Raising Nursing's Voice Beyond a Global Pandemic.

Previously I reported on the World Health Organization's (WHO) goal to elevate the visibility, voice and importance of nurses’ work and the profession during the 2020 International Year of the Nurse and Midwife. Soon after, a deadly coronavirus pandemic emerged to engage our world in a most frightening way. In response to pandemic stress placed on the profession, the WHO extended its Year of the Nurse and the Midwife into a second year and further proclaimed 2021 the International Year of Health and Care Workers.

During the first wave of Covid-19 cases encountered in the United States (US) in early 2020, nurses became more visibly present in the media as never experienced before on camera, in print, and online. This shift represented a remarkable change in the nursing profession's public exposure. The willingness of many to give interviews and explain the challenges of nursing during the pandemic fueled newfound media exposure and served to showcase nurses as invaluable, skilled, and highly educated expert clinicians who willingly risk personal harm to serve the public in diverse healthcare settings. While media outlets widely reported on infection rates and the related impact on health system resources and frontline workers daily, the lay public became increasingly aware of the critical and foundational role nurses occupy in acute care and public health settings, and in global societies. This heightened visibility was a welcome evolution but, given the relatively muted media voice of nursing's past, prompted me to wonder if nurses will remain vocal and continue to give voice to our profession on a sustained basis when the Covid-19 pandemic becomes a part of history?

A Strikingly Quiet Past

Evidence supports that the nursing profession has long been ‘missing in media action’ for multifactorial reasons.3, 4, 5, 6 In addition to facing historical challenges to advancement as a predominantly female profession, clichéd and inaccurate cinematic and television portrayals have cemented the public image of nursing as a background role versus realistically showcasing the profession as essential to the function of an interdisciplinary care team. In 1998, the Sigma Theta Tau International Honor Society of Nursing and University of Rochester School of Nursing published The Woodhull Study on Nursing and the Media: Health Care's Invisible Partner. This study aimed to analyze and document prevalent cultural views regarding the nursing profession and its relationship to healthcare in the US as reflected by media portrayals. The study publication was named in honor of career journalist Nancy Woodhull. As a gender minority in the journalism profession at the time, she worked to promote the media's reach to diverse audiences and, prior to her death from cancer in 1997, Ms. Woodhull sought to explore and advance nursing's voice through increased representation in the media. The Woodhull study's main finding revealed that “Nurses and the nursing profession are essentially invisible to the media and, consequently, to the American public.” (p.8) While the journalism and medical professions now contain higher proportions of female representation, nursing remains a 90% female profession that is poorly understood and dogged by antiquated stereotyping.

Historically, women have been insufficiently represented as news media sources. Twenty years post original 1998 publication, Mason and colleagues conducted the Woodhull study revisited with a goal of closely replicating the original study's design. Findings from phase I of their 2018 study are summarized in Table 1 . An unfortunate reality remains that health news stories are overwhelmingly devoid of nurses being used as a source for expert professional information. Frequently, despite the nursing perspective being quite pertinent for a media story topic, no nursing sources were found to be present in the discussion. ,

Table 1

Nursing in the Media

Research Item	Woodhull Study 1998	Woodhull Study Revisited 2018
Nurses referenced in quotations	Newspapers 4%Trade publications 1%News magazines 1%	Newspapers 2%Industry publications 1%News magazines 2%
Nurses identified in photos used in publication	Rare	4%
Nurses/nursing mentioned in articles	Newspaper articles 10%News magazines 1%Industry publications 8%	13% collectivelyMost often sourced regarding nursing labor, professionLeast likely sourced on health care policy, research, business

Adapted from: Sigma Theta Tau International. The Woodhull Study on Nursing and the Media: Health Care's Invisible Partner. 1997. Indianapolis, IN: Center Nursing Press; Mason D, Nixon L, Glickstein B, Han S, Westphaln K, Carter L. The Woodhull Study revisited: nurses’ representation in health news media 20 years later. J Nurs Scholarsh. 2018;50(6):695-704.

Phase II of the Mason et al study involved a qualitative exploration of 10 health journalists that sought to explore barriers and facilitators to engaging nurses as expert sources. The journalists’ reported barriers included: (1) when a nursing source was needed they didn't know how to locate one; (2) the editor required a justification to use a nurse for the source; (3) the education, work and role of a nurse was not well understood; and (4) nurses and their professional associations hadn't been forthcoming with journalists in the past about nurses’ clinical expertise or pertinent nursing research findings. , The researchers identified an overarching theme: “Biases among journalists, editors, public relations staff, and health care organizations about women, nurses, and positions of power in the health care system can obstruct journalists’ use of diverse sources in health reporting; but when used as sources, nurses can enrich a story.” (Results ¶1 )

Giving Virtual Voice to the Profession

In phase III of the 2018 Woodhull revisited study, researchers examined how 47 of the top-rated US schools of nursing with an existing public social media account (Twitter) presented nurse researchers and faculty as experts. They coded the dominant hashtags from over 3,000 tweets from the 47 schools of nursing into outward-facing or inward-facing categories. Outward-facing tweets invited engagement with user accounts from outside of the nursing school or profession. Inward-facing tweets had the intention of engaging interaction or attention from user accounts held by members of the same nursing school or university, other nurses, and nursing conference and Twitter chat attendees. The findings revealed that slightly more than 1% of the 47 nursing school account followers were held by media members. Approximately 80% of tweets having at least one hashtag were inward-facing, meaning they did not serve to attract attention from or communication with the media. Both affordability and ease of access to social media platforms enables nurses to direct market reliable information to the public and media and to correct misconceptions about the profession. Understanding and adoption of attention getting social media strategies represents another opportunity for the nursing community to increase its visibility and credibility.

Some anecdotal posts witnessed from my personal social media experience during the pandemic were concerning. Although nurses may not be well represented as media sources, their presence on social media can be influential to many based on a top spot ranking for honesty and ethics in the annual US Gallop poll for the past two decades. On several occasions during 2020 and 2021, an account holder identified themself as a nurse on social media and then posted pandemic related information lacking any scientific evidence to support the statement. In such cases, because the individual might in fact not be a nurse but was claiming to be one, I engaged with the posting to provide an informed response with a link/multiple links to reputable evidence based source material.

International Covid-19 Impact

The pandemic exposed some concerning vulnerabilities for the nursing profession and global health system workforce, for which there are no quick or easy solutions. International media reports informed on the impact of the Covid-19 virus on global health systems’ crisis preparedness and related stressors to practicing nurses’ well-being. As Covid-19 reported deaths continue to increase among healthcare workers, nurses caring for global populations represented the largest group to contract the virus. In January 2021 the International Council of Nurses (ICN) reported on the results of studies conducted with its membership around the world, revealing that anxiety and stress experienced by nurses and other health workers had intensified due to the pandemic. This information came at a time when 90% of ICN national nursing organization members have reported greater concern that stress and fatigue related to the pandemic, insufficient health system resources, and substantial and sustained workloads have precipitated a higher than usual number of nurses’ decision to leave the profession. Further, it found that nurses reported higher rates in their intention to leave the workforce in 2020 and when the pandemic ends. Last year, based on member survey findings, ICN President Annette Kennedy delivered a troubling assessment on healthcare workers’ exposure to Covid-19 and its associated risks to include infection, negative psychological impact, violence and prejudice, and death. Kennedy stated: “We talk about the new norm created by the pandemic, but it has also confirmed some long-understood truths in the nursing community, that nurses are undervalued, underpaid and sometimes treated as expendable.” (p.4) Of further concern to health systems and populations everywhere, the ICN estimates a 13 million global nurse deficit in the decade ahead. Given this dire workforce projection and inherent systemic barriers, it will be ever more important for nurse leaders, researchers, academics, and clinicians to fully engage in media opportunities that inform the public and policymakers to advocate for support and advancement of the nursing profession.

Pushing Nursing's Agenda

Research has shown that nurses and their professional associations need to become more strategic about connecting with media outlets to better engage with journalists and provide a nursing perspective. In addition, academic institutions and healthcare organization communications teams should become more proactive in promoting research findings and in the use of nurses as expert media sources. A reluctance by nurses to speak out to share their knowledge and experience in the public domain requires a change in the culture of nursing. This goal can be advanced through the inclusion of media savvy preparation techniques during nurses’ academic preparation and through professional association initiatives. Gordon's work, and that of other influential nurse advocates, can help to guide nurses on ways in which to create informative public messages for dissemination through traditional and social media outlets to inform the lay public and policymakers on the actual nature of the profession's work. Nursing academicians can advance curriculum content to better prepare nurses for media engagement to empower future nursing professionals to speak out and educate journalists and the lay public about the value of nursing's expertise and skillset. Ultimately, it is incumbent upon all nurses to speak out and explain how and why nursing care and our professional contributions to the science fundamentally drive quality outcomes in the delivery of medical treatment.

Reflecting and Progressing

The pandemic has proven to be a long, strange, and difficult experience around the world. As chair for the International Collaboration of PeriAnaesthesia Nurses (ICPAN) board of directors, I lead its monthly meetings and participate in bi-monthly meetings of the 11 member Global Advisory Council (Global Advisory Council - ICPAN). Since April 2020, our group discussions have elucidated the impact of the Covid-19 pandemic on member countries’ health systems and nurses. Country leaders navigated the deadly virus in varying ways, with some more successful than others. These trends were reflected in our conversations regarding impact on perianesthesia nursing practice. Infection rates in many countries produced a second and third wave of inpatient admissions, placing sustained demands on the nursing workforce needed to treat Covid-19 patients. As elective surgical procedures were placed on hold, perianesthesia nurses were mobilized to treat patients in critical care units, on inpatient units, and in community health roles as vaccinators and infection tracking/tracing personnel.

The pandemic did provide some positive outcomes in terms of technology advancement and acceptance. Due to restrictions intended to mitigate viral spread, telemedicine and virtual alternatives for delivering professional education advanced rapidly by necessity. While in-person conferencing was canceled for most of 2020 and 2021, professional nursing organizations adapted and began hosting virtual events. Unfortunately, the 6th international conference for perianesthesia nurses planned for September 2021 was negatively impacted by Covid-19 travel restrictions, and further difficulties encountered with rescheduling the event for 2022 forced its cancellation. In lieu of a biennial in-person event, the ICPAN Board hosted a virtual webinar and biennial general meeting in September 2021 and will continue to offer virtual international webinars and social hours until we meet again in Europe for the next biennial conference in 2023. Until then I encourage every perianesthesia nurse colleague to give voice to pandemic and professional experiences, seek to educate the public, policymakers, and journalists, using the best available evidence, and show the value of our specialty practice contributions in the promotion of evidence based care for the global population we serve.