A DISCOURSE AND CONTENT ANALYSIS OF HOW NURSING IS FRAMED IN THE MAINSTREAM PRESS IN SOUTH AFRICA: JANUARY – JUNE 2010 Greer van Zyl Research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for a Master in Public Health Johannesburg, September 2011 2 DECLARATION I, Greer Sheena van Zyl, hereby declare that this research report is my own original work, with guidance in the statistical packages STATA and MaxQDA from my supervisor. It has not been submitted in part or substance for an award at any other university. While the data set of articles was accumulated during my tenure as a part-time consultant to the University-based Nursing Education of South Africa programme (UNEDSA), permission was granted by the Programme Manager to utilise the articles for the purposes of this research report. All analysis took place subsequently and independently of UNEDSA. GREER VAN ZYL Student No: 511041 Midrand, Johannesburg September 2011 3 DEDICATION Without the unfailing support of my husband and children, I would not have been able to undertake the Master of Public Health degree. I owe them my deepest gratitude, particularly my husband, Chris. You loved me, believed in me, comforted me and supported me throughout while shouldering extra roles and responsibilities. Thank you for this gift. To Kerry and Nicholas, my muses and my world, thank you for your understanding while I was so focused on pursuing my heart‟s desire; for the shoulder-rubs and kisses which propped me up when I was tense and tired, and for your unconditional love at all times. May you, too, experience the joy of learning and grow in knowledge and wisdom as you follow life‟s path. Enjoy the ride and have fun! To my parents who cheered me on from a distance, never ceasing to uplift me in prayer and verbal affirmation for what I was tackling and always so proud of me: you are my inspiration to learn and see the world! May your legacy be the inspiration for my children. Above all, I dedicate this work to Almighty God, who held me in His hand throughout a tumultuous year, ever-faithful, kind and true. I give Him the glory and every blessing poured out, I turn back to praise. I believe He worked a miracle… “Whatever you do, whether in word or deed, do it all in the name of the Lord Jesus, giving thanks to God the Father through Him.” Colossians 3:17 4 ABSTRACT Introduction: Globally and locally, the status of nurses and their profession is diminishing, ascribed partly due to the image of nursing portrayed in the media of a profession with heavy workloads, poor pay and no longer considered a career of choice. In South Africa, the increased disease burden due to HIV/AIDS and tuberculosis, together with a deteriorating health system and significant inequities in terms of nurse distribution, has led to grave public concerns about the profession. The media play a key role in national development, helping to shape public perceptions by influencing how society understands events. This cross-sectional study aimed to explore how nursing is framed in the mainstream press over a six-month period in 2010 using mixed methods of a quantitative content analysis and a qualitative discourse analysis. Methodology This cross-sectional study used a mixed method approach of both quantitative and qualitative methodologies. The content of all articles mentioning „nurse‟ or „nursing‟ from the press cutting agency Monitoring South Africa (1 January – 30 June 2010) was analysed, yielding a total of 242 articles. From these, 91 articles were purposively selected for the qualitative discourse analysis. A data coding sheet was developed to capture key dimensions from each article for the quantitative content analysis. Both descriptive and inferential analysis was carried out. For the qualitative discourse analysis press cuttings were converted and coded, and then thematic analysis was carried out Results The results of the quantitative analysis found that nursing is not well covered in the South African lay press, and when it is featured, articles appear in community publications with small circulations. Most articles on nursing were prominent (ie. full-length) and positive. International Nurses‟ Day (IND) was seen to influence the proportion of nursing articles with more than double the number of articles appearing in May compared to the total average of other months, and all coded „positive‟. However, when IND was excluded from analysis, negative articles were dominant, mainly around strikes and unprofessional behavior which featured in daily and larger circulation newspapers. In keeping with international literature, strikes as a theme received the most coverage, but unique to this study was the finding that nursing neglect or unprofessionalism received almost as much coverage as strikes, featuring in the majority of page 1 articles and in publications with large circulations. 5 Regarding voice, this study found that nurses were quoted in just over a quarter of articles which featured quotes, but that spokespeople were quoted twice as often, remarkably so even for IND. Most nurse quotes were around strikes and poor working conditions. Nurses were quoted more frequently in community newspapers and in Western Cape newspapers. Doctors were seldom quoted, and 90% of patient quotes were negative. While females were quoted first in the majority of articles, a third of their quotes were anonymous, mainly around negative topics such as labour, protest action and service delivery, indicating their fear of reprisal from their institutions. Males were quoted more often in second and third quotes of articles, with the extent of quotes approximately in proportion to their numbers in the profession. The results of the qualitative discourse analysis revealed a profession groaning under the weight of a crumbling health system. Articles on the working conditions, salaries and shortages of nurses were mostly sympathetic, but when nurses „went too far‟, they were portrayed as unprofessional, negligent and abusive. Nurses were also not taken seriously when they raised the alarm about deteriorating health systems, which is disturbing when they are at the forefront of healthcare delivery. Very few articles dealt with nursing as a profession or academic nursing in any detail. Although there were more positive than negative articles, and IND garnered significant positive coverage for the profession with nearly a third of all articles appearing in May when IND is celebrated, the lasting impression is that of negative coverage, particularly from the discourse on patient abuse, neglect or abandonment during strikes. Nurse voices are notably absent from these articles. Conclusion South African nursing would benefit from media advocacy and partnerships to promote the profession. As the majority workforce which undertakes essential, life-giving tasks, nurses are the backbone of the healthcare system and critical contributors to quality health care. Their place at the policy table and space in the press is well overdue. 6 ACKNOWLEDGEMENTS To Vicki Pinkney-Atkinson, stalwart nursing and prayer warrior, I owe big thanks for lighting a fire for nursing in me. It is due to your passion and advocacy that I realized how important nurses are to the health system of South Africa, yet are virtually invisible in the public domain. Consider the flame well ignited; I hope to continue to fight the good fight! To Atlantic Philanthropies‟ Seyi Oyedele, thank you for your warmth, vision and financial support for this work. I would not have been able to dedicate my single-minded attention to this study without your courage and conviction that this „learning‟ would yield something positive for nursing in South Africa. Thank you for your confidence in me. To Nicola Christofides, my supervisor and mentor in Social and Behavioural Change Communication (SBCC), thank you for selecting me to be part of this inaugural MPH SBCC- specialisation cohort. You convinced me that undertaking this Master of Public Health full-time was “completely do-able”, while guiding and supporting me way beyond the call of duty. Thank you for your kindness, superb mentorship, and especially for your help with new software programmes. May this fledgling SBCC programme grow from strength to strength under your leadership and be acknowledged as a premier course, globally. To my friends, colleagues and clients, thank you for your encouragement. „Brave‟ was the word which popped out most frequently. Thank you – but bravery and courage had little to do with the compulsion I had to confirm, explore and broaden new horizons of knowledge on the „super-tube‟ of academia. It was exhilarating – I charge all of you considering a similar ride to seize the day and embark on a heady trip of a lifetime. You won‟t regret it. I keep six honest serving men: (They taught me all I knew) Their names are What and Why and When And How and Where and Who From Rudyard Kipling‟s “The Elephant‟s Child” (Kipling 1902) 7 TABLE OF CONTENTS PREAMBLE .................................................................................................................................... Declaration ...................................................................................................................................... 2 Dedication ....................................................................................................................................... 3 Abstract ........................................................................................................................................... 4 Acknowledgements ......................................................................................................................... 6 List of figures .................................................................................................................................. 8 List of tables .................................................................................................................................... 8 List of abbreviations ........................................................................................................................ 9 Definitions ..................................................................................................................................... 10 CHAPTER 1: INTRODUCTION .............................................................................................. 12 Overview ....................................................................................................................................... 12 Theoretical framework .................................................................................................................. 12 Literature review ........................................................................................................................... 14 Objectives ...................................................................................................................................... 22 CHAPTER 2: METHODOLOGY ............................................................................................. 23 Study design .................................................................................................................................. 23 Study population ............................................................................................................................ 24 Sampling and sample size ............................................................................................................. 25 Data collection and data sources .................................................................................................. 26 Data processing, analysis and management .................................................................................. 26 Ethical considerations .................................................................................................................... 29 CHAPTER 3: RESULTS ............................................................................................................ 30 Quantitative results ........................................................................................................................ 30 Qualitative findings ....................................................................................................................... 53 CHAPTER 4: DISCUSSION ...................................................................................................... 81 Limitations 90 CHAPTER 5: CONCLUSION AND RECOMMENDATIONS ............................................. 92 REFERENCES ............................................................................................................................ 96 APPENDICES ........................................................................................................................... 105 Coding sheets: quantitative and qualitative coding Press circulation & readership figures, number of articles and reporters‟ names Ethics clearance 8 LIST OF FIGURES Figure 1: Creswell‟s Concurrent Nested Strategy 23 Figure 2: Prominence of nursing articles 31 Figure 3: Proportion of quoted persons 37 Figure 4: Proportion of nurse quotes by professional category 37 Figure 5: Proportion of quotes by sex 38 Figure 6: Proportion of first person quoted by sex 42 Figure 7: Proportion of positive, neutral and negative articles 44 Figure 8: Proportion of key themes on nursing 47 LIST OF TABLES Table 1: South African coverage on health and related topics compared to nursing 13 Table 2: Extent of press coverage on nursing by media characteristic 31 Table 3: Extent of nursing coverage by article characteristic 33 Table 4: Prominence by characteristics of media 35 Table 5: Prominence by characteristics of article 36 Table 6: Quotes on nursing by characteristics of media 39 Table 7: Quotes on nursing by characteristic of article 41 Table 8: Nursing quotes by sex and characteristic of media and article 43 Table 9: Slant by characteristics of media 45 Table 10 Slant by characteristics of article 46 Table 11: Topic by characteristics of media 48 Table 12: Topic by characteristics of article 50 9 ABBREVIATIONS ABC Audit Bureau of Circulations AIDS Acquired Immune Deficiency Syndrome ARV Antiretroviral AZAPO Azanian People‟s Organisation FIDSSA Federation of Infectious Diseases Societies of Southern Africa HIV Human Immunodeficiency Virus ICU Intensive Care Unit IND International Nurses‟ Day MEC Member of (Provincial) Executive Council MOH Minister of Health MSA Monitoring South Africa NEHAWU National Education, Health and Allied Workers‟ Union NHI National Health Insurance OSD Occupational Specific Dispensation PDF Portable Document Format SAQA South African Qualifications Authority SANC South African Nursing Council SMS Short Message Service SAARF South African Advertising Research Foundation TB Tuberculosis 10 DEFINITIONS Auxiliary nurse is one educated to provide elementary nursing care in the manner and to the level prescribed (SANC 2005). Content analysis is a systematic, replicable quantitative approach to classifying text into manageable data for inferential analysis (Weber 1990), used to measure inter alia newspaper content. It is helpful for gauging “community opinions, advocacy and change” (Granner, Sharpe et al. 2010).Using raw figures and patterns of coverage in content analysis can reveal the news organisation‟s values by where it invests its human and financial resources, time and knowledge (McClellan and Porter 2007). Cathexis is the theoretical structure of „affective attachments and social norms…which dictates appropriate, normative or stereotypical sexual behaviour for women‟ (Wingood, Camp et al. 2009). It is „the conscious or unconscious attachment of emotional feeling and importance to a specific idea, person or object‟(Mosby 1986). Discourse analysis is an approach to studying texts which rejects the notion that language is a neutral way of describing events, recognizes that understanding the world is shaped by historical and cultural contexts, and that knowledge is socially constructed (Gill 2000). Discourse analysis is suitable for in-depth qualitative analysis of texts and their relation to society and culture, with reference to power relations which shape discourse practices (Fairclough 1992). Framing is the process of selecting and constructing text to promote a certain „reading‟ by the recipient. It is the “process by which someone packages a group of facts to create a story” (Wallack, Dorfman et al. 1993) to help consumers of media make sense of and construct perceptions of their world (Beaudoin 2007). Frames are influenced by a journalist‟s ideology and attitudes, accepted journalistic practices in constructing news stories, organizational constraints or beliefs of the publisher on what is „news‟, and external sources (Scheufele 1999; Beaudoin 2007). Media advocacy is the “innovative use of mass media as a strategy to promote public health”(Wallack, Dorfman et al. 1993), stimulate debate, and ensure the voice of public health is heard. Mixed methods is a research methodology which combines quantitative and qualitative approaches within a single study to collect and analyse data for exploring and explaining phenomena arising from a research question, and which are integrated to either validate findings or results from each method, or explain lack of convergence (Creswell 2003; Burke-Johnson and Onwuegbuzie 2004). News is a “product of a highly complex process of selection. Of all the myriad events that occur each day, only a tiny number are selected as „news‟. This selection is based on the unwritten laws and routines of news making, and is confined within the organizational, economic and bureaucratic constraints under which newsgathering organizations operate” (Chapman and Lupton 1994). Often, 11 newsworthy events “originate from (those) who have privileged access to the media, who are treated by journalists as reliable sources, and whose voices are the ones which are most widely represented in media discourse” (Fairclough 1992). Nursing refers to a “caring profession practiced by a person registered with the SA Nursing Council, which supports, cares for and treats a health care user to achieve or maintain health and where this is not possible, cares for a health care user so that he or she lives in comfort and with dignity until death” (SANC 2005). Power is having the capacity to influence the action of others (Wingood, Camp et al. 2009). Professional nurse is one qualified and competent to independently practice comprehensive nursing in the manner and to the level prescribed and is capable of assuming responsibility and accountability for such practice (SANC 2005). Prominence refers to how articles are treated to attract a reader‟s attention and among other things refer to article length. Articles with less than one sentence featuring nursing or nurses have low prominence; those with up to three sentences or paragraphs on nursing have medium prominence, while articles which feature nursing exclusively or predominantly are high prominence. Prominence can refer to the page on which an article appears. Sex and Gender: Sex refers to the biological differences between men and women; gender refers to the socially and culturally constructed differences between men and women and their roles within society (Gilbert, Selikow et al. 2010). Here, „sex‟ categorizes quotes between men and women, while „gender‟ is used to interpret the construct in the context of nursing quotes. Slant (or „angle‟) refers to how an article presents an issue. Here, slant refers to whether articles featured nursing in a positive, negative or neutral light. This is an ideological, interpretive construct, and refers to whether an article portrays nurses as enhancing or detracting from health service delivery, from a rights-based perspective. Student nurse is one undergoing education or training in basic nursing (DOH 2008). Unprofessional conduct is conduct which, with regard to the profession of a (nursing) practitioner, is improper, disgraceful, dishonourable or unworthy (SANC 2005). Voice refers to those who have been quoted in an article. Journalistic practice dictates that stories need to be „balanced‟ (i.e. cover more than one view of an issue) and „credible‟ (i.e. the person should be quoted due to their position or having witnessed an event). Voice is an indicator of power and agency and can confer status on a quoted person (Schramm 1964; Fairclough 1992). 12 CHAPTER 1 INTRODUCTION This chapter provides an overview and background on nursing in South Africa, together with a literature review and justification for the study. The study aims and objectives conclude the chapter. Overview: Nursing is critical to healthcare delivery, and within health systems, nurses represent the largest healthcare workforce. Health systems can be regarded as a social determinant of health (Gilson, Doherty et al. 2007) which contributes to health equity when they are appropriately managed. However, when they are not, they contribute to further alienation of disadvantaged groups such as women, the elderly and poor. This is particularly so when health workers are unprofessional and antagonistic, or when they are inequitably distributed in a country to favour access in wealthier provinces over poorer ones, or urban areas rather than rural areas (Gilson, Doherty et al. 2007). Globally, the status of nurses and their profession is diminishing, ascribed partly due to the image of nursing portrayed in the media and the perception of a profession with heavy workloads and poor pay, and no longer regarded as a career of choice for girl school-leavers with other options (Murray 2002; Hall, Angus et al. 2003; Brodie, Andrews et al. 2004). Historically, nursing in South Africa has been shrouded in power dynamics around race, class, gender, and intra- and extra professional tensions. Like their colleagues around the world, South African nurses often work in poorly serviced areas and institutions with pay below that of non- nursing contemporaries with equivalent years of study. The increased disease burden due to HIV/AIDS and tuberculosis and significant inequities in terms of distribution of nurses, both internally as an urban-rural bias, and internationally, due to neoliberal principles which see nurses migrating to work abroad, have left their toll on South African nurses leading to an „avalanche of adverse reports‟(DENOSA 2010). Theoretical framework The media play a key role in shaping public perceptions by focusing attention on an issue in choosing what to write about and whom to quote, which guides society in terms of what people know and talk about (Schramm 1964; De Vreese 2005). By conferring status and importance to issues, media coverage has been shown to influence the public‟s opinion of the importance of issues, while conversely, those groups without social power may not be used as sources of information and be excluded from the newsgathering process, resulting in having less influence (Finnegan and Viswanath 2002) The mass media can confer status to a quoted individual, help broaden policy dialogue for national development, enforce social norms by making deviations 13 known, and establish what is „normative‟ behavior (Schramm 1964). According to Finnegan, “Media institutions play a crucial role in health behaviour change because they are key gatekeepers for disseminating information in social systems and because, as socializing agents, they have a powerful effect on legitimizing social norms of behaviour” (Finnegan and Viswanath 2002). The pervasiveness of the mass media makes it one important public health approach to social and behaviour change communication, whether to influence public policy or educate individuals about health behaviour change (Finnegan and Viswanath 2002). Usually, the use of mass media is important but not sufficient to effect behaviour change. Rather, a matrix approach which embraces multiple levels of influence – at individual, interpersonal, community, social and ecological levels - is required. Bandura‟s Social Cognitive Theory of Mass Communication (Bandura 2001) emphasises the need to intervene at individual/personal, social and environmental levels since personal determinants of behaviour and change are intertwined with social and environmental determinants. Key constructs in this theory are that people learn behaviour by observing role models, and self-efficacy, where individuals believe they can accomplish certain tasks (Waisbord 2001). Media advocacy as an approach actively seeks alliances to shape debates around public health issues. Seeing public health as essentially political, media advocacy takes a political and social approach to changing environments by making social conditions the target of interventions using the power of the media to influence the major determinants of health found in the social and physical environment (Wallack, Dorfman et al. 1993). Media advocacy theory purports that since the media influence political and social interventions by shaping the public debate, claiming space in the media becomes vital. Important goals of media advocacy include advancing a policy or approach to a public health problem, ensuring the issue is framed in a way which will attract media coverage, and to „frame for context‟ by posing issues not on an individual level but as part of a larger context (Wallack, Dorfman et al. 1993). A key construct in this theory is capacity building of groups or communities to become „media-savvy‟ to shape the debate and set the media agenda from a public health point of view (Waisbord 2001). Because of nurses‟ unique role in providing and maintaining the health system, the South African public is concerned about the plight of nursing (DOH 2008). Their numbers should make nurses a force to be reckoned with, but the „voice‟ of nursing appears to be mute. A discourse and content analysis of how nursing is portrayed in the mainstream media will shed light on public perceptions of nursing. 14 Literature Review Media context The South African media context: South Africa enjoys a vibrant and free press governed by an independent regulator and is ranked 38th in the 2010 global Press Freedom Index (RWB 2010). In March 2009, the country had 21 daily newspapers, 27 weeklies, 660 consumer magazines and 470 community newspapers and magazines (GCIS 2010). Newspaper ownership is dominated by four media agencies: Caxton (130 titles), Naspers (64 titles), Independent News and Media (35 titles) and Avusa (22 titles). Over 15 million people read newspapers nationally, with Gauteng accounting for 69% of this (4.4 million readers) followed by KwaZulu-Natal (2.6 million readers)(Z-COMS 2009). Nursing in the news: How events and news are framed in the mass media can affect how the consumers of news understand these events (Price, Tewksbury et al. 1995; Scheufele 1999). News is a manufactured and subjective account of reality due to emphasis, prominence, omission and selection processes (Westwood and Westwood 1999). No literature could be found on the portrayal of nurses in the South African press. Coverage on health, science and technology issues in South Africa is generally low in favour of news on crime, politics, business and sport. Table 1 below contextualizes nursing coverage within health and related content analyses done in South Africa: Table 1: South African coverage on health and related topics compared to nursing Year Coverage Articles (N) Period studied Reference 1999 Soul City evaluation of Violence Against Women in South African print and broadcast media ±4300 (articles/bulletins) June – December 1999 (SoulCity 2001) 2002 HIV/AIDS coverage in SA print media 2204 March – May 2002; March – May 2003 (Duncan 2009) 2002 Science and technology coverage in SA print media 994 March – June 2002 (Van Rooyen 2002) 2004 Daily and weekly print media finds health is featured 10th out of 15 categories studied 1000 on health; (9000 on business) January - March (Schreiner 2004) 2006 Women in sport coverage in 2 national dailies, 2 national weeklies and 2 Gauteng newspapers 2806 3-month period (unspecified) (Goslin 2008) 2008 HIV/AIDS coverage in SA media (drop of 63% over 2002 suggesting drop in news value) 806 articles March – May 2007; March – May 2008 (Duncan 2009) Internationally, there were few scientific articles on the portrayal of nursing in the press, and of these, nurses were seen to be virtually silent in the media, despite being the largest healthcare 15 workforce and interacting most directly with patients (Buresh and Gordon 2006). A study from the United States by Sigma Theta Tau International found that nurses were referenced in only 4% of articles on health care (Sieber, Powers et al. 1998; Bridge, Dickenson-Hazard et al. 1999). Nurses are reluctant to have their voices heard and when they are quoted, it is from a „virtue script‟ which promotes caring and commitment rather than their intelligence, skills and experience (Hall, Angus et al. 2003; Gordon 2005). Physicians were the most often quoted professional group (Buresh and Gordon 2006), and nurses tend not to be included among spokespersons offered by hospitals to promote developments (Gordon 2005). When nurses were featured, although their quotes and mentions were likely to be positive (Bridge, Dickenson-Hazard et al. 1999), their quotes were brief (Schmidt 2001) or „in passing‟ (Bridge, Dickenson-Hazard et al. 1999), they may be anonymous and photographs may not even identify them by name (Gordon 2005). Using photographs in newspaper articles draws attention to text and fosters more extensive reading, with „agonistic‟ images increasing reading time twice as much as innocuous images (Zillmann, Knobloch et al. 2001). Photographs have impact because they are „evidence‟, they affect people‟s opinions, make a story seem more believable and can result in false memories for event details (Garry, Strange et al. 2007). Research on newspaper reporting of public health found a third of articles featured photographs (Westwood and Westwood 1999). A study on peri-operative nursing found that press articles featured more often in daily papers and with smaller circulations (Kalisch, Kalisch et al. 1985), and that without a dedicated day to promote this specialist nursing, „two-thirds fewer articles on operating room nursing practice would have appeared‟(Kalisch, Kalisch et al. 1985). Front pages of newspapers are the showpiece and of primary importance, together with pages 3 and 5, while pages 4, 6 & 7 are of secondary importance with page 2 being of political significance (Westwood and Westwood 1999). Many articles offered advice for nurses on how to deal with the media (Kalisch and Kalisch 1985; Bezyack 1999; Farrow and O'Brien 2005; Buresh and Gordon 2006). While few nurses use the „Letter to the Editor‟ to gain coverage, this was seen to be a good way to get a message across as „the voice of the people‟ (Kalisch, Kalisch et al. 1985; Buresh and Gordon 2006). From the literature it is clear the public‟s understanding of nursing is limited and inclined to dwell on nurses‟ care-giving and comfort role rather than their professionalism or qualifications (Bridge, Dickenson-Hazard et al. 1999; Buresh and Gordon 2006). When the public is ill-informed about the role of nurses, „neither consumers nor policymakers can be expected to support their work or allocate the required resources to carry out their responsibilities in health care‟ (Kalisch, Kalisch et al. 1985; Murray 2002), although „nursing is central to any discussion of health care‟s bottom line‟ (Bridge, Dickenson-Hazard et al. 1999). However, when the public understands the critical role of 16 nursing in healthcare, nursing‟s image can move from the stereotype of physician‟s handmaid, angel of mercy, sex object or dragon-lady (Salvage 1985; Marks 2001; Brodie, Andrews et al. 2004) to nurses being educated not born and where „schools of nursing would be viewed as major contributors to university academic enterprise‟ (Buresh and Gordon 2006). Nurses need to form opinions on issues which affect a nation‟s health and well-being and have their voices heard (Morley 2004), with both nurses and journalists being more proactive role in establishing ongoing dialogue (Bridge, Dickenson-Hazard et al. 1999) since nurses are thought to be able to explain issues to journalists in layman‟s terms better than doctors (Shapiro, Thomas et al. 2007). When nurses explain their work to journalists, they serve the public in a new way by helping the media „to do their job well‟, leading to better informed articles about the profession (Buresh and Gordon 2006). Nursing Context Class and race: From as early as 1911, nursing in South Africa was regarded as a profession to be entered only by “educated women, and not only educated but refined” (Marks 2001). Subjected to dominant political power, nurses were used by the British in 1901 to attract women to South Africa to anglicize the Boer republics*, while in 1958, Black South African nurses were used by the apartheid government to entrench the notorious pass system on African women (Marks 2001). Seen as elite in black townships, black nurses in their white uniforms were regarded as symbols of progress in black society and elevated to the middle class (Marks 2001). Hierarchy: Nurses have been subordinate to doctors despite the fact that “most people know that they can‟t get into a hospital without a doctor. What they don‟t know is that they won‟t get out of one – at least not alive – without a nurse”(Buresh and Gordon 2006). Subordination, emphasis on professionalism and middle-class status has led to nurses distancing themselves from their patients, other hospital staff and themselves through professional hierarchies which divide professional, staff, auxiliary and student nurses (Salvage 1985; Marks 2001). These hierarchies also contributed to a loss of control and power as nurses defer to those in higher authority despite having greater skills or knowledge (Doyal 1995). Gender and power: As a largely female profession, nursing has been subjected to gender subordination as nurses are seen as caring, compassionate and the „handmaidens‟ of doctors (Salvage 1985; Marks 2001). While 92% of South Africa‟s nurses are women, male nurses are often perceived as „feminine‟(Slome 2009) or a privileged minority rising rapidly to managerial positions (Salvage 1985; Evans 1997). Seventy per cent of the world‟s doctors are male, and 70% of the world‟s nurses are female (WHO 2006). *Territories established in 1800s north of the Cape by Afrikaners („Boers‟ or „farmers) to avoid British domination. 17 The theory of gender and power posits that power relations between and within genders arises from the prevailing hegemony of men over women, in terms of sexual division of labour, sexual division of power, and cathexis (Wingood, Camp et al. 2009). Being male holds advantages such as positions of authority and access to education and higher wages. Men are seen to control institutionalized power such as within the media, which can define and sustain gender norms associated with power. Women are underrepresented as newsmakers because they don‟t occupy „newsworthy‟ positions (Buresh and Gordon 2006). Nursing is portrayed as „women‟s work‟ (Salvage 1985) reflecting limited economic potential and possibly confined career paths (Brodie, Andrews et al. 2004; Wingood, Camp et al. 2009). In contrast, male nurses are seen as a privileged minority, with a disproportionate number occupying positions of status and power such as administration or heading up units (Evans 1997). Female nurses are seen to progress male nurse careers knowingly or unconsciously as „subordinates in patriarchal society, particularly in the male, physician-dominated health care system‟ (Evans 1997). South Africa‟s Forum for Professional Nurse Leaders recently made two ad-hoc male appointments to its executive committee to show its „commitment of advancing the male role in nursing‟ (Slome 2009). Male nurses were rarely portrayed in the media (Bridges 1990), and were often perceived as feminine or homosexual, or mistaken for doctors (Salvage 1985; Evans 1997; Brodie, Andrews et al. 2004; Slome 2009). Image: Hierarchy and pay disparities have contributed to the unionization of nursing, with younger, more junior nurses more inclined to participate in industrial action than their seniors who may oppose it for fear of being challenged or losing control (Salvage 1985). Society largely perceives nurse strike action as unprofessional and unethical, contributing further to the erosion of trust between nurses and their patients (Marks 2001; Dhai 2010). South Africa‟s 2007 public service strike may have spurred government‟s introduction of the Occupation Specific Dispensation which sought to remedy the historical backlog of poor nursing salaries (Breier, Wildschut et al. 2009), although the lasting perception is of nursing as a poorly paid profession, further adding to its diminished status particularly in South Africa‟s increasingly materialistic society (Breier et al., 2009). Other factors linked to their reduced status were the use of the term „nurse‟ for all categories of nursing including auxiliary nurses who are not multi-skilled, the change in nursing uniforms from white dresses to navy slacks worn by supermarket tellers and bank clerks (Breier, Wildschut et al. 2009), while internationally, the media‟s portrayal of nurses has negatively affected the image of the profession (Salvage 1985; Roberts and Vasquez 2004; Buresh and Gordon 2006). Stress: Nurses cannot do their jobs in facilities which lack water, lighting, vehicles, drugs or working equipment (WHO 2006). South African nurses are stressed because of lack of equipment, 18 poor working environments, increased patient load due to communicable diseases, lack of employer support and nurse shortages due to HIV or migration (Hall 2004). This has led to nurses feeling helpless, fatigued, angry and frustrated (Hall 2004; Ncayiyana 2004; Smit 2005). Nurse burn-out has been found to be a significant factor in adverse patient outcomes (Vahey, Aiken et al. 2004). Higher patient to nurse ratios are associated with an increase in the likelihood of dying and a 23% increase in the odds of nurse burnout (Aiken, Clarke et al. 2002), and conversely hospitals with lower nurse/patient ratios have better outcomes for patient survival and retaining nurses (Rafferty, Clarke et al. 2007) and greater patient satisfaction with care (Vahey, Aiken et al. 2004). However, no literature could be found on South African nurse/patient ratios. Denosa has campaigned for flexible, legally enforceable nurse/patient ratios (Bateman 2009), and private hospital group, Medi-Clinic, is exploring required staffing per unit per shift according to the predicted and actual workload (Aylward 2011). Nurse shortages and working conditions: South Africa has a shortage of nurses for the population in need, with 125 public sector professional nurses per 100 000 uninsured population (Day and Gray 2010), falling short of WHO‟s recommendation of 230 per 100 000 (Harrison 2009). Official SANC figures for 2010 (which include nurses who have migrated, retired or moved professions) indicate South Africa has a total of 231 086 nurses on the register to serve a population of 49 991 300 (SANC 2011). There are 115 244 registered nurses of which 8215 (7.67%) are male nurses (SANC 2011). As much as one-fifth of nurses on the SANC register in 2004 apparently no longer practiced as nurses (Hall 2004). Globally, nursing experiences significant ebb and flow due to free-market policies and as a development issue, nurse migration affects the health sector‟s ability to serve a population‟s health needs. Nurse shortages are a world-wide phenomenon, felt more acutely in developing countries that need them most (WHO 2006) with global supply expected to fall short of present or future nursing needs (Aiken, Buchan et al. 2004). South African nursing qualifications are marketable in many English-speaking countries (Breier, Wildschut et al. 2009), and United Kingdom voluntary guidelines appear not to have worked as nurse migration from South Africa quadrupled between 1999 and 2004 (Aiken, Buchan et al. 2004). Nurse shortages contribute to burn-out, greater patient loads and verbal abuse from patients. An American Nurses‟ Association survey in 2001 found 54% of nurses would not recommend their profession to their children or friends (Murray 2002), although nurses are cautioned not to speak negatively of their profession in front of others because „we will need nurses one day and we want the best nursing care available‟ (Ihlenfeld 2004). Research on the portrayal of nurses in the media 19 found that the media‟s failure to educate the public about the professional role of nurses or project a positive image may have exacerbated the nursing shortage (Mason 2002; Hall, Angus et al. 2003). Nurse clinical workloads in South Africa in 2008/09 averaged around 23.3 patients per nurse per day, although nurses in metropolitan areas average 29.5 patients per day (Day, Monticelli et al. 2010). Reflecting inequitable distribution of nurses, provinces with a higher socio-economic status have far better nurse-patient ratios (Gauteng: 1:187; Western Cape: 1:184; KwaZulu-Natal: 1:194) than poorer-resourced provinces (Eastern Cape: 1:284; Northern Cape: 1:281; Mpumalanga: 1:308) (SANC 2011). South Africa has an aging nursing workforce, particularly among registered nurses and midwives, where 60% are between 40 – 59 years, 16% are 60 years and older, while 23% are aged 39 and younger (SANC 2011) making this a critical area for policy intervention (Coovadia, Jewkes et al. 2009). Nurse professionalism: The Department of Health believes that upholding professionalism at all times is a way to restore the image of nursing in South Africa (DOH 2008), which will impact on the choice of nursing as a career (Bridges 1990). Endorsing WHO‟s findings that a motivated workforce will encourage retention and recruitment (WHO 2006), the South African government has acknowledged that nurses will remain within the profession when they are appropriately paid, have opportunities to advance professionally and participate in decision-making (Motlanthe 2009). Nurses‟ views and values inform the implementation of health policy and they should be included in policy-making (Walker and Gilson 2004). Several articles highlighted the link between recognition, respect and reward, and patient care (Aiken, Clarke et al. 2002; Vahey, Aiken et al. 2004; Rafferty, Clarke et al. 2007), while supportive supervision has been found to be one of the most effective ways to improve the competence of individual health workers (WHO 2006). A South African study found that good management was regarded as more important than salary, unless salary was substantially higher (Blaauw and Penn-Kekana 2003). A professional image can change public attitudes to nursing and increase nurses‟ power which is maximized when nurses work together as a unified force of professionals (Salvage 1985; Roberts and Vasquez 2004). Nurses who fail to identify themselves using their titles or last names, or who wear uniforms indistinguishable from other hospital workers or cleaners, diminish their status and control (Buresh and Gordon 2006). Conversely, patients identify white uniforms with being a nurse, competence and professionalism (Skorupski and Rea 2006), although nurses appear to prefer solid blue uniforms since they „hide dirt, wrinkles and blood stains‟ (Skorupski and Rea 2006; Breier, Wildschut et al. 2009). Standardized uniforms have been linked to increased patient satisfaction in hospitals (Skorupski and Rea 2006). Some scholars have warned against the professionalization of nursing, believing it fragments the healthcare team by entrenching hierarchies which reproduce 20 social inequities, and „task-oriented production line‟ nursing leading to depersonalized, non-holistic patient care (Rispel and Schneider 1991; Van der Walt and Swartz 2002). Negative nurse attitudes, experiences and unprofessionalism: Job satisfaction has been found to be significantly associated with the degree of control nurses have over their work (McLaney and Hurrell 1988). When nurses are excluded from power yet are held accountable, their sense of loss of control, powerlessness and lack of self-esteem could impact on how they treat their patients. The resultant stress may lead to abuse of those with lesser status such as peers, students, and patients (Rowell 2007; Crotty 2010). Nursing has a reputation of „eating its young‟ through unkind behaviour towards new nurses or nursing students (Crotty 2010). This negative modeling may result in nurses bullying patients by delaying responses to a patient‟s needs or refusing to keep family members informed (Rowell 2007; Crotty 2010). Several authors describe how nurse unprofessionalism, such as rudeness, physical assault and neglect particularly in sexual and reproductive health services, impacts on service delivery and health care (Jewkes, Abrahams et al. 1998; Abrahams, Jewkes et al. 2001; Wood and Jewkes 2006; Coovadia, Jewkes et al. 2009). Nurses themselves may be victims of physical or emotional abuse (Kim and Motsei 2002; Christofides and Silo 2005), which may be linked to increased sick leave, burnout and staff turn-over (WHO 2006). Some have suggested that nurses cannot care for others unless they experience caring (Salvage 1985; Armstrong 1993; Van der Walt and Swartz 2002), and their own lack of caring due to stress has led to a lack of societal respect (Breier, Wildschut et al. 2009). Poorly paid and undervalued nurses experience burnout, stress and neglect their patients. This stress may lead to „normalisation of deviance‟ where nurses interpret rules as irrational, counter-intuitive or unproductive, and when witnesses of rule violations fail to speak up for psychological reasons or to refuse to jeopardize someone on the nursing team (Banja 2010). Nurse strikes: Nurse protests are regarded as being at odds with their profession, femininity and compassion, and so are widely reported in the media (Salvage 1985; Bridges 1990). Nurses who speak out are regarded as trouble-makers, leading nurses to engage in covert and overt resistance (Garon 2006). „Nurse militants‟ were blamed for strike action in the New Zealand mental health nurses‟ strike (Farrow and O'Brien 2005), while Japan‟s militant campaign to increase the numbers of nurses successfully changed legislation as nurses, marching in white uniforms and ensuring safety agents were in wards during strikes, framed it as improved patient care which won popular support (Katsuragi 1997). In South Africa it is illegal for nurses to strike as they are regarded as providing an essential service (DOL 1995). Local patient care has been found to be adversely affected by nurse strikes (Kunene 21 1996), with media coverage of nurse strikes focusing on patient suffering rather than nurse complaints (Ehlers 2000). South African nurses have gone on strike for pay increases and better working conditions, knowing they face docked pay, demotion, dismissal or misconduct charges (Parker 2010) because of the conditions public sector nurses work in, described as „noxious‟, „shameful‟ and „horrendous‟ and „akin to being in a war with no end‟(Pinkney-Atkinson 2010): Nurse training and academic nursing: Internationally, nursing as a career was found to be „the best kept secret as a career choice‟ (Schmidt 2001), although official figures from the SANC indicate a record number of 43 325 students/pupils in training in 2010, an increase of 27.5% (n=9353) over the previous year (SANC 2011). While the majority are student registered nurses undertaking the four-year course (n=19 978), the number of „sub-professional‟ pupil enrolled nurses undertaking the two year course was 16 836, an increase of 3784 over the preceding year, more than one-third of the growth of student registered nurses (SANC 2011). However, the growth in the register does not reflect the production of nurses from the previous year, indicating that a „sizeable proportion of graduates do not enter the profession‟ beyond the natural attrition expected from nurses retiring, dying or leaving nursing (Breier, Wildschut et al. 2009). The public sector is training fewer nurses due to cuts in provincial health budgets (GMS 2010) and the rationalization of colleges which has led to closure and merging of nursing colleges into higher education sector. This resulted in a rapid growth of private training such as in-service training or bridging courses offered at private hospitals (Breier, Wildschut et al. 2009; PHS 2010) which may be limited in the training offered, for example, excluding psychiatric nursing. Academic nursing falls under both the Department of Health and Department of Education, and is facing a challenge as nurse qualifications are being realigned with revised scopes of practice (SANC 2005; DOH 2008; Breier, Wildschut et al. 2009). The new four-year qualification registered with the South African Qualifications Authority (SAQA) proposes a bachelor‟s degree as the basic qualification for a registered nurse, currently only offered in the public sector at universities or universities of technology (Breier, Wildschut et al. 2009). This will alienate the bulk of nurses who graduate through nursing colleges which are not permitted to award degrees. The degree course may also attract those wishing to earn while studying and who use nursing as a stepping stone with low motivation to work as nurses after studying due to its low morale, pay and lack of public respect (Brodie, Andrews et al. 2004; Breier, Wildschut et al. 2009). Remarkably, research shows that students were attracted to nursing because of the white uniform (Breier, Wildschut et al. 2009). 22 Summary In conclusion, the face of nursing in South Africa appears to be aged, stressed and demotivated as the status of the profession declines due to poor working conditions and heavy workload from an increasing burden of disease. This affects health service delivery and health status, may impact on the choice of nursing as a career. This study will assess how the „masculine‟ media frames the „feminine‟ nursing which could further entrench the gender and power inequities associated with nurses and nursing. Buresh and Gordon assert that nurses will acquire power “when they articulate the skill and knowledge embedded in their practice” (Buresh and Gordon 2006). When nurses describe their knowledge and competence, it helps them understand their work in a more empowering way, enhancing their ability to care for patients, and may encourage health institutions to value and reward nursing more (Buresh and Gordon 2006). Objectives Aim: This study explores how nursing is framed in the mainstream press in South Africa over the six- month period of January to June in 2010 using content and discourse analysis. Specific objectives: 1. To describe the extent of nursing coverage in the SA lay press 2. To determine the proportion of publications featuring nursing prominently 3. To identify who is given a „voice‟ or quoted in nursing articles, with attention to gender and power 4. To identify the slant of how nursing is portrayed in the mainstream press from a positive, negative or neutral perspective 5. To determine whether there is a difference in the proportion of articles focusing exclusively on nursing (ie. prominence) between January - April, and May – June 6. To explore associations between : - prominence of articles : - extent of quotes on nursing : - slant of articles : - key topics of articles by characteristics of media (eg. publication type, frequency, circulation, geographic distribution, ownership) and characteristics of article (eg. article type, page number of article, presence of photograph and language) in January – June 2010 7. To identify key topics around which nursing is framed 8. To describe and analyse the discourse used to frame nursing in articles, with attention to slant and what is being said by whom on nursing. 23 CHAPTER 2 METHODOLOGY This chapter explains the methodological approach used in the study, and describes the study design, population, sampling, data sources and analysis. The variables generated for the study are discussed in relation to the objectives. The chapter ends with how limitations and ethics were addressed. Study design This cross-sectional study used a mixed method approach of both quantitative and qualitative methodologies to address different questions of the data which were collected concurrently in a single phase reflecting this complementary convergence. It is an example of a “concurrent nested strategy” (Creswell 2003) as seen in Figure 1 below, where the quantitative portion was the dominant method with the qualitative method nested within it to explore questions distinct from those in the dominant method. The mixed methods approach has the advantages of qualitative and quantitative data, allows for richer interpretation and insights, and a broader range of study questions (Burke-Johnson and Onwuegbuzie 2004). This is an appropriate third option to breach the purist quantitative/qualitative divide in order to facilitate communication and collaboration between both journalism and public health, and the positivist versus interpretivist world views of quantitative and qualitative research (Burke-Johnson and Onwuegbuzie 2004; Crosby, DiClemente et al. 2006). Analysis of findings Figure 1: Concurrent Nested Strategy (Creswell 2003), pg 214 Data were collected from the mainstream press in South Africa over the period 1 January – 30 June 2010. Quantitative research uses objective methods which are observable and verifiable for testing a hypothesis to generalize, predict or explain results, and falls within the positivist paradigm (Crosby, DiClemente et al. 2006). The content analysis formed the quantitative component of the research to describe who, what, when, where and how nursing was portrayed in the lay press over a specific QUANTITATIVE Qualitative 24 period of time. Data was numerical or transposed to numerical values and presented as frequencies and proportions for analysis. This portion measured the extent of nursing coverage using variables of publication, frequency and article type, timeframe, ownership, geographical coverage, circulation figures and language; the prominence of articles, their page location and the use of photographs, and whether there was a difference in the proportion of articles focusing exclusively on nursing (ie. prominence) between January - April, and May – June. Associations between variables by characteristic of media and characteristic of article were included for analysis. Mixed methods research allowed for certain qualitative variables to be transformed into quantitative codes for analysis. This included the proportion of key topics of nursing coverage; the voice of nursing by means of nurse quotes, in which media and in relation to other „voices‟ with reference to gender and anonymity; and the slant of articles using a categorical variable with three levels (positive, negative and neutral). Qualitative research focuses on meaning to understand social processes and local perspectives in context. It approaches research from an interpretivist paradigm where perceptions are reflected in myriad „world views‟ and where realities are socially constructed (Crosby, DiClemente et al. 2006). It can support quantitative research to describe aspects such what is being written about nurses which cannot be quantified (Creswell 2003), and helps shed light on concepts shaping people‟s behavior. Qualitative research helps to give people a „voice‟ by enabling people to explain in their own words their worldviews and understanding of issues (Kaler 2004). Discourse analysis of newspaper articles is one way of eliciting this information. The qualitative portion used themes as the basis for analyzing how nursing is framed in the lay press with attention to slant, and voice (what is being said, by whom about nursing). Study population The study population was all mainstream press articles (ie. newspapers and magazines which are sold and free community newspapers) in South Africa during January – June 2010 from the monitoring agency, Monitoring South Africa (MSA), which monitors 1568 print media. The press was selected over broadcast items since monitoring is cheaper and likely to be more accurate. MSA identified all articles which included the words „nurse‟ or „nursing‟. All articles with these key words were included in the study, including those with the same subject matter, as the articles appeared in different media, on different pages, possibly in different geographic areas, with different audiences and editorial treatment. For the same reason, articles originating from news wire agencies such as Reuters are utilized by diverse newspapers and treated distinctively according to the newspaper‟s audience base, and so were included. The study population excludes technical, specialist, electronic and broadcast media, and press not monitored by MSA. 25 Sampling and sample size A pilot study on nursing in January – March 2010 found 98 articles on „nurse‟ or „nursing‟ which was considered low to generate richness of data for the thematic portion of the study. The decision was therefore made not to sample but to do a census of every article which mentioned the word „nurse/s‟ or „nursing‟ from Monitoring South Africa. Further cross-checking with the web-based media monitoring service, Meltwater, ensured that all available articles were captured. The census yielded a total of 242 articles, including those which were predominantly on nursing as well as passing mentions such as when nursing was listed along with other professions in a story. The period January – June 2010 was purposively chosen because International Nurses Day falls on 12 May and the researcher had not written any press articles in this period, thereby eliminating potential bias of including self-generated articles. Quantitative sampling: A total of 242 articles in 95 different lay press throughout South Africa mentioned nursing between January – June 2010. Seven publications could not be coded for circulation or readership as they did not have certified circulation figures, thus circulation figures are quoted for 235 publications. Eleven articles of the total 242 were „passing mentions‟ and did not contain sufficient information for categorization by topic, and they were dropped from analysis. The total number of articles analysed by topic was 231. In terms of voice, not all articles had quotes, and it was possible for different categories of people to be quoted in a single article hence the total number of quotes (256) is more than the total number of articles (242). Qualitative sampling: A total of 91 articles were purposively selected to ensure sufficient richness of data for analysis. Coding was both deductive, following pre-set categories aligned with the quantitative variables, and inductive, where the data itself presented newly conceived information such as nurses and society and as agents of change, nurses and the media, and descriptors of nursing. Inclusion criteria for the qualitative sample were all page 1 articles (which reflected a variety of variables such as prominence, slant, who was quoted, theme, publication types and geographic distribution); all letters (n=20) as an article type since they provide a feedback forum and indicate nurse and societal participation in public discourse; and three editorials which featured nursing prominently. Further selection was made of similar numbers of articles according to key themes guided by slant, prominence, article type, language and distribution. Low prominence articles („minimal mention‟ or „passing mention‟) were mostly excluded, except for a few minimal mention articles when they addressed a variable of interest, such as doctors quoted, the single cartoon, and the single photo 26 captioned “Angels of Mercy”. Although only one article was in Zulu, its English equivalent was included for analysis. Data collection and data sources The press articles on nursing in South Africa in January to June 2010 were collected and sent via email by MSA to the researcher. MSA included the publication name and date, circulation figures, page of article, the size of article in square centimeters, and the text and photograph if present. Quality was controlled by means of cross-checking with the web-based agency, Meltwater, to ensure no articles were omitted. Circulation and average readership figures were verified with the independent agencies, the Audit Bureau of Circulations (circulation figures), and the South African Advertising Research Foundation (average readership). Geographical distribution of media was verified through Targetmedia (www.targetmedia.co.za). A data coding sheet was developed and the researcher captured the following dimensions: o The extent of nursing coverage: publication and article type, geographical coverage and circulation figures, number and size of articles, o Who was quoted in articles in which media according to categories of nurse, patient, doctor, union, spokesperson, professional categories of nurses quoted, sex of persons quoted o The slant of the article using a categorical variable with three levels (positive, negative and neutral), o Key topics addressed in the articles, o Whether the article predominantly covered nursing or just mentioned nursing in passing o Whether there was a difference in the proportion of articles focusing exclusively on nursing (ie. prominence) between January - April, and May - June. Data processing, analysis and management Data was captured using an Excel spreadsheet. Data was cleaned and errors in data capturing corrected. For the qualitative analysis PDF files were converted to text files for analysis. For the quantitative content analysis, both descriptive and inferential statistics were calculated using STATA 9, and quantitative data were recoded when required (e.g. collapsing some categories of variables together). Objective 1: To describe the extent of nursing coverage using proportions:  Circulation figures were recoded into a categorical variable with three levels for small (<50 000), medium (50 001- 100 000) and large (>100 001). Readership was recoded similarly into small (<100 000), medium (100 001 – 1 million), and large (> 1 million). The mean and range for the continuous variables of circulation and readership was calculated and proportions were calculated for the categorical variables. 27  Publications were coded according to type of distribution using a categorical variable with four levels: national publications were those available throughout the country; regional were those distributed in provinces; community (or local) press included free and sold publications within suburbs and towns, and magazines which were a different media category and were classified independently. Proportions were calculated for the type of distribution of articles.  Articles were disaggregated according to geographic distribution. A categorical variable was created with 10 levels: national; Gauteng, KwaZulu-Natal, Western Cape, Eastern Cape; Free State, Northern Cape, North West, Limpopo and Mpumalanga. For some analysis, eg. prominence, geographical distribution was recoded into a three level categorical variable: 1=national; 2=Gauteng, KwaZulu-Natal, Western Cape and Eastern Cape, and level 3=Free State, North West, Northern Cape, Limpopo and Mpumalanga. It should be noted that figures for national publications may differ between press type of distribution (where magazines are coded independently), and geographic distribution (where magazines are included as a national publication).  Articles were coded in terms of frequency of publication. A categorical variable was generated with three levels: daily, weekly, fortnightly, monthly (Targetmedia 2010). For type of articles, a categorical variable with five levels was generated: news, letters or feedback forums, editorials, features, and photo and caption items with no articles. Nursing articles were coded for the pages they appeared on using a categorical variable that matched pages 1-6 of a publication. Articles that appeared on page 7 or more were recoded together.  The language that the articles were published in were coded using a categorical variable with four levels: English, Afrikaans, a bilingual mix of these, and Zulu. Press ownership is concentrated in four large publishing groups: Avusa, Independent Newspapers, Caxton/CTP and Media24. Caxton and CTP are one group, but since CTP prints a large national newspaper (The Citizen) and Caxton prints community newspapers (Whoownswhom 2009), they were coded separately. Objective 2: To determine the proportion of publications featured nursing prominently, articles were coded according to prominence with three levels, ie. Whether the full article was on nursing, whether just a portion of up to three sentences or a single paragraph, or a passing mention where the word „nurse‟ or „nursing was mentioned. Since photographs help to draw attention to text, foster more extensive reading, can affect people‟s opinions and distort memory (Zillmann, Knobloch et al. 2001; Garry, Strange et al. 2007), a dichotomous variable on the presence of a photograph was generated. Proportions were calculated for both these categorical variables. Objective 3: To identify who is given a „voice‟ or quoted in nursing articles, a categorical variable was generated for each of six categories of person quoted: nurse, patient/family member, doctor, union spokesperson, spokesperson/management, and other. Multiple people could be quoted per article. Since quoted people were coded as a yes/no, p-values were available for each category 28 of person quoted. Nurse quotes were coded according to professional categories into four levels where possible: professional nurse, auxiliary nurse, student nurse, and unknown. Since several articles quoted nurses and doctors who preferred to remain anonymous, this variable was added as it highlights issues of fear, censorship or lack of self-efficacy to speak out, and a dichotomous variable was generated for „identity protected‟ and „identity not protected‟. Proportions were included for each variable. Objective 4: To identify the slant of how nursing is portrayed in the mainstream press from a positive, negative or neutral perspective, each article was coded using a categorical variable with three levels: „positive‟, „neutral‟ or „negative‟ from a reader‟s perspective in terms of the overall impression gained by the reader of nurses and nursing. „Positive‟ articles were those where nursing was promoted, uplifted or conveyed positively; „neutral‟ articles were largely objective and did not take a stand for or against nursing, while „negative‟ articles were those which undermined nursing or conveyed a negative impression. Proportions of positive, neutral and negative articles were given. Inter-rater reliability was calculated (Kappa = 0.72) for this variable as the coding is potentially subjective. Proportions were then calculated for the categorical variable. Objective 5: To determine whether there is a difference in the proportion of articles focusing exclusively on nursing (ie. prominence) between January - April, and May – June, the month when the article appeared was coded as a categorical variable with six levels for each month from January to June. This was then collapsed into two levels: January – April; May – June and results were presented as proportions. Two-by-two tables were generated with the proportions of the new dichotomous variable of the time periods and the prominence variable. Chi square tests were done. Objective 6: To explore associations between prominence of articles, extent of quotes on nursing, slant of articles, and key topics of articles by characteristics of media (eg. publication type, frequency, circulation, geographic distribution, ownership) and characteristics of article (eg. article type, page number of article, presence of photograph and language) over the six month period, items were cross-tabulated and Pearson Chi-Square tests were run using STATA to determine any statistically significant associations. Objective 7: To identify the proportion of key topics around which nursing is framed, nursing articles were framed around key topics using a dichotomous variable with yes/no. Six major topics emerged inductively from the data during the analysis and each article was assigned to a single dominant theme. As this variable is also potentially subjective, inter-rater reliability was assessed and calculated by the supervisor (Kappa = 0.84). Proportions were then calculated for the categorical variable.  Nursing as a profession: sub-topics of nursing as a career or calling, scopes of practice, dress code or profiles of nurses 29  Nursing unprofessionalism: sub-topics of neglect, negative attitudes, disciplinary issues and poor service delivery  Training: sub-topics of academic nursing, research, skills and graduation  Strikes: sub-topics of protests  Labour issues: sub-topics of the occupational service dispensation (OSD), pay issues, shortages and conditions of service; and  International Nurses‟ Day (IND: sub-topics of special events and awards made. Qualitative discourse analysis: For the discourse analysis, text segments were coded and thematic analysis done. Qualitative coding was largely inductive. A sample of articles was coded by the supervisor using a set of criteria developed by the student in order to calculate the inter-coding reliability. A Cohen‟s Kappa was calculated to assess the inter-coder reliability, and discrepancies in coding were resolved through discussion. The text articles were uploaded into Software package MaxQDA for coding and to facilitate in-depth analysis. Data was stored electronically and hard-copy in a locked, damp-proof cabinet. Objective 8: To describe and analyse the discourse used to frame nursing in articles, with attention to slant and what is being said by whom on nursing, articles were coded according to theme and sub-theme. „Letters‟ and „editorials‟ were analysed separately, and discourse themes of violence, racism and blaming emerged during analysis and included under „negative slant‟. Text was coded for gender references, power, descriptors of nursing. Discourse around nursing and society was integrated into thematic analysis, while the theme of nursing and the media which emerged from the material was considered separately. All articles with quotes were explored in terms of person quoted. Ethical considerations Permission to use the MSA data was granted by the manager of UNEDSA. An ethical waiver (M10941) was issued by the HREC as this study did not involve humans or human records. The articles included in this study are available in the public domain. The newspapers or magazines where articles appeared have therefore been identified in the findings section. Summary This cross-sectional study used mixed methods of content (quantitative) and discourse (qualitative) analysis to sample, process and analyse all press cuttings on nursing in the lay press in South Africa in accordance with the study objectives. 30 CHAPTER 3 RESULTS This chapter presents the main results of the study. Quantitative findings of the extent of nursing coverage, who is quoted in nursing articles (including a gender disaggregation), prominence, slant, and key topics are described by categories of media characteristics and article characteristics. Qualitative results explore the three key issues of framing, voice and slant of nursing as reflected in the six key topics on nursing coverage. Quantitative results This section analysed the extent of nursing coverage, the prominence of nursing articles, the extent of quotes on nursing, including nurse categories and gender of quotes, the slant of nursing and the extent of coverage according to the key topics. Findings: Extent of nursing coverage There were 242 articles over six months between January – June 2010 featured in 95 different lay press throughout South Africa. The cumulative circulation of 235 publications where data was available was 21.7 million, with an estimated potential readership of 178.5 million (ABC 2010; SAARF 2010). The range for circulation was 2893 – 484 588 with a mean of 92 524.2. A total of 159 publications had readership figures, and the range was 3 000 – 4.956 million, with a mean of 1 110 232. As seen in Table 2, most nursing articles appeared in press with small circulations of less than 50 000 (n=129; 55%), but with medium readership figures of up to a million readers (n=102; 43%). The majority of articles appeared in May (n=79; 32%) which coincided with International Nurses‟ Day (IND) followed by March (n=37; 15%) and in community publications (n=86; 35.5%) followed by regional newspapers (n=85; 35%). Regarding frequency, most articles appeared in daily press (n=129; 53%), with the exception of May when 63% (n=50) of articles appeared in the weekly press. Regarding geographic distribution, most articles appeared in nationally distributed press (n=67; 28%), followed by Western Cape (n=53; 22%) and Gauteng media (n=43; 18%). The Eastern Cape media (n=33; 13%) featured nursing nearly twice as much as KwaZulu-Natal press (n=17; 7%). There was a significant association (p = 0.000) between distribution predominance and publication type with 96% (n=82) of regional articles on nursing appearing in the cluster of Gauteng, KwaZulu- 31 Natal, Western Cape and Eastern Cape, and nearly 70% (n = 60) of nursing articles in community newspapers appearing in these regions. Avusa was the media owner which covered the most nursing articles (n=61; 25%) followed by Independent Newspapers (n=55; 23%) and Media24 (n=53; 22%). However, combining Caxton and „other‟ mainly community publishers found that 65 (26%) covered nursing issues. Most of these publishers have small circulations. Table 2: Extent of press coverage on nursing by media characteristic Month N % January February March April May June Total 46 31 37 17 79 32 242 19% 12.8% 15.2% 7% 32.6% 13.2% 100% Publication type N % National Regional Community Magazines Total 64 85 86 7 242 26.4% 35.1% 35.5% 2.8% 100% Frequency N % Daily Weekly Fortnightly Monthly Total 129 107 2 4 242 53.3% 44.2% 0.83% 1.65% 100% Circulation N % Small Medium Large Total 129 44 62 235 54.8% 18.7% 26.3% 100 Readership N % Small Medium Large Total 91 102 42 235 38.7% 43.4% 17.8% 100 Geographical distribution N % National Gauteng KwaZulu-Natal Western Cape Free State Eastern Cape Northern Cape North West Province Limpopo Mpumalanga Total 67 43 17 53 4 33 1 7 7 10 242 27.9% 17.7% 7% 21.9% 1.6% 13.6% 0.4% 2.8% 2.8% 4.3% 100% 32 Predominant distribution N % National Gauteng, KwaZulu-Natal, Western Cape, Eastern Cape Free State, Northern Cape, North West, Limpopo, Mpumalanga Total 67 146 29 242 27.6% 60.3% 11.9% 100% Ownership N % Avusa Independent Media24 Caxton CTP Other Total 61 55 53 20 8 45 242 25.2% 22.7% 21.9% 8.2% 3.3% 18.6% 100% Table 3 below shows that the majority of articles were news (n=193; 80%), followed by letters or feedbacks (8.6%). The majority of nursing articles appeared on/after page 7 (n=101; 42%), with nearly 29% (n=65) of articles appearing on Page 2 or Page 4, and 7.5% (n=18) of articles appearing on page 1. While not statistically significant, most page 1 articles were on nursing unprofessionalism (n=6), with three page 1 articles each for training, strikes and labour issues. The majority of page 2 articles were on strikes (n=9) and labour issues (n=8). The majority of articles on professionalism (n=20; 59%) and IND (n=21; 51%) were on/after page 7. A total of 117 articles (48%) had photographs. There was a significant relationship (p=0.000) between the presence of photographs and publication type with nearly 70% (n=60) of articles in community press and 85% (n=6) of articles in magazines featuring photographs, but only 37.6% (n = 32) in regional press and 29.6% (n = 19) in national press had photographs. Similarly, in terms of photographs and article type, 46% (n=81) of news articles on nursing carried photographs, and 90% (9) of feature articles had photographs. Nearly 90% of articles (n=216) were in English across all the ownership groups, which reflects the language break-down of South African media. Media24 was seen to feature the best mix including the only Zulu article and all but one of the Afrikaans articles. While further analysis of the following variables appears later in the chapter, the following can be noted from the table: Of the 231 articles which were included in the analysis of topic, the majority of articles were on strikes (n=46; 20%), followed by neglect (n=45; 19%) and IND (n=41; 18%). Over 60% (n=152) of articles were prominent with the full article on nursing rather than a passing mention. Regarding slant, half (n=122; 50%) of articles were positive, while 44% (n=107) were negative. Of all quotes, spokespeople were quoted nearly twice as often as nurses (n=126; 49%). 33 Table 3: Extent of nursing coverage by article characteristic Article type N % News Letter/forum Editorial/opinion Feature Photo/caption only Total 193 21 7 10 11 242 79.7% 8.6% 2.9% 4.1% 4.5% 100% Topic N % Professionalism Unprofessionalism Training Strikes Labour IND Total 34 45 26 46 39 41 231 14.7% 19.5% 11.2% 19.9% 16.8% 17.7% 100% Prominence N % Full article <3 sentences/1 paragraph <1 sentence Total 152 60 30 242 62.8% 24.7% 12.4% 100% Slant N % Positive Neutral Negative Total 122 13 107 242 50.4% 5.3% 44.2% 100% Voice N % Nurse quotes Patient quotes Doctor quotes Union quotes Spokesperson quotes Total 64 24 9 33 126 256 25% 9% 3% 12% 49% 100% Page Number (1-6) N % Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 ≥Page 7 Total 18 34 21 36 13 19 101 242 7.4% 14% 8.6% 14.8% 5.3% 7.85% 41.7% 100% Photograph N % Photograph No photo Total 117 125 242 48.3% 51.6% 100% Language N % English Afrikaans Bilingual Zulu Total 216 24 1 1 242 89.2% 9.9% 0.4% 0.4% 100% 34 Prominence of articles Prominence in this research project refers specifically to the length of articles, ranging from a full article on nursing, less than three sentences or one paragraph, or passing mention which is less than one sentence. Prominence by characteristics of media: As seen in Figure 2 below, a total of 152 articles (63%) featured nursing prominently compared to 60 articles (25%) with a single sentence/paragraph and 30 articles (12%) which mentioned nursing in passing. Figure 2: Prominence of nursing articles The analysis of prominence by media characteristics showed there was a significant association (p=0.004) between time period and prominence, as seen in Table 4 below, where 54% of prominent articles appeared in May-June, which coincided with International Nurses Day. There was no statistically significant association between publication type and prominence, although community press gave more prominence to nursing articles than other media types. In terms of frequency and prominence, over 50% of prominent articles were in the daily press, and 46% in the weekly press. Small publications featured nursing more prominently (59%) (p=0.025) than medium or large circulations and this difference was statistically significant. There was no statistically significant relationship between prominence and geographic distribution, although it bears noting that 20% of prominent articles appeared in the Western Cape and Gauteng, while only 8.5% of full articles were Full article on nursing 63% (152) < 1 sentence 12% (30) <3 sentences/ 1 paragraph 25% (60) 35 in KwaZulu-Natal press. There was no statistically significant relationship between prominence and media ownership. Table 4: Prominence by characteristics of media i. Magazines were dropped from the chi-square analysis because of small cell sizes ii. This was not calculated because of small cell sizes iii. The <3 sentences/1paragraph and <1 sentence categories were collapsed for this analysis Time period Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value January – April May – June Total 46% (70) 53.9% (82) 100% (152) 66.6% (40) 33.3% (20) 100% (60) 70% (21) 30% (9) 100% (30) 54.1%(131) 45.8% (111) 100% (242) 0.004 Publication type Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value National Regional Community Magazine Total 24.3% (37) 34.2% (52) 38.8% (59) 2.6% (4) 100% (152) 31.6% (19) 36.6% (22) 26.6% (16) 5% (3) 100% (60) 26.6% (8) 36.6% (11) 36.6% (11) 0 100% (30) 26.4%(64) 35.1%(85) 35.5%(86) 2.8% (7) 100% (242) 0.599 i Frequency Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value Daily Weekly Fortnightly Monthly Total 52.6% (80) 46% (70) 1.3% (2) 0 100% (152) 55% (33) 38.3% (23) 0 6.6% (4) 100% (60) 53.3% (16) 46.6% (14) 0 0 100% (30) 53.3% (129) 44.2% (107) 0.8% (2) 1.6% (4) 100% (242) ii Circulation Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value Small Medium Large Total 58.9% (86) 17.8% (26) 23.2%% (34) 100% (146) 38.9% (23) 20.3% (12) 40.6% (24) 100%% (59) 66.6% (20) 20% (6) 13.3% (4) 100%% (30) 54.8%(129) 18.7% (44) 26.3% (62) 100% (235) 0.025 Geographic distribution Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value National Gauteng KwaZulu-Natal Western Cape Eastern Cape Other provinces Total 25% (38) 19.7%% (29) 8.5% (14) 20.3% (31) 12.5% (19) 13.8%(21) 100% (152) 35% (21) 8.3% (5) 5% (3) 28.3% (17) 15% (9) 8.3% (5) 100% (60) 26.6% (8) 30% (9) 0 16.6% (5) 16.6% (5) 10% (3) 100% (30) 27.6% (67) 18.1% (43) 6.6% (17) 21.9% (53) 13.6% (33) 11.9% (29) 100% (242) 0.288 iii Ownership Full article %(n) 1 sentence/para %(n) < 1 sentence %(n) Total %(n) P-value Caxton Independent Avusa CTP Media 24 Other Total 9.4% (14) 21.7% (33) 23% (35) 3.2% (5) 22.3% (34 20.3% (31) 100% (152) 3.3% (2) 26.6% (16) 28.3% (17) 6.6% (14) 16.6% (14) 13.3% (10) 100% (60) 13.3% (4) 20% (6) 30% (9) 6.6% (2) 16.6% (5) 13.3% (4) 100% (30) 8.2% (20) 22.7% (55) 25.2% (61) 3.3% (8) 21.9% (53) 18.6% (45) 100% (242) 0.723 36 Prominence by characteristics of article As reflected in Table 5 below, type of article was significantly associated with prominence (p=0.000), with news featuring nursing more prominently than other article types. There was a highly significant association between topic and prominence (p=0.000), with 95% of IND articles 80% of strike articles and nearly 70% of articles on training featuring prominently. Notably, no articles on nursing strikes or protests were given passing mention. While there was no statistical significance between prominence and page number, nine articles featuring nursing prominently on Page 1 and 20 prominent articles were on page 2. Just under half of all articles featured photographs, and most prominent articles (53%) had photographs. Table 5: Prominence by characteristics of article i. The 1 sentence/paragraph and <1sentence categories were collapsed for the chi-square analysis Article type Full article % (n) 1 sentence/para % (n) <1 sentence % (n) Total % (n) P-value News Letter Editorial Feature Photo and caption Total 84.2% (128) 3.2% (5) 1.3% (2) 5.2% (8) 5.9% (9) 100% (152) 65% (39) 21.6% (13) 8.3% (5) 1.6% (1) 3.3%(2) 100% (60) 86.6% (26) 10% (3) 0 3.3% (1) 0 100% (30) 79.3% (193) 8.2% (21) 2.8% (7) 4.1% (10) 4.5% (11) 100% (242) 0.000 i Topic Full article %(n) 1 sentence/para % (n) <1 sentence % (n) Total % (n) P-value Professionalism Unprofessionalism Training Strikes Labour IND Total 55.8% (19) 47.7% (21) 69.2% (18) 80.4% (37) 45% (18) 95% (39) 65.8% (152) 23.5% (8) 47.7% (21) 11.5% (3) 19.5% (9) 45% (18) 2.4% (1) 25.9% (60) 20.5% (7) 4.5% (2) 19.2% (5) 0 10% (4) 2.4% (1) 8.2% (19) 100%(34) 100% (44) 100% (26) 100% (46) 100% (40) 100% (41) 100% (231) 0.000 i Page Full article %(n) 1 sentence/para % (n) <1 sentence % (n) Total % (n) P-value Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 ≥Page 7 Total 5.9% (9) 13.1% (20) 10.5% (16) 17.1% (26 5.9% (9) 8.5% (13) 38.8% (59) 100% (152) 11.6% (7) 16.6% (10) 5% (3) 8.3% (5) 1.6% (1) 8.3% (5) 48.3% (29) 100% (60) 6.6%% (2) 13.3% (4) 6.6% (2) 16.6% (5) 10% (3) 3.3% (1) 43.3% (13) 100% (30) 7.4% (18) 14% (34) 8.6% (21) 14.8% (36) 5.3% (13) 7.8% (19) 41.7% (101) 100% (242) 0.373 i Photograph Full article %(n) 1 sentence/para % (n) <1 sentence % (n) Total % (n) P-value Photo No photo Total 52.6% (80) 47.3%% (72) 100% (152) 43.3% (26) 56.6% (34) 100% (60) 36.6% (11) 63.3% (19) 100% (30) 48.3% (117) 51.6% (125) 100% (242) 0.186 Language Full article %(n) 1 sentence/para % (n) <1 sentence % (n) Total % (n) P-value English Afrikaans Bilingual Zulu Total 90.1% (137) 9.2% (14) 0 0.6% (1) 100% (152) 90% (54) 8.3% (5) 1.6% (1) 0 100% (30) 83.3% (25) 16.6% (5) 0 0 100% (30) 89.2% (216) 9.9% (24) 0.4% (1) 0.4% (1) 100% (242) 0.471 i 37 Extent of quotes on nursing Quotes indicate who has been quoted or given a „voice‟ in an article. Voice is an indicator of power and agency and can confer status on quoted individuals (Schramm 1964; Fairclough 1992). Similarly, who is not quoted or given a voice is worthy of interrogation. The figure below illustrates the extent of quotes on nursing. A quarter of 256 quotes were by nurses while nearly 50% of quotes were by spokespeople. Doctors were quoted 3% of the time, and 10% quotes were by patients. Union spokespeople were quoted 12% of the time. Figure 3: Proportion of quoted persons Figure 4 below shows that in the 64 articles which quoted nurses, registered nurses were quoted more often than any other category of nurse (58%; n=37), followed by student nurses (19%; n=12). Overall, registered nurses featured in 15% of articles, and student nurses were quoted in nearly 5% of articles Figure 4: Proportion of nurse quotes by professional category Nurses were quoted once in 15% (37) of articles, twice in 2% (5) of articles, and three or more times in 9% (22) of articles. In terms of sex, Figure 5 shows that females were quoted first more frequently than males in the first quote in articles, but in second and third quotes, males were quoted more often. nurses 25% (64) patients 9% (24) doctors 3% (9) unions 12% (33) spokespeople 49% (126) Registered nurse 58%(37) Nurse auxiliary 7.8%(5) Student Nurse 18.7%(12) Unknown/ Other 15.6% (10) 38 Figure 5: Proportion of quotes by sex Quotes on nursing by characteristics of media Table 6 shows that 52% of quotes on nursing were featured during the first period (n=133), compared to 48% (n=123) in the latter period when IND took place. Nurses were quoted more frequently in the first period (55%) than in May-June (45%), in contrast to quotes by doctors or unions which were more frequent in the latter period. This was not statistically significant. Nurses were quoted more often in community publications (40%) and those which appeared weekly (51.5%). The majority of total quotes appeared in the regional press (40%); 70% of quotes by spokespeople appeared in the regional press, and 75% of their quotes were in daily papers. Over half of all quotes – and the majority of patient, union and spokesperson quotes - featured in the daily press. Along with nurses, unions and spokespersons were quoted more frequently in publications with small circulations of <50 000, while doctor quotes featured equally often in small and large circulation publications (44%). Nearly 40% of patient quotes appeared in publications with circulations of over 100 000. In terms of geographic distribution, the Western Cape press featured more nurse quotes (32%; n=21) than any other region. Gauteng papers featured nurse quotes eight times (12.5%) and only 3% of KwaZulu-Natal publications quoted nurses. Although the majority of all quotes and over 50% of union quotes were featured in press owned by the Independent Newspapers group, most nurse quotes (30%) and patient quotes (38%) appeared in Media24 publications. 39 Table 6: Quotes on nursing by characteristics of media Time period Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total Jan – April May – June Total P-value 54.6% (35) 45.3% (29) 100% (64) 0.917 62.5% (15) 37.5% (9) 100% (24) 0.386 11% (1) 88.8% (8) 100% (9) i 48.4% (16) 51.5% (17) 100% (33) 0.498 52.3% (66) 47.6% (60) 100% (126) 0.569 51.9%(133) 48.4%(123) 100% (256) Publication type Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total National Regional Community Magazine Total P-value 20.3% (13) 32.8% (21) 40.6% (26) 6.2% (4) 100% (64) 0.145 20.8% (5) 33.3% (8) 29.1% (7) 16.6% (4) 100% (24) 0.000 11.1% (1) 55.5% (5) 0 33.3% (3) 100% (9) i 24.2% (8) 69.7% (23) 6% (2) 0 100% (33) 0.000 26.9% (34) 37.3% (47) 32.5% (41) 3.1% (4) 100% (126) 0.000 23.8% (61) 40%(104) 29.6%(76) 5.8% (15) 100% (256) Frequency Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total Daily Weekly Fortnightly Monthly Total P-value ii 46.8% (30) 51.5% (33) 0 1.5% (1) 100% (64) 0.190 50% (12) 41.6% (10) 4.1% (1) 4.1% (1) 100% (24) 0.991 22.2% (2) 66.6% (6) 0 11.1% (1) 100% (9) i 75.7% (25) 24.2% (8) 0 0 100% (33) 0.009 57.9% (73) 40.4% (51) 0 1.5% (2) 100% (126) 0. 172 55.4%(142) 42.1%(108) 0.3%(1) 1.9%(5) 100% (256) Circulation Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total Small Medium Large Total P-value 48.3% (29) 20% (12) 31.6% (19) 100% (60) 0.460 43.4% (10) 17.3% (4) 39.1% (9) 100% (23) 0.333 44.4% (4) 11.1% (1) 44.4% (4) 100% (9) i 63.6% (21) 12.1% (4) 24.2% (8) 100% (33) 0.480 58.1%(71) 14.7% (18) 27% (33) 100% (122) 0.262 54.6%(135) 15.7%(39) 29.5% (73) 100%(247)iii Geographic distribution Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total National Gauteng KwaZulu-Natal Western Cape Eastern Cape Others Total P-value 25% (16) 12.5% (8) 3.1% (2) 32.8% (21) 14% (9) 12.5% (8) 100% (64) 0.149 37.5% (9) 8.3% (2) 16.6% (4) 12.5% (3) 16.6% (4) 8.3% (2) 100% (24) 0.158 44.4% (4) 33.3% (3) 11.1% (1) 0 11.1% (1) 0 100% (9) i 24.2% (8) 27.2% (9) 12.1% (4) 12.1% (4) 21.1% (7) 3% (1) 100% (33) 0.091 6.9% (34) 19.8%% (25) 10.3% (13) 15.8% (20) 13.4% (17) 13.4% (17) 100% (126) 0.087 27.7%(71) 18.3%(47) 9.3%(24) 18.7%(48) 14.8%(38) 10.9%(28) 100%(256) Ownership Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quoted % (n) Total Caxton Independent Avusa CTP Media24 Other Total P-value 9.3% (6) 23.4% (15) 17.1% (11) 1.5% (1) 29.6% (19) 18.7% (12) 100% (64) 0.349 4.1% (1) 25% (6) 16.6% (4) 4.1% (1) 37.9% (9) 12.5% (3) 100% (24) 0.425 0 44.4% (4) 11.1% (1) 0 22.2% (2) 22.2% (2) 100% (9) 3% (1) 51.5% (17) 36.6% (12) 3% (1) 3% (1) 3% (1) 100% (33) 0.000 11.1% (14) 22.2% (28) 23% (29) 2.3% (3) 23% (29) 18.2% (23) 100% (126) 0.556 8.59%(22) 27.3%(70) 22.5%(57) 2.3%(6) 23.4%(60) 16%(41) 100% (256) i) Chi-square was not calculated for Doctor quotes because there were too few observations ii) The categories ‘fortnightly’ and ‘monthly’ were dropped for chi-square analysis due to small cell sizes iii) Not all publications had circulation figures 40 Quotes on nursing by characteristic of article As expected, the majority of articles with quotes on nursing were news, as seen in Table 7. In terms of topic, strike articles featured the most quotes. Significantly, nurses were quoted most often in relation to strikes (30%; p=0.014) followed by IND. Nurse quotes featured equally in articles on professionalism and labour (15.6%), but only 6% (n=4) of articles on neglect featured nurse quotes. Significantly, patients were quoted in 75% of articles on neglect. Regarding doctor quotes, 66% appeared in relation to labour issues. Unions were quoted most often in relation to strikes, which was statistically significant. Spokespeople were also quoted most often on strikes (25%), although this was not statistically significant. There was a statistically significant association between prominence and nurse quotes (p=0.000), spokesperson quotes (p=0.000) and union quotes (p=0.005). Over 80% of nurse quotes featured in full-length articles, compared to doctors who were more often quoted in one sentence or paragraph. Regarding slant, 55% of articles featuring quotes were negative, compared to 41% of quotes which were positive. Only nurse quotes were more positive (50%) than negative; for all other categories more quotes were negative. Significantly, over 90% of patient quotes were negative (p=0.000) and over half of spokesperson quotes (n=65; 51.5%; p=0.055) were negative. The majority of nursing articles appeared on Page 7 or thereafter, although nearly two-thirds of nurse quotes appeared in the first 6 pages of publications. Nurses were quoted in eight Page 1 articles, compared to 12 articles which quoted spokespersons on Page 1. Over half of articles featuring quotes had photographs, and significantly, when nurses were quoted, 75% of articles featured a photograph (0.000). Nearly 25% of all articles had anonymous quotes, with nurse identities protected over a third of the time, followed by 42% of anonymous patient quotes, and 55.5% of doctor quotes. 41 Table 7: Quotes on nursing by characteristic of article Article type Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total News i Other Total P-value 81.2% (52) 18.8% (12) 100% (64) 0.435 75% (18) 25% (6) 100% (24) 0.187 66.6% (6) 33.3% (3) 100% (9) ii 100% (33) 0 100% (33) ii 96% (122) 4% (4) 100% (126) 0.000 89.8% (230) 10.1% (26) 100% (256) iii Topic Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Professionalism Neglect Training Strikes Labour IND Total P-value 15.6% (10) 6.2% (4) 9.3% (6) 29.6% (19) 15.6% (10) 23.4% (15) 100% (64) 0.014 0 75% (18) 4.1% (1) 8.3% (2) 12.5% (3) 0 100% (24) 0.000 v 11.1% (1) 22.2% (2) 0 0 66.6% (6) 0 100% (9) ii 12.1% (4) 3% (1) 3% (1) 60.6% (20) 21.2% (7) 0 100% (33) 0.000 vi 12.8% (16) 20% (25) 12% (15) 24.8% (31) 16.8% (21) 13.6% (17) 100% (125) iv 0.239 12.1%(31) 19.6%(50) 9%(23) 28.2%(72) 18.4%(47) 12.5%(32) 100%(255)iv Prominence Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Full article vii Other Total P-value 84.3% (54) 15.7% (10) 100% (64) 0.000 62.1% (15) 37.9% (9) 100% (24) 0.974 44.4% (4) 55.5% (5) 100% (9) ii 84.8% (28) 15.2% (5) 100% (33) 0.005 76.9% (97) 23.1% (29) 100% (126) 0.000 77.3%(198) 22.7%(58) 100% (256) Slant Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Positive Neutral Negative Total P-value 50% (32) 3.1% (2) 46.8% (30) 100% (64) 0.619 8.3% (2) 0 91.6% (22) 100% (24) ii 44.4% (4) 0 55.5% (5) 100% (9) ii 36.3% (12) 3% (1) 60.6% (20) 100% (33) 0.122 43.6% (55) 4.7% (6) 51.5% (65) 100% (126) 0.055 41%(105) 3.5%(9) 55.4%(142) 100%(256) Page Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 ≥ Page 7 Total P-value 12.5% (8) 15.6% (10) 14% (9) 9.3% (6) 1.5% (1) 9.3% (6) 37.5% (24) 100% (64) 0.094 12.5% (3) 12.5% (3) 8.3% (2) 4.1% (1) 12.5% (3) 4.1% (1) 45.8% (11) 100% (24) 0.411 0 22.2% (2) 0 0 11.1% (1) 11.1% (1) 55.5% (5) 100% (9) ii 3% (1) 15.1% (5) 21.2% (7) 18.1% (6) 6% (2) 6% (2) 30.3% (10) 100% (33) 0.142 9.5% (12) 13.4% (17) 12.7% (16) 13.4% (17) 7.1% (9) 10.3% (13) 33.3% (42) 100% (126) 0.021 9.3%(24) 14.4%(37) 13.2%(34) 10.5%(27) 6.2%(16) 8.9%(23) 35.9%(92) 100% (256) Photo Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Photo No photo Total P-value 75% (48) 25% (16) 100% (64) 0.000 58.3% (14) 41.6% (10) 100% (24) 0.302 44.4% (4) 55.5% (5) 100% (9) ii 36.6% (12) 63.6% (21) 100% (33) 0.138 49.2% (62) 50.7% (64) 100% (126) 0.780 54.7%(140) 45.3% (116) 100% (256) anonymity Nurse quote % (n) Patient quote % (n) Doctor quote % (n) Union quote % (n) Spokesperson quote % (n) Total Identity protected Not anonymous Total P-value 34.3% (22) 65.6% (42) 100% (64) 0.000 41.6% (10) 58.3% (14) 100% (24) 0.001 55.5% (5) 44.4% (4) 100% (9) ii 18.1% (6) 81.8% (27) 100% (33) 0.947 15.8% (20) 84.1% (106) 100% (126) 0.421 24.6% (63) 75.4%(193) 100%(256) i) Article type was collapsed into ‘news’ and ‘other’ because there were too few observations ii) Chi-square was not calculated because of small cell sizes iii) Multiple quotes are possible within an article, yielding more quotes (n=256) than article number (n=242) iv) One of the 11 articles excluded from thematic analysis quoted a spokesperson; the total is thus reduced by 1. v) All topics except ‘neglect’ were collapsed into ‘other’ for Patient quotes for chi-square analysis vi) All topics except strikes were collapsed into ‘other’ for Union quotes for chi-square analysis vii) The 1 sentence/paragraph and <1sentence categories were collapsed for the chi-square analysis 42 Nursing quotes by sex of first person quoted The analysis of first quotes by sex are reflected in the diagram below: Figure 6: Proportion of first person quoted by sex In terms of first person quoted by sex and article characteristics, from Table 8 below it can be seen that females were quoted first significantly more often in articles on professionalism (60%), neglect (58%) and IND (88%), while males were quoted more often in relation to training (58%), labour (52%) and strikes (35%) (p=0.000). More first quotes of nurses and patients were female which was highly significant (p=0.000), while more first quotes by unions were male which was also significant (p=0.01). There was also an association between gender and prominence of articles, with females being quoted more often in prominent articles (55%), while men were quoted most frequently in articles of passing mention (78%) or of one sentence (42%) (p=0.002). In terms of slant, females were quoted more often in positive articles (52%), while men were quoted equally in positive and negative articles (35%). Significantly, the gender of those quoted anonymously in more than half of articles was unknown, while over a third of anonymous quotes (37%) were female, compared to 10% of anonymous male quotes. While not significant, Avusa featured more male first quotes than any other publishing group, and Media24 featured more female first quotes than other media owners. Females 46% (83) Males 34% (63) Unknown 19% (34) 43 Table 8: Nursing quotes by sex and characteristic of media and article Sex of 1st quote %(n) Ownership M F U Total p-value Caxton Independent Avusa CTP Media24 Other Total 33.3% (6) 40.9% (18) 42.5% (17) 50% (2) 18.6% (8) 38.7% (12) 35% (63) 50% (9) 45.4% (20) 32.5% (13) 50% (2) 62.7% (27) 38.7% (12) 46.1% (83) 16.6% (3) 13.6% (6) 25% (10) 0 18.6% (8) 22.5% (7) 18.8% (34) 100% (18) 100%(44) 100%(40) 100% (4) 100%(43) 100%(31) 100% (180) 0.293 Topic M F U Total p-value Professionalism Neglect Training Strikes Labour IND Total 32% (8) 26.3% (10) 57.8% (11) 35% (14) 51.6% (16) 11.5% (3) 34.6% (62) 60% (15) 57.8% (22) 15.7% (3) 32.5% (13) 22.5% (7) 88.4% (23) 46.3% (83) 8% (2) 15.7% (6) 26.3% (5) 32.5% (13 25.8% (8) 0 18.9% (34) 100% (25) 100% (38) 100% (19) 100% (40) 100% (31) 100% (26) 100% (179) 0.000 Person quoted M F U Total p-value Nurse Patient Doctor Union Spokesperson 9.3% (6) 8.3% (2) 66.6% (6) 57.5% (19) 40.4% (51) 64% (41) 87.5% (21) 22.2% (2) 27.2% (9) 43.6% (55) 26.5% (17) 4.1% (1) 11.1% (1) 15.1% (5) 15.8% (20) 100% (64) 100% (24) 100% (9) 100% (33) 100% (126) 0.000 0.000 0.123 0.010 0.046 Prominence M F U Total p-value Full article <3 sentences/para <1 sentence Total 29.3% (37) 42.2% (19) 77.7% (7) 35% (63) 54.7% (69) 28.8% (13) 11.1% (1) 46.1% (83) 15.8% (20) 28.8% (13) 11.1% (1) 18.8% (34) 100% (126) 100% (45) 100% (9) 100% (180) 0.002 Slant M F U Total p-value Positive Neutral Negative Total 35.2% (30) 28.5%% (2) 35.2% (31) 35% (63) 51.7% (44) 57.1% (4) 39.7% (35) 46.1% (83) 12.9% (11) 14.2% (1) 25% (22) 18.8% (34) 100% (85) 100% (7) 100% (88) 100% (180) 0.284 Anonymity M F U Total p-value anonymous Not anonymous Total 9.7% (4) 42.5% (59) 35% (63) 36.5% (15) 48.9% (68) 46.1% (83) 53.6% (22) 8.6% 12) 18.8% (34) 100% (139) 100% (41) 100% (180) 0.000 Legend: M=male; F=Female; U = unknown 44 Slant of articles This variable examines the subjective, ideological angle of an article and the exposure of nursing in a positive, neutral or negative light: whether the article portrays nurses as enhancing or detracting from health service delivery and whether the article promotes or demotes their profession. Slant by characteristic of media Figure 7 below shows that 50% of articles (121) had positive slant; 5.7 % (14) were neutral, and 44% (107) had negative slant. Figure 7: Proportion of positive, neutral and negative articles As shown in Table 9 below, there was a significant relationship between time period and slant (p=0.007), with more negative articles occurring in January – April (51.1%), while May – June, coinciding with International Nurses Day, yielded more positive articles (54%). Statistically significant findings were that nursing articles published in community media were positive (72%) compared to nearly two-thirds of national media coverage which was negative (p=0.000); weekly publications were positive (64%) while daily publications carried more negative articles (56%) (p=0.000), and media with small circulations were positive (63.5%) while press with large circulations more often carried negative articles (66%) (p = 0.000). Geographic distribution and slant also yielded highly significant results (p=0.001): over two-thirds of national publications carried negative nursing stories and KwaZulu-Natal was the only region to have more negative reporting on nursing than other provinces. Over 60% of coverage in Gauteng and Eastern Cape newspapers was positive. A further significant finding was the relationship between ownership and slant, where the majority of articles on nursing in the Independent Newspaper Group and Avusa were negative, while 75% of articles in Caxton (which publishes community newspapers) and CTP were positive (p=0.001). Positive 50% (121) Neutral 5.4%(14) Negative 44.2% (107) 45 Table 9: Slant by characteristics of media i) All categories except ‘Daily’ were collapsed for chi-square analysis due to small cell sizes Slant by characteristic of article Nearly half (49%) of news articles were categorized as positive, while over half of the editorials were negative, as seen in Table 10. There was a strong relationship between topic and slant (p=0.000) even when the entirely positive category of IND was eliminated. When IND was included, there were more positive articles (n=113) than negative (n=104); however, with IND eliminated, there were more negative articles (n=104) than positive articles (n=74). Professionalism, training and IND were overwhelmingly positive, whereas the majority of articles on unprofessionalism, strikes and labour issues were negative. Time period Positive %(n) Neutral %(n) Negative %(n) Total %(n) P-value Jan – April May – June Total 46.5% (61) 54% (60) 50.4% (121) 2.2% (3) 9.9% (11) 5.3% (14) 51.15% (67) 36% (40) 44.2% (107) 100%(131) 100%(111) 100%(242) 0.007 Publication type Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value National Regional Community Magazines Total 29.6% (19) 44.7% (38) 72% (62) 28.5% (2) 50.41% (121) 4.6%( 3) 5.8% (5) 6.9% (6) 0 5.37% (14) 65.6% (42) 49.4% (42) 20.9% (18) 71.4% (5) 44.21% (107) 100%(64) 100%(85) 100%(86) 100%(7) 100%(242) 0.000 Frequency Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Daily i Other Total 38.7% (50) 62.8% (71) 50%(121) 5.4% (7) 6.2% (7) 5.8%(14) 55.8% (72) 30% (34) 43.8%(106) 100%(129) 100% (113) 100% (242) 0.000 Geographic distribution Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value National Gauteng KwaZulu-Natal Western Cape Eastern Cape Other provinces Total 28.3% (19) 60.4% (26) 47%% (8) 49% (26) 60.6% (20) 75.8% (22) 50.5% (121) 4.4% (3) 6.8% (3) 0 11.3% (6) 3.4% (1) 3.4% (1) 5.3% (14) 67.1% (45) 31.8 (14) 52.9% (9) 39.3% (21) 36.3% (12) 20.6% (6) 44.2 (107) 100% (67) 100% (43) 100% (17) 100% (53) 100% (33) 100% (29) 100%(242) 0.001 Circulation Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Small Medium Large Total 63.5% (82) 38.6% (17) 29% (18) 50.21% (118) 4.6% (6) 11.3% (5) 4.8% (3) 5.5% (14) 31.7% (41) 50% (22) 66.1% (41) 44.2%(104) 100%(129) 100%(44) 100%(62) 100%(235) 0.000 Ownership Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Caxton Independent Avusa CTP Media24 Other Total 75% (15) 32.7% (18) 45.9% (28) 75% (6) 41.5% (22) 71.1% (32) 50.4%(121) 10% (2) 7.2% (4) 1.6% (1)0 0 11.3% (6) 2.2% (1) 5.3% (14) 15% (3) 60% (33) 52.4% (32) 25% (2) 47.1% (25) 26.6% (12) 44.2% (107) 100%(20) 100%(55) 100%(61) 100(8) 100%(53) 100%(45) 100%(242) 0.001 46 Regarding slant and page number, while there was not a significant relationship, it bears noting that the most of the positive articles appeared further into the newspaper (ie. after page 3), while negative articles were mostly found on the first three pages. Slant and prominence was statistically significantly associated with more positive prominent articles (54%) than negative prominent articles (43%) but articles of one sentence or paragraph were mostly negative (60%)(p=0.000). There was a significant association between photographs and slant, with more positive articles featuring photographs (59%) than negative articles (37%) (p=0.018). There was a significant association between slant and anonymity, with 81% of anonymous articles being negative (p=0.000). English publications featured more positive articles (51%) than negative articles (44%), while Afrikaans publications were more balanced between positive, neutral and negative articles. Table 10: Slant by characteristics of article Article type Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value News i Letters/feedback Editorial Feature Photo & caption Total 49.7% (96) 42.8% (9) 42.8%% (3) 50% (5) 72.7% (8) 50.4%( 121) 5.7% (11) 9.5%% (2) 0 10% (1) 0 5.3% (14) 44.5% (86) 47.6% (10) 57.1%% (4) 40% (4) 27.2% (3) 44.2% (107) 100%(193) 100%(21) 100%(7) 100%(10) 100%(11) 100%(242) 0.705 Topic Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Professionalism Unprofessionalism Training Strikes Labour IND Total 76.4 (26) 9% (4) 84.6% (22) 13% (6) 40% (16) 95.1% (39) 48.9% (113) 17.6% (6) 0 7.6% (2) 4.3% (2) 5% (2) 4.8% (2) 6% (14) 5.88% (2) 90.9% (40) 7.69% (2) 82.6% (38) 56.4% (22) 0 45% (104) 100%(34) 100%(44) 100%(26) 100%(46) 100%(40) 100%(41) 100%(231) 0.000 Topic excluding IND Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Professionalism Unprofessionalism Training Strikes Labour Total 76.4 (26) 9% (4) 84.6% (22) 13% (6) 40% (16) 38.9% (74) 17.6% (6) 0 7.6% (2) 4.3% (2) 5 % (2) 6.3% (12) 5.88% (2) 88.8% (40) 7.69% (2) 82.6% (38) 56.4% (22) 54.7% (n=104) 100%(34) 100%(44) 100%(26) 100%(46) 100%(40) 100%(190) 0.000 Page Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 ≥Page 7 Total 33.3%( 6) 44.1% (15) 42.8% (9) 55.5% (20) 38.4% (5) 52.6% (10) 55.4% (56) 50.4% (121) 0 2.9% (1) 0 5.5% (2) 23% (3) 5.2% (1) 6.9% (7) 5.7% (14) 66.6% (12) 52.9% (18) 57.1% (12) 38.8% (14) 38.4% (5) 42.1% (8) 37.6% (38) 44.2% (107) 100%(18) 100%(34) 100%(21) 100%(36) 100%(13) 100%(19) 100%(101) 100%(242) 0.146 47 Prominence Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Full article on nursing <3 sentences /1 paragraph <1 sentence Total 53.9% (82) 33.3% (20) 63.3% (19) 50 % (121) 2.6% (4) 6.6% (4) 20% (6) 5.7% (14) 43.4% (66) 60% (36) 16.6% (5) 44.2% (107) 100%(152) 100%(60) 100%(30) 100%(242) 0.000 Photograph Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Photograph No photograph Total 58.9% (69) 41.6% (52) 50.4% (122) 3.4% (4) 8% (10) 5.7% (14) 37.6%( 44) 50.4% (63) 44.2% (107) 100%(117) 100%(125) 100% (242) 0.018 Anonymity Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value Identity protected Not anonymous Total 16.2% (7) 57.2% (114) 50% (121) 2.3% (1) 6.5% (13) 5.7% (14) 81.4% (35) 36.1% (72) 44.2% (107) 100% (43) 100% (199) 100% (242) 0.000 Language Positive %(n) Neutral % (n) Negative % (n) Total (n) P-value English Afrikaans Bilingual (English+Afrikaans) Zulu Total 51.8% (111) 41.6% (10) 0 0 50% (121) 4.1% (9) 20.8% (5) 0 0 5.79% (14) 44.4% (96) 37.5% (9) 100% (1) 100% (1) 44.2% (107) 100%(216) 100%(24) 100% (1) 100%(1) 100%(242) 0.035 i) All article types except ‘News’ were collapsed into ‘other’ for chi-square analysis Proportion of key topics on nursing A total of 231 articles were categorized according to main topics of professionalism, neglect (unprofessionalism), training, strikes, labour issues and IND. As seen in Figure 8 below, strikes and neglect dominated nursing topics, while training and the nursing profession were least reported on. Figure 8: Proportion of key topics on nursing Topic by characteristics of media There was a significant association between topic and the time period (p=0.000) with all IND articles appearing in May-June as seen in Table 11, and the majority of articles on professionalism, neglect, strikes and labour appearing in January – April. There was only one „spill-over‟ article on IND in June. Seventy-seven per cent of articles on training appeared in the first period. 48 The majority of articles on IND (76%) and training (54%) appeared in community press while most articles on strikes and labour issues appeared in the regional press (p=0.000). Over 90% of strike articles and more than half of neglect and labour issues appeared in the daily press, while 80% of IND articles appeared in the weekly press (p=0.000). Most articles on professionalism, training, labour and IND appeared in small circulation publications, while articles on neglect and strike action appeared in large publications with circulations of over 100 000 (p=0.001). There was a significant association between topic and geographic distribution of articles (p=0.000), with over a third of articles on neglect and labour, and nearly a third on strikes appearing in the national press. Gauteng press featured more articles on professionalism (35%) than other regions, while the Western Cape media featured nearly 40% of articles on IND and about a third of articles on strikes. KwaZulu-Natal featured only one article each on professionalism and training. Ownership and topic were significantly associated (p=0.000). Caxton and CTP which publish the national daily, The Citizen and many community newspapers, had no coverage on strikes and only one article appeared in CTP on neglect; The Citizen had no coverage on training. The Independent Newspaper group had the most coverage on neglect (32%) and strikes (37%), while Media24 covered more articles on IND (26.8%), with the exception of „other‟publishers (39%). Avusa which publishes several business newspapers, had the most coverage on labour issues (27.5%). Table 11: Topic by characteristics of media Time period Profession- alism %(n) Neglect %(n) Training% (n) Strikes %(n) Labour %(n) IND %(n) Total %(n) P-value Jan – April May – June Total 58.8% (20) 41.8% (14) 100% (34) 63.6% (28) 35.5% (16) 100% (44) 76.9% (20) 23% (6) 100% (26) 67.3% (31) 32.6% (15) 100% (46) 60% (24) 40% (16) 100% (40) 0 100% (41) 100% (41) 53.2% (123) 46.7% (108) 100% (131) 0.000 Publication type i Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P-value National Regional Community Total 17.6% (6) 38.2% (13) 38.2% (13) 100% (32) 33.3% (15) 37.7% (17) 20.4% (9) 100% (41) 23% (6) 23% (6) 53.8% (14) 100% (26) 34.7% (16) 50% (23) 15.2% (7) 100% (46) 30% (12) 42.5% (17) 22.5% (9) 100% (38) 7.3% (3) 17% (7) 75.6% (31) 100% (41) 25.1% (58) 35.9% (83) 35.9% (83) 100% (224) 0.000 Frequency ii Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P-value Daily Weekly Total 44.1% (15) 53.1%(17) 100% (32) 56.8% (25) 39% (16) 100% (41) 34.6% (9) 64% (16) 100% (25) 93.4% (43) 6.5% (3) 100% (46) 55% (22) 45% (18) 100% (40) 19.5% (8) 80.4% (33) 100% (41) 54.2% (122) 45.7% (103) 100% (225) 0.000 Circulation Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P-value Small Medium Large Total 63.6% (21) 21.1% (7) 15.1% (5) 100% (33) 34.8% (15) 20.4% (9) 43.1% (19) 100% (43) 69.5% (16) 13% (3) 17.3% (4) 100% (23) 34% (15) 22.7% (10) 43.1% (19) 100% (44) 60% (24) 12.5% (5) 27.5% (11) 100% (40) 73.1% (30) 19.5% (8) 7.3% (3) 100% (41) 54% (121) 18.7% (42) 27.2% (61) 100% (224) 0.001 49 Legend: G = Gauteng; KZN = KwaZulu-Natal; WC = Western Cape; EC = Eastern Cape; others = Free State, Northern Cape; North West; Limpopo; Mpumalanga i) Magazines were dropped from analysis due to too few observations ii) The categories ‘fortnightly’ and ‘monthly’ were dropped for chi-square analysis due to small cell sizes Topic by characteristics of article Table 12 shows that a total of 182 out of 231 articles (78.7%) were news articles. Over a third of Page 1 articles were on neglect (n=6), and strikes, labour and neglect items featured more frequently in the first four pages of the press. The majority of articles on professionalism appeared after Page 7, as did articles on IND. Significantly, 95% of IND articles were full page articles, as were 80% of strike articles (p=0.000). „Neglect‟ had the same number of prominent as single sentence articles (n=21; 47.7%) as did „labour‟ (n=18; 45%). Photographs were used most frequently with articles on IND (80%), while half of articles on training and 45% of articles on labour issues used photographs which was statistically significant (p=0.001). Regarding anonymity, over a third of articles on neglect were anonymous, and nearly a third of articles on labour were anonymous (32.5%; n=13), followed by strikes (28%; n=13). In contrast, not a single article on IND was anonymous, and over 90% of articles on professionalism and training were not anonymous. On average, 90% of articles across all topics were in English. The Afrikaans press featured 12.5% of articles on labour and 11% of articles on neglect. The single Zulu article was coded as „labour‟. Geographic distribution Profession- alism Neglect Training Strikes Labour IND Total P-value National G KZN WC EC Others Total 23.5% (8) 35.2% (12) 2.9% (1) 20.5% (7) 11.7% (4) 5.8% (2) 100% (34) 37.7% (17) 11.3% (5) 6.8% (3) 20.4% (9) 13.6% (6) 9% (4) 100% (44) 23% (6) 19.2% (5) 3.85% (1) 15.3% (4) 3.8% (1) 34.6% (9) 100% (26) 32.6% (15) 8.7% (4) 8.7% (4) 32.6% (15) 13% (6) 4.3% (2) 100%(46) 35% (14) 20% (8) 7.5% (3) 5% (2) 22.5% (9) 10% (4) 100% (40) 2.4% (1) 19.5% (8) 12.2% (5) 39.2% (16) 12.2% (5) 14.6% (6) 100% (41) 26.4% (61) 18.6% (42) 6.9% (17) 22.9% (53) 13.4% (31) 11.6% (27) 100% (231) 0.000 Ownership Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P-value Caxton Independent Avusa CTP Media24 Other Total 23.5% (8) 20.5% (7) 20.5 %( 7) 2.9% (1) 17.6% (6) 14.7% (5) 100% (34) 0 31.8% (14) 27.2% (12) 2.2% (1) 25% (11) 13.6% (6) 100% (44) 15.3% (4) 19.2% (5) 26.9% 7) 0 7.6% (2) 30.7% (8) 100% (26) 0 36.9% (17) 32.6% (15) 0 26% (12) 4.3% (2) 100% (46) 10% (4) 17.5% (7) 27.5% (11) 5% (2) 22.5% (9) 17.9% (7) 100% (40) 9.7% (4) 12.2% (5) 7.3% (3) 4.8% (2) 26.8% (11) 39% (16) 100% (41) 8.6% (20) 23.8% (55) 23.8% (55) 2.6% (6) 22% (51) 19% (44) 100% (231) 0.000 50 Table 12 Topic by characteristics of article i) Article type was collapsed into ‘news’ and ‘other’ because there were too few observations ii) Language was collapsed into ‘English’ and other because of small cell sizes Summary: This section discussed the extent of nursing coverage by characteristics of media and article, with attention to who was quoted on nursing, prominence, slant and topic. 1) A total of 242 articles were analysed. The majority were published in May (32.6%), in community press (35.5%) and daily (53%). Geographically, most articles appeared in press distributed nationally (30%), and by newspapers in the Avusa publishing group (25%). Most articles were news (80%) and featured on/after page 7 although nursing appeared on page 1 in 18 articles. The overwhelming majority of articles were in English, and 48% had photographs. Article type Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P- value News i Other Total 82.3% (28) 17.6% (6) 100% (34) 72.7% (32) 27.2% (12) 100% (44) 80.7% (21) 19.2% (5) 100% (26) 82.6% (38) 17.3% (8) 100% (46) 82.5% (33) 17.5%(7) 100% (40) 73.1% (30) 26.8% (11) 100% (41) 78.7% (182) 21.2% (49) 100% (231) 0.401 Page Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P- value Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 ≥Page 7 Total 5.8% (1) 6.4% (2) 5.8% (1) 11.7% (4) 7.6% (1) 26.3% (5) 20.6% (20) 14.7% (34) 35.2% (6) 16.1%% (5) 25% (5) 11.6% (4) 23% (3) 10.5% (2) 19.5% (19) 19% (44) 17.6% (3) 6.4%% (2) 10% (2) 14.7% (5) 23% (3) 5.2% (1) 10.3% (10) 11.2% (26) 17.6% (3) 29% (9) 20% (4) 23.5% (8) 15.3% (2) 31.5% (6) 14.4% (14) 19.9% (46) 17.6% (3) 25.8% (8) 30% (6) 11.7% (4) 23% (3) 15.7% (3) 13.4% (13) 17.3% (40) 5.8% (1) 16.1% (5) 10% (2) 26.4% (9) 7.65% (1) 10.5% (2) 21.6% (21) 17.7% (41) 100% (17) 100% (31) 100% (20) 100% (34) 100% (13) 100% (19) 100% (97) 100% (231) 0.372 Prominence Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P- value Full article <3 sentences/ <1 sentence Total 55.8% (19) 23.5% (8) 20.5% (7) 100% (34) 47.7% (21) 47.7% (21) 4.5% (2) 100% (44) 69.2% (18) 11.5% (3) 19.2% (5) 100% (26) 80.4% (37) 19.5% (9) 0 100% (46) 45% (18) 45% (18) 10% (4) 100% (40) 95.2% (39) 2.4% (1) 2.4% (1) 100% (41) 65.8% (152) 25.9% (60) 8.2% (19) 100% (231) 0.000 Photograph Profession- alism Neglect Training Strikes Labour IND Total P- value Photograph No photograph Total 38.2% (13) 61.7% (21) 100% (34) 38.6% (17) 61.3% (27) 100% (44) 50% (13) 50% (13) 100% (26) 43.4% (20) 56.5% (26) 100% (46) 45% (18) 55% (22) 100% (40) 80.4% (33) 19.5% (8) 100% (41) 49.3% (114) 50.6% (117) 100% (231) 0.001 Anonymity Profession- alism Neglect Training Strikes Labour IND Total P- value Anonymous Not anonymous Total 2.9% (1) 97% (33) 100%(34) 34% (15) 65.9% (29) 100%(44) 3.8% (1) 96%(25) 100%(26) 28.2% (13) 71.7%(33) 100%(46) 32.5% (13) 67.5%(27) 100%(40) 0 100% (41) 100%(41) 18.6% (43) 81.3% (188) 100% (231) 0.000 Language Profession- alism %(n) Neglect %(n) Training %(n) Strikes %(n) Labour %(n) IND % (n) Total %(n) P- value English Other Total 91.1% (31) 8.8% (3) 100% (34) 88.6% (39) 11.3% (5) 100% (44) 96.1% (25) 3.8% (1) 100% (26) 86.9% (40) 13% (6) 100% (46) 85% (34) 12.5% (6) 100% (40) 92.6% (38) 7.3% (3) 100% (41) 89.6% (207) 10.4% (24) 100% (231) 0.699 51 2) Regarding prominence, 63% of articles mentioned nursing prominently, with 54% of prominent articles appearing in May - June. Small publications (59%) and those distributed nationally (25%) featured nursing more prominently. Significantly, 84% of prominent articles were news. Linking prominence and topic, 95% of articles on IND and 80% of articles on strikes were prominent. 3) Nearly 50% of quotes were by spokespeople. They were quoted twice as often as nurses who were quoted in just over a quarter of articles. Of articles quoting nurses, registered nurses were quoted nearly 60% of the time, followed by student nurses (18%). Nurses were quoted more frequently in community publications (40%) which were weekly (51.5%) and with small circulations (48%). Nurses were also quoted more frequently in Western Cape articles and in publications owned by Media24. The majority of quotes on nursing featured on/after page 7 (37.5%). Most articles quoting nurses used photographs (75%). Overall, 50% of nurse quotes were in positive articles, and nurses spoke most about strikes (29%) and IND (23%). Regarding patient quotes, 91% were in negative articles, and 75% concerned nursing neglect. Over a third of nurses and over half of doctors spoke anonymously. 4) Females were quoted first in the majority of articles (46%) but this was inverted for second and third quotes, when males were quoted more frequently. Females spoke more often on professionalism, neglect and IND, while males were quoted more frequently on issues around training and labour. Females also featured more frequently in full articles (54.7%), compared to male quotes which appeared more often as single sentences in nursing articles (77%). More than a third of female quotes were anonymous, compared to 10% of male quotes. 5) In terms of slant, 50% of articles were positive compared to 44% which were negative. More positive articles (54%) appeared in May-June, compared to 51% of negative articles in January – April. However, when IND was excluded, the majority of articles were negative (54%). The majority of articles in community, weekly and small circulation publications were positive, while articles in national, large circulation and daily publications were inclined to be negative. Eastern Cape and Gauteng papers covered nursing more positively than negatively, but 67% of national papers and 53% of KwaZulu-Natal papers covered nursing negatively. Most articles on professionalism, training and IND (95%) were positive, compared to the majority of articles on neglect, strikes and labour issues which were negative. Over half of prominent articles were positive, with photographs appearing in nearly 60% of positive articles, compared to 38% of negative articles. Most English articles were positive, while Afrikaans articles were balanced between positive, neutral and negative articles. 52 6) Topic yielded several significant results: the majority of articles on all topics except IND appeared more frequently in January – April, while IND articles only appeared in May-June. Strikes featured in 20% of articles, and over a third of articles on neglect and strikes appeared in national publications; 43% of articles on these topics appeared in large circulation press, compared to the majority of IND articles which appeared in community and weekly papers, with small circulations. Most articles on neglect and strikes appeared in nationally distributed and Western Cape papers, Gauteng featured more articles on professionalism, and the Western Cape featured the most articles on IND. Labour as a topic was covered most in national (35%) and Eastern Cape (22.5%) papers. Most letters were on neglect and strikes. The overwhelming majority of IND articles were prominent (95%), as were articles on strikes (80%) and training (69%). Photographs appeared in most IND articles (80%), followed by strikes (43%). 53 Qualitative findings This section describes how the discourse of nursing is framed through an analysis of key themes. It also explores who has a „voice‟ by being quoted on nursing issues, with discussion around constructs of gender and power. The slant of articles is also investigated. The framing of nursing Framing refers to the selection and treatment of text to promote a certain reading or understanding by the recipient. It is influenced by individual and organizational ideologies, and in the Western model of mass media by the dominant paradigm of what is news from a liberal-capitalist point of view i.e. what will „sell‟ the product (McQuail 2000). The framing of nursing was established using key themes around nursing discourse with attention to whether patterns emerged such as co- occurrences and relationships between themes. i. Going too far Articles on strikes and protests in the nursing sector mostly framed nurses as unruly, defiant health workers whose actions shocked and disgusted the public, „going too far‟ by causing violence, death and discomfort instead of being caring and compassionate. The overlapping themes of nurse strikes and nursing unprofessionalism were most evident during the student nurses‟ strike and two Sowetan articles which reported that 36 people died during the nurses‟ strike to „demand‟ restructuring of their posts. In January, student nurses at the Western Cape College of Nursing went on strike to complain among other things that they did not have the experience to work night shifts without supervision. The press featured graphic headlines of the strike: “Nursies bleed – nursing students‟ protest gets ugly” (translated) [Community newspaper, circ 121 500]; and the front page banner headline: “Sick Day – flats nursing students‟ march of terror...full shocking story on pages 4&5”, followed by a double-page spread headline: “Sickening – student mob take riot from campus to campus – two hurt as nurses vent their anger at colleges” [Regional newspaper, circ 90 000]. These headings are reminiscent of the apartheid reporting of „civil disobedience‟ by citizens not granted voting rights in South Africa. Photographs accompanying the article featured full-page spreads of multiple students, marching and chanting with upraised arms and clapping hands, together with arrested male nurses in a police van, crying staff members, a sheet-covered gurney of an injured student, smaller pictures of the broken windows and upturned rubbish bins, and crowds of students emerging from the train when they moved their protest to another suburb. In a statement, Denosa framed the event as students exercising legitimate rights, and appealed for the Western Cape College of Nursing not to „cowardly deploy monsters to attack citizens genuinely exercising 54 their democratic rights‟. The „monsters‟ alluded to were the security guards who physically tried to stop the students‟ march, resulting in injuries to three students and five guards. Nurses were portrayed as both the victims and perpetrators of physical violence when one threatened to burn down the building. Strike action by nurses at Thabazimbi Hospital in Limpopo seriously affected service delivery. In an article entitled “Nursing crisis causing deaths – Hospital beset by problems”, Sowetan newspaper (KZN edition) [national newspaper, circ 125 900] alleged that 36 patients had died in the previous month due to a serious shortage of nurses at the hospital due to their strike „demanding the restructuring of their posts so they could move to another level‟. Here nurses were portrayed as stubborn and victimised: We are going to remain firm, we will not move because we have had enough of the bad treatment by the department. [Anonymous nurse, national newspaper] Confusingly, a similar article on the same day by the same reporter appeared in the national edition of Sowetan [circulation 125 900], entitled: “36 die because of doctor strike – nurses”. Here nurses were portrayed as overworked, and the deaths were attributed to a serious shortage of doctors who had reportedly vacated the hospital because their OSD had not been paid and for managerial maladministration. This discourse often overlapped with labour issues such as the occupational service dispensation, wage issues and conditions of service, and framed as a last resort to achieve better working conditions, wages or improved qualifications when nurses were powerless to do anything else. Nurses employed as part of the poverty alleviation programme at Maphutha Malatji Hospital in Limpopo protested to „demand the opportunity to improve their qualifications‟ since they had not had the opportunity to upgrade in ten years: We are tired of our college continuing to empower nurses from other institutions while it fails to empower us [Anonymous assistant nurse] In a covert show of power, nurses also protested silently by taking sick leave. Matrons and registered nurses at Town Hill Psychiatric Hospital in KwaZulu-Natal took sick leave in protest at the government‟s reneging on a 2007 wage agreement. They escalated their protest to strike action at the suggestion of their union, Denosa, „because no one is hearing them‟. Using a battle discourse, the union representative spoke on behalf of the nurses, saying: Nehawu does not plan to apply for a strike permit. We do not need one. This is a war and we will take it as it comes. Nurses at the four other hospitals were joining the strike because they were fed up with corruption, the head of department always being overseas and too busy to address their problems, and outsourcing. [Denosa representative] 55 Nurses in the Eastern Cape district of Buffalo City used the same tactic of taking sick leave because of dissatisfaction about wage increases, although one of the nurses, while supporting their protest action, said: I just had to come to work because I care too much about the patients. Some of them need chronic medication. [Buffalo City Clinic nurse, anonymous] Strikes were seldom framed in terms of improved service delivery or patient care, but mostly as nurses‟ efforts to improve their financial situation such as the payment of OSD, being „overlooked‟ in favour of „outsiders‟ to upgrade their qualifications, and in the Eastern Cape, as an attention- seeking strategy for the MEC to „listen‟ to them for overtime pay. Unlike in Japan, South African nurses have not protested about nurse shortages or deteriorating conditions leading to poor service delivery. ii. Nurses as workers Nursing labour was frequently framed in terms of „critical shortages‟ within dichotomies between public and private sectors, rural and urban settings, and provincial and local services. Government was portrayed as self-defeating for banning labour broking in the nursing sector, and for hobbling private sector efforts to expand its training or import nurses from India. The private sector was framed as seeking an „innovative‟ solution, yet frustrated for having to clear numerous hurdles before the Indian initiative was successful. Framed as a vicious cycle, the shortage of nurses was seen to impact on nurse workloads and stress, causing them to leave the country. Nurses were reported to take employment wherever they could find it, even if it meant they couldn‟t use their specialised training: Most of them (nurses) have said that if offered less stressful posts, they would take them. [Anonymous doctor, KZN Sunday newspaper] A Mail & Guardian article [circ 45 700] reported on nurses going overseas „when they have had their fill of local conditions‟ and where they are „in great demand‟. Those who remain behind are further compromised, with the situation in KwaZulu-Natal described as „a dangerous shortage of trained nurses‟. Nurses undertaking community service in rural areas were framed as „adding value‟ and addressing the acute shortage of nurses at rural clinics. However, in rural Free State, staff turnover was high with nurses remaining only six months before accepting transfers or resigning. A key frame was wage disputes: Government was portrayed as reneging on its agreement to pay nurses OSD, with a health spokesperson in the Eastern Cape acknowledging that „unfortunately, there simply isn‟t money now (in this budget) for them‟. Here, the provincial government is portrayed as incompetent and possibly even corrupt. The Vaal Weekly writes of an „exodus of 56 professional nurses‟ at local clinics due to the tardiness of the local municipality to pay the OSD, which affects service delivery, could have „serious repercussions‟ and is …a total disregard for the nurses in the region's clinics. How can we get paid the same as the man who takes rubbish out of the street with not even matric? [Anonymous source, community newspaper] Another key frame was lack of finances and resources which were the main reason for the deterioration of health service delivery, and which in turn resulting in nurse frustration and stress. Again, the government was blamed for not acting on nurses‟ earlier complaints about the lack of proper equipment and staff shortages: The blame should be squarely on the government because of its short-sighted policies that are counter-productive, the budgetary constraints on health, and the failure of the government to listen to complaints by health workers. [Nursing sister, national Sunday newspaper] iii. Nurses failing public expectations Articles reported patient views of nurses as unprofessional, uncaring and tardy for long waiting times. Nurses were framed as being violent and abusive, particularly of vulnerable elderly patients, as portrayed in the Page 1 Daily News article [Circ 39 000], headlined “Nurses hit my mom”. The article concerns the writer‟s mother, an 88-year-old Alzheimer‟s patient in a private hospital in KwaZulu-Natal. Her caregiver witnessed a nurse slapping her mother, saying “Hey, Ouma, I‟ll moer (derogatory: beat/punch) you” and then „knuckled‟ her on the head so that bruises under the hairline would be inconspicuous to families. The nurses were portrayed as negligent, careless and inefficient for failing to change a drip, for incorrectly filling in the medical chart, and for offering boiling oats in a drinking cup to the patient. After being reported for „knuckling‟, the nurses were seen to be vindictive by dropping her bed suddenly, resulting in a „pitiful cry.‟ Nurses were blamed for patient deaths as seen in the Sowetan article and in a feature in Drum [circ 116 690], entitled “Nurses let my Koko (grandmother) die”. Here nurses were portrayed as cruel, denying an elderly patient sustenance despite family members requesting tea for her, and verbally abusive of the patient and her relatives, whom they had escorted out of the building by security: They shouted at her, saying she must stop acting weak and sit up properly. She was scared of the very people who were supposed to be taking care of her. [Patient’s relative; national weekly family magazine] When she raised the alarm about her grandmother‟s high blood sugar levels, „all the nurses could do was look away insolently‟, and after requesting a glucose „shot‟ for her grandmother, another nurse „told me not to tell them what to do‟. The article portrayed nurses as incompetent and negligent for failing to monitor the patient‟s diabetic status. This was echoed by another article in which a general practitioner said that nurses had to be taught to consult the electronic gadgets they see in a ward: A monitor is useless if no one looks at it or listens to the alarms. [General practitioner, national news magazine] 57 The failure to monitor the diabetic patient resulted in a coma and subsequently a stroke and death. The Department of Health was quoted as saying that nurses should treat patients with „utmost dignity and respect‟ and that it was „unacceptable that patients are subjected to insensitive treatment‟. The public was urged to lay complaints as a mechanism to improve services. Nurse negligence was a key frame. An article in the Mafikeng Mail [circ: 10 700] entitled “Doctor, nurses face expulsion”, nurses drew the community‟s anger and disbelief for refusing to challenge the doctor‟s order that a patient with a still-born baby return after the weekend to deliver the foetus. The patient had been referred from the clinic to the provincial hospital, where the attending doctor told her to return after the weekend as there was a shortage of beds. She went back to the clinic, and was again referred to the hospital where nurses refused to admit her „against the order of the doctor‟. Here, nurses were said to be „totally negligent‟, „a danger to society‟, and „very unprofessional‟. Another article quoted a patient as saying her baby‟s death was due to staff negligence after it „coughed blood and then died‟. Nurses „shrugged‟ and were perceived to be „harsh‟ when the patient/journalist enquired about getting a TB test, and they failed to offer HIV testing. iv. The profession of nursing: Very few articles – with the exception of profiles of nurses during IND – gave attention to the actual content of nursing and what nurses do. A full-length feature in the Afrikaans women‟s monthly magazine, VroueKeur feature was framed as hearing from a nurse herself about service delivery at state hospitals. Sub-headings guided the reader‟s interpretation: “She sees everything,” (a reference to her working experience in both public and private sector hospitals, in South Africa and in Australia); “It‟s hard work”, “People don‟t understand”, and “To make a difference”. This article portrays nurses as creative, selfless, caring, working in a team, having to deal with unpleasant, sometimes violent situations, but doing it for the „adrenalin rush‟ and for „making a difference‟ in people‟s lives. Nursing was framed as both a calling, mainly by older nurses, and as a career, mainly by male and younger nurses. In an article entitled: “The dedication and devotion of nurses”, a former patient was reportedly „so impressed‟ with the care given by nurses that he decided to change careers from electrical engineering to nursing. He reports seeing how the nurses were „giving back‟ to the community: Those nurses inspired me deeply and I realized that nursing was something that I would like to do. Taking up nursing as a career was the best decision I ever made and I feel that my life now has a much higher purpose. [ Electrical engineer-turned-nurse, KZN regional newspaper] Several articles raised the issue that nurses should look distinctive. A number of special nursing events such as the day of prayer and several IND nurse walks featured nurses „wearing white‟. 58 Nursing dress code was framed as „going back to basics‟ to enhance respectability and how Florence Nightingale would feel („proud‟), and a senior government official openly supported the return of standardised nurse uniforms, although not necessarily white. I agree with the minister and public that nurses should wear standard uniforms. They should go back to basics. At some hospitals you meet nurses in the corridors but you cannot tell what they are because they wear civilian clothes. That must stop. [Gauteng MEC for Health, national daily newspaper] The image of nurses as skilled professionals was boosted with several articles reporting on research showing that nurses can manage HIV treatment as well as doctors. A supporting article discussed the possibility of nursing scopes of practice being extended for them to prescribe ARV drugs and other essential medicines for HIV-positive patients. v. Desperately seeking nurses Nurse training was often framed in terms of increasing „desperately needed nurses‟. Government‟s stonewalling of private sector in-house training was portrayed as „bureaucratic bungling‟, calling into question election promises to prioritise health and education. A number of articles featured nursing colleges which had been closed or amalgamated into multi-campuses to strengthen their governance and administration. The reopening of colleges was framed as a key driver for increasing the number of nurses in the country. Several articles addressed the reopening of some colleges, and one politician in the Free State admitted the closures there had been a „mistake‟. Others featured the opening of new nurse training campuses in both rural and urban areas to make nursing education accessible to all. The Minister of Health announced an audit of public and private nursing colleges and schools to establish the status of infrastructure, enrolment figures, the qualifications of nurse educators, and programmes offered by the institutions. The audit would help inform a national nursing college revitalisation plan and motivate funding for this in a sustainable way. Training was often framed as a collaborative effort between the private sector, public sector hospitals, and academic institutions. A nurse education training centre run by the private sector in KwaZulu-Natal boasted having results which were „the best and consistently high‟. It was seen to take place in both the private and public sectors, in rural areas and cities, and for up-skilling nurses to specialisation in maternal, child and women‟s health care. Training provided by the Limpopo Department of Health and Social Development was also framed as upliftment and a poverty-alleviation programme for auxiliary nursing students from needy families. Articles about graduation ceremonies featured photographs of happy students wearing white, who were urged to give back to their communities using their newly acquired skills. 59 vi. IND Celebrated annually on Florence Nightingale‟s birthday, 11 May, this was one theme which framed nursing entirely positively, and nurses as a hard-working, though stressed, united workforce. It was linked with nursing as a profession as it gave newspapers the opportunity to write in depth about nursing and how it had transformed over the years with changing disease profiles such as increasing HIV prevalence, tuberculosis and unplanned pregnancies. Headlines helped to frame the reading of articles: “Treats for local nurses on special day”, “Nurses unite in care”, “Nurses get awarded for hard work”, “Lessen nurses‟ stress”, “Matron‟s passion a true legacy”, “Nurses celebrated”, and “Health Department reaches out to retired nurses”, among others. Only one article was headlined with the now-disparaging „angels of mercy‟ term. Nursing was framed as a historic profession, with many articles mentioning the centenary celebration of the death of Florence Nightingale who „set up the world‟s first training institution for nurses‟. However, only three articles featured the international theme calling for nurses to „Lead the fight against chronic diseases‟ and assist in health promotion efforts by personally eating more healthily and exercising more. The North-West government called on the public to help reduce nurses‟ stress by adhering to their chronic medication regimes. TB patients were singled out as being „notorious‟ for defaulting which added costs to the government and the work of nurses. One publication (Ridge Times, circ: 29500, community newspaper) erroneously said the aim of the day was to highlight challenges in the nursing profession such as staffing levels, remuneration, and „lack of tools and production‟. Instead, IND in South Africa was framed in terms of service delivery where retired nurses, administrators and those not actively involved in patient care were called on to devote 100 minutes to nursing care in any environment on the day. Proposed by the Forum of University Nursing Deans in South Africa and the Nursing Education Association, nurse leaders said this was …an opportunity to celebrate nursing as a noble profession and to focus on the provision of quality patient care, like Florence Nightingale who introduced the profession. It is also an opportunity to positively influence the image of the nursing profession, especially in terms of care, commitment and compassion. [Chairperson, NEA; regional community newspaper Eastern Cape Today] Politicians acknowledged nurses, framing their work in terms of „significant challenges‟ such as ageing infrastructure and equipment, and long working hours. The Minister of Health stressed the importance of nurses in quality health care delivery, particularly in primary health care where „nurses had always played a critical role‟: I want to make sure that they are at the forefront of prevention of diseases and saving lives, this is what nurses have always done and should continue doing. [Health Minister, community newspaper] 60 In an article in the Daily Sun (national newspaper, circ: 433 250), the North-West Health MEC framed nursing in terms of quality service delivery which required mutual respect between patients and nurses; patients were requested to help ease nurses‟ stress, and nurses to be accountable for their actions: We need to hold our nurses accountable for their actions because sometimes they snap and forget their oath. While the job is demanding and sometimes frustrating, it is important for them to remain level-headed. [Health MEC: North West province, national daily newspaper] Gauteng Province framed IND in terms of mentoring young nurses by launching the Retired Nurses‟ Forum. Retired nurses were portrayed as selfless by helping out regularly when their services were needed, and in Gauteng, about 480 retired nurses were working in primary health care clinics and hospitals to „deliver the best health care service to residents‟. The day allowed publicity for special events which would not otherwise have received media attention, such as the Day of Prayer held by Denosa in Bethlehem, where nurses prayed to see their work as a God-given calling, to receive healing in their lives, for unity, love and respect in the multi-disciplinary team, and for the shortage of nurses in health centres to be relieved. The majority of nursing articles featuring photographs fell within the IND theme, and 80% of IND articles used photographs to help guide how articles are to be understood, and reinforce textual interpretation. Several photographs featured nurses in navy blue uniforms wearing stethoscopes. One photograph with an article entitled: “Nurses Unite in care” [Eastern Cape Today, circ: 32 700] showed a retired nurse and grand-daughter of the „legendary‟ nursing pioneer, Dora Nginza after whom an Eastern Cape hospital is named, managing a drip for a premature baby. Wearing a dark uniform with her epaulettes clearly visible, Sister Phyllis Nhose is surrounded by monitors and cables in the background as she stands over the crib, guiding an interpretation of a mature, caring, skilled professional. In another photograph, a nursing sister (interviewed in the accompanying article) is portrayed as what the public perceive a typical nurse to do: leaning over a „patient‟ (colleague) with her hand on her forehead to feel the temperature. She is wearing a stethoscope, a short jacket with a print blouse and her epaulettes are clearly visible but the beaming face of the nurse and the „patient‟ clearly indicate the photograph is staged. Another article featured a young attractive nurse smiling at the camera, wearing a white coat with a stethoscope around her neck, writing on a clipboard. The article was entitled: „Nurses get awarded for hard work‟, and the nurse appears to be happy, but no epaulettes are visible so the reader is unsure if this was a „mock-up‟ (staged) photograph. One publication, Rekord [community newspaper, circ: 65 120] commissioned a comical cartoon of Florence Nightingale carrying a candle, while modern nurses wearing white uniforms and caps with crosses are quoted as saying: “I must say, Florence takes her „night‟ingale very seriously”, with 61 others responding “Wonder if I should tell her we actually do have electricity here?” which is ironic in South Africa‟s current era of power shortages. Male nurses may be a perceived as a novelty and thus newsworthy, and were featured in several IND articles, often portrayed as leaders. While the bulk of a story, “Remembering Florence Nightingale” quotes a female nurse of 23 years‟ experience, the photograph is of a male nurse who is also quoted in the article. The caption reads: “Male nurse Feizil Francis started his career at Conradie Hospital and is now in charge of the renal unit at Tygerberg Hospital.” Wearing a white, V-neck shirt over dark trousers with epaulettes and a name badge clearly visible from his collar, this male nurse leader demonstrates that nursing attire for men can be masculine, and portrays nursing as a suitable profession for men. One article on nursing as a career specifically framed it for men: „Guys, this isn‟t just women‟s work – you could become a nurse too!‟ Several private hospitals honoured their nurses with special awards. One was won by a male nurse who is quoted and photographed alone with his award, and is portrayed as ambitious, a hard worker, and a leader among his peers. The other award was won by a female nurse who is not quoted or featured in the article, only in the photograph, flanked by her male and female managers. Since Florence Nightingale‟s „greatest achievement was to raise nursing to the level of a respectable profession for women‟, it is ironic that 150 years later, female nurses are being overshadowed in the media by minority male nurses, mostly in leadership positions. The ‘voice’ of nursing „Voice‟ refers to those quoted in articles, which are selected for their authority, credibility and position to endorse an angle or offer an alternative view to reflect „objectivity‟ of reporting. The voice of nursing was explored by analysing categories of quoted persons. Given that nurses are likely to work in institutions with regulations around speaking to the press, a third of nurse quotes, yet 50% of doctor quotes, were anonymous. This construct was added to contextualise when identities were protected and when nurses felt free to be quoted. i. Nursing and the media Both nurses and patients used the media to have their voices heard. Nurses mostly sought out the media „under condition of anonymity‟ around labour, protest and service delivery issues. They spoke of being overworked, underpaid, the shortage of doctors and the „atrocious conditions‟ at hospitals which led to a spate of baby deaths. When nurses raised the alarm with management about high infant death rates in Eastern Cape, the problem was not reported to the provincial government, leading the nurses to speak to the press as „this situation was completely unacceptable and we needed to act.‟ Nurses also spoke of budgetary constraints, lack of resources and protesting for 62 better pay or opportunities to improve their qualifications. Nurse academics used IND as a platform to speak about the South African theme of „100 minutes of nursing care‟. The nursing union, Denosa, used the media to report of its research to investigate the „avalanche of adverse reports‟ about the deteriorating professionalism of nursing, and used the media to defend the actions of nurses, such as striking for „legitimate‟ reasons, or denounce the framing nurses as „murderers‟. Patients turned to the media to report unprofessional behaviour and patient abuse. The editorial column in a newspaper is often written by a person on the senior editorial team, and positions the newspaper politically and ideologically, guiding readers on how to interpret societal issues. It is a powerful column which highlights issues, framing them in accordance with editorial policy and organisational ideology. Notably, three editorials were devoted exclusively to nursing. One editorial in the Daily Voice [circ: 90 000, regional newspaper] entitled: “Violence is no answer” focused on the student nurses‟ strike and highlighted the lack of respect that nurses now have, “(who) used to be respected pillars of society”. Another editorial in the Mafikeng Mail [circ: 10 700, community newspaper] was entitled: “Shame on you!” and concerned the refusal by health professionals to treat a woman whose baby had died in utero. The editorial termed the behaviour by the doctor and nurses as „totally unprofessional, inhuman, frustrating and degrading.‟ It (the attitude) shows that our health institutions and many other public places where ordinary people go to for a variety of services are infested with poor attitudes, lack of respect and general undermining of ordinary people and lack of commitment towards service delivery. [Mafikeng Mail] The third editorial was devoted to International Nurses‟ Day [Eastern Cape Today, circ: 32 700, weekly regional newspaper) which described nursing as: …a profession that embodies the preservation and restoration of health along with the care of the terminally ill…the role of the nurse has evolved into one of the most crucial support functions of modern medicine. [Eastern Cape Today] ii. Nurse voices on strikes: striking nurses no longer an oxymoron Voice is an indicator of power and agency and can confer status on a quoted person (Schramm 1964). Most nurse quotes were in relation to strikes and protests, which nurses used to empower themselves and make their voices heard. Several visceral Western Cape articles featured the student nurses‟ strike and gave the nurses significant „voice‟ by quoting them extensively: We do our practical work at various hospitals and now the school tells us we will have to work nightshift. We are at a high risk in hospitals at night. We could be assaulted and there is no mentor to oversee everything and we don’t get an allowance. The second problem here is racism and the other one is that we are registered at APUT for a B.Tech but when we get here, we are told that we’re studying for a diploma. [Western Cape student nurse, regional community newspaper] This strike turned violent and „things took a turn for the worse‟ when the police entered the building and fired rubber bullets at them. Racism was alleged: 63 We were attacked by the red jackets (security guards on campus with red shirts)....only black students were arrested.[ nursing students, regional community newspaper] Another article quoted a student nurse as saying: While we were protesting, the security guards just went for a first-year student and dragged him to the ground and started hitting him. They kicked, hit him with sticks and even used the red helmets they had to break both his legs….A student was thrown out of a first-floor window and at this point nobody really knows what happened. [student nurse, regional community newspaper] The nursing trade union, Denosa, „slammed the attack‟ on the nursing students who were reportedly „protesting peacefully‟ for their justified demands and it was their right to strike. After the students were evicted from campus, they were quoted as saying they didn‟t have transport money to go home or even for food, and would sleep on pavements if necessary, implying their refusal to submit, and affirming their power. This article prompted a reader to respond in the SMS column: I don’t feel sorry for those trainee nurses. Before doing the course, read the requirements – don’t go in blindly. [Anonymous member of public] In another student nurses‟ strike, students boycotted classes at Lilitha College of Nursing for the institution‟s failure to act on misconduct allegations against a department head who allegedly had driven a government car while drunk and had partied with students. The students reported feeling „unsafe‟ because although investigations took place, the „serious allegations were not given the attention they deserved‟. In what could be perceived as a threat, they undertook not to allow first year nursing students to start the academic year until the matter was resolved. In several protests on salaries, nurses strived not to inconvenience patients by picketing during lunch-time. An article entitled: “Nursies looking for their money” (translated) in the Son Oos newspaper captioned the photograph thus: “Peaceful. Nurses protested during their lunch-time,” and quoted a nurse regarding delayed OSD payments which were allegedly only outstanding in the Eastern Cape: We give our best for the patients. The least we ask for is that we get the money that is due to us. It still remains a privilege for us to serve our fellow human beings. [Protesting nurse, regional newspaper] Nurses at the Livingstone Hospital in Port Elizabeth picketed at lunch-time during the Health Minister‟s “World Cup Readiness” visit to the institution for their OSD which was overdue since 2000: Then we were promised that we would be paid in 2009. But still we have not been paid. We have also not been paid for public holidays and for overtime. And we are forced to buy our own uniforms… Nurses who work at TB hospitals receive no extra pay, in spite of being at high risk of contracting the disease. [Nurse trade unionist, national newspaper] In June, nurses at the private hospital group, Netcare, went on strike to voice their displeasure at the average salary increases offered despite good company profits. Here, nurses were quoted by their trade union representative as saying “Look, we don't really want to inconvenience patients, let's see 64 if picketing will help.” Ironically, just two weeks earlier, Netcare‟s coastal regional director had said on the occasion of International Nurses Day: We are Netcare are truly blessed to work with such an outstanding and devoted group of nurses. [regional director, regional newspaper] iii. IND: Nurses in the headlines Second to strike action, nurses were most frequently quoted in relation to International Nurses‟ Day, a day dedicated to profiling nurses and nursing and a golden opportunity for their voices to be heard. However, spokespeople (including politicians) were quoted more often than nurses, with one describing nursing as „a dying trade in this country‟. In articles about special awards, spokespeople said: Nursing is a very unappreciated profession. If I had three wishes, it's that nurses are appreciated, respected and that they are included in a patient's treatment. [Male private hospital manager, community newspaper] and We need to educate the public on the importance of nurses. The journey of Florence and the lighting of the candle hasn't stopped as we continue to be role models for the community, taking care of ourselves and each other. As nurses as we are constantly confronted with new challenges. but it's in those challenges that we grow, thrive and heal. [Female private hospital manager, community newspaper] One retired nurse spoke of how nursing had „definitely evolved‟, particularly in the use of apparatus and machines which was regarded as a challenge for modern day nurses who were required to keep abreast of latest developments. Nurses were believed to be better equipped – „they‟ve got everything at their fingertips‟ - which meant that nurses spent less time with patients and relied more on machines. Retired nurses spoke of nursing being a „calling‟, doing it „for the love of it‟, requiring „passion‟ for the job as a coping mechanism, and one spoke of being in a „relationship‟ with her nursing job as she had never married. Reminiscing about nursing, one retired nurse recalled that her entry into nursing was „completely by chance‟, and she was „hooked‟ after the verbal testimony of a nurse on a train about her work. Several articles featured male nurses. The head of the renal unit, Feizil Francis, acknowledged that nursing wasn‟t a popular profession for men in the 1980s: It was a female dominated profession but it was what I wanted to do. At Tygerberg I got the opportunity to gain experience in many departments and I learnt a lot. Working with people is a very rewarding job. [Male nurse, community newspaper] A male nurse at Limpopo Medi-Clinic won the hospital‟s Compassion Award. Although he wanted to be a doctor, he did not meet the maths and science requirements and „instead decided to become a nurse‟, a somewhat disparaging reflection on the four-year academic requirements needed to study nursing. However, Once I started studying, I really fell in love with nursing. I look forward to work every day and enjoy the challenges, whether it is a complaint or a compliment. [Male nurse, community newspaper] 65 Nurse voices were also largely absent from articles on nurse unprofessionalism with the exception of two articles where nurses spoke anonymously about wanting to deliver a service when other nurses were on strike, or for blowing the whistle on unacceptable practices. iv. Nurse voices on nursing: challenges and rewards Nurses who spoke of the profession discussed the challenges they faced, which coincided with health service delivery and quality of care, and skills training as themes. Many of these nurses spoke anonymously, indicating their fear of retribution for speaking out, possibly in contravention of institutional regulations, and/or lack of self-confidence and self esteem to be associated with their comments. These included the vacuum being created because nursing was no longer a choice profession and many nurses were reaching retirement age. According to an anonymous nurse, this resulted in „no transfer of skills and expertise to the new generation of nurses‟, and what was urgently required was the employment of more nurses or caregivers who could perform non- medical tasks „so that nurses could get on with what they are supposed to do.‟ Another anonymous nurse said the lack of skills which followed the closure of nurses‟ training colleges and the „exodus of skilled staff overseas‟ made it „almost impossible‟ to deliver the kind of service they had sworn to provide the ill and incapacitated. This nurse also outlined the challenges presented by long visiting hours: Antibiotics are not being given when they were supposed to, we don't have enough time to bath and turn patients, make the beds and do all we need to do before we hand over to the night shift… The constant traffic through neonatal units was also cause for concern which had serious adverse effects on infection control. [Anonymous nurse, national Sunday newspaper] Hospitals with financial constraints were also reported to impact on nurses‟ ability to perform their professional duties. According to a „frustrated nursing sister‟ who spoke to the Sunday Independent on condition of anonymity, „Budgetary constraints are the main evil destroying the health-care system.‟ The lack of resources „compromised their ability to provide quality care to their patients‟ which may have caused the outbreak of diarrhoea in Johannesburg‟s Charlotte Maxeke Hospital where six babies died in the neonatal unit. The nurses said they were „tired of being unable to provide proper patient care because they did not have the necessary equipment,‟ for which government was blamed: Free care attracts more and more patients and in South Africa that includes the thousands of people from other countries…The government needs to stop looking at health models from other countries and start looking at our own situation and see how it can improve it. You should not be fixing what was not broken when democracy came. We should have built on what worked and made it better. [Anonymous senior nurse, national Sunday newspaper] Here, a blaming discourse arose: The blame should be squarely on the government because of its short-sighted policies that are counter- productive, the budgetary constraints on health, and the failure of -the government to listen to complaints by health workers. [Anonymous senior nurse, national Sunday newspaper ] 66 This nurse claimed many health workers had been open about service delivery problems, „but the government is not listening‟, and until such time that it was prepared to listen, „things are not going to come right.‟ A full-length feature article on nursing as a profession appeared in VroueKeur, an Afrikaans women‟s magazine (circulation 82 600). Here, the only quotes were those of a trauma nurse at the public sector Steve Biko Academic Hospital with local and international experience in both the private and public sectors. From this, the journalist establishes the nurse as credible and authoritative source to comment on nursing, which is seen as conferring power and status on her. In discussing her work, Marjanie Roose outlined some of the challenges facing nurses including the „serious‟ shortage of nurses, having to find beds for patients when the Unit is full: Given a choice of the floor or a bed, most patients definitely choose a bed. Those who are not too sick sit on a chair. (Marjanie Roose, national women’s magazine] This encourages nurses to be „creative‟ in finding solutions, having to refer patients when a plan no longer can be made to accommodate them, and working 12-hour shifts. She is „crazy about her work‟, commenting that the best days were those when they worked together as a team, and that „the State looks after its staff‟ who work fewer hours with better pay than nurses in the private sector. She spoke about making a difference in people‟s lives: There are days when I have blisters under my feet – my takkies are already worn through – but a person sometimes has great stories to tell, stories about the difference you made to a person’s life. Although we all complain because we have to work so hard, no one resigns because the adrenalin rush is great. [Marjanie Roose, national women’s magazine] The article describes in some depth Marjanie Roose‟s perceptions that there are threats to nurses. For example, she mentioned violence which nurses are occasionally subjected to, mainly by family members or patients who are drunk and who physically manhandle the nurses, swear or threaten to report them to the newspapers. She reveals that mostly, when hospitals get the media‟s attention, it is due to situations „outside of their control and because people don‟t understand the circumstances‟. Usually the abuse is as a result of non-critical patients (and their families) having to wait to see a specialist who „create problems‟: It is so bad that we now have bullet-proof glass in front of our counter. [Marjanie Roose, national women’s magazine] v. Nurse voices on labour: “The backbone is broken” Nurse quotes in the labour theme overlapped with poor service delivery and training, as seen in the feature article in Drum (circulation: 16 700) entitled “Our babies are dying”. Here, a specialist neonatal intensive care nurse who spoke anonymously indicated the huge discrepancy in the nurse- patient ratio required for the ward: 67 You need about six nurses to look after one baby…You need one to help the baby breathe, another to compress the heart, another to put up a drip, one to draw medication and another to record all the medication that's been dispensed. But there is such a serious shortage of staff that nurses work 12 hour shifts…The nurses are overworked and slip ups do happen. [Anonymous ICU nurse, ] Another nurse specialist noted that infection control guidelines suggest one patient to a nurse, but in the public sector, there are eight patients to one nurse. Nurses in training are left without supervision, while there are neonatal nurses who do not have the necessary skills to run the ward. The President of the Neonatal Nursing Southern Africa Association states that „too little training is a huge problem‟: Up until 1996 there was a training course for neonatal nurses but the six-month course is no longer accredited. Without proper training it's difficult to do a proper job. Even when they do make provision for nurses to attend conferences its hard because so few can get time off from work. [President: Neonatal Nursing Southern Africa] In a move to empower nurses and have their voices heard, she urged policymakers to include nurses when decisions are made „because they‟re the ones who face these problems every day.‟ Another nursing expert appealed to government and the public to support nurses who are on their own „because a unit manager, who is supposed to supervise them, now performs the duties of an administrator‟. While more and more is being expected of nurses who are regarded as the backbone of the health system, a young nurse pointed out that „the backbone is broken,‟ and nurses are portrayed as frustrated, powerless and exhausted. Despite the shortfall of trained and experienced nurses, no nurse voices were heard when the Gauteng government planned to implement a labour broking ban. Labour brokers use nurses permanently employed by private and public hospitals to complete shift staffing requirements. A labour broking ban would „reduce or eliminate nurse rotation between hospitals, forcing state hospitals which have a 40% vacancy rate, to ultimately close wards and turn patients away‟. vi. Nurse voices on training and neglect: What voices? Surprisingly, few articles on training at either under-graduate, in-service or basic training levels featured nurse quotes. An article in Mopani Herald (community newspaper, circ: unknown) on the graduation ceremony of auxiliary and enrolled nurses quoted the graduates‟ representative, a male auxiliary nurse, as saying the poverty alleviation programme which enabled them to study had uplifted their living conditions. This male nurse and a female colleague both won awards for being the best performing students in Auxiliary Nursing; however, only the male nurse – who was also the graduates‟ representative - was quoted, indicating the power both the media and other nurses confer on males. Not surprisingly, only four articles out of 50 featured nurse quotes in relation to neglect. This could be due to subjective reporting which favoured patient quotes on the subject, or that nurses did not wish to be quoted. 68 vii. Patients‟ voices: a) ‘Rude’ nurses who ‘don’t care’: Many stories portrayed patients at the mercy of nurses, and they were largely critical of public health nursing, with the exception of a single letter from a maternity patient. Nurses were described as „rude‟, „nonchalant‟ and „taking their time‟, and shouted at maternity patients. When a patient in labour complained she was being hurt and for the nurse to „hold on a bit‟, the nurse „told me I mustn‟t tell her how to do her job‟. This patient‟s dignity was affronted when a group of five nurses stood watching her give birth, and only once a male visitor walked past was the bedside curtain closed. Another maternity patient, who requested a Caesarian section after being in „serious pain‟ after two hours of labour, said the staff had not „bothered‟ with her, and one nurse told her to „hurry up and give birth‟ because she was hot. Her aunt said: A person can see on the staff’s faces they don’t care about patients. Two nurses ate grapes and sweets while she screamed in pain. [Patient’s aunt, community newspaper] The patient in North-West who spent five days with a dead in utero, said: The thought of me having to spend the whole weekend with the dead baby inside me totally devastated me. I will never forget this experience. "What was more painful was the attitude of the doctor and nurses towards me. They treated me with total lack of respect. They were rude and very unprofessional towards me. [Patient, community newspaper] Categorised as a spokesperson, the province‟s Health and Social Development MEC, Rebecca Kasienyane, who was coincidentally in the area, immediately called for an investigation: We certainly cannot accept this kind of behaviour from our health professionals… I am very angry and concerned about what had happened… This is a case of gross negligence and cannot be tolerated… The doctors and nurses must explain what happened. They failed her… We need quality health care service delivery. Everybody must do his or her part. People cannot be monitored forever. Every employee must know his or her area of work. [North West MEC for Health, community newspaper] At a community clinic in Gauteng, patients claimed they were confronted with nurses who seem „more concerned with talking in the kitchen‟ while patients wait for assistance. Describing the situation as „very bad‟, „exasperating and disgusting‟, one patient said the nurses „do not seem to care at all‟ as they drink tea and talk while „more than 50 patients spend hours in queues waiting for help‟: It is as if they are getting paid for nothing while the patients are suffering… It seems the staff are only there to socialize, not to help the patients at all. The staff spend a lot of time talking about what they were doing over the weekend, instead of helping patients...and we can hear them… You come early but you will eventually leave without being helped because of the way the staff behave. [Patient, community newspaper] Another elderly male patient admits he becomes „incensed‟ whenever he thinks about visiting the clinic because of the time he will waste because of „uncaring‟ staff: 69 This has got to stop! The government is paying them to help us, not to come to work to drink tea and talk. We are, in more ways than one, sick and tired of this clinic. [Patient, community newspaper] Nurses were perceived as being unhelpful and harsh, and seen to exercise power over a patient disbelieving her concerns of tuberculosis, instead administering „children‟s cough mixture and antibiotics‟. This patient, a journalist, was referred to another clinic and then not attended to „because the nurse was out for the day‟. When she returned, the nurse exercised her power by „glancing at the doctor‟s note‟, saying it couldn‟t be confirmed unless sputum samples had been taken. The journalist noted that she had not received any counselling or information, was still not on any medication five days after the diagnosis, and when she asked for a HIV test, the nurse told her the counsellor was not in „and she didn‟t know when she was coming back‟. Following a friend‟s intervention, the „nurse gave me a hard time‟ when she returned to the clinic, simply saying „You do have TB‟. After explaining the treatment regimen, she „ordered‟ the journalist to fetch water in order to „gulp down‟ the tablets. Despite requesting caregivers of her two-year-old daughter in KwaZulu-Natal to take her for a TB test, the child was not tested because a nurse there „had taken one look at her and proclaimed she didn‟t have TB‟. b) Abusive nurses: A television presenter reported her grandmother‟s unnecessary death in a feature in Drum magazine (circulation: 116 700) entitled: “Nurses let my Koko die – Salamina Mosese says her beloved gran died because of nursing staff‟s neglect and abuse.” In a battle for power, the presenter tried to use her fame to get service delivery, but in the nurses‟ territory, this was to no avail and may have spurred the nurses to deliberately ignore her grandmother: Nurses ignored us and seemed to show they didn’t care who we were, even shouting and swearing at us when we asked for help. [Patient’s relative, national family weekly magazine] She called on nurses to be advocates for their patients: I'm not saying all nurses are bad. There are excellent nurses who go home with swollen feet because they've been working hard. We appreciate them and need them, but I want them to take a stand against those who give their calling a bad name. [patient’s relative, national family magazine] In the case of the Alzheimer‟s patient who was „knuckled‟, the patient‟s daughter said patients should receive „top class nursing service and care‟ at this private hospital, but In my opinion, the many so-called nurses attending to the sick do not have the compassion to be in the profession. [Patient’s daughter, regional newspaper] Only one article, based on international research about giving sugar water to babies to reduce pain, encouraged the public to „work with their nurse‟ to determine if this would help babies‟ pain, thus conferring mutual power to the nurse and patient/public . 70 viii. Doctors‟ voices Doctors are perceived as being more powerful than nurses, and journalists may seek their quotes rather than those of nurses who are not vociferous advocates of their profession. Doctors were mostly supportive of nurses, particularly of the conditions under which they work. Despite having power, several doctors spoke to the media on condition of anonymity. A KwaZulu-Natal doctor commented on nurse-patient ratios: We sometimes have three nurses in a ward, when there should be 10 of them, and because of this, nurses are overworked and cannot pick up on the critical patients. In most cases, it is too late to resusciate these patients once the deterioration in their condition is detected. Most of them have said that if offered less stressful posts, they would take them. [Anonymous doctor, regional Sunday newspaper] Other doctors in the province have confirmed there were critical shortages of theatre and ICU nurses. Another doctor, speaking anonymously, indicated that poor health systems posed „huge challenges‟ for nurses: We are expected to save lives under these conditions but we really need to be looking at the entire health system. When we conduct training, for example. we have to explain to a nurse how to wash their hands and dry them properly but then you find there's no paper towel in a ward. This compromises cleanliness, a basic hygiene condition. [Anonymous doctor, national weekly family magazine] A doctor quoted under a pseudonym regarding the shortage of medication in some Eastern Cape clinics defended nurses at the clinics who „were doing their best‟ and should not be blamed but rather „those in power should shoulder the blame.‟ Chairman of the South African Medical Association, Norman Mabasa, defended nurses involved in the baby death scandal, suggesting that standards had dropped long before the tragedy happened, and blamed could not be individually apportioned. However a general practitioner writing in Noseweek [circ: 22 000] under a pseudonym, claimed that nursing care in hospitals was „a time bomb‟ where there is lack of accountability with „no chain of command‟: Years ago there was a hierarchy in the hospitals. Matron was in charge and under her were the ward sisters who supervised the senior and junior nurses and nursing aides. Everyone worked under supervision and never took on what they were not qualified or trained to do. [general practitioner, national news magazine] Now, doctors find there is no one accountable when a doctor‟s instructions are not carried out, and any reprimands would have the unions come out in force. This GP suggests incompetence by outlining „elementary principles‟ not followed, such as holding a drip below the patient when transporting them on a trolley. ix. Union voices on nursing: Unions spoke on nursing mainly in relation to strike action and labour demands. Denosa defended the Western Cape nursing students‟ strike, calling for an „urgent meeting‟ between the management 71 of the University and student leaders to address issues raised. It denounced the branding of nurses as „murderers‟, and „took very seriously the latest reports of the deterioration of professionalism in the nursing sector, announcing research into nursing „malpractices and the reasons that contribute to the conduct of nurses.‟ The union regards nursing‟s main problem „a gross shortage of staff in all departments‟, leading to a ratio of „one nurse to 20 patients. This deprives patients of quality care.‟ Denosa welcomed „progressive‟ proposals for expanding nursing scopes of practice to prescribe anti-retrovirals, and called for the reopening of nursing colleges. The union also said fewer nurses were leaving to work overseas, but We cannot become complacent, though. We need a sustainable solution to our problems, of which the staff shortages, which lead to unmanageable workloads, with a lack of resources and poor remuneration, are key. [Union spokesperson, national weekly newpaper] The National Education, Health and Allied Workers Union (Nehawu) was quoted as saying national government was „dilly-dallying regarding their demands regarding a once-off OSD payment for psychiatric nurses in KwaZulu-Natal. The union also alleged that although nurses who had left the country wanted to come back, there was no money to employ them and there was a „negative attitude‟ by the Department and hospitals against nurses who had left the country, „even though they have the skills that we need in South Africa they are not being employed.‟ The Health and Other Service Personnel Trade Union of SA (Hospersa) was quoted on the nursing picket at private hospital, Netcare, where the picketing for wage increases was framed against the hospital group‟s „best financial results‟ resulting in „a huge profit‟: “All we are saying is: 'You need to plough some of that profit back to workers'." [Union general secretary, regional business newspaper] x. Spokesperson voices on nursing As the official voice of institutions, spokespeople were the channel of communication to the press around negligence, nurse shortages affecting service delivery, and strike action, with most provincial spokespeople quoted on these nursing issues. The National Department of Health spokesperson warned nurses to „treat patients with utmost dignity and respect‟ and encouraged the public to lay complaints for „corrective action‟; the Western Cape health spokesperson urged two women to lay charges at the hospital where they both lost babies, while Limpopo‟s spokesperson acknowledged an investigation was underway regarding the nursing strike which contributed to patient deaths. Nurse shortages were addressed by Eastern Cape and Free State health spokespeople, while Gauteng dealt with shortages by announcing the help rendered by retired nurses working in the province‟s hospitals and clinic. Private hospital group, Medi-Clinic‟s head of nursing services said they were importing Indian specialist theatre and ICU nurses to alleviate the „bidding wars‟ between 72 rival hospitals which resulted in lost revenue when they had to turn patients away. A private labour broking company acknowledged that nurses used shift work to supplement their incomes, and that a labour broking ban would „force state hospitals to ultimately close wards and turn patients away.‟ Spokespeople commented on strikes, with the Western Cape health spokesperson saying talks were underway to resolve the student nurses‟ strike, although the college was temporarily closed. A spokesperson for Buffalo City municipality in the Eastern Cape said since nurses were part of essential services, „they were not allowed to participate in any strike action‟. Spokespeople were able to promote nurses reluctant to raise their own profile, such as the graduation ceremony of auxiliary students, successful graduates of advanced midwifery training where the spokesperson described midwives as „the backbone of maternal, child and women‟s health care‟, the nursing awards given on IND, or when journalists undertook „theme‟ articles such as wearing national soccer jerseys on Fridays to support the World Cup where time and access to nurses for comment may have been constrained. The regulatory authority, the South African Nursing Council, was seldom quoted, with the exception of the „bureaucratic bungling‟ article on private sector nurse training where the acting registrar was seen to offer stumbling blocks rather than solutions for the accreditation of training facilities quoted as saying the SANC could not accredit new facilities. xi. Public voices: ‘Letters to the Editor’: „Voice‟ includes those who write about nursing. „Letters to the editor‟ included traditional letters and the more accessible mobile phone texting (SMS) and help to gauge public opinion of nursing issues(Westwood and Westwood 1999), and provide the public with a platform for discourse, and demonstrates the media‟s efforts to encourage societal participation. Nine items were coded „positive‟, nine were coded „negative‟, and one was neutral. The themes covered nursing care, strike or protest action, nurse salaries and conditions of service, training, and the nursing profession. Of the 20 items, ten were actual letters. The other 10 SMS cuttings had a total of 20 comments. Nurses identified themselves either as „nurse‟, „former nurse‟, „former nursing student‟ in eight of the total 29 feedbacks published. a) The student nursing strike which took place at the Western Cape College of Nursing elicited the most comments from both the public and nurses, published as SMS feedback, with 11 coded „negative‟ and two „positive‟. These latter comments were by students at the college who alleged corruption was taking place at the College. The public responded angrily to the strike, with SMS texts berating the nurses who were seen to be starting their nursing careers early with a bad attitude; 73 they were „causing havoc‟; going „too far‟ for alleging subsequent student arrests were racist, and a nurse wrote in saying the student should leave nursing now since „efficient nurses, not barbarians‟, were required on nursing teams. A former student at the College wrote: We also did night duty without pay and it only made us better sisters today and believe me, you don’t get much night allowances once you qualify. Don’t be stupid, you are only falling behind in your course and now you must sleep on the streets so start being professionals, which you will be, and stop your nonsense. [Former student, regional daily newspaper] In response to a nurse‟s SMS that she was „gatvol‟ (fed-up) with these „lazy students‟, two student nurses texted anonymously about their belief that the College was stealing from them by charging for courses not offered, and that they graduated after four years with a diploma rather than a degree. „No one is lazy to work, we‟re just looking for fairness‟, one wrote. In other strike correspondence, a former member of the nursing student leadership at Lilitha College in the Eastern Cape defended the intention of nursing students to protest against the provincial head of health who had allegedly „forgotten Lilitha‟. In response to the proposed private sector strike of Netcare nurses, “Heatseeker” texted: I'm siding with the nurses. Nurses work 12-hour shifts and then still have to work overtime to make ends meet. Not to mention that they contribute to society… [Heatseeker, national daily newspaper] b) In other contexts, members of the public wrote in support of nurses, particularly for their salary situation (“Don‟t forget the doctors and nurses”); and the poor attitudes of male patients who belittled nurses around cleaning up after their „blapses (misses) with the bedpan‟. Another health worker, in response to the death of a patient, appealed to the public in the Eastern Cape to “Stop blaming the nurses” by clarifying that doctors, rather than nurses, made decisions around operations. Only one of the letters was by a patient for the „excellent service‟ received in hospital, described as „five-star treatment‟. Here, „Proud Resident of Cradock‟ spoke of nurses in terms such as „efficient‟, „tolerant‟, „patient‟ „caring‟ and „motherly‟, and acknowledged the team effort. Notably, most of the nurses were named according to their status and surname (e.g. Sister Goniwe, Sister Membe). c) Letters also reported poor nursing practice. A male patient in the Eastern Cape wrote of nurses who were „filled with self-importance‟ and refused to give him painkillers, and „told me to go back to bed‟ when he „ran‟ to inform them of another patient who had collapsed beside him and who subsequently died. A female patient in the Western Cape wrote of „rude nurses‟ at a Mitchells‟ Plain Midwife and Obstetric Unit, and the wife of a patient at the hospital patient agreed: No one seems to care and the nursing staff take their own time by being nonchalant and patients just have to wait. [Benita Adams, Portland, community newspaper] 74 Conversely, in the same letter‟s column in the Plainsman (circulation: 86 300), a community newspaper for the Mitchells‟ Plain community, a mother wrote in to chastise the community for expecting nurses to clean the toilets, and that respect is mutual. Nurse negligence was coupled with deteriorating health services. The spokesperson of AZAPO Youth wrote under the headline of “Freedom Day, but there is no freedom”, equating the health system with the „disaster and spectacular failure‟ of the Department of Social Development. In addition to nurse shortages, Patients die under the nose of doctors and nurses who won’t lift a finger because they are watching a television soapie. [AZAPO youth leader, community newspaper] A former nurse responded at length in The Star, Johannesburg‟s largest daily newspaper (circ: 160 130) to the tragic deaths of babies in the city‟s Charlotte Maxeke Hospital. This she described as a „blot on the nation…due to negligence of state employees. Shame on them!‟ Referring to the deterioration of the health system and „cattle-pen like conditions‟, she wrote: …if our hospital staff haven't yet got beyond the basics of simple hygiene, like regular hand washing, then maybe the battle will never be won. As far back as the 17th century Florence Nightingale inculcated the necessity of personal hygiene by medical staff. I draw from my personal experience of nursing in an era when our State hospitals were world class. [Former nurse, regional daily newspaper] Another letter-writer concurred about the former state of the health systems, saying his domestic worker was treated by an outstanding surgeon and „the aftercare rendered to her by the team of nurses was exceptional‟. This is the only example of public recognition for nurses‟ post-operative expertise, as noted by Buresh and Gordon: …most people know that they can’t get into a hospital without a doctor. What they don’t know is that they won’t get out of one – at least not alive – without a nurse. (Buresh and Gordon 2006) d) Regarding the nursing profession, the former nurse also referred to the discipline instilled by matrons, described as both „dragon ladies‟ and „wonderful disciplinarians‟ who „knocked into shape‟ nurses who were ill-suited to the calling or who left the profession when they found they were „not suited to the dedication and discipline required to make a good nurse.‟ A retired matron wrote that while government could set standards, it was only matrons or sisters-in-charge or nurses who could maintain them. The closure of bogus nursing colleges also elicited public comment with one writer suggesting that before new colleges are opened, the current ones should be brought „up to scratch‟, and another commenting that the closure of former nursing colleges was short-sighted. 75 The slant of nursing This section explores the how the articles created a positive, neutral or negative slant. i. Positive slant: These were articles which promoted and uplifted nursing, conveying a positive impression of the profession. Nurses were described as „lifesavers of the population‟ playing a „critical role in healthcare‟, and a „crucial support function in modern medicine‟. Nursing was defined as „a noble profession‟, „not being about the money‟, „very rewarding‟ and „highly skilled‟. Words such as „unsung heroes‟, „care‟, „compassion‟, „passion‟, „dedication‟, „commitment‟, a „love of serving others‟ and simply “I love nursing” summed up the positive slant of these articles. a) Nursing profession: Most articles on the nursing profession and nurse training evoked positive feelings about the profession (See Table 10, Page 46). One article portrayed nurses as entrepreneurs helping to uplift society when a clinical nurse practitioner who „saw a great need‟ in the Cape Town community of Khayelitsha opened up a clinic from a corrugated iron container „to provide medical services to the impoverished at affordable prices‟. Headlined „New private health care clinic helps‟, the nurse is profiled in glowing terms for offering extended operating hours for poor people who cannot afford „the best doctors‟, with the article listing her services and her qualifications including a dispensing licence. Three articles based on a scientific paper on nurse monitoring of HIV patients at two South African sites uplifted the profession by highlighting a study which showed nurses with appropriate qualifications could manage HIV patients as well as doctors, with potential to change scopes of practice to include ARV prescription. Nurses were described as being „on par with doctors‟ although one article from an international wire agency quoted the paper‟s somewhat derogatory finding of nurse-monitored ARV treatment being „non-inferior to doctor-monitored therapy.‟ Other positive articles included the feature article in Vroue Keur, the only substantive item on what it means to be a nurse, and that returning to standard uniforms may confer respect on the profession. b) Nurse training: The overwhelming majority of articles on training were positive (See Table 10, page 46) as they covered issues such as new facilities opened to train nurses, often framed as collaboration between provincial government and academic institutions; the reopening of training colleges; , the completion of highly specialised advanced training by midwives; and graduation ceremonies of student nurses which would „give them tools and knowledge to make a difference in their communities‟, and upliftment of society by training auxiliary nurses as part of a poverty alleviation 76 programme. One article gave information on where to study nursing, while another portrayed compulsory community service as nurses bringing healthcare to under-served areas. c) Nurse strikes: Two student nurse strike articles were positive. One entitled „Denosa slams attack on protesting student nurses‟, saw the union calling for an urgent investigation into the strike of nurses who were „protesting peacefully‟. Another entitled „Nursing students protest over disciplinary inaction‟ featured an article and photograph of chanting nursing students at Lilitha Nursing College who protested about the misconduct of an academic head. Articles on practicing nurses who went on strike or picketed during their lunch times to avoid inconveniencing patients uplifted the profession as the nurses put their patients needs foremost. d) Nursing and labour: Innovative steps by private hospital groups to address the nursing shortage resulted in a positive article about specialist nurses brought from India. Two other positive articles on labour did not feature nursing prominently, but included quotes from doctors defending nurses by highlighting the „gross shortage of staff‟, non-adherence to nurse-patient ratios, and blaming „those in power‟ or government for the poor working conditions. e) IND: This theme yielded only positive articles, the overwhelming majority of which were placed in May. South Africa‟s theme of „100 Minutes of Care‟ was a fitting response to the shortage of nurses and poor service delivery. Nurses in the private sector were honored for their „compassion and care‟ which was a dominant theme, although nursing as a career was punted at several special functions. Positive testimonies of retired and active nurses in several articles uplifted the profession by offering a glimpse of what nursing entails and the motivation for becoming a nurse. A school pupil decided to become a nurse after following a theatre nurse for the day. Nurses also rededicated themselves to nursing at a prayer meeting, and in a commitment ceremony where they promised to serve humanity and have „utmost respect‟ for human life. ii. Neutral slant: These articles did not take a stand for or against nursing and were objective. Not many articles were dispassionate about nursing (See Table 10, Page 46). a) Nursing profession: An article on whether nurses could wear shirts in support of „Football Fridays‟ ahead of the World Cup Soccer Tournament was regarded as neutral as it was a factual article on which institutions would allow their nurses to participate in this initiative. 77 b) Nurse strikes: One neutral article reported on the talks to end the Western Cape student nurses‟ strike in objective terms by outlining both the violence and the nurses‟ grievances, reporting that everything was „peaceful‟ again at the college. An article on Livingstone Hospital nurses who protested during a lunch time visit by the Health Minister was regarded as neutral since it reported nursing neither as favourable nor unfavourable. The reader was left with an understanding both of the nurses‟ grievances and their willingness not to compromise patient safety, and the unsuitability of their action during a ministerial visit. c) Nursing and labour: One neutral „labour‟ article balanced the fact that nurses did not accept or remain for long in transfers to rural areas with plans by the Free State health department to reopen nursing colleges in rural areas to alleviate the nursing shortage. iii. Negative slant: These were articles which undermined nursing and nurses or portrayed the profession negatively. Headlines such as „Nurses hit my mom‟, „Nurses let my Koko die‟, „Doctor, nurses face expulsion‟, „Nurses skopped‟ (translated: kicked), „Nurses bleed‟, „Nursing crisis causing deaths‟, and sub-headings such as „Livingstone patient dies as nurses eat a meal‟ and „Student mob take sick – two hurt as nurses vent their anger‟ portray the profession negatively. Nurses were described as „being a danger to society‟, „grossly negligent‟. Words such as „murderers‟, „swearers‟ and „shouters‟, having „negative attitudes‟ and „unacceptable behavior‟, „not caring‟, being „rude‟, „unprofessional‟, „apathetic‟ and „nonchalant‟, and showing a „lack of respect‟ to patients clearly demonstrate a negative portrayal of nurses and nursing. a) Nursing unprofessionalism: All articles under the theme „nursing unprofessionalism‟ with sub-themes of nurse attitudes, negligence, poor service delivery and disciplinary issues, were negative (See Table 10, Page 46). Several quoted patients who voiced their anger about „uncaring nurses‟ who appeared to want only to „socialize‟, were not concerned about long queues or waiting times for patients, and were seen to be drawing a salary for „drinking tea and talking‟. Nurses were portrayed as callous for eating „grapes and sweets‟ while a mother in labour cried with pain. Another article by a journalist seeking a TB test portrayed nurses as unprofessional and arrogant for not offering HIV counselling, questioning the doctor‟s diagnosis, and „ordering‟ the patient to fetch water so that the treatment could be observed. One article described the horror of a mother whose baby had died in utero whose life was at risk by being referred from the clinic to the provincial hospital and back for four days. The MEC for Health and Social Development described this treatment as „total negligence‟. Denosa announced a probe 78 into the „concerning‟ deterioration in nurse professionalism. Articles on the physical abuse and neglect of elderly patients were clearly negative as nurses were portrayed as bullies, striving to assert their dominance and power in their own environment. b) Nurse training: An article which undermined nursing concerned the „bureaucratic bungling‟ between the health and education sectors regarding private sector efforts to expand training programmes. Private hospitals cannot be accredited for training until the curriculum for new nursing qualifications is finalized in line with the National Qualifications Framework Act of 2009. The delay and confusion has undermined nursing as it impacts on the number of nurses which the private sector can train. c) Nurse strikes: Most strike or protest articles were negative as they portrayed nursing negatively (See Table 10, Page 46), with the exception of articles which showed nurses protesting peacefully or during lunch- time. The two Sowetan articles on patient deaths following the nurses‟ strike in Limpopo were clearly negative, as were most of the articles covering the Western Cape nursing students‟ strike since nurses were portrayed as violent; „blood flowed‟ and nurses reportedly „vented anger‟ at colleges and were referred to as a mob, „surging,‟ and „screaming‟. Their removal from campus cast a negative light on the profession as nurses were seen as homeless and unrepentant, vowing to „spend the weekend on the pavement with all their belongings‟. Despite the legitimacy of their grievances, nurses at a psychiatric hospital who protested silently by taking sick leave were perceived to portray the profession negatively because of the service delivery implications for mentally ill patients who are particularly vulnerable. Similarly, nurses in Buffalo City who planned to go on sick leave en masse due to unsatisfactory wage increases also portrayed the profession negatively as service delivery was stopped in several cases. A bizarre article featured the week-long closure of a clinic in an impoverished part of Port Elizabeth when all the nursing staff went on study leave. Although the dispute was between the municipality and the province which provided the staff, it is inconceivable that all the nurses went ahead with their study leave without making contingency plans to ensure service delivery. d) Nursing and labour: Slightly more than half the articles under the theme of labour were negative as they undermined nursing (See Table 10, Page 46). These dealt with the labour broking ban which would „hit nursing hard‟, nurses leaving community or rural clinics because of poor working conditions or the failure to pay the OSD, as well as a feature in the Mail & Guardian entitled: „A profession in need of a cure‟, implying nursing was sick due to the poor working conditions, long hours, lack of equipment and wages not commensurate with these challenges. 79 An article in the Sunday Independent was headlined: „More babies may die if state does not act fast: overworked nurses speak out about atrocious conditions at hospitals that have led to a spate of babies‟ deaths‟ also undermined nurses. Even when nurses did try to raise the alarm about unusually high infant death rates, they were not taken seriously enough for the provincial government to act, as they had insufficient power. Staff only spoke on condition of anonymity after a „witch hunt‟ began at the local hospital following media reports. Another article outlined the serious shortage of trained nurses in state hospitals in KwaZulu-Natal, where the nurse:patient ratio was 1:20, which „deprives the patients of quality care‟, not to mention the workload of the nurse. A feature in Drum entitled “Our babies are dying” indicated the frustrations nurses have being blamed for the baby deaths for failing to sterilize bottles, while they work in „appalling conditions‟ with severe staff shortages. Summary The main findings of the discourse analysis are as follows: 1) Nurses‟ voices are not heard prominently with regard to research, scopes of practice, dress codes, their profession or training, but they are vocal about the challenges of the profession. As expected, nurses were seldom quoted in articles around unprofessionalism, abuse or neglect. Very few articles gave attention to the actual content of nursing and what nurses do. 2) In overlapping themes, nurses‟ voices are most acutely heard when they are protesting what they regard as legitimate labour grievances such as working conditions, OSD or perceived unfair practices. Here nurses were mostly quoted anonymously. IND and nursing as a profession overlapped, presenting nurses with an excellent opportunity to be heard, although spokespeople almost overshadowed them in this regard. Nurses speak of their profession and themselves in terms such as „caring‟ and „compassionate‟, and nursing being a „calling‟. Nurses also speak of being „tired‟ and „frustrated‟. Very little substantive discourse was entertained regarding the higher academic learning, skills and competencies of nurses. Doctors are largely sympathetic towards nurse working conditions, while patients are mainly negative toward nurses, with the exception of a few letters. Patients speak of nurses as „rude‟, taking their time,‟ „harsh,‟ and several articles highlighted gross negligence or abuse by nurses. 80 3) In terms of slant, the theme which only portrayed nursing positively was IND which framed nurses and nursing as being „passionate‟ and „a united front‟, deserving of a special day to spotlight their hard work. Other mainly positive articles featured under „professionalism‟ and „training‟. Nursing is given a glimmer of hope as government plans to reopen of nursing colleges, while nurse attire is given scrutiny to bring it back into line with „what the public expects‟. The theme which portrayed nursing only negatively was nurse unprofessionalism, followed by mostly negative articles around strikes and labour. Striking nurses are mostly framed as unruly, defiant health workers who „go too far‟. A blaming discourse featured in several labour articles where government was blamed for staff shortages and not acting on nurses‟ warnings, while nurses were blamed by patients for negligence, unprofessional behavior and lack of service delivery. 81 CHAPTER 4 DISCUSSION This chapter outlines some limitations of the study, and discusses the findings in the context of the literature and objectives. Introduction The aim of this study was to explore how nursing is framed in the mainstream press in South Africa between January – June 2010 using a content and discourse analysis. Specific objectives were to quantify the extent of nursing coverage, identify whether nursing is portrayed prominently or not, identify the slant of nursing articles, and who is given a „voice‟. Additionally, the study sought to determine if the proportion of articles is influenced by International Nurses Day which falls in June, and identify the key themes of press articles on nursing. Extent and prominence of nursing coverage: As is the case internationally and in contrast to the studies on South African health and related press coverage (See Table 1), nursing has a low profile in the media with only 242 articles in total over a period of six months. As suggested by Finnegan (Finnegan and Viswanath 2002), the lack of coverage on nursing may indicate the media‟s belief and framing of the profession as unimportant. Nearly 40% of the articles having medium to low prominence and mostly featuring on or after page 7 which is of lower importance than the right-hand pages of a newspaper ie. Pages 1, 3 or 5. As with international studies regarding frequency, nursing featured more often and prominently in daily papers although locally these articles were more likely to be negative rather than positive. This study found nursing was featured more frequently in community papers with small circulations but with medium readership of up to one million readers. There was some variability in the reporting of nursing articles by national newspapers, ranging from two articles (one of which was an international article) in the Mail & Guardian, established in 1985 (Weekly Mail) as an anti-apartheid newspaper (GCIS 2010), and two articles in South Africa‟s fastest growing newspaper, The Times (ABC 2011) to 15 in the Daily Sun, South Africa‟s largest newspaper which is aimed at the black working class (GCIS 2010), followed by the Sowetan, the Daily Sun‟s closest competition for black English readers. While it is important for nurses as frontline health service providers in communities to be featured in community press, if nursing is going to be perceived as important and influential, more positive newsworthy articles of primary importance need to be featured in press with larger circulations which reach funders, policy makers and politicians. Since the mass media are gatekeepers of what is regarded as „newsworthy‟ (Finnegan and Viswanath 2002), media advocacy which frames nurses 82 and nursing from a public health perspective becomes critical to influence social and behavioural change (Wallack, Dorfman et al. 1993). In line with one international study, this research also found that a special day dedicated to nursing increased coverage and prominence of articles, with 32% of articles appearing in May when International Nurses‟ Day was celebrated, double that of the next month which was March when 15% of articles appeared. In accordance with mass media communication theory of how the media frame issues and through coverage increase status and influence, an international event which profiled nursing was regarded as newsworthy, conferring status and attention to nurses (Schramm 1964). More than half of prominent articles appeared in the May-June period. This event also influenced the slant of articles, with the majority of positive articles appearing in May and June, compared to the majority of negative articles coinciding with the nursing strike and neglect articles in January – April. When IND was excluded from analysis, there were substantially more negative articles than positive articles. Most regional articles appeared in the cluster of Gauteng, KwaZulu-Natal, Western Cape and Eastern Cape provinces. It is notable that KwaZulu-Natal, where an estimated 2.6 million people read newspapers, only featured 17 articles on nursing despite having eight major daily and weekly newspapers. In contrast, Eastern Cape newspapers covered nursing nearly twice as much with only two major daily papers (GCIS 2010). KwaZulu-Natal also featured only one article on training, although it has nearly 21% of the country‟s nursing students (GMS 2010), the highest number of private nursing education institutions (36%) in the country compared to Western Cape‟s 10% (PHS 2010), and 21% of public nursing education institutions countrywide, second only to Limpopo (23%) (GMS 2010). The voice of nursing Overall, while nursing as a topic may be virtually invisible in the press, nurses were quoted in about a quarter of articles. In 9% of articles, nurses were quoted extensively ie. three or more times. Most of those quoted were registered nurses, and interestingly, 18% of nurse quotes were from students, generally reflected in the literature as a less powerful group. Also of interest is that nurses were quoted more frequently in the first period of January – April rather than in the latter period which featured International Nurses‟ Day, a perfect opportunity for nurses‟ voices to be heard. Nurses were quoted more often in community papers which appeared weekly, reflecting an opportunity for them to confer status on the profession in hegemonic regional and national newspapers. The Western-Cape featured nurse quotes in a third of all articles quoting nurses (n=21), compared to KwaZulu-Natal‟s 3% (n=2). 83 As is the case internationally, South African nurses were anonymous in over a third of articles quoting nurses, most of which were negative, while over half of quotes by doctors were anonymous. Many institutions place limitations on staff regarding media engagement which may explain their fear to be attributed by name in press articles. While it is encouraging that some nurses did have the self-efficacy to engage with the media in an effort to influence change on a social level in accordance with Bandura‟s Social Cognitive Theory of Mass Communication (Bandura 2001; Waisbord 2001), individual nurses spoke anonymously on topics dealing with labour, protest and service delivery, indicating fear of reprisal from their institutions. They were framed in the media as anonymous whistle-blowers on failing health systems issues such as budgetary constraints, the critical shortage of staff in some facilities and the lack of skills transfer from aged to younger nurses. However, nurses who tried to raise the alarm about babies dying in deteriorating state hospitals were not taken seriously by the provincial government. Nurses can be the canary in the coal-mine, serving to warn about health systems failures:“When courageous nurses take controversial positions to protect their patients and the public, this sends a powerful message about the value of professional nursing” (Buresh and Gordon 2006). International literature has called on governments for nurses to participate in policy decisions, and nursing has been included in at least six World Health Assembly (WHA) resolutions (WHA42.27; WHA45.5; WHA 49.1; WHA54.12; WHA 59.27; WHA62.12) (WHA 1989; WHA 1992; WHA 1996; WHA 2001; WHA 2006; WHA 2009; WHO 2010) aimed at strengthening the profession, improving health care delivery, health outcomes and cost-effectiveness (WHO 2010). Constraints in delivering on this resolution include poor working conditions, shortages and lack of participatory decision-making (WHO 2010). Yet nurses are frequently not considered key stakeholders for policy reviews: “With the clock ticking down to 2015, governments, civil society and professional associations must work together with educational institutions, NGOs and a range of international and bilateral organizations to remedy the situation so that the input of nurses and midwives is more actively sought and acknowledged”(WHO 2010). This view was echoed in the discourse by several nurses who appealed to have their voices heard, although nurses missed an opportunity to contribute to the public debate around labour brokers. Capacity building among nurses to use the media to advocate on public health issues will help to frame them as critical contributors to policy debates. Most nurse quotes were around strikes, mainly related to wage issues such as unpaid OSD or increases, and in relation to poor working conditions which were associated with „budgetary constraints‟, where the government needed to „come with the funding, the money, to get us out of the situation.‟ Several articles quoted student nurses almost exclusively, particularly when the issue was around lack of supervision or management which the discourse analysis showed was an 84 important issue to nurses. Of interest is that not all strike articles were negative, particularly when nurses used their lunch-hours to strike to avoid inconveniencing patients. Nurse voices were largely absent from articles dealing with unprofessional behaviour, signifying either that journalists had not sought their comments, or that in line with Banja‟s normalisation of deviance (Banja 2010), nurses preferred not to speak out about colleagues, a significant missed opportunity to take a stand to protect patients and the public. When nurses are silent in the face of deviant behaviour, they are not serving public health or their profession. Similarly, by not providing perspective on an issue around perceived unprofessional behaviour, nurses entrench media framing and public perceptions of individual nurses as deviating from normative behaviour which may well have deeper, public health significance. Very few articles on training featured nurse quotes, another missed opportunity. In contrast to international literature which finds that nurses‟ voices are drowned by the views of physicians (or doctors) (Salvage 1985; Bridges 1990; Sieber, Powers et al. 1998; Bridge, Dickenson-Hazard et al. 1999; Schmidt 2001; Gordon 2005; Buresh and Gordon 2006), this study found that nurses were quoted in just over a quarter of articles on nursing. However, it is spokespeople‟s voices which dominate the discourse on nursing with more than half of articles quoting spokespersons, and more than half of these articles being negative. Spokespeople spoke about nursing negligence, shortages and strike action, although they also promoted nursing and nurses reluctant to „blow their own trumpet‟. Remarkably, spokespeople were quoted more often on IND than nurses, reflecting Fairclough‟s view that newsworthy events “originate from (those) who have privileged access to the media, who are treated by journalists as reliable sources, and whose voices are the ones which are most widely represented in media discourse” (Fairclough 1992). As the official voice of institutions, nurses cannot expect spokespeople to represent their interests when their actions conflict with service delivery or in the contexts of strikes, where the power contest is between nurses and management. Nurses need to be proactive by contacting media directly, or by setting forth their agenda clearly to spokespeople which stresses the importance of nursing framed in support of patient care. If spokespeople know about nursing issues, they are more likely to deliver balanced statements to the media. South Africa‟s Nursing Strategy outlines a specific objective to ensure quality service and protection of the public by promoting and advancing the profession‟s values in the public and ensuring mechanisms exist for the public to communicate freely with the SANC (DOH 2008). However, the official regulatory authority of nursing, the SANC, was seldom quoted in the press and there was very little evidence of the strategy to promote nursing as a career of choice through marketing or „creating attractive employment opportunities for nurses‟(DOH 2008). 85 This study found that doctors were quoted in only 4% (n=9) of articles. They were seen to be supportive of nurses, speaking about the poor working conditions of nurses, and apportioning blame to „those in power‟ rather than nurses with regard to drug shortages at clinics and the deaths of babies in hospitals. However, over half of doctor quotes were anonymous, and while seen to support nurses, the question is whether they really are „friends‟ without being prepared to be associated with their comments. Their quotes indicate they believe nurses are powerless, and while they as doctors traditionally hold power in hospitals, they appear fearful of having their identity revealed, suggesting that the power base of doctors may be shifting. In line with international literature (Salvage 1985; Bridge, Dickenson-Hazard et al. 1999; WHO 2006), most of the doctors quoted were male, while the majority of nurses quoted were female. True to the stereotype which sees women conforming to social norms of femininity as non-aggressive and compliant, women were quoted in more positive articles than men, while men were quoted equally often in positive and negative articles. Women were also significantly more likely to remain anonymous than men for fear of speaking out. Women were quoted first more often in the positive themes of professionalism and IND, while males were quoted more often in the more negative themes of strikes and labour. The finding that women were quoted first more often than men in relation to neglect was somewhat surprising but is likely to be due to the fact that most patients quoted were women. That most first quotes in relation to training were by men was also an unusual finding, but could be ascribed to the articles where males were quoted in favour of females at graduation ceremonies, illustrating the media‟s regard of male nurses as newsworthy. Unlike international findings where male nurses were seldom quoted, this study found that male nurses were quoted approximately in proportion to their numbers in the profession (9.3%). This study confirms international findings that male nurses are seen to be occupying leadership positions with accompanying status and power. It is interesting to note that Media24 which is part of Naspers, Africa‟s largest media group (GCIS 2010; Whoownswhom 2011) and the most linguistically diverse media owner in this study, featured more females (32.5%) as first quotes than any other publisher, particularly as it was historically the bastion of the conservative Afrikaans press. The framing of nursing around key themes This study has contributed to understanding the conditions under which nursing is framed in the South African lay press and how these frames have operated in forming public opinions as evidenced in the discourse portion of the study (De Vreese 2005). As with findings from international research, strikes as a theme received the most coverage with 80% being full page articles. However, nurses failed to present strikes in terms of better patient care or healthcare delivery, but rather in terms of wage disputes or using it as a tactic to have grievances heard. The Western Cape student nurses‟ strike was framed particularly negatively and featured 86 graphic photographs of rioting students clashing with security guards. While most articles framed nurse grievances as legitimate, when strikes escalated to violence or flagrantly disregarded patients‟ rights to health, sometimes resulting in death, these nurses were portrayed as „going too far‟. Their simmering anger is at odds with their profession and the image of caring, compassionate nurses which the public finds may not exist anymore and who do not „have sympathy‟ with nurses who strike in this way. Unique to this study was the finding that nursing neglect or unprofessionalism received almost as much coverage as strikes, and the majority of page 1 articles were on nursing unprofessionalism, featuring with strike action most often in large circulation publications of over 100 000. Here the media framed striking or unprofessional nurses as non-normative and contradicting the traditional view of nurses as social role models and nursing as a caring profession. Unfortunately, the reach of large circulations, even with a few articles, is such that negative articles such as strikes and neglect have deeper penetration and impact, especially when accompanied by photographs which can distort memory (Garry, Strange et al. 2007) and increase attention and reading of text (Zillmann, Knobloch et al. 2001), despite the fact that more articles may be positive. This may contribute to the pervasive perception that nursing coverage in South Africa is negative. Patients were seen to be vociferous in their criticism of unprofessionalism in the nursing sector with over 90% of patient quotes being negative, mostly around issues of neglect and unprofessionalism. Reinforcing earlier South African research on nurse unprofessionalism, this study found many articles where patients labelled nurses as „rude‟ „unprofessional‟ and „uncaring‟, deliberately bullied vulnerable patients or were „nonchalant‟, making patients wait for service. As with the earlier work (Jewkes, Abrahams et al. 1998; Abrahams, Jewkes et al. 2001; Coovadia, Jewkes et al. 2009), these articles showed how nursing unprofessionalism impacted on service delivery, with patients refusing to visit facilities after poor service, and where alarmingly, nurses were portrayed as openly abusive in front of witnesses and „grossly negligent‟ for causing patient deaths. Nurses here are seen to be agents promoting health inequities, which undermines calls for them to be included in policy-making. In a case of „damned if we do, damned if we don‟t‟, the themes of unprofessionalism and labour are linked when nurses are required to turn patients away from full hospitals or when bureaucratic procedures are not complied with. This results in a blame discourse by patients who label nurses „unprofessional‟, and yet nurses come under attack when overcrowding results in the deaths of babies. While nurses were seen to use covert strategies such as taking sick leave to sidestep the issue of embarking on illegal strikes, the conditions under which they work led to the Mail & Guardian headline: “A profession in need of a cure” and a nurse‟s comment that the backbone of the health system is broken. 87 Critical nurse shortages and working conditions which made it „almost impossible‟ for nurses to deliver the service which they had sworn to provide (DOH 2011) rendered them tired, stressed and frustrated; unlike international studies, the term „burn-out‟ didn‟t feature in the discourse (Aiken, Clarke et al. 2002; Murray 2002; Vahey, Aiken et al. 2004). Yet no articles around the proposed labour broking ban featured comments from nurses, and none of the articles analysed reported nurses striking or protesting because of nurse shortages. In contrast, Japanese nurses took their nurse shortages protest to the streets, framed as „wanting to provide better care to patients‟(Katsuragi 1997). This resulted in massive popular appeal for their strike and although it took three years, finally nurse-patient staffing ratios were legislated. Within six years of California legislating nurse- patient ratios, the state reported a 45% increase in the number of new nurse graduates (Bateman 2009). The lack of local guidelines has resulted in speculation as to what appropriate staffing levels should be, with one nurse specialist quoted in Drum as saying „infection control guidelines suggest one nurse per patient‟. Enquiries with the Federation of Infectious Diseases Societies of Southern Africa (FIDSSA 2011) yielded no such local nurse-patient infection control guidelines. It is possible the journalist misquoted the nurse specialist, or the nurse used incorrect information to support an agenda and the angle of the article. There was a glaring gap regarding articles which discussed the nursing profession in terms of the skills and intelligence required to deliver professional nursing care. As is the case internationally, most articles framed nursing in terms of care and compassion, with some elderly nurses referring to their „calling‟ rather than „career‟, and nursing „for the love of it‟(Bridges 1990; Hall, Angus et al. 2003). It is remarkable that an entire campaign in the United States profiled peri-operative nurses, when the only reference to specialisation in this study‟s sample was to midwives who graduated which gave no details about what the specialisation really meant for the public (Kalisch, Kalisch et al. 1985). Only one Afrikaans magazine feature discussed nursing as a profession in any depth. Using a specialist trauma nurse as the only source, the article presented nursing as a challenging but fulfilling career where nurses can „make a difference in people‟s lives‟. Contrary to research suggesting that professionalization of nursing fragmented healthcare teams, this research showed nursing as a multi-disciplinary team effort (including hospital security) which enhanced nurses‟ experiences of their work (Rispel and Schneider 1991). This was observed as support of other team members, including learning new languages such as Tamil and Afrikaans with imported Indian nurses, and an „us against the world‟ bond in relation to violent patients or relatives. Glimpses of divisions were seen when less stressed wards „did not understand‟ the work of a specialised ward, and when nurses prayed for „unity, love and respect within the multidisciplinary team‟, which suggests it may be lacking. 88 The lack of a standardized uniform for South African nurses may detract from their professional image. White uniforms have traditionally been associated with nursing, and may be an incentive for school-leavers to consider nursing as a career (Breier, Wildschut et al. 2009), while several articles featuring IND indicated that nurses „donned their white uniforms‟ to celebrate the day. Japanese nurses successfully championed a new law by walking the streets in their whites, garnering massive public support for their cause (Katsuragi 1997). Nurse training as a theme received scant attention, with the exception of articles which profiled graduation ceremonies of nursing auxiliaries. No research produced by nurses was covered; the finding that nurses were equally good at monitoring HIV patients was not produced by a nurse academic (Sanne, Orrell et al. 2010). It is registered nurses who are expected to move beyond clinical practice to research and management, and academic nursing as a career option should receive media attention. Furthermore, while the 29% growth in the two-year enrolled nursing courses between 2009 and 2010 is encouraging, it should be noted that this period was categorised by local and international job cuts and the discourse showed that discontent within the profession was frequently associated with wage issues. Those entering the profession may have been attracted to nursing which offers a way to earn money while studying or study with bursary support. For some, nursing may not have been a first choice, as seen in the article about the top male nursing student from a rural area who dreamt of becoming a doctor but did not have adequate resources or academic results. Whatever the reasons for choosing nursing as a career, the nursing register is not reflecting the growth, indicating that more nurses may be leaving the profession than entering it (Breier, Wildschut et al. 2009). While the private sector plays an increasingly important role in nurse training, its efforts to be accredited as training institutions appears to be stymied as the national qualifications need to be aligned with the Qualifications Framework Act before curricula can be finalised (Breier, Wildschut et al. 2009). This is „bureaucratic bungling‟ between government departments and authorities is paradoxical as government is responsible for ensuring all citizens have a right to health care, yet efforts to realise that right by rectifying the „enormous shortfall of trained, skilled and experienced nurses‟ appeared frequently to be blocked. It is hoped the 2010 nursing audit will shed light on this issue and provide impetus for both public and private sector training to resume. Influence of IND on coverage IND without a doubt helped to raise the profile of nursing in the media. The dominant theme was of nurses being recognised, rewarded and cared for, and this was the only theme giving some attention to what nurses actually do. Nearly a third of all articles appeared in May, and all of IND articles were coded „positive‟, helping to sway the tenor of nursing coverage. It was statistically significant 89 that when IND was omitted from statistical analysis, nearly 55% of the articles were negative. While it is fitting that the majority of IND articles appeared in the community press, IND presents a good opportunity for nursing to be profiled more strategically in regional and national newspapers. In line with the thinking that upholding professionalism will help restore nursing‟s image, nurses‟ personal testimony of their experience as nurses can „hook‟ people to the profession as seen by a nurses‟ verbal testimony about her work while travelling on a train. Similarly, the change of careers from engineer to nurse for a male patient was as a direct result of the care he received in hospital. These articles reflected the media‟s response to an international day and therefore was inherently newsworthy. Here, nurses were framed as passionate and professional, encouraging positive „readings‟ of these articles. The decision to celebrate a uniquely South African theme – delivering 100 minutes of care in honour of 100 years since Florence Nightingale‟s death - was strategic in the light of earlier negative publicity around nursing negligence and lack of care. Presenting nursing as a unified front, IND was an opportunity for nurses to be photographed and recognised for their care for others, as well as for special events where nurses themselves were cared for and treated. Despite it being regarded as a „female dominated profession‟, males were featured in several articles who framed nursing as „a very rewarding job‟ with them „enjoying the challenges‟. One article punting nursing as a profession stated that „it wasn‟t just women‟s work‟, while another reported a hospital‟s celebration by allowing a schoolgirl whose father had been hospitalised there to follow a nurse for a day, leading to her decision to study nursing. It is noteworthy that coverage featured both private and public nurses at their places of work, and the Western Cape appears to have put the most effort into generating publicity, with double the number of articles than Gauteng. It is ironic that just a fortnight after IND was celebrated, several prominent negative articles about the deaths of babies in hospitals and nurse neglect appeared in the media, which may have nullified the positive impact of the day. 90 Limitations In considering the findings of this study, it is important to bear in mind the following limitations: The six-month period was likely to be sufficient to obtain a general idea of how nursing is portrayed in the mainstream press, but may not be representative of the entire year. Indeed, the period did not include the major public sector strikes which took place in mid-August 2010 which involved nurses, teachers and police among other state employees. The study was restricted to mainstream press cuttings sent by MSA to the student, and did not include articles which appeared in small, unmonitored media, and excluded broadcast media which were not included in the subscription. No industry norms exist for categorisation of circulation and readership into „small‟, „medium‟ and „large‟. The categorization of circulation was partly guided by industry award categories, although these only have an upper and lower circulation limit, and the delineation of „medium‟ was subjective. Since readership figures for all the community press were unavailable, readership for this sector was based on circulation rounded off to the nearest 1000, and so is at best an estimate. For this reason, analysis did not focus on readership to any extent. The category „community press‟ may draw criticism from some journalism academics who define true community press as grassroots, self-funded community publications, and who refer to for-profit publications as „local press‟. For the purposes of this study, the choice of the term „community press‟ was convenient and based on available information to allow differentiation from regional and national publications, and includes both free distribution publications and those sold in small towns. Quantifying the size of individual articles was not possible, since MSA occasionally reduced the size of articles in order to scan individual PDF pages. This variable was dropped from analysis, as the researcher had no access to physical articles, only those sent electronically. As the qualitative portion of the study, the discourse analysis was inherently a subjective process. Researcher bias should be taken into account, both for the sample selection which was purposive, and the analysis which may have been influenced by the where the lived experience of the researcher. The volume of cuttings (242) precluded a discourse analysis on all cuttings, and the sample selected delivered volumes of data which was time-consuming to decode and analyse. Although efforts were made to ensure the qualitative sample contained positive, neutral and negative articles and a similar 91 number of articles per theme, conclusions drawn may not apply to the entire census of nursing articles. A newspaper‟s selection of what is newsworthy is also a subjective process. With the possible exception of letters and public feedback columns, what appears in the press needs to have news or interest value. Therefore, only coverage deemed newsworthy or appealing to a publication‟s readers appeared in the press. This may guide what people think about nursing, but may not reflect reality. Addressing limitations Since news is socially constructed and its interpretation is influenced by individual ideologies and personal interpretation of signs and underlying meanings, perceptions of what constitutes „positive‟, „negative‟ and „neutral‟ may still differ between coders. To address this, a random sample of articles was coded by the supervisor, the results subjected to a Cohen‟s Kappa, which found substantial agreement for inter-coding reliability measuring slant (Kappa=0.72) and almost perfect agreement for theme (Kappa = 0.84), where values of Kappa from 0.60 to 0.79 are regarded as substantial and 0.80 as outstanding (Landis and Koch 1977). Since the researcher does not understand Zulu, one Zulu article appearing in Drum magazine was given to a Zulu-speaking staff member in the School of Public Health to compare with the English version of the same article. The articles were declared to be identical; hence the English version was used for discourse analysis. 92 CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS Conclusions Nursing is not a topic well-covered in the South African lay press. When it is featured, articles appear in community newspapers with small circulations, mostly on or after page 7 which is regarded of low importance. A positive finding is that nursing articles were mostly full-length news items, which has promising implications for improving coverage. Since IND was clearly seen to positively influence the extent and slant of coverage, producing nearly double the number of articles in May than any other period although in smaller, community newspapers, efforts by South African nursing associations to utilise the day to promote nursing should continue and be strengthened. When IND was excluded from analysis, negative articles dominated, mainly in national publications and press with large circulations focusing on strikes and unprofessional behavior/nursing neglect. Scathing comments from the public and media editors on the actions of a few nurses can cause lasting negative perceptions about the entire workforce. Nurses should be seen to advocate for health equity and quality care rather than be portrayed as the cause of inequity, ill-health and death. The lasting impression of nursing from the discourse analysis is that of a profession groaning under the weight of a crumbling health system. Sufficient attention is given to the working conditions, salaries and shortages of nurses for the public to have empathy with them up to a point. It should be noted that reporting on strikes was not inherently negative, particularly when nurses were portrayed as being unfairly treated. However, when norms of nursing behavior and professionalism are eroded, the public responds angrily when nurses do not „behave‟ as society expects them to and they are perceived as unprofessional, negligent and abusive. Although the negative publicity around nursing does not appear to have deterred entrants to the profession, more worrying is the overwhelming discontent expressed by the public about poor nursing care, a clear deterrent from seeking healthcare. It is incumbent on nurse advocates to be vocal in the interests of the patients they serve. While the voice of nursing is not silent - over a quarter of articles featured nurse quotes – their voices are drowned by spokespeople who were quoted twice as often. Nurse voices were most strident around predominantly negative themes of strikes and labour issues, yet they were fearful and spoke anonymously in a third of reports which solicited their comments. South African nursing would benefit from media advocacy which frames nurses as intelligent professionals, claiming their rightful place at the policy table and their space in the press as critical contributors to quality and equitable healthcare for all South Africans. 93 Recommendations Policy/Advocacy i. Talk about it: South Africa‟s constitution promises freedom of speech, and nurses need to feel free to speak out without fear of reprisal. Although speaking to the press is usually governed by in-house regulations, nurses and spokespersons need to be more closely aligned to ensure their message is conveyed accurately and that they do have an opportunity to be heard. IND is a day used by SA nurses and nursing associations to promote the profession. It is recommended that as far as possible, nurses should be seen and heard to promote their profession, not spokespeople. Additionally, nurses should be photographed with permission of genuine patients to portray the profession as honestly as possible. “Nurses must start to talk before they can expect to be heard” (Morley 2004). The dearth of articles on the professional practice of nursing in South Africa is alarming. Few people outside of nursing will appreciate what nurses do if they fail to talk about it in terms which showcase the academic capabilities of 21st century nurses, which complement the 19th century pervasive view of nurses as caring, compassionate health workers. “An accurate picture of nursing will emerge only when nurses and their organisations tell journalists not just who they are and how virtuous they can be but what they do and why it is important” (Buresh and Gordon 2006). If nurses believe they are overworked and underpaid as a result of shortages, what evidence do they have that their numbers are insufficient without some nurse-patient ratio guidelines? It may be time for South African nurses to champion quality health care delivery by advocating for institutionally- tailored guideline staffing ratios and skills mixes in both public and private institutions in order to better serve the public‟s health needs and their own (Bateman 2009). ii. Write about it: Very few letters or mobile phone messages were written by nurses about nursing. This is an avenue which can easily be exploited by the nursing profession to raise alarms, endorse action, or comment on any aspect of society where nurses have an impact. In reasonably small numbers, letters can be used as advocacy tools to alert newspaper editors to issues. iii. Picture it: Since nearly half of all articles featured photographs which are used to attract readers to text, nursing advocates should try to link photo opportunities with their news stories when possible. iv. Responsiveness: Regrettably, shortly after the overwhelmingly positive coverage which IND afforded the profession in May, several feature articles about nurse neglect, labour issues and strikes hit the headlines, most of which had large circulations and readership. This would undoubtedly have diluted any goodwill generated by the positive coverage of IND. Nurse spokespeople should move quickly and strategically in future to promote accurate framing and coverage of negative publicity, 94 ensuring that nurse voices are heard and the integrity of the profession is promoted. While the mass media may affect lightly held attitudes (Schramm 1964), South Africa‟s communication initiatives around HIV/AIDS have confirmed that deeply engrained customs, practices and beliefs require expensive, sustained and pervasive communication programmes often involving inter-personal interventions for behaviour change to be influenced. Nursing advocates need to collaborate now to manage negative perceptions before they become deeply-held beliefs. Capacity building Media training: Nurse spokespeople are likely to require up-skilling in terms of media engagement, in order to shape the media agenda in favour of nursing and to garner more extensive, positive coverage. Nurse leadership associations should cultivate relationships with regional media owned by the major newspaper groups, Avusa and Independent Newspapers which featured the majority of negative articles. In particular, the KwaZulu-Natal press need to be informed of the importance of nursing and particularly nurse training, given the widespread opportunities for coverage. Since the overwhelming majority of articles were in English, all nurse spokespersons feel comfortable communicating in English, while efforts should be made to boost coverage in Afrikaans and Zulu publications. Similarly, although nurses as frontline health service providers should be seen in their local community newspapers, if nurses are to be perceived as important, efforts should be directed to gaining positive coverage in press with larger circulations which influence funders, policy makers and politicians. Leadership and accountability: Leadership capacity of all nurses should be developed in order to empower them to speak out without fear of retribution about health system inequities which promote ill-health. Nurses should use the media to raise alarms about failing health systems and hold stakeholders such as government accountable. With media and advocacy skills training, nurse leaders will learn how to frame their actions as accountability and transparency to improve healthcare for all. Health systems Improving nurse-patient relations: This research has shown that some nurses as portrayed in the media have poor relations with their patients over whom they exert power, and their negative attitudes are impacting on service delivery. The innovative, locally designed “Health Workers for Change” programme utilises behavioural change at the interpersonal level through a series of workshops with health workers of all ranks to improve their communication skills, team work, problem- solving abilities. Implemented to scale, this programme may lead to improved nurse-patient relations, advice rather than rebuke, improved team spirit and openness to discuss problems, and better functioning of health services (Onyango-Ouma, Laisser et al. 2001). Given a more responsive 95 and open management and supportive environment, health workers will respond in a positive way with renewed commitment (Fonn and Xaba 2001). Partnerships and alliances: Nursing stakeholders should capitalise on collaboration established for IND to boost their profession and strengthen national health systems. As frontline workers, nurses are best-placed to guide policy and resource allocation, and their voices should be heard. Using the media is one way of including the voice of nurses in health service delivery particularly effectively if done in partnership with other nurse practitioners or associations. Partners could establish and utilise web-based communities of practice and bulk emails to encourage advocacy for an issue, and stimulate group discussion and networking to improve nursing research, evidence, practice, and service delivery (WHO 2010). Similarly, nurses should reframe their grievances about shortages, working conditions and pay issues in terms of patient care, which would contribute to a more empathetic public response and help civil society to act in support of nurse grievances rather than oppose them. Research Gaps: Not much appeared in the press on nursing research. This is a gap which can easily be filled once articles are published in academic journals. Research results should be disseminated to broader society in order to raise the profile of the profession, add to the evidence-base of practice and policy, and inform the public of nurse-led research findings. Research is essential for advocacy, and results need to be disseminated beyond nursing journals, which are likely not to be priority reading matter for policy-makers. Further research which sheds light on those who use nursing as a stepping stone to other careers could assist with retention strategies. The simple issue of a uniform may well help to improve the profile of nurses and nursing. While nurses may favour uniforms of dark colours, the pristine white uniforms of a previous era may have done more for the public‟s perception of nurses being hygienic and professional. Research should be undertaken to determine the South African public‟s perceptions of standardised nursing uniforms (white and otherwise), to determine if this relatively simple remedy may help to separate nurses from other workers, and renew confidence and esteem in the profession. Methodology, monitoring and evaluation: Analysing what is in the public domain through a discourse and content analysis of press cuttings on nursing is an additional, novel approach to public health research methods. This benchmark research report contributes to monitoring and evaluation of nursing press coverage, and is a barometer of public perceptions of the profession for the period January – June 2010. It should be replicated at intervals to determine if the profile of South African nursing is improving after interventions such as the April 2011 National Nursing Summit among other things. 96 REFERENCES ABC (2010). "Average sales _newspaper." Retrieved 21 January, 2011, from http://www.abc.org.za. 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Appendix 1: Coding Sheet Page 105 Item: Unique number assigned to each article to assist with computer coding Month: Month in which article appeared: 1 = January; 2=February; 3=March; 4=April; 5=May; 6=June Date: When article appeared Page: Page on which article appeared Heading: Title of article SA/Non-SA: Whether the article is on SA nursing or non-SA nursing. SA = 1; non-SA=0 Author: Who wrote the article; source of the article Publication: Name of the newspaper or magazine in which the article appeared Ownership: Who owns the publication : 1=Caxton; 2=Independent; 3=Avusa; 4=CTP; 5=Media24; 6=Other Circulation: The number of newspapers bought/distributed, usually audited by the Audit Bureau of Circulation: Small = 1 (<50 000); medium = 2 (50 001-100 000); Large = 3 (>100 001) Readership: The average number of reaaders per publication (Jul’09-Jun’10) from All Media Products Survey (AMPS) compiled by the SAARF (www.saarf.co.za); Small = 1 (<100 000); Medium = 2 (100 001-999 999); Large = 3 (>1 million) Publication: Type:1=national; 2=regional; 3=community; 4=magazine Frequency: The frequency of the publication: 1=daily (5x per week); 2=weekly; 3=fortnightly; 4=monthly Distribution: The geographic distribution of the publication: 0=national; 1=Gauteng; 2=KwaZulu-Natal; 3=Western Cape; 4=Free State; 5=Eastern Cape; 6=Northern Cape; 7=North-West; 8=Limpopo; 9=Mpumalanga Type: 1=news; 2=letter/discussion forum; 3 = editorial/opinion piece; 4 = feature; 5 = photo plus caption Prominence: The space allocated to nursing: 1=full article on nursing; 2=≤ 3 sentences/1 paragraph; 3 = < 1 sentence Slant: Identifies overall impression of article from readers’ perspective: 1=positive (nursing is promoted/uplifted/conveyed positively; 2=neutral (article does not take a stand for or against; objective); 3=negative (nursing is undermined or negatively conveyed) Language: 1=English; 2=Afrikaans; 3=bilingual; 4=Zulu Photo: Whether photo accompanies the article: 1=yes; 2=no Quoteno: How many people are quoted in the article in relation to nursing, in absolute numbers (1-6) Nursequote: Was a nurse quoted? 1=Yes; 0=No Patientquote: Was a patient quoted? 1=Yes; 0=No Drquote: Was a doctor quoted? 1=Yes; 0=No Unionquote: Was a union member quoted? 1=Yes; 0=No; Spokesperson: Was a person from management or a spokesperson quoted? 1=Yes; 0=No Unknown: Is the catogory of quoted person unknown? 1=Yes; 0=No Catnursequote: What is the category of nurse quoted? 1=Registered nurse; 2=nurse auxiliary; 3=student nurse; 4=unknown/other; 0=no nurse Gender 1: Gender of first person quoted: 0=Male; 1=Female; 2=Unknown; Gender2/Gender 3: gender of 2nd?3rd person quoted 0=Male; 1=Female; =Unknown Nursequoteno: How many times were nurses quoted? 1=Once; 2=twice; 3=three times; 4=more than 3 times; 0=no nurses quoted ID protect: Was the person quoted anonymous? 1=Yes; 0=No Themes: What is the key theme/topic of the article: 1=nursing profession/dress code/career/scope of practice/profiles; 2=neglect/negative attitudes/unprofessionalism/fraud/ negative service delivery; 3=academic nursing/training/skills/graduation; 4=strikes/protests; 5=labour issues/OSD/pay/shortages/nursing work conditions; 6=IND; 7 = other/passing mention APPENDIX 2: Page 106 Press Circulation, & Readership Figures: January – June 2010; No. of articles; Reporters with Bylines National Dailies: Circulation1 Readers (/’000)2 No. articles Journalist/s Beeld 95128 562 6 Antoinette Pienaar (4); Susan Cilliers; Lizel Steenk Business Day 36116 76 12 Tamar Kahn (7); Sibonakonke Shoba; Lupert Chilwane (2); Alistair Anderson (2) Citizen 71757 438 3 Daily Sun 433224 4 956 15 Mkuseli Sizani (5); Zingisa S/Sabelo M (2); Peter L; Niabulo Ngcobo; Vuyo S; Botwekazi N Sowetan 125130 1 457 13 Zinhle M; Katlego Moeng (3); Sibongile Mashaba(3); Frank Maponya (2) The Times 130093 377 2 Nivashni Nair National Weeklies/Sundays City Press 176025; 2122 2 City Press (2) Mail & Guardian 47 156; 437 2 Naweek Beeld 84974; 198 1 Sunday independent 39 493; 125 1 Eleanor Momberg Sunday Times 461 433; 4 085 6 Agiza Hlongwane; Henry Pelser; Lucas Ntyintyane; Subashni Naidoo Regional Dailies: Bus Report (Pta News) 26163 - - 4 Slindile Khanyile Business Report (Star) 160135 - - 1 Cape Argus 56455 312 5 Sipokazi Maposa(2); Bronwyn Jooste Cape Times 47631 253 3 Quinton Mtyala; Lyndon Khan Daily Dispatch 30249 280 11 Eddie Botha; Patrick Cull; Sizwe Kupelo; Justin L(2); Lubabalo Ngcukana Daily News 40 054 509 3 Lyse Comins (2); John Weekes; Daily Voice 90 000 627 6 Tshego Lepule; Anele Mjekula Die Burger 61756 431 3 Alet Rademeyer; Pretoria News 26163 136 5 William Tshabalala; Mogomotse Magome Son Kaap/Oos 121599 984 11 Leon Bonthuys (3); Bryan Goliath; Elridge J; The Herald 23830 270 12 Dineo M; Marius R; Mthetho N(2);Luyolo M; Sizwe Kupelo; Xolisa Mgwatyu; Mawande Jack The Mercury 35002 269 12 Gugu Mbonambi; Sharika REgchand The Star 160135 561 7 Lungi Langa; Angeliq Serao; Anel Lewis;Burgie I The Witness 21455 157 3 Chris Ndaliso; Volksblad 27233 159 3 Cathy Dlodlo; Regional Weeklies: Eastern Cape Today 32 713 - (new title) 4 Aretha Linden; Asanda Nini Pretoria News Wkend 15833 64 2 Sheree Bega (2) Saturday Argus 52815 248 3 Saturday Dispatch 25553 138 1 Asa Sokopo; Saturday Star 115998 361 2 Carvin Goldstone; Sheree Bega Sunday Argus 32 580 248 1 Edwin Naidu Sunday Tribune 90428 657 2 Edwin Naidu; Buhle Mbonambi Magazines Women’s: Living&Loving 30118 540 1 Carlien Wessels Vroue Keur 82662 539 1 Tanya de Venter Family: Drum 126 081 2 673 2 Tembisile Makgalemele C/Affairs: Noseweek 21 978 56 2 1. Circulation: ABC audited figures 1st quarter; 2nd quarter (www.abc.org.za) 2. Readership: AMPs (www.saarf.co.za/AMPS/PDF/AMPS%20June): Jul 2009 – June 2010 (SA Advertising Research Foundation); readership for all community papers not available) 107 Community newspapers (includes local ‘for sale’ papers and free ‘knock ’n drops);(readership not calculated) Newspaper: Circulation: Atholone News 55996 Benoni City Times 37 997 Chiawelo Urban News 25 000 City Vision (Khayelitsha) 50 453 Comaro Chronicle 21031 Corridor Gazette 4550 Cosmos Gazette 50 000 Eastern Free State 20 934 Eldorado Park urban News 30 000 George Herald 16370 Highvelder 16 883 Hoedspruit Herald nc Jabavu Urban News 27 500 Klerksdorp Rekord 14570 Knysna Plett Herald 3382 Krugersdorp News 30273 Lentswe 13 245 Limpopo Informant 4173; Mafikeng Mail 10 734 Middelburg Observer 17733 Mopani Herald nc Northcliff/Melville Times 32 240 NorthEast Tribune 24333 Northern Review 6403 Northglen News 27 400 Northside Chronicle 29 000 Our Times 2893 Paarl Post 15053 People’s Post 30252 Phoenix Tabloid 51 480 Plainsman 86333 Polokwane observer 6227 Randfontein West Herald 19800 Rekord East (Brooklyn) 65 120 Rekord 65120 Ridge Times 29 545 Sandton Chronicle 55160 Southern Coast Herald 15 730 Southern Courier 39 671 Southern Mail 45 460 Springs Advertiser 25702; Springs African Reporter 14 104 The Echo 18915 The Mirror 65 300 The Rep 5185 TygerBurger (Kraaifontein) 17 140 TygerBurger (Kuilsriver) 17 642 TygerBurger (Milnerton) 16 788 TygerBurger (Tableview) 28310 Tygertalk 29 789 Vaal Weekly 8242 VanderBijlpark Ster 27331 Vereeniging Ster 23487 Vukani 81 160 Weskus Nuus 14974 White River Post 4900 Witbank News 21 891 Worcester Standard 9616