JONA Volume 44, Number 5, pp 298-302 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Image Is More Than a Uniform The Promise of Assurance Lucia D. Wocial, PhD, RN Kelly Sego, BS Carrie Rager, BS, MA
Shellee Laubersheimer Linda Q. Everett, PhD, RN, FAAN, NEA-BC
OBJECTIVE: The purpose of this qualitative study was to explore the meaning of the phrase ‘‘image of the nurse’’ in the context of the desired brand experience of assurance. BACKGROUND: A brand is a promise that lives in the minds of consumers. Nurses play a key role in delivering on the brand promise of a hospital. METHODS: Using focus groups, the authors applied a deductive approach to generate data. Discussion transcripts were analyzed by establishing codes and identifying themes. RESULTS: The most frequent comment from participants was that for nurses to communicate assurance, they must 1st be clean, well groomed, and understated in overall appearance. Nurse behaviors that reassure patients include being present with patients, helping patients know what to expect, and demonstrating a consistent team approach. CONCLUSIONS: Overall appearance and behaviors define the image of nurses and contribute significantly to the brand of assurance.
how a patient perceives the nurse. Despite being the most trusted profession, nurses struggle with their image. In the media, nursing is portrayed in various ways: from matronly in white with a cap to sensual and cute in a tight miniskirt. In reality, patients’ confidence in nurses’ abilities may be compromised when nurses wear rumpled, ill-fitting scrubs and dirty shoes. The nurse uniform and overall appearance convey both a literal and figurative image for our patients. Few topics in nursing can inspire such animated debate as nurses’ uniforms. Enhancing the professional image of nurses requires a hard look at the uniform that nurses wear.1
An image is both literal and figurative. It is a physical representation and a reputation, an idea, or conception. First impressions are formed in an instant, so how a nurse appears can have a significant impact on Author Affiliations: Nurse Ethicist (Dr Wocial), Nursing Senior Marketing Coordinator (Ms Sego), Director of Market Research (Ms Rager), Nursing Project Coordinator (Ms Laubersheimer), Executive Vice President and Chief Nursing Executive (Dr Everett), Indiana University Health, Indianapolis. The authors declare no conflicts of interest. Correspondence: Dr Wocial, Indiana University Health, 340 W 10th St, Indianapolis, IN 46202 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000070
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Background Image is more than a uniform, yet a review of the nursing research literature related to the ‘‘image of the nurse’’ reveals a number of studies that focus specifically on what the nurse wears as representative of the image of nursing.2-6 The studies have been largely descriptive in nature. The methodology has focused on showing constituent groups pictures of nurses in different uniform colors and styles and asking questions about the image a nurse portrays, based on the uniform. The typical study involved showing participants pictures of nurses in varying uniforms, doing different nursing tasks, and asking participants to rate pictures using different professional traits (skill and knowledge). Ultimately, the literature reflects long-standing tension between these professional traits of nurses and the softer side of nursing (caring behaviors) and disparities between uniform preferences of nurses and those they serve. Many studies used an inductive approach focusing on the uniform as the key feature defining a nurse’s image. For example, participants were shown several
JONA Vol. 44, No. 5 May 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
different pictures of nurses in uniforms and asked to identify 1 type/color of uniform they prefer (reflecting nurse caring behaviors) and a potentially different color/ type of uniform representing a professional nurse (reflecting nurse skill and knowledge).3 Indiana University Health (IU Health) is a statewide integrated health system that includes large academic and critical access facilities. The system member facilities are united in a single mission, vision, and values, yet each facility is encouraged to foster a sense of individuality within its constituent community. Indiana University Health is committed to a system-wide approach that communicates a consistent brand across the member facilities. Launching a brand proved to be a unique opportunity to evaluate the image of the IU Health nurse. A brand is not just a logo, a spokesperson, a product, or a name.7 A brand is something deeperVmore emotional. It is a collection of perceptions and experiences with a product or service. A brand is the set of tangible and intangible attributes distinguishing a product, company, organization, or cause. Ultimately, a brand is a promise that is reflected in the mind of the consumer.7 The tangible aspects of a brand include a logo, tagline, colors, uniforms, packaging, and product characteristics. The intangible characteristics include the way the product, company, or employees make a person feel (eg, proud, well-cared for, safe). Market research for IU Health led to the establishment of the IU Health brand of assurance. Assurance inspires confidence and alleviates fears. The IU Health brand is the promise of assurance that patients are making the right choice when choice matters most. One might apply principles of branding to exploring the image of nursing. The tangible aspect of the brand would be the nurses’ uniform. The intangible aspect would be influenced by how the nurse behaves. Members of the IU Health Nurse Executive Council (NEC) identified improving nurse professionalism as a strategic initiative for the organization. The NEC formed an Image of Nursing (ION) task force of nurses in a variety of roles (direct care, supervisory, education, advance practice) representing all the system member facilities. Their charge was to use an evidencebased approach and to make a recommendation to NEC regarding IU Health nurse uniforms and the image of the IU Health nurse (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review). Task force members participated in an appreciative inquiry exercise where they were asked to reflect on positive images of nursing over their careers. Task force members identified the power and influence that
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a nurse’s physical appearance, particularly the uniform, can have on the overall image of that nurse. As was noted by Pearson et al,8 task force members expressed the feeling that a nurse’s uniform is a powerful way for a nurse to identify with the profession of nursing. After reviewing relevant literature on previous efforts related to the image of nurses, the task force selected a deductive approach to explore how an IU Health nurse could help deliver on the brand promise of assurance. Instead of showing participants different pictures of nurses in different uniforms, participants were given a definition of the new IU Health brand and were asked to imagine what would define the ‘‘ideal’’ IU Health nurse based on the new brand identity. Task force members determined that it would be crucial to gather input from frontline nurses as well as patients, families, and community members. The purpose of this study was to identify attributes and interactions of nurses that would deliver on the desired brand experience of assurance. The results of focus groups with nurses are reported.
Methods Subjects Nurses working and employed in the inpatient and ambulatory care areas of any IU Health facility were invited to participate in focus group discussions about the image of the IU Health nurse. Nurses in traditional roles (eg, direct care providers, educators, managers, directors, care coordinators, and clinical nurse specialists) were eligible to participate, as were nursing students. Nurses in non-traditional nursing roles such as research nurses and nurse practitioners (considered a blended medical and nursing role) were excluded from this study. Procedures Recruitment After approval from institutional review boards for each of the IU Health member facilities was obtained, The Synergist, an electronic newsletter distributed via e-mail once a week to all nurses employed in IU Health facilities, announced the ‘‘Image of the Nurse’’ project with information about the opportunity to participate in focus groups and featured weekly reminders about the project throughout the data collection period. The number of focus groups was determined largely by size of the nursing workforce. Participants were able to attend focus groups at the hospital where they worked or at another facility that was more convenient to their home. Three weeks before a site visit, potential eligible participants at the designated site were recruited via
299
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
an e-mail invitation sent to their IU Health e-mail account, via standard communication methods selected by nursing leadership at each participating facility, and by invitation from nurse leaders. Nurses had 1 week to express interest in participating. Focus group participants were provided light refreshments during the discussion and were paid for their time spent in the focus group. Nurses who expressed interest but were unable to participate in a focus group were provided a link to an electronic survey that consisted of the focus group questions. In this way, interested nurses were able to provide input into the process even if they were unable to attend a focus group.
the meaningful essence running through the data was identified.10 Initial codes were consistent with traits from the Nurse Image Scale2 and traits found in the internal market research related to establishing the IU Health brand. Credibility was established by reviewing the process for data analysis with members of the research team and other key stakeholders within the organization (nursing, marketing, and corporate leaders). Stakeholders were shown coded focus group transcripts, categories of codes, and the abstracted theme. Stakeholders agreed that they were able to recognize the essence of the meaning of the identified theme based on coding and categorical sorting.
Focus Groups Once assembled, before initiating the discussion, focus group participants were reminded of the voluntary nature of the project and asked to give verbal consent to participate. Focus group sessions began with an introductory slideshow with information about the NEC ION charge and an explanation of what a brand is, with a particular focus on the new IU Health brand. After the brief introduction, participants were led in discussion using scripted questions. Table 1 reflects the questions used for the focus group discussion. All focus groups were led by the same skilled small-group facilitator. Focus group sessions were audiotape recorded and transcribed to facilitate qualitative analysis. All transcripts were subjected to content and thematic analysis. All identifying information, including names, nursing units, or other identifiable characteristics, were removed from the transcripts.
Results
Analysis Focus group transcript data were 1st consolidated by facility then analyzed using an inductive content analysis process described by Elo and Kynagus.9 This process began with open coding of transcripts, creating categories by identifying codes that have strong relationships with one another. The abstraction process continued until a unifying theme that represented
A total of 39 nurse focus groups were conducted with 363 participants, and an additional 63 direct care nurses completed online surveys. The number of participants represents nearly 5% of the IU Health’s 9000 nurses. Table 2 details the demographic characteristics for participants. Focus groups ranged in size from 4 to 16 participants. Discussions lasted, on average, 1 hour and ranged from 45 to 90 minutes. Coding transcripts proved to be challenging for 2 important reasons. The sheer volume of information was overwhelming. In addition, focus group participants frequently used the same words to describe a nurse’s behavior as were used to describe a character trait. The volume of data helped the research team focus on the essential meaning uncovered in the abstraction process. As the analysis progressed, it became apparent that neither listing all the traits nor determining which ones were most identified was as important as identifying the overarching theme the traits represented. The dominant code categories were appearance qualities, nurse behaviors, and character traits. A sample of the abstraction process, text to code to subcategory, and category is available via Table, Supplemental Digital Content 1, http://links.lww.com/ JONA/A304.
Table 1. Focus Group Questions 1. Imagine one of your loved ones is a patient in an IU Health facility. How would you describe the ‘‘ideal’’ nurse taking care of that person? 2. What behaviors of the nurse provide assurance to patients and their family that they made the right choice when they selected IU Health? 3. What would assure you that your loved one was being cared for by an ideal nurse? 4. What does that nurse look like? 5. How do you think patients and family members identify nurses? 6. What tangible things represent the ideal IU Health nurse? 7. What intangible characteristics describe the ideal IU Health nurse? 8. What will lead to us achieving consistency in nurses living this ideal image? 9. What barriers will prevent us from achieving consistency in nurses living this ideal image? 10. How will we know the change is an improvement?
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 2. Demographic Characteristics Ethnicity % Age % Educational training Years in practice % Gender % Practice Setting % Nursing credential % National certification Direct patient care
White 95 20-30 21 Diploma 4 0-5 27 Female 97 Inpatient 86 RN 99 43% 72%
Other 5 31-40 21 Associate’s degreea 31 6-10 15 Male 3 Ambulatory 12 LPN 1
41-50 28 Bachelor’s degreea 49 11-20 22
51-60 25 Master’s degreea 11 21-30 18
961 5 Other 931 18
a
Percentages totaling less than 100% represent missing data (participants failed to provide).
Appearance When asked about how a nurse should look, without question, the number 1 response was that the nurse be clean. Participants consistently stated that nurses should be well groomed and understated in make-up, jewelry, perfume, and so on. Participants also identified the importance of being able to easily identify the nurse. Participants had significant difficulty identifying tangible things that represented the IU Health nurse. The nurse’s nametag, complete with the IU Health logo and large red and white ‘‘RN’’ hang tag worn beneath all RN’s name badges, and the nurse’s uniform were the only tangible things consistently identified. When nurses identified the uniform as a tangible aspect of the IU Health brand, the description differed depending on the facility because across the system, there were 8 different uniforms for nurses. Behavior When asked about how the ideal IU Health nurse should behave, participants identified several essential behaviors. The overarching code related to behavior was genuine (representing approachable) and advocate (representing professional). Being genuine included many different things such as being respectful, attentive, and caring. Being an advocate included being informative, reliable, and being collaborative with other members of the healthcare team. Character When asked ‘‘What would assure you that your loved one was being cared for by an ideal nurse?’’ beyond behaviors, participants identified characteristics of a nurse. Important traits of a nurse included being compassionate, approachable, attentive, and caring. Having good manners and being gracious were other ways participants described nurses who assured pa-
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tients. The overarching code for character was being genuine and service oriented. Accountability Analysis of the discussions revealed an unexpected finding. One of the most powerful messages from the focus group participants was that as nurses, they expected to be treated by their peers and leadership the same way IU Health expects them to treat patients and families. Leaders who demonstrate respect, compassion, and integrity toward frontline nurses supported those nurses in their ability to convey assurance to patients. Participants expect leaders to hold everyone accountable to uniform and code of conduct standards. Environments where professionals respected each other and worked well as a team also supported nurses in their efforts to convey assurance. Participants also identified a need to hold each other accountable. As the abstraction process continued, the theme assurance was identified as the unifying theme that represented the meaningful essence running through the data.
Discussion Although the volume of data generated by 39 focus groups was overwhelming to manage, the ION task force felt that it was essential that nurse leaders demonstrate in a meaningful way the desire to listen to the voices of nurses from across the IU Health system. The voluntary nature of participation and method of recruiting participants may have excluded the voices of some nurses. However, the focus group strategy and traveling around the state provided some keen insights into the state of nursing in the various facilities. Some coding schemes became apparent when participants discussed examples of how not to convey
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
assurance. Sharing of negative examples reinforced the opportunity that existed in redefining the brand of the IU Health nurse and setting expectations for appearance and conduct. For example, the unexpected and prominent message of nurse accountability had a significant influence on the ION task force recommendations to NEC. Members of the ION task force interpreted the code of accountability as representative of nurses’ desire to reconnect with what it means to be a nurse in the best sense of the profession and to be part of an organization that is focused on offering patients assurance when they are in our care at IU Health. The theme of assurance is complex. The most significant and consistent meaning found in the data was that rather than a specific color, it is a nurses’ overall appearance, being clean, well groomed, and wearing a modest well-fitting uniform that establish the tangible elements of the brand of assurance. The intangible elements of assurance cannot be defined by any one individual trait or behavior. Comments from participants suggested that character and behavior traits are mediated by interpersonal skills, confirming what has been reported in the literature.11 Interpersonal skills can reinforce skills and behaviors of nurses and communicate assurance. Application Beyond the format of nurses’ nametags, the tangible aspects of the IU Health nurse lacked consistency, which detracts from a brand identify. If nurses are responsible for delivering on the brand promise, there needed to be some consistency in the tangible representation of the brand. The members of the ION task force evaluated the results of this project and offered recommendations to the NEC. Establishing a clear policy outlining specifics of a uniform, including consequences for failing to uphold the standard would also support accountability. The policy and standards of assurance are available via Documents, Supple-
mental Digital Content 2, http://links.lww.com/JONA/ A305, and Supplemental Digital Content 3, http:// links.lww.com/JONA/A306. The ION task force recommended 1 uniform, not just a single color scheme, but a standard uniform style. The team recommended a bold, easily identifiable uniform: an IU Health red top and black bottom, both branded with the IU Health logo. This meant a new uniform for all 9000 nurses in the system. This meant a new uniform for all 9000 nurses in the system (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review).
Conclusion Our research demonstrated that it is not simply the color of the nurse uniform that influences the image of nurses. More important than color and style, a uniform must communicate well to patients and families who the nurse is. How ever he/she is dressed, the nurse must be clean and well groomed. The methods used to collect data for this study were instrumental in engaging direct care nurses in thoughtful reflection about their impact on patients’ experiences. The evidence gathered in this work also served as a foundation for the implementation of an initiative to improve the professional image of nurses in our organization (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review). Every aspect of the nurse, uniform, behavior, attitude, and overall appearance, not only reflects on the nurse but also delivers on the brand promise of an organization, in the case of IU Health, that is the promise of assurance. Assurance is communicated through actions but significantly influenced by how the nurse presents her or himself, the overall appearance. More than uniforms, it is nurse behaviors (what we do, how we act, the care we provide) that define the patient experience.
References 1. Everett LQ. On changing RN uniform color: may the bridges I burn light the way. Nurse Lead. 2012;10(6):34-35. 2. Albert NM, Burke J, Bena JF, Morrison S, Forney J, Slifcak E. Is There an Association Between Nurses’ Uniform Color and Feelings/Emotions of Children Receiving Hospital or Ambulatory Care? Paper presented at: Sigma Theta Tau 21st International Research Congress; 2010; Orlando, FL. 3. Albert NM, Wocial L, Meyer KH, Na J, Trochelman K. Impact of nurses’ uniforms on patient and family perceptions of nurse professionalism. Appl Nurs Res. 2008;21(4): 181-190. 4. Campbell S, O’Malley C, Watson D, Charlwood J, Lowson SM. The image of the children’s nurse: a study of the qualities required by families of children’s nurses’ uniform. J Clin Nurs. 2000;9(1):71-82. 5. Skorupski VJ, Rea RE. Patients’ perceptions of today’s nurs-
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ing attire: exploring dual images. Nurs Adm. 2006;36(9): 393-401. Thomas CM, Ehret A, Ellis B, Colon-Shoop S, Linton J, Metz S. Perception of nurse caring, skills, and knowledge based on appearance. J Nurs Adm. 2010;40(11):489-497. de Chernatony L, McDonald M. Creating Powerful Brands in Consumer, Service and Industrial Markets. 3rd ed. Oxford, UK: Elsevier; 2005. Pearson A, Baker H, Walsh K, Fitzgerald M. Contemporary nurses’ uniformsVhistory and tradition. J Nurs Manag. 2001;9:147-152. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-115. Morse J. Confusing categories and themes. Qual Health Res. 2008;18(6):727-728. Rupp Wysong P, Driver E. Patients’ perceptions of nurses’ skill. Crit Care Nurse. 2009;29:24-37.
JONA Vol. 44, No. 5 May 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
Image Is More Than a Uniform The Promise of Assurance Lucia D. Wocial, PhD, RN Kelly Sego, BS Carrie Rager, BS, MA
Shellee Laubersheimer Linda Q. Everett, PhD, RN, FAAN, NEA-BC
OBJECTIVE: The purpose of this qualitative study was to explore the meaning of the phrase ‘‘image of the nurse’’ in the context of the desired brand experience of assurance. BACKGROUND: A brand is a promise that lives in the minds of consumers. Nurses play a key role in delivering on the brand promise of a hospital. METHODS: Using focus groups, the authors applied a deductive approach to generate data. Discussion transcripts were analyzed by establishing codes and identifying themes. RESULTS: The most frequent comment from participants was that for nurses to communicate assurance, they must 1st be clean, well groomed, and understated in overall appearance. Nurse behaviors that reassure patients include being present with patients, helping patients know what to expect, and demonstrating a consistent team approach. CONCLUSIONS: Overall appearance and behaviors define the image of nurses and contribute significantly to the brand of assurance.
how a patient perceives the nurse. Despite being the most trusted profession, nurses struggle with their image. In the media, nursing is portrayed in various ways: from matronly in white with a cap to sensual and cute in a tight miniskirt. In reality, patients’ confidence in nurses’ abilities may be compromised when nurses wear rumpled, ill-fitting scrubs and dirty shoes. The nurse uniform and overall appearance convey both a literal and figurative image for our patients. Few topics in nursing can inspire such animated debate as nurses’ uniforms. Enhancing the professional image of nurses requires a hard look at the uniform that nurses wear.1
An image is both literal and figurative. It is a physical representation and a reputation, an idea, or conception. First impressions are formed in an instant, so how a nurse appears can have a significant impact on Author Affiliations: Nurse Ethicist (Dr Wocial), Nursing Senior Marketing Coordinator (Ms Sego), Director of Market Research (Ms Rager), Nursing Project Coordinator (Ms Laubersheimer), Executive Vice President and Chief Nursing Executive (Dr Everett), Indiana University Health, Indianapolis. The authors declare no conflicts of interest. Correspondence: Dr Wocial, Indiana University Health, 340 W 10th St, Indianapolis, IN 46202 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000070
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Background Image is more than a uniform, yet a review of the nursing research literature related to the ‘‘image of the nurse’’ reveals a number of studies that focus specifically on what the nurse wears as representative of the image of nursing.2-6 The studies have been largely descriptive in nature. The methodology has focused on showing constituent groups pictures of nurses in different uniform colors and styles and asking questions about the image a nurse portrays, based on the uniform. The typical study involved showing participants pictures of nurses in varying uniforms, doing different nursing tasks, and asking participants to rate pictures using different professional traits (skill and knowledge). Ultimately, the literature reflects long-standing tension between these professional traits of nurses and the softer side of nursing (caring behaviors) and disparities between uniform preferences of nurses and those they serve. Many studies used an inductive approach focusing on the uniform as the key feature defining a nurse’s image. For example, participants were shown several
JONA Vol. 44, No. 5 May 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
different pictures of nurses in uniforms and asked to identify 1 type/color of uniform they prefer (reflecting nurse caring behaviors) and a potentially different color/ type of uniform representing a professional nurse (reflecting nurse skill and knowledge).3 Indiana University Health (IU Health) is a statewide integrated health system that includes large academic and critical access facilities. The system member facilities are united in a single mission, vision, and values, yet each facility is encouraged to foster a sense of individuality within its constituent community. Indiana University Health is committed to a system-wide approach that communicates a consistent brand across the member facilities. Launching a brand proved to be a unique opportunity to evaluate the image of the IU Health nurse. A brand is not just a logo, a spokesperson, a product, or a name.7 A brand is something deeperVmore emotional. It is a collection of perceptions and experiences with a product or service. A brand is the set of tangible and intangible attributes distinguishing a product, company, organization, or cause. Ultimately, a brand is a promise that is reflected in the mind of the consumer.7 The tangible aspects of a brand include a logo, tagline, colors, uniforms, packaging, and product characteristics. The intangible characteristics include the way the product, company, or employees make a person feel (eg, proud, well-cared for, safe). Market research for IU Health led to the establishment of the IU Health brand of assurance. Assurance inspires confidence and alleviates fears. The IU Health brand is the promise of assurance that patients are making the right choice when choice matters most. One might apply principles of branding to exploring the image of nursing. The tangible aspect of the brand would be the nurses’ uniform. The intangible aspect would be influenced by how the nurse behaves. Members of the IU Health Nurse Executive Council (NEC) identified improving nurse professionalism as a strategic initiative for the organization. The NEC formed an Image of Nursing (ION) task force of nurses in a variety of roles (direct care, supervisory, education, advance practice) representing all the system member facilities. Their charge was to use an evidencebased approach and to make a recommendation to NEC regarding IU Health nurse uniforms and the image of the IU Health nurse (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review). Task force members participated in an appreciative inquiry exercise where they were asked to reflect on positive images of nursing over their careers. Task force members identified the power and influence that
JONA Vol. 44, No. 5 May 2014
a nurse’s physical appearance, particularly the uniform, can have on the overall image of that nurse. As was noted by Pearson et al,8 task force members expressed the feeling that a nurse’s uniform is a powerful way for a nurse to identify with the profession of nursing. After reviewing relevant literature on previous efforts related to the image of nurses, the task force selected a deductive approach to explore how an IU Health nurse could help deliver on the brand promise of assurance. Instead of showing participants different pictures of nurses in different uniforms, participants were given a definition of the new IU Health brand and were asked to imagine what would define the ‘‘ideal’’ IU Health nurse based on the new brand identity. Task force members determined that it would be crucial to gather input from frontline nurses as well as patients, families, and community members. The purpose of this study was to identify attributes and interactions of nurses that would deliver on the desired brand experience of assurance. The results of focus groups with nurses are reported.
Methods Subjects Nurses working and employed in the inpatient and ambulatory care areas of any IU Health facility were invited to participate in focus group discussions about the image of the IU Health nurse. Nurses in traditional roles (eg, direct care providers, educators, managers, directors, care coordinators, and clinical nurse specialists) were eligible to participate, as were nursing students. Nurses in non-traditional nursing roles such as research nurses and nurse practitioners (considered a blended medical and nursing role) were excluded from this study. Procedures Recruitment After approval from institutional review boards for each of the IU Health member facilities was obtained, The Synergist, an electronic newsletter distributed via e-mail once a week to all nurses employed in IU Health facilities, announced the ‘‘Image of the Nurse’’ project with information about the opportunity to participate in focus groups and featured weekly reminders about the project throughout the data collection period. The number of focus groups was determined largely by size of the nursing workforce. Participants were able to attend focus groups at the hospital where they worked or at another facility that was more convenient to their home. Three weeks before a site visit, potential eligible participants at the designated site were recruited via
299
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
an e-mail invitation sent to their IU Health e-mail account, via standard communication methods selected by nursing leadership at each participating facility, and by invitation from nurse leaders. Nurses had 1 week to express interest in participating. Focus group participants were provided light refreshments during the discussion and were paid for their time spent in the focus group. Nurses who expressed interest but were unable to participate in a focus group were provided a link to an electronic survey that consisted of the focus group questions. In this way, interested nurses were able to provide input into the process even if they were unable to attend a focus group.
the meaningful essence running through the data was identified.10 Initial codes were consistent with traits from the Nurse Image Scale2 and traits found in the internal market research related to establishing the IU Health brand. Credibility was established by reviewing the process for data analysis with members of the research team and other key stakeholders within the organization (nursing, marketing, and corporate leaders). Stakeholders were shown coded focus group transcripts, categories of codes, and the abstracted theme. Stakeholders agreed that they were able to recognize the essence of the meaning of the identified theme based on coding and categorical sorting.
Focus Groups Once assembled, before initiating the discussion, focus group participants were reminded of the voluntary nature of the project and asked to give verbal consent to participate. Focus group sessions began with an introductory slideshow with information about the NEC ION charge and an explanation of what a brand is, with a particular focus on the new IU Health brand. After the brief introduction, participants were led in discussion using scripted questions. Table 1 reflects the questions used for the focus group discussion. All focus groups were led by the same skilled small-group facilitator. Focus group sessions were audiotape recorded and transcribed to facilitate qualitative analysis. All transcripts were subjected to content and thematic analysis. All identifying information, including names, nursing units, or other identifiable characteristics, were removed from the transcripts.
Results
Analysis Focus group transcript data were 1st consolidated by facility then analyzed using an inductive content analysis process described by Elo and Kynagus.9 This process began with open coding of transcripts, creating categories by identifying codes that have strong relationships with one another. The abstraction process continued until a unifying theme that represented
A total of 39 nurse focus groups were conducted with 363 participants, and an additional 63 direct care nurses completed online surveys. The number of participants represents nearly 5% of the IU Health’s 9000 nurses. Table 2 details the demographic characteristics for participants. Focus groups ranged in size from 4 to 16 participants. Discussions lasted, on average, 1 hour and ranged from 45 to 90 minutes. Coding transcripts proved to be challenging for 2 important reasons. The sheer volume of information was overwhelming. In addition, focus group participants frequently used the same words to describe a nurse’s behavior as were used to describe a character trait. The volume of data helped the research team focus on the essential meaning uncovered in the abstraction process. As the analysis progressed, it became apparent that neither listing all the traits nor determining which ones were most identified was as important as identifying the overarching theme the traits represented. The dominant code categories were appearance qualities, nurse behaviors, and character traits. A sample of the abstraction process, text to code to subcategory, and category is available via Table, Supplemental Digital Content 1, http://links.lww.com/ JONA/A304.
Table 1. Focus Group Questions 1. Imagine one of your loved ones is a patient in an IU Health facility. How would you describe the ‘‘ideal’’ nurse taking care of that person? 2. What behaviors of the nurse provide assurance to patients and their family that they made the right choice when they selected IU Health? 3. What would assure you that your loved one was being cared for by an ideal nurse? 4. What does that nurse look like? 5. How do you think patients and family members identify nurses? 6. What tangible things represent the ideal IU Health nurse? 7. What intangible characteristics describe the ideal IU Health nurse? 8. What will lead to us achieving consistency in nurses living this ideal image? 9. What barriers will prevent us from achieving consistency in nurses living this ideal image? 10. How will we know the change is an improvement?
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 2. Demographic Characteristics Ethnicity % Age % Educational training Years in practice % Gender % Practice Setting % Nursing credential % National certification Direct patient care
White 95 20-30 21 Diploma 4 0-5 27 Female 97 Inpatient 86 RN 99 43% 72%
Other 5 31-40 21 Associate’s degreea 31 6-10 15 Male 3 Ambulatory 12 LPN 1
41-50 28 Bachelor’s degreea 49 11-20 22
51-60 25 Master’s degreea 11 21-30 18
961 5 Other 931 18
a
Percentages totaling less than 100% represent missing data (participants failed to provide).
Appearance When asked about how a nurse should look, without question, the number 1 response was that the nurse be clean. Participants consistently stated that nurses should be well groomed and understated in make-up, jewelry, perfume, and so on. Participants also identified the importance of being able to easily identify the nurse. Participants had significant difficulty identifying tangible things that represented the IU Health nurse. The nurse’s nametag, complete with the IU Health logo and large red and white ‘‘RN’’ hang tag worn beneath all RN’s name badges, and the nurse’s uniform were the only tangible things consistently identified. When nurses identified the uniform as a tangible aspect of the IU Health brand, the description differed depending on the facility because across the system, there were 8 different uniforms for nurses. Behavior When asked about how the ideal IU Health nurse should behave, participants identified several essential behaviors. The overarching code related to behavior was genuine (representing approachable) and advocate (representing professional). Being genuine included many different things such as being respectful, attentive, and caring. Being an advocate included being informative, reliable, and being collaborative with other members of the healthcare team. Character When asked ‘‘What would assure you that your loved one was being cared for by an ideal nurse?’’ beyond behaviors, participants identified characteristics of a nurse. Important traits of a nurse included being compassionate, approachable, attentive, and caring. Having good manners and being gracious were other ways participants described nurses who assured pa-
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tients. The overarching code for character was being genuine and service oriented. Accountability Analysis of the discussions revealed an unexpected finding. One of the most powerful messages from the focus group participants was that as nurses, they expected to be treated by their peers and leadership the same way IU Health expects them to treat patients and families. Leaders who demonstrate respect, compassion, and integrity toward frontline nurses supported those nurses in their ability to convey assurance to patients. Participants expect leaders to hold everyone accountable to uniform and code of conduct standards. Environments where professionals respected each other and worked well as a team also supported nurses in their efforts to convey assurance. Participants also identified a need to hold each other accountable. As the abstraction process continued, the theme assurance was identified as the unifying theme that represented the meaningful essence running through the data.
Discussion Although the volume of data generated by 39 focus groups was overwhelming to manage, the ION task force felt that it was essential that nurse leaders demonstrate in a meaningful way the desire to listen to the voices of nurses from across the IU Health system. The voluntary nature of participation and method of recruiting participants may have excluded the voices of some nurses. However, the focus group strategy and traveling around the state provided some keen insights into the state of nursing in the various facilities. Some coding schemes became apparent when participants discussed examples of how not to convey
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assurance. Sharing of negative examples reinforced the opportunity that existed in redefining the brand of the IU Health nurse and setting expectations for appearance and conduct. For example, the unexpected and prominent message of nurse accountability had a significant influence on the ION task force recommendations to NEC. Members of the ION task force interpreted the code of accountability as representative of nurses’ desire to reconnect with what it means to be a nurse in the best sense of the profession and to be part of an organization that is focused on offering patients assurance when they are in our care at IU Health. The theme of assurance is complex. The most significant and consistent meaning found in the data was that rather than a specific color, it is a nurses’ overall appearance, being clean, well groomed, and wearing a modest well-fitting uniform that establish the tangible elements of the brand of assurance. The intangible elements of assurance cannot be defined by any one individual trait or behavior. Comments from participants suggested that character and behavior traits are mediated by interpersonal skills, confirming what has been reported in the literature.11 Interpersonal skills can reinforce skills and behaviors of nurses and communicate assurance. Application Beyond the format of nurses’ nametags, the tangible aspects of the IU Health nurse lacked consistency, which detracts from a brand identify. If nurses are responsible for delivering on the brand promise, there needed to be some consistency in the tangible representation of the brand. The members of the ION task force evaluated the results of this project and offered recommendations to the NEC. Establishing a clear policy outlining specifics of a uniform, including consequences for failing to uphold the standard would also support accountability. The policy and standards of assurance are available via Documents, Supple-
mental Digital Content 2, http://links.lww.com/JONA/ A305, and Supplemental Digital Content 3, http:// links.lww.com/JONA/A306. The ION task force recommended 1 uniform, not just a single color scheme, but a standard uniform style. The team recommended a bold, easily identifiable uniform: an IU Health red top and black bottom, both branded with the IU Health logo. This meant a new uniform for all 9000 nurses in the system. This meant a new uniform for all 9000 nurses in the system (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review).
Conclusion Our research demonstrated that it is not simply the color of the nurse uniform that influences the image of nurses. More important than color and style, a uniform must communicate well to patients and families who the nurse is. How ever he/she is dressed, the nurse must be clean and well groomed. The methods used to collect data for this study were instrumental in engaging direct care nurses in thoughtful reflection about their impact on patients’ experiences. The evidence gathered in this work also served as a foundation for the implementation of an initiative to improve the professional image of nurses in our organization (Wocial LD, Sego K, Rager C, Laubersheimer S, Everett LQ. Transforming the image of nursing: the evidence for assurance. JONA. January 2014. Resubmitted for review). Every aspect of the nurse, uniform, behavior, attitude, and overall appearance, not only reflects on the nurse but also delivers on the brand promise of an organization, in the case of IU Health, that is the promise of assurance. Assurance is communicated through actions but significantly influenced by how the nurse presents her or himself, the overall appearance. More than uniforms, it is nurse behaviors (what we do, how we act, the care we provide) that define the patient experience.
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