In recent decades, organizational and economic changes, alongside sociological and demographic changes, have been transpiring in global health systems [1, 2]. Scientific developments, multiple innovative technologies, and an inundation of medical information have increased the public’s demands and expectations of health services. New models of caring for sick people and the aging population have expanded the definition of medical care. There is, hence, a need to cover health expenditures, on one hand, and to increase the delivery and accessibility of services and availability of medical staff, on the other hand .
The ability to provide solutions for the ever-increasing needs of the health system, specifically those related to the upsurge of chronic morbidity, depends on a country’s economic resilience, allocations for healthcare, and the health systems’ ability to recruit workforce, facilities and technologies to cope with the rapidly increasing trials. However, the combination of the challenges of increased chronic morbidity, on one hand, and the lack of workforce that can satisfy them, on the other hand, poses a significant challenge to even the most developed countries. The gap between the financial allocations and the increasing actual needs is a challenge that is common to most health systems worldwide .
Recent decades have witnessed many developments in the global nursing profession, due to the increase in life expectancy, chronic diseases, reduced hospitalization time in general, medical and technological developments, and the perception of the patient as a client. These trends have resulted in developments and progress in the nurse’s role including academization, extended responsibilities, and widespread use of technologies and electronic equipment . In Israel, the most common degrees for nursing are a 4-year B.A. program leading to a Registered Nurse diploma (R.N.) and a Bachelor’s degree in nursing (B.A.), which offers theoretical and practical courses in anatomy, mental health, physiology, pediatric nursing, critical thinking, etc. The nursing programs prepare specialists to provide care for different patients. The nurse has a key role in reducing health gaps, providing a wide range of treatments on the health-illness spectrum, active involvement in health education and promotion, developing treatment and assessment programs, participation in multi-professional teams, and standing at the forefront of technology with the evolvement of online services .
Nursing image (NI)
The attempt to recruit nursing personnel depends to a great extent on the image of the nursing profession, and is one of the many challenges that health systems must overcome. Ever since the nineteenth century, the issue of nurses’ image has been described as problematic, and although it has changed drastically since then, it is still not high. At first, the profession was perceived as feminine and maternal, comprising activities such as protection, care, bathing, and laundry . The maternal image is still partially relevant today, and nurses’ main role is related to caring . But, over the years, some changes have occurred. The profession has become academic; nurses are better educated, and aspire to independent careers. In general, the NP has become slightly more prestigious [9, 10].
The perception of the NP has many implications. Among policymakers in health systems, the image affects the allocation of resources and the development of the field. Among nurses, self-image affects relationships with other professions, nurses’ work performance, violence against nurses, the public’s trust in the health system, low pay and work overload, burnout, and work satisfaction . Studies have found that most active nurses have a positive self-image of their profession, and only a minority have a negative one. Most feel pride in their chosen profession, although a small percentage have negative feelings such as shame .
It has been shown that the decision to become a nurse, and remain in the profession over time, is significantly related to the profession’s image, from both the nurse’s and the public’s perspective [11, 13]. The image of the NP affects the health system. For example, a positive NI influences students’ choice of a nursing career . A positive significant relationship was found between how nurses perceive the public NI and their own self-image . Also, the perceived public image was found to affect nurses’ work performance and intentions to leave the profession. When nurses believe that their public image is positive, they work better, and display more motivation to remain in the profession [16, 17].
The question is not only about the positive or public NI, but also the perception of who is suited to a nursing career, how much expertise is needed, how hard it is, and which personality traits are required to work as a nurse. For example, nursing has always been considered a feminine profession, less suited to men. This perception impacts how the profession is perceived in general .
In recent years, changes have occurred, and more men are choosing a nursing career . This, in turn, affects the changes in the profession’s image . Men have always worked in the nursing profession, but their numbers have always been much smaller than women . The number of men who choose a nursing career has been rising in the United States, England and Australia in recent years, and is expected to keep rising , although their numbers are still low. In Canada and the US only about 5% of the nurses are men, 10% in England, and 4% in Ireland. A relatively large number of male nurses was reported in Iran, where 23% of the nurses are men .
As mentioned, the small number of men in nursing affects its image. Professions with fewer men are considered ‘female’, and thus related less to power and more to caring. Men are typically managers, whereas women are typically in caring professions . Studies have found differences between men and women’s assessment of the nursing profession. Men appreciate the technical aspects of nursing, whereas women are more drawn to the relationships . Women value the care for the patient, including respect for the patient’s autonomy, privacy and confidentiality . Women also believe in a higher status of the NP [20, 24]. Yet, it is unclear if there are sex differences in self-image of the NP and self-reported quality of provided care.
In Israel, many duties and heavy workload would reduce the NI [25, 26]. It was found that most of the public perceive nursing mainly as a therapeutic profession that includes technical skills, or as a doctor’s helper. Similarly, findings elsewhere in the world have shown that nurses are perceived primarily as those who dispense medications, and listen to doctors’ instructions without asking questions . The nurse’s image is affected to a large extent by how nursing is presented in the media – articles and ads in newspapers, TV series, and films. Usually, the nurse’s media image is stereotypical, and rarely presents the reality of the profession .
A study conducted in Vietnam  found a direct association between the public image of the NP and the quality of nursing care. Nurses reported that when they felt that the public was critical of them, did not respect their work, and the patients treated them in a negative way, it impacted their ability to focus on the job, their motivation declined, they made more mistakes, and their attitude towards patients was less patient and respectful.
Quality of care (QOC)
The concept QOC is not new, and has been discussed frequently in the nursing context. However, to this day, there is no consensus on its definition, mainly because ‘quality’ is a general and somewhat vague term . Quality of medical care is, thus, defined differently by various bodies, according to their agenda . The American Medical Association defined quality of healthcare as a process that generates improvement or preservation of life expectancy on an ongoing basis .
One approach maintains that QOC includes two elements: technical quality and human-cultural quality. The technical aspect includes the actions required to achieve the desired results. This element is relatively easy to measure by professional criteria. The second element involves the quality of the relationship formed by the health professional with the patient, the communication between them, cooperation in decision making, empathy, satisfaction, and all other aspects included in the caregiver-patient relationship. This element is harder to assess . Another approach defined four components of QOC: communication, human resources, patient satisfaction, and control of infections [29, 33].
Various factors were found to predict the patients’ perceptions of QOC. The strongest predictor was the patient’s feeling that he or she was in good hands. Another important factor was the nursing team measure, which includes the intake process, a respectful and kind attitude, a feeling that the nurses listen and relate to questions and concerns, and their explanations are clear and understandable, and then, in order of importance – physical conditions and the medical staff . An additional factor that contributes to the quality-of-care perception is the informal support system, particularly by family members. On the other hand, the two factors that impair the QOC are the caregivers’ fatigue due to long shifts, and burnout .
Most studies measure the QOC by patients’ reports, but it is no less important to examine QOC from the health professionals’ perspective. For example, Moen and colleagues (2020) found that health professionals typically report high QOC .
It is important to understand the factors that predict QOC, because QOC affects the treatment’s success on many parameters such as reducing mistakes, better treatment results, and better recovery percentages [37, 38]. Nurses’ QOC is essential for the success of the health system in general. Nevertheless, the health system has found it hard to improve its QOC. Various intervention programs throughout the world have produced very small improvements [37, 39]. In recent years, the Israeli healthcare system has adopted several mechanisms for promoting quality and patient safety and care at various levels. These include legislation, financial incentives, quality indicators, patient experience, prevention and control of infection, accreditation, and the widespread use of electronic medical records. In addition, outcomes are heterogeneous: quality indicators, infection control and patient experience in primary care and the emergency department have all shown substantial improvement by minimizing disparities, and achieving greater improvements in patient safety and care .
In Israel, the percentage of male nurses has increased over the years. In 2009, 9% of all those licensed to engage in nursing were men, and it rose to 15% by the end of 2020 . Men and women experience different difficulties and challenges in the nursing profession, the public’s attitude to them, and their support, so that their attitude towards the profession and the image they develop of it are also different . Nursing has traditionally been considered a female profession, and its perception is linked to this image. Research conducted in Turkey found big differences between male and female nursing students concerning the profession’s image. Women believed that men joining the NP would not affect its image, whereas men tended to believe that men joining the NP would impact its public image negatively . Also, a majority of men believed that the NP should remain female.
The QOC of nurses is central to the success of the healthcare system. Good quality treatment is associated with higher recovery rates, smaller number of errors, and better overall treatment outcomes . A better understanding of the factors that affect QOC, should make the health system and its services better and more efficient. Hence, the aim of this study was to examine whether there is a relationship between the self-image of nursing and the nurses’ QOC, and whether men and women differ in their NI. Based on the literature, the following hypotheses were formed:
H1: A positive relationship will be found between nurses’ positive image of the NP and their QOC, so that the better the NI is, the better the QOC is.
H2: Differences will be found between men’s and women’s NI, so that women believe more than men in a positive image.