Image of nurses in Chile through children's drawings: An iconographic study

A imagem de enfermeiras(os) no Chile por meio de desenhos infantis: um estudo iconográfico

Abstract

Objective

To reveal the image of nursing professionals in Chile through the analysis of children’s drawings.

Method

This is an exploratory qualitative study, involving the collection of information through nine drawings made by children aged between 7 and 10 years, using free technique, and then were analyzed with the Iconographic Method proposed by Erwin Panofsky.

Results

Most drawings depict clinical activities of nurses, focusing predominantly on the technical dimension of the profession. Although nursing is commonly associated with a mostly female occupation, permeated by gender stereotypes, some participants were able to identify the presence and importance of the male role in this professional field. No iconographic elements were identified that would reinforce stigmas associated with nursing professionals, such as the view that they are supporters, aides, or mere medical assistants.

Conclusions and implications for practice

Children’s drawings serve as a reflection of the collective imagination of society. By studying them in relation to nursing, we can identify the advances of the profession and glimpse its near future. This research contributes to understanding the current image of the profession in society, and allows an analysis that goes further, helping to establish future directions and the evolution of this collective perception.

Keywords:
Child; Drawing; Nursing; Nurse’s Role; Qualitative Research

Resumo

Objetivo

Revelar a imagem do profissional de enfermagem no Chile por meio da análise iconográfica de desenhos infantis.

Método

Estudo qualitativo exploratório, envolvendo a coleta de informações por meio de nove desenhos elaborados por crianças com idades entre 7 e 10 anos, utilizando técnica livre e posteriormente examinados com base no Método Iconográfico proposto por Erwin Panofsky.

Resultados

A maioria retrata as atividades clínicas do enfermeiro, enfocando predominantemente em sua dimensão técnica. Embora a enfermagem seja comumente associada a uma ocupação majoritariamente feminina, permeada por estereótipos de gênero, alguns participantes conseguiram identificar a presença e a importância do papel masculino nesse campo profissional. Não foram identificados elementos iconográficos que reforçassem estigmas associados aos profissionais de enfermagem, como a visão de serem simples assistentes, ajudantes ou meros auxiliares dos médicos.

Conclusões e implicações para a prática

Os desenhos infantis são reflexo do imaginário coletivo da sociedade. Ao estudá-los em relação à enfermagem, podemos identificar avanços na profissão e vislumbrar seu futuro próximo. Esta pesquisa contribui para compreender a imagem atual da profissão na sociedade e possibilita uma análise que ajuda a estabelecer direções futuras e a evolução dessa percepção coletiva.

Palavras-chave:
Criança; Desenho; Enfermagem; Papel do Profissional de Enfermagem; Pesquisa Qualitativa

Resumen

Objetivo

Revelar la imagen de los profesionales de enfermería en Chile a través del análisis de dibujos infantiles.

Método

Estudio cualitativo exploratorio, que involucra la recolección de información a través de nueve dibujos en técnica libre realizados por niños entre siete y diez años, posteriormente analizados mediante el Método Iconográfico propuesto por Erwin Panofsky.

Resultados

La mayoría representa las actividades clínicas de las enfermeras, centrándose predominantemente en la dimensión técnica. Aunque la enfermería se asocia comúnmente a una ocupación mayoritariamente femenina, impregnada de estereotipos de género, algunos participantes identificaron la presencia y la importancia del papel masculino en la profesión. No se identificaron elementos iconográficos que reforzaran estigmas asociados a los profesionales de enfermería, como la visión de que son simples asistentes, ayudantes o meros auxiliares médicos.

Conclusiones e implicaciones para la práctica

Los dibujos son reflejo del imaginario colectivo de la sociedad. Al estudiarlos en relación con la enfermería, podemos identificar avances en la profesión y vislumbrar su futuro próximo. Esta investigación contribuye a comprender la imagen actual de la profesión en la sociedad y permite un análisis que ayuda a establecer las orientaciones futuras y la evolución de esta percepción colectiva.

Palabras clave:
Dibujo; Enfermería; Investigación Cualitativa; Niño; Rol de la Enfermera

INTRODUCTION

Chile has a long tradition of health policies aimed at mothers and children, which have been sustained and implemented through the formulation of programmatic activities whose design has responded to the epidemiological profile and socioeconomic context of the country in different periods. This has resulted in the achievement of successful indicators for the reduction of mortality and morbidity in childhood. Today, the challenge of public policies aimed at children is to contribute to a better quality of life in childhood, promoting comprehensive development. These policies have been driven by nursing teams, who have largely influenced the care of the health condition of children and mothers, providing quality care at all levels of promotion and health intervention.¹

It should be noted that, in recent years, there has been an increasing emphasis on involving children in research, considering children worthy of research in their own right, and researchers as entities in the search for learning about children's knowledge, perspectives and interests.²

Much of the existing research examines the graphic, perceptual, and psychological aspects of children's drawings.³ And much of it has focused on the human figure and the connections between children's mental models and their drawings.¹,⁴

Unveiling the nursing image, from the child's developmental point of view, is important for the development of an age-appropriate healthcare approach. It is a current concern of nursing to strengthen interventions whose development ensures the child's right to be heard and placed at the center of their care.⁴

The image of the nurse has historically been associated from the beginning to the care and attention of the sick within the family environment, competence and responsibility attributed to the female sex, where the role of the caregiver, socially was linked to women, thus, by defining human care as the foundation of nursing, the association between the female gender and the profession was favored.⁵,⁶

This conception of nursing is so internalized that some authors even point out that, when speaking of the professional identity of nursing, it is inherently feminized, and is associated with those who suffer and are in need, in contrast to men, who are limited by not possessing the biological capacity to reproduce.⁷ Similarly, this thought was also suggested at the time by Florence Nightingale, who imagined nursing as a profession more suitable and appropriate for women, considering it as an extension of motherhood.⁶

Subsequently, at the end of the 20th century and beginning of the 21st century, the public image of nurses is varied and not very congruent, as it is perceived as a profession that is not highly valued and misunderstood by society. This is associated with incorrect information about the functions performed by nurses, with stereotypes and misconceptions, which were perpetuated by the media, where the nurse was identified as an angel of mercy, highly sexualized and as the doctor's servant; and in contrast, the male nurse was characterized as effeminate, homosexual or invisible to society.⁸

At present, prejudice still persists in nursing due to beliefs based on its past,⁹ but its image has changed and evolved with the passing of time. These changes have been associated with the development of legislation that strengthens the professional role and autonomy of nursing, as in the case of Chile, through the law of care management; the incorporation of nursing specialties and the creation of postgraduate programs such as master's and doctoral degrees.¹⁰

In Chile, since 1997, nursing is a regulated profession in Book V, Article 113 of the Sanitary Code.¹¹ It establishes the exercise of care management, by which, through legal mandate, nursing fulfills a function, by solving a specific problem of society, thus, care management is what the profession offers in a unique way to the Chilean population.¹²

The idea that care is the work of nurses has expanded as a result of the inclusion of nursing in the Health Code, and the regulation to implement care management in exclusive care, all these regulations have been decisive for the work of nursing, as they have allowed the growth and empowerment of the role.¹³ However, despite all these advances for the development of the profession, currently some authors make an imperative call to change the social representation and the image of the role of nursing in the health system and society, in order to eliminate the negative stereotypes that are still perpetuated.¹⁴

A crucial fact occurred with the arrival of the COVID-19 pandemic, in which nursing professionals were exposed to public opinion, where they were classified as heroes and their stories were made visible in the news and media,¹⁵ achieving a massive approach of the population to the management of nursing care in its assistance role, which until before the pandemic, was presented with biases that tended to generate a stereotyped media image of nursing and rarely presented the reality of the profession.¹⁶,¹⁷

In this scenario, today it is accepted that the majority of the population has predetermined ideas about the professional role of nursing, based on conceptions and images created in the community about what the profession implies, secondary to media exposure.¹⁵ From an anthropological point of view, the social image is understood as the manifestation resulting from a personal or collective symbolization, which is more than a product of perception.¹⁸

This social image is defined as a set of characteristics that identify a certain group as unique and distinctive, constructs the identity of the professional collective through cultural factors, traditions, customs and ways of life, contributing social and economic value to the group itself.¹⁹ Thus, the social or public image of nursing is a key component of the professional identity of the group.²⁰

From this point of view, children's drawing is a way to achieve an approach, to know this image built on the role of nurses in society, from the perspective of children and infants. In this sense, studying children's drawings allows us to know how they express their emotions, the way they see and understand things and the reality that surrounds them, allowing us to reproduce a figure or an image as they think, feel and see it, expressing their experiences in a drawing.²¹

Thus, any subject, object or character related to nursing in any of its periods or variants can be analyzed and studied from the iconographic point of view.²² Therefore, through the iconography of children's drawings, an approach to the social image of nursing can be obtained, and then, as suggested by some authors, contribute to the proper development of their identity and disseminate their professional skills for society to recognize them.²⁰

For the aforementioned reasons, the objective of this article is to unveil the image of the nursing professional in Chile through the iconographic analysis of children's drawings.

METHOD

The iconographic analysis of children’s drawings is a way of accessing their points of view and experiences, listening to the voice of the children while they draw and paying attention to their narratives and interpretations through these.²³

The research corresponds to a qualitative study of exploratory scope, the latter being understood as those intended to provide an overview and approximation to a certain fact or context, this scope was chosen, since they have as a characteristic, their less rigidity in the planning of the instruments for the collection of information, such instrument, corresponded to drawings made by children, which were analyzed based on the Iconographic Method proposed by Erwin Panofsky,²⁴ which consists in:

• Pre-iconographic description: primary or natural interpretation of what is seen.

• Iconographic analysis: the conventional or secondary meaning of the work is addressed, corresponding to the iconographic analysis itself.

• Iconographic interpretation: the unconscious meaning hidden behind the creator’s intention is sought. To perform the iconographic interpretation, the principles and beliefs of society are taken into consideration.

According to Panofsky, the analysis process was carried out in levels. The primary level corresponded to a basic level of understanding, that is, to a natural perception of the drawing. Here we do not work with cultural knowledge or domains. The second level corresponded to an understanding of iconographic knowledge. At this point began the actual interpretation of the drawing and its meaning. The third level sought to interpret the drawing from a historical, social and cultural dimension, seeking interrelationships to broaden the meaning. Each stage was worked with 6 nurses participating in a master’s degree course in nursing and the results were triangulated with two experts in qualitative methodology.

For the selection of the sample, we used the strategy of selection by convenience and snowball, being recruited participants from two cities in the south of Chile. Inclusion criteria were established as follows: Children between 7-10 years of age who knew the nurse's work and were asked if they attended health centers or hospitals; informed consent from parents or legal guardians and informed consent from the participant. Those infants who were unable to understand the indications for drawing the picture or did not have knowledge of the role of the nursing professional were excluded from the sample.

The children were recruited from six health centers, accompanied by their mothers and others were children of health professionals.

The activity was carried out during the month of October 2023, in an educational room of the health center, with the presence of the mothers, who were informed about the objective of the research and whether they wished to participate. Those who agreed to participate were asked for their authorization and signed the informed consent.

The activity lasted an average of 40 minutes. The drawings were saved and recording was planned, but the interaction of the children was minimal.

The instruction given to the participants by the researchers was: “You could draw a picture about the work performed by the nursing professional”, thus, by using the neutral language of “nursing professionals”, it was ensured that the results were not oriented to the gender stereotypes of the profession. The drawing was free, the child was only urged to draw the figure of a nurse, therefore, the information given to the child was minimal, some potential participants did not agree due to shyness. It should be remembered that the children are assigned to health centers in an impoverished region, with high rates of rurality and indigenous population.

The sample was chosen with these age characteristics because, from a developmental point of view, according to Piaget and Vygostky, the participants are in the concrete operative stage, during which the child bases much of their thinking on what is seen, touched and heard; in turn, at this stage, children learn what is appropriate to the masculine, the feminine social roles and moral development.²⁵,²⁶

Nine drawings made on a white sheet of paper 37 cm long by 26.5 cm wide were analyzed, the technique for the elaboration of the drawings was free, being subject to the choice of the participants.

During the development of the research, maximum respect and protection of the identity of the subjects was guaranteed, who, being a child population, are considered as a vulnerable population; therefore, only their age and a code name chosen by them were recorded on the back of the drawing, in order to omit sensitive data that could reveal the identity of the participants. To guarantee ethical rigor, the research was carried out respecting the 7 ethical requirements proposed by Ezekiel Emanuel for research and was evaluated by the Scientific Ethics Committee of the Araucanía Sur Health Service.

RESULTS

The sample consisted of nine drawings made by children in three main dimensions: Assistance role; Professional image; and Care relationship (Table 1).

Table 1
Dimensions, categories and subcategories of children’s drawing results. Southern Chile, 2023.

DIMENSION	CATEGORIES	SUBCATEGORIES
Assistance role	Care Interventions	Accompaniment
		Preventive-promotional activities
Professional image	Gender link	Female role
		Feminine care
		Social recognition icons
Care relationship	Nursing Practice	Art
		Hospital care

In the first dimension assistance role, the category of care interventions emerged in two drawings (Figure 1a and 1b), which describes the different strategies perceived by the children that nursing professionals use to provide care in clinical settings.

Figure 1
Assistance role dimension.

In the care interventions category, the subcategories accompaniment and preventive-promotional activities were established.

The subcategory accompaniment is described on the basis of how children identify the nursing professional as a close figure, in most cases performing clinical procedures at the bedside of adult and pediatric patients. From the iconography of the drawings included in the subcategory, it is possible to appreciate several elements that infer an act of presence of the nursing professional in front of the person receiving care. The main elements emerge in the physical proximities arranged in the artworks, as well as in those body language actions that insinuate a nurse-patient relationship in a context of trust. The subcategory could be expressed in Figure 1a.

The subcategory preventive-promotional activities (Figure 1b) highlights how the participants manage to identify the role of the nurse as a health promoting agent. In this sense, professionals are visualized as a figure that delivers health-relevant information. In the drawings, the child population is mainly highlighted as the object of care and educational actions, which are demonstrated through elements such as notebooks, social actions outdoors and in an environment conducive to an educating action, which idealize the figure of a nurse willing to generate bonds of trust with the students. From the iconographic interpretation, crucial community actions are established, which are inferred to have had an impact at some point in the life of the subjects of study, as they are exposed through their memories.

In the second dimension professional image, the category care interventions emerged, in which the mental images with which the children identify and link the nursing professional are described.

In the gender link category, the subcategories feminine care, feminine role and social recognition icons were established.

The subcategory feminine role refers to how the nursing profession, from the children's point of view, is currently conceived with a predominance of the feminine gender. The elements that stand out in the drawings allude to feminine clothing, combed hair, long eyelashes and curves facing the forehead; all these elements are associated with women, which establishes a tendency to relate the profession to this gender, with clear stereotypes of it, by drawing women with a thin, curvy and voluptuous physical appearance. However, the results also showed some drawings in which there is a presence of male professionals providing care. The subcategory could be expressed in the drawing Figure 1b

The subcategory feminine care shows how children perceive nursing as a close, maternal and protective profession. The action of care has been predominantly represented in the various drawings through the female figure. In the children’s representation, it is the mother who provides this care, according to the culture of the subjects of study, being the one who is in charge of the care at the moment of physical weakness, translated into illness in childhood. Although it is not possible to observe the figure of the mother in the results presented, it is possible to interpret a parallelism with the nurse, who substitutes this maternal care in a professional manner. The subcategory could be expressed in the following drawing:

The subcategory social recognition icons describes how children present a cognitive association with elements of clinical use that are linked to nursing professionals, in this sense they manage to appreciate in the drawings: clinical beds, syringes, curatives, in a context mostly intrahospital. In general, the children are able to recognize in the blue uniform the color that identifies the profession.

In one drawing, it was difficult for a participant to differentiate between nursing care and the role of the medical professional by drawing elements traditionally associated with this profession, such as the white coat and the use of a stethoscope. The subcategory could be expressed in the drawings in Figure 2a-c.

Figure 2
Professional image dimension.

In the third dimension, care relationship, the nursing practice category emerged, which conditions an ideal relationship between the nurse and the patient, by defining the therapeutic relationship in a caring environment (Figure 3).

Figure 3
Care relationship dimension.

The subcategory art refers in the drawings to the creative and imaginative state that is provided through intellectuality and cognitive processes the knowledge of the service to the human being. It is here where the nursing professional, links the social and behavioral action, represented by the corporeality manifested in the artworks, as well as, of those actions to the human assistance, in this case infantile, which provides an interaction and therefore a transactional retribution between the caregiver and the cared being. Through the reflective act of the artworks, it is possible to identify actions of knowledge and sensitivity through subjective actions of care, attending those needs of comfort and intersubjective understanding exposed in the children’s representations. The subcategory could be expressed in drawing 3a.

The subcategory hospital care, manages to identify the drawn scenes that occur during the disease process in the hospital context, where care is derived from medical treatment. Nursing care was represented in highly specialized and technical clinical units, which would evidence certain experiences of the study subjects, precisely in these hospitalization areas. The mass media, as well as the invasion of series and/or audiovisual resources to which the children have been exposed, could generate images to be characterized, without having lived them. From the iconography, the level of detail of the technical elements exposed stands out, which suggests a long exposure time for such a representation. The subcategory could be expressed in the drawing 3b.

DISCUSSION

Studying children’s drawings in boys and girls allows us to know how they express their emotions and the way they see the things that surround them, not only by showing what they observe, but also by revealing the diverse experiences of their environment.²¹

Studies conducted 30 years ago have shown that nursing professionals carry different gender stereotypes associated with their social image.²⁷ The nursing profession, with approximately 28 million workers, is the largest group of health workers and is the largest and fastest growing labor sector in the world, especially for women.²⁸

For children, nursing is still a mostly feminine profession,²⁸,²⁹ which can be evidenced by the fact that, although the participants in the study recognize the male figure as part of the profession, most of the drawings made are of nurses, as evidenced by the Mexican children in their drawings.³⁰

In a review of the historical evolution of nursing in Chile, the inclusion of men in the profession began in 1966, with the graduation of the first male nurse in the country. In the last two decades, the male presence has increased due to the characteristics of the professionalization of nursing. With regard to the expansion of nursing as a field of work, the entry of men has been a different process from the inclusion of women.¹³

In relation to this minority male role, as observed in Benjamin's drawing, it tends to be related to highly technological clinical units, similar to what was referred to in a Spanish integrative review.³¹

In most of the drawings analyzed, the infants identify the social image of the nursing professional associated with care in the practice of assistance, in the context of hospitalization, where direct care and the execution of clinical procedures predominate. This is one of the main conclusions reached in a Spanish study, aimed at identifying the characteristics of the image and the social value of nursing by first-year nursing students, who identified the “assistance role” as the main function of nursing.³²

The aforementioned can be explained by the context of the COVID-19 pandemic, where the general and specialized press showed greater public visibility to the direct clinical work, and to the care provided by nursing professionals, the working conditions where they worked and also the impact of the pandemic on the professionals themselves.¹⁹ In this sense, some authors claim that movies and TV series should present positive images of the nurse, since an image, negative or positive, has consequences on health policies, the allocation of resources and influences the perception that patients and users have of the nursing profession.²⁷

Most of the drawings made by the child population only reflect the clinical actions of nursing: accompanying the sick, taking blood samples, monitoring, administering injectables, etc., similar to other studies, where the children's drawings only reflect the technical part of care management.⁶,³⁰

In our research, elements similar to those found in Slovenia, in which the representation of the female (skirt) and male (pants) gender is clear in the drawings,⁶ however, in our study, only one participant relates the white color of the uniform to the profession. This color in words is typical of the old and current uniforms and can be related to the purity and angelic stereotype of nurses.³³

This image of the angelic nurse has also been reflected in the cinema, in which the characteristics of the sweet, sacrificed and kind nurse symbolize all the virtues that a caregiver and, by extension, a woman can have.³⁴ The social image of a profession is conditioned, to a large extent, by the way in which the media present it.³⁵

In the drawings studied, the nursing professional is presented as an empathetic, affectionate, kind and close person with her patients, this is evidenced by the figures representing hearts in the care environment, which manifests an affective nurse-patient relationship; these characteristics are the most valued by patients according to an African study, who perceive the role of nurses as that of providing care to patients in a compassionate, affectionate, kind, respectful and professional manner.¹⁷

It is interesting to note as a new finding that, based on the results presented, no iconographic elements were found that could be related to the stigma of nursing professionals fulfilling a role of assistant, helper or auxiliary to the doctor, that is, without their own field of competence, where they only perform assistance-type activities, delegated and dependent on the doctor, a phenomenon that is widely described in the literature.³¹,³⁶

According to the pattern of aesthetic knowledge in nursing, it is necessary to abstract that which is individual, particular and unique. It is possible to exemplify with the establishment of a meaningful bond between the nurse and the child; by talking, listening, consenting, understanding, being creative in the use of resources contributing to the achievement of the expected results. Likewise, in the face of a mother's fears, the nursing professional may be able to recognize the suffering she is experiencing due to her child’s health condition, a situation that requires skill and proactivity, reflecting the art of caring. The above is shown in the results in the subcategory art, being the bond exposed through the artworks, a projected reality of the nurse and patient intersubjectivity.³⁷

A limitation of the study is the strategy of selection by convenience for the choice of the sample, which conditions that a small percentage of the participants corresponded to children of health workers; this characteristic of the sample could have influenced the realization of the drawings, as they were familiar with the role of health personnel.

CONCLUSIONS

The study fulfills the objective, revealing through iconography, the image of the nurse among children. In the dimension, clinical or assistance role, category care interventions, which are translated into accompaniment and preventive actions. In the professional image dimension, the link with the feminine gender and role – feminine care and icon of social recognition emerge, and in the last dimension, care relationship, nursing practice is expressed, linked to art and hospital care.

In general, the drawings show an old vision of nursing, centered on clinical technique, feminized, and with an important and overvalued vocational component. Perhaps, associated with constructions in their collective imaginary, influenced by their family upbringing and school world, and influenced by their emotions, thoughts, observations and experiences, which is far from the status of scientific profession and differs from what is stipulated in the Care Management law, which is recognized as a sign of progression of the nursing profession is modern roles.

The interpreted representations emerge in public interaction, in the child imaginary, collective, as an image of a person, woman, formulated in the social construction of a family, or school world. This archetype places the cultural expectation of children, in the eradication of disease or healing; and the image of the nurse emerges in a mixture with the disease, the latter constructed from the knowledge of the factors that determine and condition its visual expression in the social and cultural contexts in which the child develops. And the disease manifests itself in a real and visible way from a biological, medical, religious and social point of view. Approaches of a sociological nature, which can be seen in the image of the nurse, as an expression of visual culture.

For its part, the iconographic apparatus for the analysis of the image, comes essentially from the drawing, and the representative areas of these drawings linked to the scientific, medical and religious contexts, achieving a global and holistic vision.

IMPLICATIONS FOR PRACTICE

The development of the study on the image of nursing is relevant, since it reflects the image of the nurse in society and allows the development of strategies to advance in making the current image of the profession visible, revealing the power and responsibility in the care of users or patients. These efforts will have an impact on the public policy of human resources in health.

The method is relevant for the study of the position of the nurse, and phenomena associated with culture and tradition, which include images and icons full of symbolisms, which are part of history. History allows the articulation with the roots of the nursing profession and its visualization; a fundamental process in its development.

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Edited by

ASSOCIATED EDITOR

Eliane Tatsch Neveshttps://orcid.org/0000-0002-1559-9533

SCIENTIFIC EDITOR

Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Publication Dates

• Publication in this collection
  11 Mar 2024
• Date of issue
  2024

History

• Received
  12 Oct 2023
• Accepted
  11 Jan 2024