave’s room to give him his meds, Dave grinned and naughtily paraphrased the words he had just read on one of his cards: “Nurse, are you coming in to give me one of those famous sponge baths? If you are, I’m ready!”

In shock, I looked down at the newest card on his nightstand. There, with plenty of cleavage, a miniature white uniform and cap, black heals, and black mesh hose, was this young fashion doll nurse rhetorically asking, “Are you ready for your sponge bath?”

We have all seen similar greeting cards, and as healthcare professionals, we have all felt violated and offended by such portrayals. More than mere professional offense, however, we need to be concerned about the impact these greeting card images have on the nurse-patient relationship and ultimately, patient health outcomes.

My senior baccalaureate nursing students at Oregon Health & Science University (OHSU) School of Nursing on the Klamath Falls campus researched the greeting card images of nurses as part of their research in nursing practice course. This course project, to which each class member contributed, was an original, theory-based research study. For this investigation, students described and compared nurse images as represented on paper and Internet greeting cards with each card type and with the current reality of professional nursing.

Greeting cards that portray nursing images, whether paper or online, are media representations. Media images of nurses affect public perception of the professional role and expected behaviors of members of the nursing profession. Therefore, realistic images facilitate goal-oriented, patient-centered health outcomes in alignment with King’s Theory of Goal Attainment. We expected, however, that nurse images portrayed on greeting cards would differ from reality and each other.

The Theory Behind the Study

King’s Theory of Goal Attainment established the theoretical basis for our comparative, descriptive study. Patients’ preidentified perceptions of the nurse impact the nurse-patient relationship. Therefore, interactions taking place within the nurse-patient relationship will be affected by the patient’s prior bias or preconceived ideas of nurses and nursing.1

“The greater the degree of perceptual congruency between nurse and patient related to the illness situation and nursing care required, the greater the degree of goal attainment or satisfaction with nursing care.”2 Thus, whatever perceptions the patient may have about the nurse impacts the way the patient views the nurse. With this theoretical guidance, we assumed that as individuals view media images, those images become part of that person’s perceptions. Moreover, people think and behave on the basis of perceptual information, and nurses and patients establish and maintain relationships based on these perceptions.

Although multitudes of expository articles discussing nursing’s image are available worldwide,3-9 precious little current research has been published in this area although Kalisch and Kalisch published many articles of original research on nursing portrayal in film, television shows, novels, and print media in the early 1980s.

In a study analyzing nursing images in pictorial advertisements located in hospital administration journals (from 1930 to 1950), Lusk found nurses were portrayed as young, female, eager to please, powerless, and without apparent intelligence or critical-thinking abilities.10 Lusk’s work supports the efforts of Kalisch and Kalisch, who reported a better image during the 1940s than in the 1930s or 1950s.11-15 Unfortunately, based on work by Woodhull and Sieber, Powers, Baggs, Knapp, and Sileo, lay media sources, such as newspapers, news magazines, and healthcare industry publications virtually ignore the contributions of nurses.16-17 Thus, they reported, nurses have become invisible.

Why Care About Greeting Card Images?

In her study of “welcome, baby” greeting cards, Wilier found pronounced gender stereotyping between the two groups (boy/girl) of gender-specific cards.18 Dillon and Jones explored attitudes toward aging as inferred on birthday greeting cards.19 They reported that attitudes of the elderly or aging population portrayed on greeting cards were at times offensive, negative, and stereotypical.

In another greeting card study, Finn studied alcohol use portrayed on greeting cards and suggested that because of many humorous themes, consumers may believe alcohol isn’t harmful and could actually be beneficial to one’s physical and psychological health.20 Importantly, Peloquin found that images on greeting cards were persuasive and impactful and capable of mobilizing thoughts and senses of the consumer.21

But are greeting cards that important? Conover, Libbin, and the Greeting Card Association (GCA) identified the following greeting card facts —22-24

  • Women purchase 80% of all cards, and most of these women are between 30 and 65 years old
  • Half of all cards sold are seasonal
  • Each person, on average, receives about 20 cards per year
  • Cards are priced between $0.38 and $10, with an average card cost of between $2 and $4
  • Ninety percent of all US households purchase at least one greeting card a year; the average participating US household purchases 35 individual cards per year
  • American Greetings reported a 15.8% sales increase for 2001
  • The industry generates $7.5 billion in retail sales from consumer purchases of more than 7 billion cards
  • Greeting cards and letters are the primary types of mail people most want to open and thoroughly read
  • Greeting cards are found in about 100,000 US retail outlets
  • According to the GCA, Internet-based cards may actually help increase paper card popularity

More than 2,000 greeting card companies exist, and the two largest greeting card manufacturers are Hallmark and American Greetings. Retail stores report large profit margins from greeting card sales. Clearly, traditional paper cards are still thriving.25

Concurrently, online greetings rose 20% during the 2001 winter holiday season, and in October 2001, American Greetings’ online sites had more than 21 million hits — that is one of every five Internet users.26 At least one Internet-based greeting card is sent monthly by 55% of Internet users, and online greeting cards are the second-most popular form of online entertainment (e-mail jokes and gossip are first).27

In 2001, the Greeting Card Analysis Tool (GCAT) was developed and tested28 by our Oregon nursing students. Tool testing and retesting took place during pilot and implementation phases of that initial study.

Study Methods

Three main strategies were used for obtaining the total sample of nurse-image cards: purchasing the cards through retail stores, writing letters of request to potential greeting card purchasers (requests were made to student groups from all 50 states), and searching the Internet.

Internet greeting cards were acquired by accessing multiple Internet search engines. To reduce duplication and ensure expansive access, student researchers were divided into six groups, each of which had an assigned list of search engines. This list was derived from the most well-known, well-used, and dependable Internet search engines.29 In total, 19 trained researchers spent 58 hours obtaining samples using 30 different search engines and multiple Internet greeting card websites

The GCAT was used in the data analysis of both paper and Internet greeting cards. Three trained researchers rated each card. Importantly, raters achieved a 95% inter-rater agreement level.

Findings

The average cost of a paper card was $2.53, and the most often found theme was “get well.” With a total of 131 units, we found that nurse images were female (94.9%) and Caucasian (99.0%). Nurses wore white uniforms (99%) with caps (92.1%), and when patient gender was able to be determined (51 cards), 92.2% were male. When a patient expression was observed (44 cards) patients showed sadness, fear/anxiety, or wore a frown 57% of the time.

Young nurses (49.6%) were depicted more frequently than middle-aged (35.1%) or older nurses (3.8%). Greeting card units displayed human nurse images 77.9% of the time, with the majority being cartoon forms (87.2%).

Using Chi Square statistical analyses and Statistical Package for the Social Sciences software, significant differences between reality and the following categories were found: age, race, cap, smile (as identified with a yes or no), uniform, uniform color, patient gender, and presence of pronounced secondary sex characteristics on the nurse. Nurse gender was the only category that fairly represented US nurses. Data for expected frequencies was obtained from US Census data,30 the US Department of Health and Human Services,31 and a 13-member expert nurse panel. This panel identified expected frequencies for pronounced secondary sex characteristics, hat, smile, uniform, and uniform color.

Using nonparametric analyses (Mann-Whitney U and Spearman rho), images on the paper and online cards were different in several areas. Paper cards were larger than Internet printouts, paper cards were more likely to have a get-well theme, and Internet cards were more likely to have varied themes. Paper cards were also more likely to show nurse images that were somewhat older and to have more than one nurse image represented on the card. No statistically significant difference between card types was found in the following categories: nurse race; presence of pronounced secondary sex characteristics; nurse expression; presence of hat, smile, uniform; uniform color; gender of nurse image; cartoon caricature of image; if image was portrayed as human; and if a patient was present, and if so, the gender and expression of that patient.

Discussion of Findings

Study findings present a greeting card image that does not represent reality. In 2000, approximately 12.3% of US nurses were of racial/ethnic minority backgrounds. The average age of RNs in America was 45.2 years, and an estimated 5.9% of nurses were male.32

In general, the depiction of the nurse on greeting cards was inconsistent with reality. The representation of this stereotype can negatively affect the nurse-patient relationship and patients’ expectations of professional nurse behavior and care. Patients may expect that their assigned nurse will be young, female, attractive, buxom, and wearing a white uniform, only to have a more realistic, 40-year-old in scrubs caring for them. In addition, patients with negative images (they may perceive nurses as bungling or unintelligent) may believe their nurse is not qualified or competent to provide skilled care. Conversely, patients may avoid contact with nurses. Patients may believe the greeting card image that she will cause fear and anxiety, often threatening to inflict pain while using devices such as syringes, thermometers, or whips.

Misconceptions brought about by nurse images depicted on greeting cards could adversely influence the patient’s behavior, health outcomes, the nurse-patient relationship, and recruitment into the profession. Nurses must aggressively try to change the stereotype depicted on greeting cards.

What Can We Do?

It became apparent that the image presented by the collected cards was one of disrespect and distortion. Disguised as humor, this disrespect and lack of understanding echoes back to the hard, commanding, uncaring image of Nurse Ratched in the movie One Flew Over The Cuckoo’s Nest. Or, in contrast, the young, overly sexy, and less-than-astute antics of the sitcom nurses of Nightingales (1989). The sum of these investigations confirms an ongoing detrimental distortion of the function and image of the nurse.

Nursing curricula should include an exploration of the nurse’s character based upon the Code of Ethics for Nurses and how that character and role differs from public perception. Thus armed, we students and graduates can passionately demonstrate to patients, communities, and media the true nature and image of the nurse. By being conscious of the manner in which we represent the profession, we can foster our professional image and the profession of nursing.

The best way to educate is by example. This exemplification must start with us. Joining together, we can foster a public awareness of the true image of nursing. Our joining together could take the form of American Nurses Association, regional or state nursing organizations, or two nurses talking. We also must reach out to media sources when nurses are misportrayed.

We recommend that results from this research investigation be used as the basis for targeted action aimed at improving communication among nurses, communities, and media sources. We suggest mentoring youth to promote a positive image of the nurse, possibly through a shadowing program or panel presentations.

We further suggest the formation of action groups to monitor media images on local, regional, national, and international levels. When media portrayals are established to be incongruent with reality, letter-writing campaigns, telephone trees, and perhaps even product boycotts can be implemented. Members of these committees would be proactive in their endeavors to facilitate a positive image and future for nurses and nursing. It will take all of our combined efforts to defeat incongruent media portrayals of our beloved nursing profession and us.

*Name has been changed.

Linda S. Smith, RN, MS, DSN, is an assistant professor at Oregon Health & Science University, Klamath Falls Campus. She wrote this article with help from her senior nursing students.

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