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Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital and Centre for Nursing and Midwifery Research, Northern Sydney Local Health District, St Leonards NSW 2065 AustraliaFaculty of Health, University of Technology, Ultimo NSW 2007 Australia
During the COVID-19 pandemic, the use of the labels ‘heroes’ and ‘angels’ to describe nurses (and especially critical care nurses) became prevalent. While often well intentioned, the use of these labels may not be the most positive image of nurses and the nursing profession. Critical care nurses have not previously been given the opportunity to provide their perceptions of the angel/hero narrative and the impact this may have on their practice and working environments.
Objectives
The objectives of this study were to explore the perspectives of critical care nurses and discover their perceptions about the angel/hero narrative and its impact on their clinical practice, safe working environments, and professional development during the COVID-19 pandemic.
Methods
A semistructured qualitative virtual interview study was conducted with critical care nurses from the United Kingdom, Australia, and North America. Digital audio data were transcribed verbatim. Thematic analysis of the transcribed data was performed. The COREQ guidelines were used to report the study.
Findings
Twenty-three critical care nurses located in the United Kingdom, Australia, and North America participated. Four themes were synthesised: history repeating, gender stereotypes, political pawns, and forgotten heroes.
Conclusions
Critical care nurses did not perceive the hero and angel labels positively. Participants were concerned about unrealistic expectations, potential safety workplace risks, and poor remuneration related to these narratives. Participants perceived that context and intention were important in the interpretation of these narratives; they spoke with pride about their work and called for improved representations of their role, recognition, and work conditions.
The COVID-19 pandemic has raised the profile and visibility of the nursing profession among the general public and mainstream media. For example, there was a threefold increase in media news items about nurses during March–April 2020 (COVID-19 was declared a pandemic by the World Health Organization in March 2020) compared to the previous year.
This increase has been particularly evident for the critical care specialty because of the key role critical care nurses played in response to the COVID-19 pandemic.
One notable characteristic of the increased profile of nurses was the tendency for the collective or individual labels ‘angels’ or ‘heroes’ to be used.
These labels are undoubtedly bestowed on nurses with good intentions, in an attempt to acknowledge the courage, care, and commitment that underpin the profession.
However, there is increasing evidence that nurses are concerned about these stereotypical labels, the wider narrative, and the underlying message they convey, particularly in relation to the potential impact on the provision of safe work environments.
A Danish ethnographic study highlighted nurses' aversion to the angel or hero label, citing the increased personal risk associated with the promotion of a voluntary sacrificial choice which placed the burden on the individual, as opposed to the system.
Additionally, Canadian researchers identified the emotional burden of nursing during the pandemic and its link to nursing identity. This related in part to a perceived urgency to provide care ‘at all costs’—for example, not donning personal protective equipment (PPE) prior to helping a deteriorating patient.
Personal risk and a lack of adequate PPE, skilled staff shortages, and low nurse-to-patient ratios (particularly in critical care) have been highlighted as ongoing concerns during the pandemic. Arguably, the media portrayal of nurses and other healthcare workers as angels or heroes exacerbates these potential harms by normalising risk,
Beyond the impact of the media narrative on risks faced by nurses, there is also a concern regarding the wider perception of nurses as skilled practitioners. Bennett et al highlighted the superficiality of the media discourse, suggesting that the narrative presents nurses as a “… homogenous, selfless, and unquestioning group” (p2754) and fails to take account of the role and characteristics of those who work within the profession.
This superficial labelling of nurses as heroes and angels arguably detracts from the skills required to undertake the role, moving the perception of the profession from one of skilled practitionership to one of tireless servantship.
The discourse analysis of Mohammed et al went further to argue that the narrative is a deliberately deployed political tool, which seeks to offer ‘hero status’ as a reward in itself, offered in lieu of tangible improvements in nurses' pay or working conditions.
Much of the literature related to the angels and heroes narrative takes the form of editorials, commentaries, or discourse analysis. Therefore, we sought to investigate, through the voices of critical care nurses themselves, how this narrative has contributed to nursing identity, the profession, and critical care nursing practice. This important phenomenon has yet to be thoroughly investigated, and its impact on nursing and nurses is poorly understood. In this study, we sought to explore the perspectives of critical care nurses and their feelings about the angel and hero narratives impact on the nursing profession throughout the COVID-19 pandemic. The findings from the study will offer new and important insights into the impact of this narrative on the professional identify of critical care nurses and will provide researchers with potential opportunities to explore this phenomenon more widely. The findings may also provide useful information for educators and faculty in relation to curriculum development that clearly outlines the effect of these labels on nursing and nurses.
2. Methods
2.1 Design and setting
We conducted a qualitative descriptive study involving thematic analysis of semistructured interviews. Individual, semistructured virtual interviews were conducted with critical care nurses. Participants were interviewed at a place and time of their choosing, with a single interviewer. Interviews were conducted virtually and conducted by the researchers over a 12-week time scale (October to December 2021). The COREQ guidelines were used to report the study.
A purposive sample of critical care nurses who were exposed to the angel/hero narrative either directly (e.g., hearing patients or relatives using the terms) or indirectly (e.g., watching or reading the narrative in the media) were recruited. All researchers were nurses and therefore ‘insiders’ or part of the social group under examination.
Recruitment and data collection continued until data saturation was achieved. We defined data saturation in line with Fush and Nest (2015), that is, no new patterns or categories are synthesised from the data.
An invitation to participate in the study was circulated via social media platforms, through email lists for critical care nursing organisations (e.g., British Association of Critical Care Nurses) and through the researchers’ personal networks. Potential participants who expressed an interest were emailed a formal invitation, a participant information sheet, and a consent form. Potential participants were given a week during which the principal investigator can be contacted to arrange an interview time.
2.3 Data collection
Semistructured interviews with critical care nurses were guided by a brief interview schedule (Table 1) incorporating four publicly accessible images depicting the hero and angel narrative (see Fig. 1) and were undertaken by most members of the research team. Participants were shown images depicting the hero and angel narrative by sharing the researcher’s computer screen and asked about their perceptions of the images. Images were selected by the research team who agreed they were representative of international public sentiment in the middle of 2020. A UK National Health Service (NHS) image was used from their campaign to “send a million hearts to our NHS heroes”,
The interviews were conducted online on a platform of the participants choosing (i.e., Zoom, Teams, Skype) and audio recorded after the researcher had verbally reconfirmed informed consent. Recordings were transcribed verbatim by a commissioned commercial third party with no links to the research team. The researchers documented their reflections and impressions after each interview in field notes to enable the researchers to consider the data contemporaneously. The interviewer performed preliminary checking and clarification of some comments with the participant at the conclusion of the interview.
2.4 Data analysis
Thematic analysis was guided by the methods of Braun and Clarke
with primary data analysis undertaken independently by two researchers (J.S.-P. and D.M.) after all interviews were completed. Two primary researchers conducted line-by-line coding and analysis, using paper and post-it notes. The first step, ‘immersion’, involved developing familiarity with the interview data by listening repeatedly to the audiotapes and reading the transcription and field notes. The researchers' field notes containing reflections and impressions after each interview contributed to the thematic analysis. Generation of initial codes included identification of raw data which could be categorised in a meaningful way. Moving from creating codes to synthesising broader themes involved examining commonalities with the findings of published studies, then searching for and collating broader themes that captured the essence of participants' responses and patterns of responses. All researchers developed an in-depth understanding of the data through a combination of conducting or listening to interviews and reading transcripts and field notes. The process was iterative, with outcomes from different stages of analysis presented to the whole research team for discussion and revision over several rounds.
2.5 Validity and reliability/rigour
We drew on the work of Braun and Clarke (2006) to ensure trustworthiness and rigour in our data collection and analysis.
Data were digitally recorded and professionally transcribed to ensure accuracy and to enable review by the full team, all of whom have experience in qualitative work. Coding and theme development was conducted and checked by at least two team members as indicated above. Disagreements were resolved through discussion reexamination of the. Regular team meetings were held to discuss and review analytic progress, and all team members were involved in decisions to finalise the themes.
The research team was comprised of experienced critical care nurses who now work primarily in the tertiary education sector with three researchers still active clinically (J.-S.P., D.M., and R.E.). Five out of six researchers were female (J.S.-P., D.M., R.E., K.R., and N.C.), four held PhDs (J.S.-P., D.M., D.B., and R.E.), one holds a doctorate (K.R.), and one holds a master’s degree (N.C.). While researchers drew on their experience and background to inform their interpretation of the data, they deliberately and consciously avoided making assumptions and challenged each other during the data analysis stage to ensure a shared understanding of the data and themes. None of the researchers had a working relationship with any of the participants.
2.6 Ethical considerations
The study was conducted in accordance with the Good Clinical Practice (GCP) guidelines and the National Statement on the Ethical Conduct of Human Research.
Local ethical approval was provided by the university in which the lead researchers worked (application number: 15783). All participants provided informed written consent prior to the interview and were advised that they could decline further participation any time and without reason. No participants declined to participate. This information was again provided verbally by the researcher prior to starting the interview.
All identifiable data were anonymised. The audio recordings, transcripts, and field notes were saved securely and only accessible by the research team and audio transcriber. Recordings were deleted immediately after the transcripts were cleaned and data analysis was complete.
3. Findings
3.1 Number of participants and duration of audio recordings
Interviews were completed with 23 of the 28 critical care nurses who initially agreed to take part, with five not responding to follow-up emails. Participants were critical care nurses located in the United Kingdom (n = 17), Australia (n = 5), and North America (n = 1). The mean duration of digital audio recordings was 19 minutes (range: 11–56 minutes).
Four themes were developed: history repeating, gender stereotypes, political pawns, and forgotten heroes. A conceptual representation of how themes are connected is shown in Fig. 2.
Reflecting on the angels and heroes narrative, participants identified that the term ‘angel’ was strongly associated with historical representations of nursing and reflected the religious origins of nursing (e.g., the linkage between nuns and nursing):“I think that the idea that nursing was a vocation that, you know, single women gave up their lives in the same way that they gave up their, you know, they became nuns in that same kind of idea … you’re so self-sacrificing to become a nurse” (Participant 1)
Participants rejected the ‘angel’ label, stating that nurses were often the direct opposite of angels. One nurse noted “I don’t think angels would have the dark humour … the dark ways of, of seeing the world. I don’t think that’s necessarily very angelic” (Participant 12). Participants also expressed discomfort with the purity associated with being an angel, “we are a profession … able to stand up for ourselves … not just fall back into this handmaiden, angel, hero, you know, that kind of from Florence Nightingale time” (Participant 5).
By being described as angels, participants felt they were viewed as passive, submissive, and disempowered, when in reality, the challenges of critical care require intelligence, critical thinking, and problem-solving skills. Participants recognised that critical care nurses must be able to reflect on practice and respond to changes in patient condition in a proactive, responsive, and autonomous way. In the participants' narratives, knowledge, skill, and professionalism were clearly identified. Again, participants rejected notions of the historical construction of nurses as angels in their professional role and everyday life choices. Several participants highlighted that the sense of immortality and ‘calling’ associated with the angel label created unsafe work practices for critical care nurses—“we can be trodden upon … because it’s a calling” (Participant 19). They felt it led to unrealistic expectations, unsafe nurse-to-patient ratios, and inadequate access to PPE and other important resources such as education. One participant stated:“[they]… make it sound like it’s, like a Mother Teresa type profession, so to me it’s trying to make it a more emotional thing and like an emotional calling or something like that rather than people actually having a paid professional job” (Participant 9).
Another voiced: “It really has a significant impact in that, my concern is that policymakers will assume that no matter what comes along, we will just step up to that … without any reward, without any recognition” (Participant 32). When asked “how would you like to see nursing portrayed”, interviewees expressed a desire to see the diversity of nursing portrayed, both in role and cultural background. They also highlighted the need to be recognised for their critical thinking, education, and skills as a nurse.
3.1.2 Gender stereotypes
Participants also identified that the angel label was gendered and promoted the passive submissive construction of the nurse as to “caregiver, mother, surrogate, make everything better … we’ll take anything” (Participant 3). The gendering of critical care nurses was also evident through the identification of feminine roles assigned to critical care nursing as ‘women’s work’. The term ‘dirty work’ was used by participants to reflect how they felt their role was tainted (e.g., through contact with bodily fluids), acknowledging that this was an element of their role that nobody else was willing to do. Participants also highlighted that the gendered stereotypes occurred as a result of history. For example, one participant noted, “traditional gender roles … how that informs even if it’s subconsciously” (Participant 3). Participants also noted the predominance of women used to portray nurses—“if you ask the public to physically describe a nurse, nine out of ten times I will guarantee they’d describe a woman” (Participant 5). Participants described the expectation of nurses to be smiling all the time as a uniquely feminine role. One participant observed that men make up most of the senior nursing positions (Participant 5), and another posed, “what if they had a male nurse with angel wings? would that create an impact of us getting more money?” (Participant 8).
Other participants raised media representations as a contributor to the perception of gendered stereotypes in critical care nursing. For example, some participants cited the 1970s/1980s British television series ‘Angels’. Others interpreted the portrayal in media as a form of sexism, portraying nurses in Halloween costumes as a “sexy nurse kind of thing …” (Participant 16). This tension was also evident between the genders of the interviewees—the male respondents responded more positively to the hero label but found it hard to relate to being an angel “the sentiment is right … but … as a male nurse, like identifying as an angel is … it’s not easy” (Participant 27) (which the authors note as ironic, given that biblical angels are portrayed as male!
). Participant 15 noted that he was frequently called ‘doctor’, despite being a nurse. Another participant stated that it was easy to relate to the heroes as he had ‘served in the forces’.
Participants also explained that there was a difference in their perception of the angel label, considering that context and intention influenced their perception of the use of language. Participant 22 described an experience where a patient regained consciousness and said, “Are you an angel? Am I in heaven?‘ … if it’s a family member or a patient then that’s [ok]” (Participant 22).
3.1.3 Political pawns
Participants described a sense of dismissal and betrayal from employers and politicians—“they were saying oh we’re heroes, giving free coffee … when you know, we were being worked to the bone” (Participant 7). While other workers could work from home, nurses were required to attend and work extra hours in challenging environments and oppressive PPE. Participants felt the focus on heroes and angels served to benefit politicians by allowing them to appear as if they were doing something, without actually doing anything.
There was an overwhelming sense of tokenism whereby one day nurses were publicly acknowledged with clapping from doorsteps and balconies and the next day were greeted by protests as they arrived for work. One participant reflected that perhaps “the narrative fits for people who can’t imagine the dirty work … so it’s … butterflies and rainbows” (Participant 3). Participants felt this political tokenism had a negative impact on addressing their fundamental needs such as levels of pay and safe working conditions. One participant said, “Our Emergency Department is so unsafe, we are so busy, we are so bed-blocked and it’s so unsafe and it’s well communicated and just not addressed” (Participant 23).
3.1.4 Forgotten heroes
While there was strong dislike and rejection of the label ‘angel’, participants were conflicted about their portrayal as a hero. On the one hand, they did ‘suit up with armour’ (PPE) in the uncertainty of the early days of the COVID-19 pandemic, when they were respected by their community for doing jobs that no one else would do, risking their lives by turning up to work in the presence of an unknown pathogen, for example,“it’s just kind of this Hollywood patriarchal fantasy that, that everyone just goes oh yeah, yeah, they’re heroes, they’re angels … we’ve got this awful pandemic but someone’s there to help us and it’s more palatable maybe” (Participant 3)
Conversely, critical care nurses quickly felt the respect dwindle to such a point that nurses were villainised. Nurses were abused by families they cared for and disrespected by the community who saw nurses as part of the ‘global agenda’ or who actively thwarted public health efforts. Participants described receiving verbal aggression; one participant said, “I’ve seen comments and all sorts of things...[they] called us all sorts of things” (Participant 8). Some reported that their friends had accused them of killing patients, and others recounted experiences of the public ridiculing them when wearing masks “what are you wearing a mask for, you going to rob the place?” (Participant 19). Beyond this, critical care nurses felt that the angel and hero labels lead to the public having unrealistic expectations. For example, “angels and heroes don’t get sick” (Participant 9) and nurses being obliged to provide care in any circumstances. Over time, participants expressed a sense of being forgotten after all the fanfare of “stunt throwing of public companies … and then all of a sudden it stops because the pandemic’s over … you can’t now book a Thomson holiday and get an NHS discount because, oh we don’t care about you anymore” (Participant 15).
Fig. 2 is the conceptual framework showing how the four themes interlink to represent how critical care nurses perceived the angels–heroes narrative during the COVID-19 pandemic. The angel imagery portrays the historical and religious origins of nursing with the outcome of reinforcing nursing as a calling rather than a profession with a delineated scope of practice and scientific basis. This willingness to sacrifice supports the gendered stereotype of nursing as feminine work, which is especially borne out when the public describes a nurse. During the initial months of the pandemic, politicians lauded nurses as heroes for their dedication to their jobs, using them as pawns to deflect from system failures but as time progressed have failed to provide any tangible benefits, such as a safe working environments or adequate compensation. Similarly, public sentiment towards nurses was generally positive during the first part of 2020; however, as crisis fatigue set in, this sentiment changed to one in which nurses were publicly vilified. While participants could understand there were contexts where the labels might be appropriate, there was a shared sense of dismissal, disregard, and diminishing of the identity of and contributions by critical care nurses throughout the pandemic. Despite the seriousness of the potential impact of these themes, the critical care nurses expressed a strong sense of pride when highlighting their expertise and professionalism. For example, “As highly educated professionals who, you know, work collaboratively but also independently from the multidisciplinary team” (Participant 23).
4. Discussion
Critical care nurses were interviewed about their unique experiences of the angel and hero narrative during the COVID-19 pandemic. Our analysis of the interviews revealed significant and important concerns associated with the continued and ongoing use of the labels, particularly regarding potential impact on safety in work environments, clinical practice, and professional identify. These concerns have been echoed by other researchers.
Our work is important because it reveals that critical care nurses mostly did not agree with these narratives and view them as detrimental to the societal image of nursing as a profession. In a clinical environment that has been challenged by the pandemic in relation to staffing skill mix, recruitment and retention, issues and increasing burnout,
It is hardly surprising, therefore, that the participants in our study rejected these historical, gendered, and outdated narratives, as they have done in other studies.
Critical care nurses strive to deliver high-quality care to patients, but participants suggested that they struggled with feeling insufficiently protected (lack of PPE), suboptimal work conditions, and other obligations outside their jobs. The angel and hero narratives undermine these valid concerns because they normalise unsafe work practices and instill a culture of ‘showing up at all costs’.
Interestingly, this history is repeated, as nursing experienced similar narratives in the 2003 SARS pandemic. In a media analysis of the portrayal of nurses during this time, researchers found that nurses were portrayed as heroic and self-sacrificing, fighting an invisible enemy and “willing to put themselves in danger and ultimately sacrifice their lives for the sake of others” (p214).
In a digital world, this effect has no doubt been amplified during the recent pandemic as the use of social media to spread ideas has become ubiquitous.
The nurses we interviewed felt it was important that their professional capabilities, skills, and knowledge were recognised by the public, by the organisations they worked for, and by politicians. However, the interviews illustrated that angel and/or hero narrative was perceived to be an inaccurate portrayal widely adopted by politicians so that safe staffing ratios could be ignored and dangerous working conditions accepted.
concluded that the nurse-as-hero discourse was positioned as a reward for nurses and as a convenient means to ignore the lack of support that nurses receive from their places of work, managers, and governments. We acknowledge that nurses have been responsible for extraordinary feats in their response to the pandemic and while they appreciated the early recognition and respect associated with this work, they still preferred tangible and measurable rewards, for example, better working conditions and improved remuneration. At the time of writing, these tangible rewards were still outstanding.
Importantly, healthcare organisations are now faced with significant recruitment and retention challenges as experienced clinical nurses have increasingly expressed a desire to leave the profession.
The participants acknowledged that the angel or hero narrative was not always intended by the public and media to be derogatory, quite the opposite in fact. Arguably, the angel or hero label should be used cautiously and with sensitivity so as not to facilitate increased risk of burnout. There has been increasing acknowledgement of the negative impact of the COVID-19 pandemic on critical care nurses’ mental health and wellbeing.
Many of the factors contributing to worsening mental health in critical care nurses are related to poor communication, unrealistic role expectations, and unsafe work environments.
It is therefore essential that critical care clinical working environments are safe and that nurses are rewarded appropriately for their role. Without this, highly qualified and skilled clinical nurses from the critical care environment may leave.
Dawson AJ, Stasa H, Roche MA, Homer CSE, Duffield C. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies.
To ensure the trustworthiness of study outcomes, the research team wove the principles of credibility, dependability, confirmability, reflexivity, and transferability into the study design. Credibility in interpretation was promoted by all researchers immersing themselves in the data. Member checking was undertaken to address credibility and dependability. Multiple quotes are used to illustrate themes and provide confirmability; discussions about the themes ensured consistency, robustness, and transparency.
This study sought to explore the perspectives of a group of critical care nurses almost 2 years into the COVID-19 pandemic, a global health emergency that has challenged the way health care is delivered and how critical care nurses practice. It is therefore likely that the labels and narratives used to describe critical care nurses' roles will change and that critical care nurses’ responses to these labels will evolve as COVID-19 moves into the endemic phase. Countries experienced the pandemic differently, and these varying experiences may also have influenced how participants felt about the angel and hero narrative; however, we were unable to explore differences between hospital setting type (i.e., private, public). The transferability of findings may be limited given that most participants were geographically located in two countries: Australia and the United Kingdom. However, the findings do offer important insights into the perceptions of critical care nurses regarding the widespread use of the hero or angel narrative.
5. Conclusion
Critical care nurses perceived the angel and hero narratives as damaging to workplace conditions, remuneration, and professional expectations. They felt these narratives perpetuated stereotypes of nurses as being self-sacrificing and ‘superhuman’. However, nurses perceived that context and intention were important in their interpretation of the meaning of these narratives, with important distinctions between patients and politicians. They spoke with pride about their expertise and professionalism and called for improved representations of their role, recognition, and work conditions.
Conflict of interest
Dr Elliott is an associate editor of Australian Critical Care. Dr Rolls and Associate Professor Deb Massey are editorial board members of Australian Critical Care. This manuscript was handled independently during the review process overseen by the Editor-in-Chief.
Funding
This work was supported by a grant awarded by the British Association of Critical Care Nurses.
Credit authorship contribution statement
Nicki Credland: conceptualisation, methodology, data acquisition, funding acquisition, investigation, validation, synthesis, formal analysis, writing- original draft preparation, writing-reviewing and editing, visualisation; Jessica Stokes-Parish: conceptualisation, methodology, data acquisition, investigation, validation, synthesis, formal analysis, writing-original draft, reviewing and editing, visualisation; David Barrett: conceptualisation, methodology, data acquisition, funding acquisition, investigation, validation, formal analysis, writing-reviewing and editing, visualisation; Rosalind Elliott: conceptualisation, methodology, data acquisition, writing-reviewing and editing, visualisation; Deb Massey: conceptualisation, methodology, data acquisition, synthesis, formal analysis, writing- original draft preparation, reviewing and editing, visualisation Kaye Rolls: conceptualisation, methodology, data acquisition, writing-reviewing and editing, visualisation
Acknowledgements
We wish to thank all the participants for taking the time to be interviewed.support
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Beyond tropes: towards a new image of nursing in the wake of COVID-19.
Dawson AJ, Stasa H, Roche MA, Homer CSE, Duffield C. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies.
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