The Dark Side of an Idealized Picture of Nursing

Firefighters, nurses, teachers, military service members, and doctors tend to be fixtures in lists of our society’s most-respected-jobs. Many of these professions are also the ones that children most frequently offer when asked about their career aspirations—and the jobs depicted most glowingly in pop culture, featured in children’s literature, and packaged as Halloween costumes.

A new paper from Yale SOM’s Julia DiBenigno suggests there may be a dark side to lionizing certain professional roles in a way that encourages children to calcify career dreams early in life—with consequences for both professionals and organizations.

Over the course of two years observing and interviewing nurses in two medical surgical units at a top U.S. hospital, DiBenigno noticed that nurses who’d felt called to a romanticized version of the nursing role (a calling that often struck when they were children) performed their jobs differently than the nurses who’d landed in the profession via more practical, adult-minded discernment. The former group were more likely to display evidence of clinging to what DiBenigno termed “idealized professional identities,” which she defines as “identities rooted in the image and history of an occupation rather than in reality”—in this case, an image of a respected maternal caregiver, rooted in the profession’s history and its heavily gendered associations.

DiBenigno observed how some nurses sought to enact and protect this identity, particularly in their interactions with patients. They did so by infantilizing their patients—addressing them with pet names, for example—and then displaying a distinct preference for patients who played into the maternal-caregiver dynamic (and avoiding those who rejected it).

Though this identity-protective behavior may have served as an adaptive mechanism for some nurses as they sought to shoulder a grueling work load, DiBenigno also highlights the ways in which it adversely impacted some patients and counteracted the healthcare organization’s broader goal to boost patient satisfaction.

The implications of DiBenigno’s findings extend far beyond healthcare, she says, and are crucial to understand within any profession where misalignments may fester between the fantasy versions and the on-the-ground versions of the job. Indeed, idealized professional identities may be more likely to flourish unchallenged in workplaces than ever before, DiBenigno adds, because of weakening on-the-job socialization.

“There are a lot of compounding pressures that might make it such that more people start a job based on a fantasy that they do not get sufficient time to unlearn,” DiBenigno says. “And that could later surface in various ways.”

In recent decades, the nursing profession has drastically transformed its systems for training and socializing new nurses. Over 30 years ago, recruits attended nursing school concurrent with a three-year apprenticeship in a hospital, where they could see the role’s reality for themselves before stepping into a job. In more recent decades, the profession has moved away from the apprenticeship model and now requires a four-year academic degree. “Then it’s basically ‘sink or swim’ when thrown into your first job,” DiBenigno says.

In her ethnographic observations of the 39 nurses in her study (the majority of whom were in their first four years on the job), DiBenigno was struck by the difficult conditions they faced. Nurses encountered heavy patient loads that induced them to arrive to shifts early and rush between rooms; they were frequently short-staffed and they found themselves caring for patients who they felt treated them as “waitresses” or “maids,” rather than respected caregivers. She saw first- and second-year nurses crying regularly, she says; later, the nurses often adopted a more jaded affect.

DiBenigno also observed another pattern, which she found befuddling at first. She noticed that the majority of the nurses displayed clear preferences for certain, select patients. The nurses hurried excitedly to respond to these patients’ calls and even bought them gifts. In other cases, however, nurses took the opposite tack, ignoring patients’ calls and talking about them in the nurses’ station.

She began to suspect the pattern might have something to do with another set of behaviors that she was seeing: the majority of nurses were treating their all-adult patients like children, using language such as “pee-pee,” describing them as “acting out” or “acting fresh,” asking if they need a “big-boy bed.” Many of the nurses using such language wore scrubs printed with cartoon characters or other juvenile designs, even though the units treated only adult patients. In her paper, DiBenigno notes that these behaviors directly contradicted the hospital’s mandate to treat patients “with respect” and not be overly familiar with them.

Even more striking, DiBenigno observed that the majority of patients rejected this mother-child dynamic, saying things like, “Don’t talk to me like I’m a baby.” Often, nurses reacted to these comments with frustration, complaining that patients were treating them like “waitresses” or “maids”—not the identities they’d signed up for.

DiBenigno wondered why more of these nurses weren’t quitting, and the interview portion of her research started to illuminate an answer: the nurses engaging in infantilizing behavior were drawing satisfaction from enacting a long-cherished identity, even if enacted infrequently, and it was helping them sustain themselves amid difficult working conditions.

In her interviews, she discovered that the main commonality among the nurses treating patients like children was a strong attachment to an idealized maternal-caregiver identity prior to becoming nurses. She heard again and again about “[wanting] to be a nurse since I was five years old” and about dressing up in nurse costumes as a child. “The uniform itself featured prominently in this image,” DiBenigno says, “almost like the attachment was to a fantasy and an image even before they went to nursing school.”

On the other hand, a smaller group of the nurses DiBenigno studied did not engage in infantilizing identity enactments. They stuck to plain scrubs, addressed patients as “sir” and ma’am,” and did not show the same predictable patient preferences. What DiBenigno learned in interviews with these nurses supported her theory about the power of idealized professional identities: these nurses chose the role while in college after exploring other career possibilities, and initially had neutral or negative expectations for the nursing profession. Notably, all six of the male nurses in her study fell into this subset.

“The few male nurses I studied were much more open to the nurse-as-customer-service-agent identity,” DiBenigno says. “And if you think about it, there’s no place for men in this maternal-caregiver idealized identity that’s very gendered at its core. In a way, I think that made the customer-service role perhaps less identity-threatening to male nurses.”

DiBenigno acknowledges that that the identity-protective behavior displayed by most of the nurses in her study may help them cope with the demanding conditions of their work. But, she suggests, going to great lengths to maintain a grip on idealized professional identities may not be a healthy way to adapt to those conditions—especially if it conflicts with the organization’s larger goal of positioning patients as empowered customers.

“Is this good for patients, professionals and the organization? I would say not in this case, if the majority of patients aren’t eliciting these identity-affirming practices,” DiBenigno says.

She emphasizes that for organizations, understanding idealized professional identities and how they’re perpetuated is a necessary starting point for harnessing the power of these strong identities rather than pushing against them. The hospital in her study, for example, could have taken a step to align the nurses’ idealized identities with the patients’ and hospital’s interests by inverting one of its “patient-empowerment” policies: instead of requiring nurses to thank their patients, the hospital could leave thank-you cards in patients’ rooms to encourage them to offer thanks to nurses. Such a policy would tap into patients’ sense of gratitude while recognizing the desire for respect and acknowledgement at the core of the idealized nurse identity.

Organizations across industries, DiBenigno says, can and must become savvier to their workers’ idealized professional identities. In some cases, this will mean working harder to disabuse new workers of their preconceived notions of a role, perhaps by creating opportunities for more realistic job previews or simply “giving space to myth-bust,” as DiBenigno puts it. In other cases, it will mean finding small or large ways to bring a job’s reality closer to its idealized version.

“It’s critical for managers to understand the images and ideals that attracted new hires into a profession,” DiBenigno says, “and to see whether they can create work environments that can deliver on some of those expectations.”

DiBenigno’s findings contain a message for individuals as well: beware of the professional “calling” that is rooted in an identity-based idealized narrative, rather than around the reality of the work itself.

“I find that those for whom callings involve strong identity-based commitments (versus callings to the actual work), may be at risk of not only experiencing negative individual-level effects,” she writes, “but also engaging in work practices that undermine their organizations’ client satisfaction goals.”