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March 2010, Volume 37, Number 2
Online Exclusive, Open Access, Journal Club Article
The Invisibility of Nursing: Implications From an Analysis of National Cancer Institute–Designated Comprehensive Cancer Center Web Sites
Deborah A. Boyle, RN, MSN, AOCN®, FAAN
Purpose/Objectives: To identify the degree of oncology nursing representation on public Web sites of the National Cancer Institute (NCI)-designated comprehensive cancer centers (CCCs) in the United States.
Design: Qualitative, descriptive.
Setting: Web sites.
Sample: 40 CCCs.
Methods: Using the Google® search engine, a query was undertaken using the term National Cancer Institute-designated comprehensive cancer center. The search resulted in linkage to the site www.cancer.gov, which provided Web site addresses for 40 CCCs. The CCCs were classified into five categories based on the degree of nursing representation evident throughout each Web site.
Main Research Variables: Presence and quality of four themes in the Web site specific to oncology nursing activity at the CCC: (a) recognition of nursing on the CCC home page; (b) citations and/or descriptions of nursing personnel, programs, or recognitions within the Web site; (c) existence of a dedicated nursing Web page; and (d) acknowledgment of the chief nursing officer at the CCC.
Findings: Only 2 of the 40 CCCs revealed broad representation of oncology nursing throughout their Web site. Nearly 63% of CCC Web sites had no or minimal content about nursing.
Conclusions: Public Web sites offer important information to patients with cancer, their families, and the general public. The absence of nursing in lay-oriented media devalues oncology nurses’ highly specialized knowledge and skill.
Implications for Nursing: Considerable opportunity exists to enhance the public’s awareness of the scope and complexity of contemporary oncology nursing within the 40 CCCs in the United States. Omission of positive messages about nurses’ work in hospital-related media misleads the public that nurses are not integral members of the multidisciplinary team. With the continued absence of both descriptive and results-oriented work quantification, oncology nurses will remain unable to communicate their worth to the public, nor take credit for their care.
The image of nursing is problematic in large part because of the negative and erroneous portrayal of nurses by mass media (Barnet, 2007; Boyington, Jones, & Wilson, 2006; Buresh & Gordon, 2000; Fletcher, 2007; Fulton, 2007; Gordon & Nelson, 2005; Kalisch, Begeny, & Neumann, 2007; Powers, 2001; Takase, Kershaw, & Burt, 2002). Of comparable concern is the under-representation of nursing in healthcare communications targeting the public (Barker, 2001; Boyle, 2008; Buresh & Gordon, 2000; Carty, Coughlin, Kasoff, & Sullivan, 2000). The absence of a nursing presence in these media has numerous negative consequences, including
· Inadequate recognition of nursing’s contributions to patient care outcomes.
· Deficient distinction of specific components of nursing care rendered (i.e., safe administration of therapies, comprehensive management of symptom distress, provision of patient and family education and counseling, oversight of care among numerous disciplines, and provision of end-of-life care).
· Insufficient description of skill sets required within subspecialties of nursing specialties (i.e., those related to the care of patients undergoing surgery and receiving radiotherapy or biochemotherapy).
· Lack of delineation of parameters of advanced practice nursing roles.
· Unsatisfactory reporting of nursing research endeavors, quality improvement projects, and evidence-based practice outcomes that confirm nursing contributions to the science and quality of patient care.
· Adverse effect on recruitment into the nursing profession.
· Unfavorable influence on the potential to lobby policymakers to enact legislation supporting the financing of nursing education and services.
· Detrimental effect on nurses’ self-images from a devaluation of the nurse’s role.
The interdisciplinary nature of cancer care has fostered ongoing partnerships, collaborations, and shared goals among healthcare team members (Boyle, 2008; Haylock, 2008). The role of the oncology nurse on the team has historically been a highly valued one, articulated as such by physician colleagues. However, a waning of the importance of the oncology nurse role has become evident in recent years.
Although the majority of cancer care occurs in community settings, comprehensive cancer centers (CCCs) are perceived as flagship facilities offering the most innovative, cutting-edge, novel therapies. In particular, patients with rare forms of malignancies or those who have exhausted standard regimens and seek participation in early phase clinical trials often receive cancer care in CCCs. Designation as a CCC requires provision of a wide array of services. The National Cancer Institute ([NCI], 2009) stated
A comprehensive cancer center has demonstrated reasonable depth and breadth of research activities in each of three major areas: laboratory, clinical, and population-based research, with substantial transdisciplinary research that bridges these scientific areas. An NCI-designated comprehensive cancer center must also demonstrate professional and public education and dissemination of clinical and public health advances into the community it serves (p. 1).
Forty CCCs currently exist in 23 U.S. states and the District of Columbia. Nurses offer a cadre of services within CCCs with their role being indispensable to facility function and success. The portrayal of the nursing role in CCCs should integrate proficiencies as provider and collaborator of care, educator, and investigator. The goal of this survey was to identify the degree of nursing representation on public Web sites of the nation’s NCI-designated CCCs.
Using Google®, a search was undertaken using the term National Cancer Institute-designated comprehensive cancer centers. This search resulted in the site www.cancer.gov, which was accessed. Another search was then prompted on the NCI Web site with the term comprehensive cancer center. This elicited the finding NCI-designated cancer centers, which offered a choice of listings for comprehensive cancer centers and cancer centers. The link for comprehensive cancer center delineated a list of the 40 CCCs. Each CCC provided an e-mail contact and a Web site address. The 40 Web sites from this listing were used to access individual CCC Web sites which were, in turn, used for this survey.
Four areas were the focus of the Web-based survey: acknowledgment of nursing on the CCC home page; access to information on nursing personnel, programs, and services within the CCC; presence of a Web page devoted to nursing within the CCC; and identification of the chief nursing officer (CNO) at the CCC. Operational processes undertaken to delineate survey findings included evaluation of the CCC home page for the presence of any mention of nursing. From the home page, the search term nursing was used and results were critiqued for the presence of multiple citations of nursing employees, news, events, recognitions, programmatic services, or educational offerings. Two “hits” of results were allowed, multiple citations were required for a positive ranking, and credit was not given if employment opportunities or a linkage to a school of nursing or the primary hospital affiliate was the sole result from the search. A nursing department Web page was defined as a designated link within the CCC Web site that described nursing services or the practice of nursing at the CCC. If a Web page was not revealed from the nursing search term, other searches using the terms nursing department and division of nursing were used.
Numerous search terms were used to ascertain the identification of a CNO at the CCC, such as nurse executive, chief nursing officer, nurse administrator, and nursing director. Additionally, if an icon on the CCC home page was present identifying leadership team or administrative staff, this site was accessed to determine the presence of a nurse in a leadership position responsible for nursing practice at the CCC.
Table 1 depicts the results of the survey. Only two CCC Web sites—Dana-Farber Cancer Institute at Harvard University and Roswell Park Cancer Institute—revealed broad representation of oncology nursing throughout. Sixty-three percent (n = 25) of the CCC Web sites had no or minimal content on nursing. The 40 CCC Web sites were categorized for their degree of representation of oncology nursing (see Figure 1). Five categories were identified.
· CCCs with the most comprehensive nursing coverage (all four survey items present)
· CCCs with well-integrated nursing content on the Web site (nursing was not mentioned on the home page but was identified in the other three categories)
· CCCs with moderate nursing representation (two of the four survey categories present)
· CCCs with minimal representation (only one of the four survey categories present)
· CCCs with no acknowledgment of nursing on their Web site (no survey categories identified).
Public Web sites offer critical information to patients with cancer and their families and are the public face of an organization (Song et. al., 2009; Summers & Summers, 2009). Results of this survey reveal considerable need to address the invisibility of oncology nursing within the nation’s NCI-designated CCC Web pages. The absence of nursing in mass media fosters two negative corollaries: It devalues the knowledge and skills required to care for the patient with cancer and it fails to take advantage of the opportunity to educate the public about the scope and complexity of today’s specialty of oncology nursing.
In reviewing Web sites, not only was the absence of nursing significant, the predominance of medicine was poignant. The exclusionary depiction of physicians as being the epicenter of the healthcare universe contributes to their receiving credit for every positive practice and research outcome, even when credit should be given to nurses (Buresh & Gordon, 2000; Kalisch et al., 2007). In reality, although nurses work with physicians, they are managed by senior nurses and frequently are taught by nurse scholars about the art and science of autonomous nursing practice. Summers and Summers (2009) identified that physicians lack the experience and training nurses have and, therefore, cannot do nursing work.
Additionally, although nursing was an obvious omission, of note was the presence of other disciplines on the CCC Web sites. Dietitians, social workers, volunteers, biostatisticians, pharmacists, psychologists, case managers, physical therapists, pastoral care, and lymphedema therapists all were depicted as part of the healthcare team. Within the context of interdisciplinary cancer care, the obvious absence of oncology nursing was startling and disconcerting. The lack of acknowledgment of the CNO at the cancer center was particularly troublesome. Only nine CCCs had any mention of the role within their center. However, in the majority of instances, the CNO leads the largest department of cancer center employees, oversees a considerable budget, and is held responsible for the quality of care rendered to all patients.
Nursing in the United States is a paradox (Friedman, 1990). Although nurses help others live and die, in the public depiction of health care, patients seem to emerge from hospitals and other settings of care without ever benefitting from their assistance (Gordon, 1997). Although the public holds nurses in the highest regard (Needleman & Hassmiller, 2009; Summers & Summers, 2009), they have little idea what nurses really do. Nursing is the most populous profession in health care; however, despite its pervasiveness, it is an invisible profession, virtually omitted from the media.
A poll of 1,500 opinion leaders (i.e., corporate executives, university faculty, insurance directors, health services administrators, government officials, and industry thought leaders) identified that a top barrier to nurses having more influence and exerting more leadership in healthcare arenas is related to the perception that nurses lack roles as key decision makers (Gallup, 2010). Other polls reinforce the belief that nurses generally are prized for their virtues, not their knowledge (Gallup, 2009; Gordon & Nelson, 2005). This is, in part, because of the fact that the core and essence of nursing work is unknown (Ebright, 2004). The intricacy of nursing care makes it difficult for non-nurses to comprehend the dynamic and multiple components of nurses’ professionalism. Additionally, the advent of increasing technology in practice and the use of computerized documentation masks nurse decision making, problem solving, and critical thinking (Boyle, 2008). Therefore, a significant charge for nurses is to help the public construct an authentic meaning for the term nurse that conveys its depth, scope, and indispensability (Buresh & Gordon, 2000).
Investigation of the characteristics of nursing work delineates its significant depth and complexity (Ebright, Patterson, Chalko, & Render, 2003). The intricacies of nursing emanate from the need to manage highly complicated processes and environmental variables while providing individualized patient interventions (Institute of Medicine, 2004; Potter et al., 2004). Examples of complex processes in oncology nursing include coordinating a discharge following bone marrow transplantation, linking conflicting family and care provider information to establish do not resuscitate status, assessing patients’ needs for intensive care unit transfers, and retrieving critical information for healthcare teams to advocate for improved pain control. Other workplace issues that heighten complexity are interruptions and delays in care, staff shortages, and the ongoing introduction of new work delivery methodologies that increase nurse’s cumulative cognitive load (Potter et al., 2005). This then creates the potential for disrupting the nurses’ focus and subsequent decision making. These realities promote a work culture for nurses exemplified by continuous vigilance of patient status, collaboration, conflict resolution, and high-level critical thinking. The expansive scope of nursing is eloquently depicted in Diers (2004):
The activities of nursing that directly connect the nurse and the patient are crucial, but what is less often understood is the extent of nursing’s entirely separate but equally compelling responsibility: No less than manage the whole experience—the entire environment of healthcare practice of all other professional groups. The nurse is in charge of all the healthcare system and must make it work in the service of those who need and want it (p. 144).
Without question, nursing care requires definition beyond a common act of simple intuition and compassion. However, another problem needs to be addressed: Nurses themselves may downplay the scope of their professional expertise or refrain from taking credit for outcomes of patient care. Speaking out in this manner often is perceived to be self-serving or calling too much attention to oneself. These beliefs are exemplified in common responses to expressions of gratitude for exemplary nursing care. Nurses often can be heard answering thank yous from patients and families with comments like, “Oh, it was nothing,” “I didn’t really do that much,” or “It was just my job.”
In an Oncology Nursing Society survey, oncology nurse respondents were asked to list three words that they believed most accurately described themselves and their peers (Krebs et al., 1996). From the 558 responses, more than 100 words were identified; most common were caring (22%), and compassionate (11%). Only 7% of responses identified the term knowledgeable, and only 4% identified the term intelligent as key descriptors. Irrespective of the etiology of nursing invisibility, the current paradigm must change.
The absence of messages about the contributions, qualifications, and accomplishments of nurses on hospital Web sites may subtly but negatively influence the public’s perception of care that they can expect to receive in hospitals (Boyington et al., 2006). Additionally, omission of positive messages about nurses’ work in hospital-related media constrains the attraction of prospective nurses to the profession. Disregarding nursing promotes a subliminal message misleading the public that nurses are not integral members of the healthcare team. Nursing oversight and responsibility for the orchestration of total patient care fails to be recognized. Literature depicting first-hand accounts of days in the lives of nurses can offer testimony to the tapestry of nurse work (Heron, 1998).
The popularity of the Internet among healthcare consumers has not gone unnoticed (Boyington et al., 2006; Sanchez, 2000; Song et al., 2009). The Internet, in general, portrays nursing more favorably than mass media (Kalisch et al., 2002). Representation online offers a viable venue for enhancing the public image of nurses. In particular, identifying who nurses are, what they do, where they do it, and how it is done are essential distinctions to convey (Fletcher, 2007; Kasoff, 2006). A concerted effort must be undertaken to present nursing in a contemporary image reflective of professionalism and grounded in science, technology, and knowledge. This image then must be endorsed by nursing professionals en masse (Gordon & Nelson, 2005). Such distinction also augments colleagues’ understanding of nursing work.
A data-driven representation of nursing work is aligned with increasing pressure to connect practice with outcomes. In the absence of a results-oriented quantification of nursing work, nurses will remain unable to communicate to the public their worth or take credit for their care. Therefore, a new vocabulary is required that focuses on outcomes, integrates quality, addresses fiscal elements of patient care, and prompts economic visibility—the presence emanating from being measured, a value recognized by conventional societal norms (Diers, 2004). When these attributes are delineated, the education of non-nurses (both lay and professional) is enhanced, and the nature, scope, and complexity of professional nursing is heightened.
An important articulation of nursing will require a heightened capability to depict the paradigm of the nursing mosaic. Diers (2004) said,
Nursing is too big and complicated to be submitted under any particular way of thinking about it, and that’s part of our problem in explaining it, in using its power, in relating nursing to the larger world. Anything less than an appreciation for that complexity demeans our work and our issues (p. 190).
Critical partnerships, then, require increasing cultivation between nurses who practice and those who investigate, teach, and write; those who teach students; and those who coordinate clinical trials and provide community forums. Intraprofessional connections market nursing success.
Steps for Improvement
Patients are admitted to hospitals because they require nursing care. Oncology nurses should critique the Web sites of their respective employers and determine the status of how nursing is represented. The presence and quality of nursing coverage should be considered. In the event that representation is substandard, rather than merely offer complaints, recommendations for improvement should be enumerated and communicated (Diers, 2004). Some of these suggestions include the following.
Ensure the inclusion and representation of oncology nursing leadership throughout the Web site: The CNO role, in particular, should be integrated within all listings of CCC administrative and leadership directories. Nursing department phone contact information should be cited and easily accessible. When nurses hold leadership positions within non-nursing departments, their citations should include their RN professional credentials.
Lobby for the creation of a nursing Web site that is easily accessible and prominently displayed: A nurse should lead or co-lead the development of the Web site. A well-defined process should be in place for keeping the site current. The site should include listings of nurses in leadership positions, a depiction of advanced practice nurse presence throughout the CCC, certified nurses, overviews of nursing subspecialties, and competencies required of nurses within these areas. Other Web page components could include listings of educational offerings, committee participation and leadership, nurse-driven activities describing quality improvement and evidence-based practice projects, research initiatives, and descriptions of best practices. Presentations, publications, commentary provided on radio and television, legislative work and testimony rendered, and community advocacy also could be included.
Scharfe-Pretino and Von Bacho (2006) delineated nursing Web site components, some of which could be depicted in links where the lay public has access. These included patient satisfaction initiatives and scores, safety goals, the mission and vision of nursing practice, the professional practice model, links to patient education resources, provision of an e-mail or contact link to the department of nursing for patient education questions, and information about the American Nurses Credentialing Center’s Magnet Recognition Program®.
Create a process for sending details about nursing accomplishments to public relations and other contributors to media sources: Data should include information about new certifications, attainment of advanced degrees, and professional recognitions. If an annual report is available, establish a link to the report that allows the user to fully access its details.
A critical partnership needs to be established with those responsible for Web site design and content. Many public relations staff are ingrained in the belief about the medical hierarchy within health care (Gordon, 2005); therefore, they should be educated about the variety of healthcare issues in which nursing care is critical to positive practice outcomes. For example, the following facts can be stressed. Nurses spend the most time with patients; therefore, they can articulate the patients’ views and poignantly relay what transpires in patients’ lives. For this and numerous other reasons, nurses make excellent medical health experts. Nurses represent the largest cohort (over 2 million) of women in science (Auerbach, Buerhaus, & Staiger, 2007). Their critical involvement in biomedical research involves nurses to deliver novel therapies and collect, analyze, and communicate findings. Oncology nurses’ collaboration with drug companies is a good example of where acknowledgement of oncology nurses’ expertise is well founded and has existed over time. Interventions to counter the minimization and invisibility of nursing work in the healthcare media are cited in Figure 2.
Nurses must take credit for the value of their work. The scope of concern about nursing invisibility on public Web sites is considerable. Summers and Summers (2009) stated,
Use [Web sites] to explain nursing at your institution to the public. Nursing schools often profile their faculty, letting the public know about professionals’ credentials and interests. But try finding anything about a specific nurse on a hospital Web site. We have not seen one that highlights nursing care or the people who deliver it in any detail, much less the detail devoted to physicians, even though hospitals exist mainly to provide nursing care (p. 305).
A profession’s public status and legitimacy is linked to having its expertise acknowledged in the journalistic media (Buresh & Gordon, 2000). Although medicine is the focus of advertising, a lack of nursing presence on hospital Web sites remains a standard industry practice and marginalizes nurses (Boyington et al., 2006; Wineberg, 2003). Critical dangers are created by an absence of nursing in the public eye (Styles, 2006). A lack of understanding about the nature and scope of nursing practice and expertise affects professional cohesiveness and viability. Kasoff (2006) described consequences to healthcare consumers who do not understand what the role of the nurse is and what services are provided. They may misperceive what they can expect in the receipt of nursing care or fail to request assistance that nurses can provide.
Oncology nurses believe the need exists to enhance understanding of the dynamics of their multifaceted role (Krebs et al., 1996). This relates to professional colleagues and the real and potential lay consumers of oncology nursing care. Because of the current and future projected popularity of Web sites in healthcare communications, ensuring the presence of nursing on these sites is critical. Critiquing CCC Web sites and making recommendations for improvement of the depiction of oncology nursing represents an initial and important step to ensure nursing is consistently portrayed as an indispensable body of professional colleagues within cancer care.
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Deborah A. Boyle, RN, MSN, AOCN®, FAAN, is the Magnet® coordinator at Banner Good Samaritan Medical Center in Phoenix, AZ. No financial relationships to disclose. Boyle can be reached at email@example.com, with copy to editor at ONFEditor@ons.org. (Submitted January 2009. Accepted for publication May 26, 2009.)
Digital Object Identifier: 10.1188/10.ONF.E75-E83
Journal Club Questions
This article has been chosen as particularly suitable for reading and discussion in a Journal Club format. The following questions are posed to stimulate thoughtful critique and exchange of opinions, possibly leading to changes on your unit. Formulate your answers as you read the article. Photocopying of this article for group discussion purposes is permitted.
1. Does this article represent qualitative or quantitative nursing research? Distinguish between qualitative and quantitative nursing research.
2. What is the main research question in the article?
3. Does your facility or practice have a Web site to provide information to the public?
a. If not, what are some of the reasons you do not have a Web site?
b. If so, when was the last time you looked at the content of the Web site?
c. Is nursing represented on the Web site?
d. Are you happy with the contents of the Web site?
4. As oncology nurses, what can we do to improve the perception of our role as key players in patient outcomes?
At the end of the session, take time to recap the discussion and make plans to follow through with suggested strategies.