In the January-March 2010 From the Editors column titled "Advanced Practice Nursing: Do We Have an Identity Issue?" we discussed the public identity problem currently facing advanced practice nurses. Of course, we all know that advanced practice nurses are not the only nurses challenged with identity and public perception problems. Nurses are often portrayed by the entertainment media as handmaidens or sex objects-if they enter into the storyline at all. Television shows and movies that tarnish our self-image raise a hue and cry from the nursing community including individual protests to the networks and sponsors in addition to letters of condemnation from professional nursing organizations. However, nursing is not alone in being portrayed in a less-than-flattering light. Physicians must cringe when they see the Vicodin-addicted Gregory House behaving like a jerk toward patients and colleagues alike-even though he is a superb diagnostician. Law enforcement officers, fire fighters, and attorneys have long been the focus of television shows and movies. Some portrayals are flattering, some not, but many, if not most of them, are undoubtedly inaccurate. Yet protest from these professions appears to be minimal, if not nonexistent.
In spite of our concerns, it is clear that the public is savvy enough to see the difference between entertainment and real life. For the eighth consecutive year, the Gallup (2009) poll of professions found that nurses are the most trusted profession in America. In this, the 10th year since nursing was added to the poll in 1999, 83% of respondents replied that nurses had very high/high honesty and ethical standards. In fact, because nursing was added as a category to the poll of professions, nursing has held the top spot every year except in 2001, when fire fighters were ranked first and nursing was ranked second. Pharmacists most often rank second to nurses although they trail by 10% or more and medical doctors usually follow at number 3 (but with 15 or more percentage points less than nursing's rankings). Clergy members were listed fourth in 2009 but only had a 50% rating of having very high/high honesty and ethical standards-33% lower than nursing.
Being recognized as the most of honest and ethical of professions is high praise indeed and we can speculate on the reasons for this acclaim. Perhaps it is clear that we are not in nursing for the money and certainly not for the hours or working conditions. Perhaps it is because we spend the most time stretcher-side answering questions, giving comfort, and allaying fears. While the public does think highly of us in this regard, there is still an opportunity to improve the accuracy of perceptions about nurses and nursing. This is true especially with regard to the scope of independent nursing activities, the complimentary roles played by the members of the health care team, and the vast amount of knowledge and skill needed to be a nurse. Smart young women and men are often encouraged to go to medical school if they express an interest in nursing and many a bright nurse has been asked why she or he did not become a doctor. This leads us to believe that the average layperson does not think that nurses need to be smart and that nurses "only do what the doctors tell them." These are misperceptions we must continue to fight among the public and among public policy makers because we are sometimes forgotten when public policy decisions are made.
While working to improve the accuracy of perceptions about our roles and knowledge base is important, we need to remember the trust the public places in us. This is sacred trust. As Gordon and Fagin (1996) so elegantly phrased it, we need to "preserve the moral high ground." Once lost, this moral high ground may not easily be regained.
How do we do this? Three words, familiar to nurses everywhere, sum it up: put patients first. Daily practice presents us with a myriad of opportunities to visibly demonstrate our belief that patients come first. Advocating for appropriate pain relief, involving other disciplines to plan for and meet a patient's needs at home after discharge from the emergency department (ED), referring patients to low-cost sources of prescription drugs, spending time providing well-baby education for frightened new parents, keeping advance directives in mind as resuscitative care decisions are made, questioning inappropriate medication orders, peer-policing or going up the chain of command when individual practitioners behave in an unprofessional or unethical manner-all of these activities happen every day in EDs around the world.
And, we must not let ourselves be bullied into gate-keeping and preventing patients from receiving the care they need (Gordon & Fagin, 1996). We must visibly "serve as patient advocates in assuring that all patients presenting to the emergency department are provided appropriate treatment regardless of social or economic status" (Emergency Nurses Association, 2006, p. 1). Fortunately in the ED, because of the federal Emergency Medical Treatment and Active Labor Act, we are rarely in a position to turn people away. In those facilities where a medical screening examination is performed by the triage nurse and low acuity patients referred to non-ED facilities, it is important that it is clear to patients that they are being referred to a more appropriate venue for their care because their condition is not an emergency. If we are seen as obstacles to care, the public's trust in us will be shaken.
On a larger scale, we need to work to create systems that ensure timely access to appropriate care. The Emergency Nurses Association position statement on access to care states, "Emergency nurses are global advocates for the elimination of health disparities and the improvement of health and quality of life for all people" (Emergency Nurses Association, 2006, p. 1). This is an important role for nursing in general and specifically for advanced practice nurses. In the face of healthcare reform in any forum, large or small, it is essential that we insist on a seat at the table along with our physician colleagues to create a healthy health care system.
Make the real face of nursing visible through your actions and interactions with others. Let us redirect our energies from complaining about entertainment media and focus on what is more important-patient care and a healthcare system to deliver it.
-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN
Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH
-K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP
Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA
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