Highlights 
● Based on the reports, Iranian people moderately interact with national broadcasting.
● Iran's national broadcasting creates a non-professional image of nursing.
● Social attitude associates nursing with non-professional duties.
Plain Language Summary 
As mass media influence grows more prominent, it creates more effect on society and its opinion about the health care system. Nurses are affected by mass media as a result of their engagement with the community. Nurses work as the first line of the health care system in society. Our results showed that engagement with national media is associated with a wrong attitude toward nursing and its profession. This poor attitude can lead to less efficacy of health care and even aggressive behavior of patients toward nurses.
1. Background
The growth of social media has led to some tension affecting the perception of the professionalism of nurses in the healthcare system (Mather et al. 2016). One of the most important issues in nursing is talking about the public image of this field in the community which in turn can lead to the adoption of strategies that demonstrate an academic and professional public image of nurses. 
It can lead to the formation of self-concept and the professional identity of nurses. The public face of nursing has great diversity. Nursing professional self-concept largely depends on public attitudes toward this field. Thus, if a negative public image of this profession is received by a person, it can lead to a poor self-concept (Hoeve et al. 2014). Despite the strong influence of media on public opinion, they do not reflect the official and professional dimension of nursing.
In many of these images, nursing is introduced as a non-specialized activity for the care of family members just by women and not as a scientific profession in health care. Also, there is not a difference between the nursing profession and the role of the nurse and other members of the health care team in most images that can affect the nursing professional identity (Kemmer and Paes da Silva 2007; Takase et al. 2006). Some researchers believe that the improper image of nursing in the community leads to a sense of frustration in nurses (Nasrabadi et al. 2004). 
Nowadays, mass media; as the golden key to the awareness of the communities, their role in the culture and also formation and development of different aspects of human identity, especially national identity; has drawn the attention of scholars and researchers in humanities and social sciences (McCombs 2013). Social scientists believe that mass media is useful and effective in this area, so that they have considered the media as a personality factor, and believe that the mass media can strengthen or weaken social norms (Baecker 2016). 
In other words, mass media can help a lot toward the cultural leveling and uniformity of thoughts and patterns (Duggan & Smith 2013). In past arguments on the impact of TV on global culture, politics, social life, and identity, the critics have considered TV as a continuous flow of simplified ideas and emotional images for unaware viewers (Seel & Winn 2012).
By reviewing the history of media studies, it can be concluded that the impact of media has always been considered by the operators, scholars of media studies and governments. In fact, for those who are responsible and in charge of media, there is always this question: “Can media have an impact on the audience and help them in achieving their goals”. Expanding mass media (e.g. radio, TV, the Internet, etc.) has brought up a serious question about how they affect various aspects of people’s life such as lifestyle, fashion, interests, and different perspectives (Goh et al. 2013).
The social image of a profession is dependent on how it is reproduced within the different communication media. It has been demonstrated that mass media has a lot of power to reflect the truth of what has already happened in society and providing native culture monitoring (Heierle Valero 2009). 
It is believed that the image represented by the social collective in the media is not desirable for nurses and do not represent an image which can help understand the nurses’ abilities or the work carried out by them (Mather et al. 2016). Nurses choose to become healthcare professionals and learn a great deal of medical knowledge. However, most people are usually not aware of the nurses’ skills and competencies they have acquired through education and innovation. 
According to many studies, the public image of nursing is dissimilar and inappropriate. Nurses are partly responsible for this image because of their lack of public participation. Nurses assume their self-concept and professional identity from their public image, work environment, job values, education, and traditional social and cultural values (Hoeve et al. 2014). Regarding the importance of the public attitude toward the nursing profession and its impact on nurses’ professional identity, this study was carried out to investigate the role of the Islamic Republic of Iran Broadcasting (IRIB) in the public attitude toward the nursing profession in people living in Arak City, Iran.
2. Materials and Methods 
This cross-sectional study was carried out in Arak, a crowded industrial city in Iran in the first six months of 2018. The researchers went to five regions of the city at different times of the day and requested the passengers who agreed to participate in the study to complete the questionnaires. The study sample comprised of 400 above 16 years old citizens who were selected by cluster sampling method.
The public engagement with Iran national broadcasting and people’s attitude toward the nursing profession were measured using two researcher-made questionnaires. The first part of public-media engagement questionnaire included personal profile such as age, sex, marital status, education, occupation, etc.
The public engagement with Iran national broadcasting was measured by a 6-point Likert-type researcher-made scale from “low” to “high” with 14 questions. The total score ranged from 6 to 84. In sum, the scores were classified into three categories: low engagement with the media (<32), moderate engagement with the media (32-58), and high engagement with the media (>59).
The information about people’s attitude toward the nursing profession was collected by another researcher-made questionnaire. This questionnaire contains 33 questions with yes/no answers. Items were categorized into three dimensions, including non-professional duties, professional duties level 1 and professional duties level 2 as follows: Non-professional such as giving surgical instruments to surgeons during operation, unconditional obedience to the doctor, serving the doctor, cleaning patients, foot bath, etc.; Professional level 1 including checking vital signs, writing a nursing report, giving injections and collecting blood samples, collaboration with doctors in cardiopulmonary resuscitation, medication, blood transfusions, etc.; Professional level 2 including intubation, mechanical ventilation, upper respiratory airway suctioning, etc. 
To assess the validity of the questionnaires, they were given to 5 nursing faculty members of Arak University of Medical Sciences, and their comments were applied to the questionnaires. Reliability of the questionnaires was evaluated by a pilot study with a sample of 40. The Cronbach's α values of public-media engagement questionnaire and public attitude towards nursing profession questionnaire were 0.79 and 0.85, respectively. 
The sample size was estimated as 400 people using Cochran sampling formula. The city was divided into 5 areas, and the crowded places in each region were marked to obtain the samples using the cluster-sampling method. This study data were collected by survey method. The captured data then were analyzed by the Spearman’s test in SPSS V. 16. 
3. Results 
In this study, 400 people aged over 16 years participated. The Mean±SD age of the participants was 31.49±13.27 years. Table 1 presents the demographic characteristics of the participants. Table 2 demonstrates people’s engagement with the media. The Spearman’s test results showed that engagement with the media was related to non-professional attitude toward nursing and not with professional attitude level 1 and level 2 (Table 3).
4. Discussion
The findings of this study showed that the majority of the participants have engaged with the media at a moderate level (67%). Average non-professional attitude toward the nursing profession was more than professional attitude level 1 and level 2. The results also showed a significant correlation (P=0.032) between engagement with the media and non-professional attitude toward nursing profession while it was not associated with professional attitude level 1 (P=0.62) and level 2 (P=0.22).

 

In this regard, Jackson believed that common scenes of nursing were often negative about the profession and was based on a limited range of stereotypes which would defame the attractions of this profession for nursing students. Drama series cast at hospitals was one of the most popular genres since the very beginning of TV broadcasting (Jackson 2009). Showing nurses in medical programs is important because it plays an important role in the recruitment and retention of nurses in the profession (McAllister et al. 2014).

 

In another study, nursing students stated that public television could influence people and mentioned the negative consequences of distorting the image of the nursing because it leads to a false negative image of the nursing profession. After watching these kinds of programs, some people may believe that nurses do not work hard. But when they see what they do in real situations, they realize how hard the nurses work.
It has been shown that most nurses complain and believe that TV shows do not display the reality and the programs do not reflect the impact of nurses on patient’s care, safety, and rehabilitation (Koch 2013). It is believed that there is a contrast between what nurses do and what people think, i.e. what nurses do is entirely different from what people have in their mind. This false professional belief may challenge nurses to search for a better strategy to increase their confidence and show their valuable contribution to the health care system. In other words, nurses are hardly seen as a professional consultant or expert in the media (Stuart 2014). 
Harris and Gordon point to three essential ways for educating the public about nursing, including presentation of the profession, historical descriptions of nursing, and mass media. Different surveys about people’s idea about nursing and their role in the health care system have shown that people generally had a positive impression and believed that nurses are an important part of the medical team. It is expected that applying for the nursing profession as a career will improve in the future and it makes us think more about this profession and its place in public opinion and the national media (Harris & Templin 2006; Gordon & Nelson 2005). 
Many studies have shown that the majority of nurses have the necessary skills to take care of patients (Baillie 2011; Wilson & Hockenberry 2014; Oermann & Gaberson 2016). Other studies have demonstrated that the perceived image of nurses by the public is the same as portrayed in the media (Casella et al. 2014; Heshmati Nabavi et al. 2014; Neishabouri et al. 2017; Averill & De Chesney 2015; Valizadeh et al. 2014; Weaver et al. 2013).
These studies show that the perceived public image of the nursing profession has never been matched with professional reality in this field and most of the people do not have a real picture of nurses in their minds. Nurses and their profession is not shown as useful in the media, and public awareness of this field is based on theories and scientific resources with a considerable impact on the treatment of patients, and one that requires a college education is very low (Brennan & Bakken 2015; Kathreena et al. 2015).
The image of the nursing profession is dependent on what nurses have in their minds and what the people think about it. Previous studies have shown that what the nurses have in their mind were entirely different from what people had. The public image that most people have in their minds is rooted in distorted stereotypes in the media and the nursing profession. The media play an essential role in showing nurses as angels of salvation, or physician assistants (Almalki et al. 2011; Chitty & Black 2007; Kelly et al. 2012; Peck 2014; Rezaei-Adaryani et al. 2012; Rosen 2015).
Another study also shows that nurses and the nursing profession can be an eligible skillful, and respectful occupation. It can be concluded from this study that the image of the nursing profession in the media is not consistent with its professional and real picture (Kalisch & Kalisch 1983). It is believed that people’s view of nursing has become more positive, and nurses have been considered as knowledgeable, qualified, and highly skilled care providers (Donelan et al. 2008). In contrast, other studies have shown that nurses have poor communication with people and somehow are not seen and recognized by the media (Takase et al. 2006). 
A common theme which can be concluded from these studies is that nurses must have a great deal of effort to improve the negative image in the people’s minds and change their attitude towards nursing profession to some extent. Nurses need to raise the awareness of the public and the media about the different roles and many opportunities that are ahead of them and let the people know about the professional level of their valuable work as well. To let people know more about specialized and scientific roles that nurses play, they must improve their strategies and use social media, the Internet, and press to improve people’s awareness of this issue (Finkelman 2013; Kamran et al. 2012; Matthews 2012; Zuzelo 2014)
The results of our study showed that people’s view of nursing is non-professional because they had frequently witnessed non-professional images from national broadcasting about the nursing profession. People should know that nursing is not only about caring and working in hospitals but also researching which plays an important role in the patient’s safety. This public notification of nursing research creates a positive image of the profession in people’s minds and can be considered as a firm step in nurses’ empowerment. It seems that some people see a nurse as a female who provides care for the patients, not as an independent health care provider (Kemmer & Paes da Silva 2007; Takase et al. 2006). Also, nursing has been seen as a profession with limited employment opportunities (Natan & Becker 2010; Huffstutler et al. 1998).
Although the nursing profession is highly academic, the public image of this discipline is not a developed, academic, and professional one. The media image of the medical field has also influenced nurses’ role, status, position, and their public image (Emeghebo 2012; Huffman & Rittenmeyer 2012; Pennbrant et al. 2013; Varaei et al. 2012).To change the people’s perspective towards nursing and to leave a positive impact on their minds, the media planners should consider the professional and scientific requirements of this field because neglecting these issues creates bad effects on people’s views (Blais 2015; Hallam 2012; Schmitt et al. 2012).
This study aimed to investigate the role of IRIB in the public attitude toward the nursing profession. The results showed that the average score of non-professional attitude toward nursing was more than professional level 1 and level 2. Moreover, the results showed that the people’s engagement with the media is correlated with non-professional attitude to nursing; this means that people who are more engaged with broadcasting, have more non-professional perspective toward nursing. This condition happens because the media probably shows unrealistic images of the nursing profession, which is not congruent with the professional dimensions of this field. 
It is recommended that the broadcasting authorities make appropriate series with a more accurate understanding of the profession to help people with recognition of nursing. Nurses should also work harder to communicate their professionalism to the public. Nurses should increase their public appearance to promote their social image and obtain a stronger position in the healthcare system. Continuing education and a challenging work environment encourage nurses to stand up for themselves. Furthermore, nurses should engage more in key positions such as case manager, nurse educator, or clinical nurse specialist and show the public what their work really entails. This research was carried out as a cross-sectional study on relatively small sample size. It is suggested that other studies be carried out with larger samples countrywide.
Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Arak University of Medical Sciences (code: IR.ARAKMU.REC.1394.145). The participants were assured of the confidentiality of their information and agreed to participate in the study. 


Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' contributions
Conceptualization: All authors; Methodology: Farzad Ameri, Farzaneh Golaghaie, Ali Jadidi; Investigation: All authors; Writing original draft: Hossein Poorcheraghi; Writing, review & editing: Amir Rahbarian; and Supervision: Mehdi Harorani, Ali Jadidi.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors would like to appreciate the Research Deputy of Arak University of Medical Sciences.


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