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Nursing Work and Life

Promotion or marketing of the nursing profession by nurses I. Kagan1,2 RN, PhD, E. Biran3 RN, BA, L. Telem4 RN, BA, N. Steinovitz5 RN, BA, D. Alboer6 RN, BA, K.L. Ovadia7 RNM, MPHA & S. Melnikov1 RN, PhD 1 Lecturer, Department of Nursing, Tel Aviv University, Tel Aviv, 2 Senior Coordinator, Quality and Patient Safety in Nursing, 3 Nurse Manager, 4 Nurse Supervisor, 5 Nurse Manager, Operating Room, 6 Emergency Nursing Coordinator, Beilinson Hospital, Rabin Medical Center, Clalit Health Services, Petah Tikva, 7 Nurse Manager, Delivery Room, Assaf Harofeh Medical Center, Tzrifin, Israel

KAGAN I., BIRAN E., TELEM L., STEINOVITZ N., ALBOER D., OVADIA K.L. & MELNIKOV S. (2015) Promotion or marketing of the nursing profession by nurses. International Nursing Review 62, 368–376 Background: In recent years, much effort has been invested all over the world in nurse recruitment and retention. Issues arising in this context are low job satisfaction, the poor public image of nursing and the reluctance of nurses to promote or market their profession. Aim: This study aimed to examine factors explaining the marketing of the nursing profession by nurses working at a general tertiary medical centre in Israel. Method: One hundred sixty-nine registered nurses and midwives from five clinical care units completed a structured self-administered questionnaire, measuring (a) professional self-image, (b) job satisfaction, (c) nursing promotional and marketing activity questionnaire, and (d) demographic data. Results: The mean scores for the promotion of nursing were low. Nurses working in an intensive cardiac care unit demonstrated higher levels of promotional behaviour than nurses from other nursing wards in our study. Nurse managers reported higher levels of nursing promotion activity compared with first-line staff nurses. There was a strong significant correlation between job satisfaction and marketing behaviour. Multiple regression analysis shows that 15% of the variance of promoting the nursing profession was explained by job satisfaction and job position. Conclusion: Nurses are not inclined to promote or market their profession to the public or to other professions. The policy on the marketing of nursing is inadequate. Implications for nursing or health policy: A three-level (individual, organizational and national) nursing marketing programme is proposed for implementation by nurse leadership and policy makers. Among proposed steps to improve marketing of the nursing profession are promotion of the image of nursing by the individual nurse in the course of her or his daily activities, formulation and implementation of policies and programmes to promote the image of nursing at the organizational level and drawing up of a long-term programme for promoting or marketing the professional status of nursing at the national level.

Correspondence address: Dr Semyon Melnikov, Department of Nursing, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel. Tel: 972-3-640-8394; Fax: 972-3-640-9496; E-mail: [email protected]

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest No conflict of interest has been declared by the authors. The manuscript has not been published before and is not being considered for publication elsewhere.

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Keywords: Job Satisfaction, Marketing of Nursing, Professional Image, Promotion of Nursing, Image of nursing, Nurse Recruitment, Nurse Retention

Introduction In recent years, in view of the shortage of nurses, much effort has been invested in their recruitment and retention in Israel as well as around the world. One of the issues that arises in this context is the motivation of nurses to promote their profession. According to the model of Magnet hospitals, the image of nursing is of great importance as integral members of the healthcare team, should be characterized as essential by all other members of the team [American Nurses Credentialing Center (ANCC) 2013]. The subject of promoting nursing as a profession is discussed in the literature, but even when an entire book is devoted to the subject (‘From Silence to Voice . . .’), the use of the term ‘marketing’ is avoided (Buresh & Gordon 2013). In the past, nursing suffered from a lack of knowledge and research data on the profession as a competitive career, while a poor public image in the social media added to its negative impact (Seago et al. 2006). At the time, the active marketing of nursing and promotion of its public relations were considered undesirable and even taboo. At present there is a growing awareness that marketing of the nursing profession requires deeply needed rethinking (Sayman 2014). Somers et al. (2010) point out that awareness and image building, which are key issues in addressing nursing shortages, are issues that are related to marketing theory (Somers et al. 2010). Few studies have attempted to examine the processes that drive the motivation of nurses themselves to promote public relations and to market their profession and the factors affecting this motivation. The current study attempts to undertake this task and examine whether the promotion or marketing of the nursing profession by nurses is affected by their professional self-image and job satisfaction. ‘Marketing’ the nursing profession

According to the American Marketing Association (AMA 2013), ‘marketing is the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large’. Despite the power of marketing and its potential positive impact on promoting the public image and public relations of nursing, this issue is still not fully recognized and supported within the profession. Recently, nursing literature began to point out the need for research based on concepts and models from business and marketing in the aim to assist nursing leadership in addressing the

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shortage of nurses worldwide (Peltier et al. 2008). Reports in the literature claim that in order to promote and to improve the public image of nursing, a structured and well-planned marketing campaign is necessary (Somers et al. 2010). Among the target audiences for marketing the nursing profession are (a) the public, (b) nurses’ colleagues in other healthcare professions and (c) nurses themselves. Marketing activities can be both internal and external (Ting 2011). Internal marketing is based on the concept that an organization’s employees are both its internal customers and – potentially – its marketing agents and, as such, can contribute to the organization’s image promotion (Abzari 2011). Internal marketing in a hospital would adopt a marketing approach to employees designed to achieve their loyalty and retention by reinforcing job satisfaction (Peltier & Curley 2013). According to Ting (2011), internal marketing is a prerequisite for successful external marketing (Ting 2011). The authors have located no studies dealing explicitly with this aspect of nursing management and practice but a few that touch on related issues. For instance, some studies found that internal marketing improved organizational commitment and quality of service (Tsai & Wu 2011) and that successful internal marketing to nurses was associated with their increased organizational commitment (Chang & Chang 2009). The purpose of external marketing, on the other hand, is to influence the perception of an organization by persons outside it, to make the public aware of the services offered by the organization or profession and to attract or retain customers (Sharma et al. 2010). With respect to nursing, external marketing would focus on making the public aware of the social contribution of nursing to public health and to the quality and safety of medical care and its key role in bedside and community health care and the marketing of nursing as a profession. The authors identified three different levels of external marketing of the nursing profession. (a) The individual level relates to the activities of individual nurses and midwives in their personal contacts and interactions with clients (patients, family members), on the one hand, and in their professional and social contacts with other nurses, colleagues in other healthcare professions, the general public, nursing students and so on. (b) The organizational level relates to activities by healthcare providers (hospitals, community health services and commercial services) focused on promoting the image of nurses and nursing practice at specific clinical sites (departments/wards/clinics/specialized

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units). (c) The national level relates to the marketing of the profession by national policy-making bodies, such as the Ministry of Health, and by nursing organizations, such as unions and professional associations. The current study focuses on marketing at the individual level, namely when a nurse is involved in marketing of the nursing profession. It is important to state here that although the literature up to now has avoided the use of the very professional and business-oriented term ‘marketing’, the message behind such books as From Silence to Voice: What Nurses Know and Must Communicate to the Public (2013) and The Nurses’ Social Media Advantage (2011) is that nurses need to move forward and present themselves as professionals and no longer be satisfied with the ‘virtuousness’ of nursing to protect and be our image. In other words, as professionals wishing to be seen as such, the authors believe that the use of precise terminology – ‘marketing’ – is more appropriate than ‘promoting our image’ etc. Searches of the literature found two publications that emphasize the importance of marketing the nursing profession (Avila et al. 2013; Somers et al. 2010). However, no studies exploring the antecedents of marketing behaviour among nurses were found. The current study examines the contribution of job satisfaction and professional self-image to marketing of the nursing profession by nurses working in clinical care units. Job satisfaction

Job satisfaction has been defined as a positive attitude towards the workplace manifested in the desire to continue working there (Herzberg 2003). Job satisfaction is of great importance in managing nursing staff (McHugh et al. 2011) and several studies have investigated the antecedents of job satisfaction in nursing (Gilson 2013; Peltier & Curley 2013). Recent studies report evidence of the influence of job satisfaction on nurse turnover (Applebaum et al. 2010), motivation (Gaki et al. 2013) and professional commitment (Lu et al. 2012). Higher job satisfaction was found to predict a lower burnout level among public health nurses (Ein-Gal et al. 2014). Moreover, a positive relationship between job satisfaction and employee engagement, which means being energetic and passionate about one’s work, was found (Brunetto et al. 2012). The authors found no research dealing with the impact of job satisfaction on efforts to market one’s profession and to promote its public image, either in general or in nursing in particular. Professional image

Kalisch & Kalisch (1987, p. 2) defined the professional image of nursing as ‘the sum of beliefs, ideas, and impressions that

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people have of nurses and nursing’ (Kalisch & Kalisch 1987). At that time nursing in different countries in the developed world had long suffered from negative public stereotyping as a lowskilled occupation. Nurses were stereotyped, especially in films, as either handmaidens to physicians, battle axes, nymphomaniacs or sadists (Muff 1982). The modern public image of nursing appears to be more positive but is still based on myths, misconceptions and stereotypes (Morris-Thompson et al. 2011). Furthermore, it was claimed that though the public respect nurses, they would not recommend this profession as a career choice for themselves, their children or their pupils (Morris-Thompson et al. 2011). The nursing profession in Europe suffers from a devalued image in society and a lack of prestige and social recognition (Manzano-García & Ayala-Calvo 2014). As such, in the UK nurses were not even included in the Ipsos Mori poll on the most trustworthy professions and in media reports nurses frequently appear in the negative stories (Dean 2014). In the USA the widely held view of nursing is of a not intellectually demanding or challenging occupation (Cabaniss 2011), although over the years the Gallup surveys show that the public perceives nursing as the most honest and ethical profession (Gallup 1999 through 2014) (Gallup 2014). Morris-Thompson et al. (2011) found that UK nurses themselves have an image of nursing that is quite different from the public’s image of nursing (Morris-Thompson et al. 2011). Nurses’ image of nursing was found to be distinctly positive and was derived from nurses’ experience of diversity, privilege and fulfilment they gain through being a nurse. USA nurses working in hospitals were found to have negative perceptions of the profession, whereas nurses working in maternal–child unit were found to have positive perceptions of the nursing profession (Emeghebo 2012). On the other hand, previous studies of Israeli nurses found high levels of professional self-image (Hendel & Kagan 2011; Toren et al. 2011). A negative image of the nursing profession was identified as one of the factors contributing to the present major shortage of nurses around the world due to its negative impact on the ability to recruit and retain nurses in health care (Neilson & Jones 2012). However, little is known about the impact of professional self-image on the behaviour of marketing the nursing profession.

Aim

The aim of this study was to examine nurses’ behaviour in promoting or marketing the nursing profession and the contribution of professional self-image and job satisfaction to the explanation of this behaviour among nurses who work in the operating rooms (ORs), dialysis units (DUs), general intensive

Promotion and marketing of nursing profession

care units (GICUs), intensive cardiac care units (ICCUs) and delivery rooms (DRs) of a large medical centre.

Methods Participants

This study was based on a convenience sample of 169 registered nurses who work in five specialized clinical care units at a large medical centre in central Israel. In order to work in these units, post-basic training and licensing over and beyond the registered nursing exams is required for nurses. In other words, we examined a select group of highly educated professionals. Of the total sample, 37.5% worked in an OR, 29.2% in DUs, 11.9% in GICUs, 14.3% in ICCUs and 7.1% in DRs. Women comprised 85.6% of the sample. The average age was 43.6 [standard deviation (SD) = 10.16], with a range of 25–66. The proportion of Israeli-born nurses and midwives was 51.8%, and 48.2% had emigrated from the former Union of Soviet Socialist Republics (USSR). A total of 23.3% had a registered nursing diploma, 64.4% had a bachelor’s degree in nursing and 12.3% had a master’s degree in nursing. Of all respondents, 87.2% were staff nurses, 6.4% nurse educators and 6.4% nurse managers and deputy nurse managers; 79.6% worked full time, and the sample had a mean of 17.8 (SD = 11.44) years’ experience in nursing and midwifery. In Israel, midwives belong to the nursing sector and function as part of the nursing profession. Therefore, the study refers to nurses and midwives as a single group and profession. Tools

The variable marketing of the nursing profession was measured by an 18-item questionnaire constructed by the authors (see Appendix S1). To help construct the tool, the authors set up a multidisciplinary focus group, consisting of two spokeswomen from the medical centre, two public relations managers, two senior nursing administrators, one physician and two human resources coordinators specializing in nursing staff development. The group was asked to define general domains related to the marketing of nursing, to identify target audiences for this marketing effort and to identify and map activities through which hospital nurses could market nursing to those audiences. Twenty-four items were identified. All seven members of the focus group reviewed the questionnaire for face validity, feasibility and comprehensibility. All members had to be in full agreement for an item to be included, and their comments were taken into account in the construction of the final questionnaire. At the end of the revision process, 18 items associated with marketing to three major target audiences were included. These audiences were (a) the nursing community (items 1, 2, 5,

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7, 11, 17), (b) the general public (items 3, 4, 14, 15) and (c) physicians and other healthcare colleagues (items 6, 8, 9, 10, 12, 13, 16, 18). The final tool was piloted among 10 staff nurses working in specialized units. Respondents were asked to give their reply to each item on a scale of 1 (never) to 6 (weekly). The overall score was represented by the mean. Cronbach’s alpha for this part of the questionnaire was 0.95. The variable professional self-image was measured by the Porter Nursing Image Scale (Porter & Porter 1991) translated into Hebrew and modified by Altman (1995). The tool consists of 21 items divided into two parts. The first part assesses professional self-image and comprises a list of 10 matched pair, bipolar (positive and negative) adjectives reflecting characteristics of the nursing profession as a whole (interesting, attractive, diverse, challenging, etc.). The second part examines the image of the respondent’s particular field of practice and consists of 11 positive- and negative-paired items referring to the characteristics of the field, such as ‘work in an interesting clinical field’, ‘challenging nursing practice’ and so on. The respondents were asked to rate the questionnaire’s items on a Likert scale ranging from 1 to 6 (higher scores indicate a more positive image). The overall score for self-image was represented by the mean of the 10-item scores in the first part. The overall score for the image of the nurse’s clinical field was represented by the mean of the 10-item scores in the second part. The score for the overall image of the profession as perceived by nurses was represented by the mean of all 20 items. The scale’s reliability (Cronbach’s alpha) reported for the first part ranges from 0.85 to 0.91 (Altman 1995; Hendel & Kagan 2011; Toren et al. 2011) and for the second part is 0.90 (Toren et al. 2011). In the present study Cronbach’s alpha for the first part was 0.87 and for the second –0.92, while for the whole questionnaire it was 0.93. The variable job satisfaction was measured by a tool that combined two previous questionnaires (22 items in all). The first questionnaire was constructed by Toren et al. (2011) and comprised 12 items reflecting emotional and behavioural expressions of nurses’ job satisfaction, such as ‘I would recommend working in the clinical field of . . . to my children’ or ‘My current position meets my idea of an ideal job’. In order to express the self-fulfilment aspects of job satisfaction we added a second questionnaire (Meir & Yaari 1988) that focused on the achievement of personal and professional goals, belonging, social recognition and self-fulfilment at work. The tool consisted of 10 statements such as ‘My work and duties are interesting’, ‘I feel satisfaction in dealing with the challenges of my work’, ‘My work is recognized and appreciated by others’, ‘I enjoy my work’ or ‘I have a sense of success and accomplishment in my work’. Respondents were asked to rank the extent of their agreement with the statements on a scale of 1 (very low) to 5 (very high).

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Two items in the first part were recoded. In a previous study Cronbach’s alpha for the first part was 0.80 (Toren et al. 2011). The internal reliability score for the second part in earlier studies was 0.91–0.92 (Meir & Yaari 1988). In the current study, the overall job satisfaction score for the whole instrument was represented by the mean. Cronbach’s alpha for the present questionnaire (22 items) was 0.89. The respondents’ demographic data collected were gender, age, marital status, place of birth, level of education, professional rank, general work experience, seniority in the current specialized unit, job title and full- or part-time work. Procedure

The study was a cross-sectional, correlational analysis with a prospective design. The structured self-administered questionnaire comprised four sections which measured (a) the marketing of nursing, (b) professional image, (c) job satisfaction and (d) demographic information on the respondent. Before beginning data collection, a pilot study was conducted (n = 10) to evaluate the data collection procedure and respondents’ understanding of the questionnaire. Some items were altered in light of comments received. The questionnaires were distributed by the researchers, together with a letter explaining the aim of the study and guaranteeing respondent anonymity and data confidentiality, to 217 nurses (with a compliance rate of 77.8%). The return of a completed questionnaire was taken as consent to participate in the study. Completion of the questionnaire took about 20 min. Ethical considerations

Approval for this study was obtained from the management of the medical centre at which the study was conducted. This is in accordance with the ethical committees’ decisions in Israel. Data analysis

Descriptive statistics were used to analyse the nurses’ sociodemographic data and to describe the research variables. Pearson correlation coefficients were used to test relationships between variables, and t-test analysis (for independent samples) was used to compare means between groups. To examine differences between multiple groups, we performed a one-way analysis of variance (ANOVA) followed by Tukey’s post hoc tests to determine in which specific nursing fields nurses differed significantly in marketing of nursing profession. Multiple regression analysis was used to measure the unique contribution of the independent variables to the explanation of dependent variables. The level of significance employed throughout was 0.05. Data were analysed using SPSS v19.0 (SPSS Inc., Chicago, IL, USA).

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Results Descriptive statistics and differences between groups

The mean score for general professional self-image (GPI) for the whole sample was 5.12 (SD = 0.64) (on a scale of 1–6). The mean scores for the components of GPI were as follows: for the image of nursing as a whole, 5.09 (SD = 0.66), and for the image of nursing in a particular field of practice, 5.15 (SD = 0.73). The mean scores for job satisfaction and for marketing of the nursing profession as ranked by all respondents were 4.0 (SD = 0.57) (on a scale of 1–5) and 2.42 (SD = 1.16) (on a scale of 1–6), respectively. The mean scores for the components of marketing nursing were as follows: marketing to the nursing community, 2.75 (SD = 1.20); to the public, 2.82 (SD = 1.14); and to other healthcare staff, 2.13 (SD = 1.30). The one-way ANOVA demonstrated significant differences between groups only on the variable of marketing the nursing profession (F = 3.88, degrees of freedom = 4, P < 0.005). A Tukey’s post hoc tests showed that nurses working in ICCU scored a significantly higher level of general marketing of nursing profession (M = 3.33, SD = 1.39), marketing to other nurses (M = 3.49, SD = 1.33), to the public (M = 3.4, SD = 1.32) and to other staff members (M = 3.17, SD = 1.58) than those working in other fields except for DR (see Table 1). No significant differences were found in the level of general marketing nursing profession between other groups. The mean scores for GPI and its components, for job satisfaction, and for marketing nursing and its components are given in Table 1. Significant differences were also found in the marketing of nursing between nurses in management positions and regular ward nurses. Nurse managers and their deputies (n = 10) reported higher levels of nursing marketing activity compared with first-line staff nurses (M = 3.05 vs. M = 2.33, respectively; t = 2.04, P < 0.05). There were no gender- or education-related differences in these variables. As to ethnic differences in professional image, Israeli-born nurses demonstrated higher levels of GPI than former USSRborn nurses (M = 5.21 vs. M = 5.01, respectively; t = 1.99, P < 0.05). There were no differences by ethnicity in the job satisfaction and marketing of nursing variables. Nurses working full time demonstrated higher GPI scores than nurses working part time (M = 5.17 vs. M = 4.85, respectively; t = 2.30, P < 0.05). Relationships between variables

The results of the correlation analysis between the research variables are given in Table 2. There was a strong and significant correlation between GPI and job satisfaction and a significant correlation between job satisfaction and marketing activity. Positive significant correlations were also found between the

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Table 1 Mean scores of research variables by fields of nursing practice (n = 169), mean (SD) Clinical field

DR

ICCU

DU

OR

GICU

F

P

Marketing nursing – general (scale 1–6) Marketing to nurses Marketing to the public Marketing to other staff General professional image (scale 1–6) Image of nursing Image of nursing specialty Job satisfaction (scale 1–5)

2.47 (1.23) 2.75 (1.37) 3.11 (1.09) 1.80 (0.87) 5.30 (0.35) 5.14 (0.39) 5.40 (0.40) 4.20 (0.37)

3.33 (1.39) 3.49 (1.33) 3.40 (1.32) 3.17 (1.58) 5.10 (0.78) 5.20 (0.80) 5.10 (0.85) 4.12 (0.56)

2.46 (1.22) 2.69 (1.24) 2.68 (1.26) 2.18 (1.34) 5.10 (0.64) 5.10 (0.62) 5.10 (0.76) 4.02 (0.57)

2.30 (0.99) 2.60 (1.07) 2.77 (0.99) 1.84 (1.12) 5.09 (0.61) 5.05 (0.64) 5.15 (0.70) 3.99 (0.57)

2.17 (0.81) 2.41 (1.01) 2.50 (0.93) 1.81 (0.86) 5.10 (0.68) 4.96 (0.77) 5.27 (0.65) 3.72 (0.62)

3.88 3.87 2.80 4.44 0.22 0.49 0.63 1.90

0.005* 0.005* 0.028* 0.002* 0.93 0.75 0.64 0.11

*Significant difference is between ICCU and at least three other groups. DR, delivery room; DU, dialysis unit; GICU, general intensive care unit; ICCU, intensive cardiac care unit; OR, operating room; SD, standard deviation.

Table 2 Correlation analysis of the relationships between research variables (n = 169) Research variables

1

2

2.1

2.2

2.3

3

1. General professional image 2. Marketing of nursing 2.1 to nurses 2.2 to the public 2.3 to colleagues 3. Job satisfaction

– 0.15 0.21** 0.21** 0.07 0.67**

– 0.94** 0.90** 0.95** 0.22**

– 0.85** 0.82** 0.31**

– 0.78** 0.28**

– 0.07



**P < 0.01.

mean score for seniority in nursing and general professional image (r = 0.22, P < 0 .001). There were no correlations between socio-demographic characteristics and research variables. To measure the unique predictive contribution of selected variables to explaining the marketing of the nursing profession variable, a multiple regression analysis was performed. All sociodemographic and research variables were included as independent variables while marketing nursing activity (overall index) was the dependent variable. This analysis demonstrated that job satisfaction (t = 2.10, B = 0.51, β = 0.28, P < 0.05) and job position predicted the dependent variable (t = 2.10, B = 0.25, β = 0.24, P < 0.05), explaining 15% of the variance in marketing activity.

Discussion This study investigated nurses’ individual activity of promoting or marketing their profession both internally (to other nurses) and externally (to other healthcare staff and to the general public). In addition, the association and contribution of professional self-image and job satisfaction to nursing marketing

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activity was examined. Having found no other research reports on the marketing of nursing by nurses, we cannot compare our data to existing knowledge and so most of the following discussion will review our own findings from our perspective as researchers and in light of a few study reports and our professional experience. We found that nurses reported relatively low levels of engagement in promotion or marketing of the profession. Of the three target audiences for marketing, although some level of marketing activity reported was directed at patients and nurses from other clinical fields, almost none was directed at physicians and other healthcare staff. Nathanson et al. (2011) found that nurses’ scores regarding various aspects of teamwork, such as planning together to make decisions about care, conducting open communication and work collaboration were lower than those of physicians (Nathanson et al. 2011). We would hypothesize that these findings were the result of disparities in status, authority, responsibility, gender and education, in particular between nurses and multidisciplinary healthcare staff primarily physicians. This is probably also the reason why, in the current study, nurses avoided marketing

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their profession to other hospital staff and in particular to physicians. Our own experience leads us to the conclusion that the difference between the professional status of nurses and of their colleagues in other professions discourages nurses’ initiatives to change the attitudes and behaviour of other colleagues, especially physicians. In contrast, nurses feel more confident in interactions with other nurses and with patients and their families. Another explanation for the paucity of marketing activity by nurses might be the lack of policy and programmes for promoting the image and status of the profession on a national or organizational level. Although nurses are considered an important and significant part of Israel’s healthcare system, we found no mention of reports, protocols or projects on the ministerial level or policy-making level for promoting the profession to strengthen their professional status. The lack of policy and programmes, on the one hand, and the existence of sporadic and unplanned marketing activities with no proven effectiveness, on the other, form a state of affairs that is also evident at the organizational level of hospital and community services throughout the country. As far as regard Israeli nurses’ professional self-esteem, the results of this study are consistent with previous findings (Hendel & Kagan 2011; Toren et al. 2011) and seem to reflect an ideally desirable professional self-image. The high correlations between perceived professional image and job satisfaction were expected as that is what was previously found (Takase et al. 2002). On this basis, Ting (2011) proposed to incorporate nurses’ high level of job satisfaction into marketing strategies in order to attract more recruits (Ting 2011). Because we found no direct association between nurses’ professional image and their efforts to market the profession, we assume that these two constructs have an indirect relationship mediated by the job satisfaction variable. In other words, nurses reporting higher professional self-image will demonstrate higher job satisfaction, which will subsequently lead them to take on more marketing activities. An interesting finding of this study relates to the contribution of nurses’ position and rank to marketing of the nursing profession, as the more senior the nurse’s position and rank the more marketing they engaged in. Nurses at senior executive levels are responsible, among other things, for public relations, marketing, information and technology (Duffield et al. 2001). Their higher awareness of and commitment to public relations and nursing-wide issues could explain why they performed much more promotion or marketing of the profession than staff nurses in specialized units. A further interesting finding was the differences between nurses from different clinical areas. We found that nurses

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working in ICCUs engaged in significantly more marketing than nurses from other intensive care fields (DUs etc.) and midwives. In our experience senior management in cardiac care is highly oriented towards marketing and public relations and invests much effort in promoting the positive public image of this service within and outside the hospital. For example, the cardiac division at the Rabin Medical Center in Petah Tikva maintains its own web site, its own pages on the hospital’s web site, its own newsletter and also promotes campaigns for marketing its activity to the general public and hospital staff (Rabin Medical Center 2013). We suppose, therefore, that a local organizational climate that emphasizes the importance of professional image and public relations, combined with the personal drive and commitment of senior managers, encourages ICCU nurses to be more marketing oriented. This highlights the importance of management’s awareness of its role in establishing and implementing long-term marketing efforts. It was especially noticeable in the present study that ICCU nurses scored the highest of all fields of practice in marketing the nursing profession to other healthcare staff, something which nurses from other clinical fields avoided almost entirely. This could also indicate that the organizational culture, as it exists in an ICCU, considers nurses an integral part of the multidisciplinary team and colleagues of equal status. Limitations of the study

The study’s main limitations are related to its relatively small convenience sample of nurses working mostly in advanced acute clinical areas. An additional limitation could be related to the use of a sample recruited from a single tertiary medical centre. Future research in other clinical settings and areas with a larger sample is needed to confirm the generalizability of the findings.

Conclusions Despite the growing need to improve the image of the nursing profession in order to increase public support and recruit new nurses, the issue of promoting or marketing the profession is not receiving proper attention. Together with a lack of policy and long-term programming at the national and organizational levels, nurses in specialized units are not mobilized to promote the professional image of nursing on the individual level. In this regard they are passive. Implications for health policy

Based on the findings of this study, the literature review and our own experience with the nursing system in Israel, we would recommend improving marketing of the nursing profession through the following steps:

Promotion and marketing of nursing profession

1. At the individual level (particular nurse): While providing high-quality nursing care nurses need to be proud of themselves and their work and not be ashamed to promote the image of their profession in the course of their daily activities. 2. At the organizational level (particular healthcare organization): a. Formulate and implement policies and programmes to promote the image of nursing. b. Initiate local public relations and marketing campaigns that would highlight the achievements of nurses and their contribution to successful patient care and clinical outcomes. c. Encourage and train nurses to take part in marketing activities. 3. At the national level: a. Draw up a long-term programme for promoting or marketing the professional status of nursing. b. Establish training programmes for developing marketing skills among nurses at all levels of the system from bedside nurses to senior executives. c. Define goal achievement indicators for the above programmes. d. Assemble the budgets and other resources required to maintain the marketing of nursing programmes. It is important that we remember that at no point should the ethics of our profession be sacrificed to the needs of marketing. Possibly, there might even be the need for ethical experts to accompany the process. We recommend this programme in spite of the fact that nurses in our experience and in the literature we read are reluctant to promote or market themselves or the profession. Research on the reasons for this could be fascinating and we would be interested to know how much is gender specific, a function of the manpower in various units or wards, an expression of the organizational and historical culture of nursing and more. Whether further research is performed or not, in our opinion, time is running out and nursing must be more proactive in promoting its professional image and status.

Author contributions IK, EB, LT, NS and DA: Study conception/design. IK, EB, LT, NS, DA and SM: Data collection/analysis. IK, KLO and SM: Drafting of manuscript. IK, EB, LT, NS, DA, KLO and SM: Critical revisions for important intellectual content. IK and SM: Supervision, statistical expertise, administrative/technical/material support. All the authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data.

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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Appendix S1 Nursing promotional and marketing activity questionnaire.

Promotion or marketing of the nursing profession by nurses.

In recent years, much effort has been invested all over the world in nurse recruitment and retention. Issues arising in this context are low job satis...
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