There are three nurses for every doctor in the U.S. But nurses appear as sources in only 2% of health care stories.

Jennifer Garrett was beginning to think she wasn’t very good at her job.

As a content strategist for the School of Nursing at the University of Wisconsin-Madison, one of her duties was to get nursing issues into news stories and her nursing faculty in those stories as expert sources. She was trying different approaches — picking people she thought would resonate as sources and cultivating them — but she wasn’t getting the kind of traction she thought her program deserved.

And then she saw the headline: “Woodhull Study Revisited.” Published in 1998, Woodhull was a landmark look at the invisibility of nurses in news coverage of health care. Nurses accounted for just 4% of sources and quotes in health stories in leading national and regional newspapers and just 1% in industry publications like Modern Healthcare. A team from George Washington University’s School of Nursing had redone the research 20 years later and found that nothing had changed. Nurses accounted for 2% of health news sources. (While this was down from 4% in 1998, the difference was not statistically significant.)

The Woodhull study showed Garrett’s experience was representative of health journalism in the United States, where nurses are all but completely overlooked as sources. Garrett wasn’t bad at her job. But Woodhull begged the question: Were journalists bad at theirs?

While it would be easy to credit gender bias for the invisibility of nurses in news, the full story is more complex. A combination of gender, journalistic routines and constraints and the culture of nursing itself explains the Woodhull results. Understanding that combination also offers a path forward for both news and nurses, ultimately giving more voice to health care’s most trusted profession and improved coverage for patients.

Journalism’s gender problem

The U.S. news industry faces widely reported gaps between men and women, both in who produces the news and who is represented in it. A 2017 study by the Women’s Media Center found that men account for 62% of bylines and other credits in U.S. news stories across all outlet types, while women claim 38%. Those numbers closely mirror the 2015 Global Media Monitoring Project, which found disproportionate representation among expert sources featured in news stories. While women were seen more frequently in news stories than in the 2010 monitoring, they still accounted for only about a third of expert sources.

The Woodhull authors noted Bureau of Labor Statistics data, showing nurses — at 3.5 million — are the largest group of health professionals in the United States. The country has three nurses for every one doctor, and Gallup polls consistently demonstrate nurses are the most trusted of health care professionals. In 2018, four out of five Gallup respondents rated nurses’ honesty and ethical standards as “high” or “very high.” Yet they appear as sources in 2% of health care stories studied. Why? The study authors argue part of the reason is that 90% of nurses are women.

“There’s no way to have this conversation without calling out the elephant in the room — that this is a female-dominated profession,” says Gina Bryan, a clinical professor in the UW-Madison nursing school and one of Garrett’s go-to sources for journalists. “That brings with it some of the cultural components of what it is to be a woman, how we communicate, how we’re held up as experts. You can’t ignore that piece of it.”

A Misunderstood Profession

Yet Bryan and other experts emphasize that it’s not enough to highlight gender bias. It certainly is one of the veils between nurses and health care journalism, but it combines with other shades that hide nurses and their impact. Diana Mason, who led the Woodhull Revisited study with her team at George Washington, said a fundamental misunderstanding of the range of nurses’ skills and expertise also explains journalists’ failure to use nurses in sourcing. Preliminary results from the second phase of her study, which involved qualitative interviews with journalists, showed some stuck in old stereotypes.

This resonates with Katharyn May, former dean of UW-Madison’s School of Nursing. She points to iconic images of Florence Nightingale, arguably nursing’s most important historical figure, and paintings showing the caring nurse tending to soldiers in the Crimean War. The “lady with the lamp” takeaway, May argues, creates an “angel imagery” that attaches to nurses to this day. But Nightingale wasn’t simply comforting those soldiers. By lamplight, she was building sophisticated statistical analyses of the dead and dying that she was sending to political leaders to influence policy and develop guidelines for medical care. She balanced care with intellect and skill, yet the latter qualities are often absent from our modern understanding of nursing.

“What you need in a nurse is this driving intellect balanced with this passion for caring about people,” May said. “Without the intellect, without the science, without the understanding of how humans recover, the niceness isn’t going to get you anywhere. Nurses are more than just nice people who know a few tricks.”

Even when people move beyond this angel imagery and see the expertise nurses bring, they often fail to understand what nurses do. May notes that people often think of nurses in hospital practice as carrying out the orders of a physician. Yet in reality, about 70% of what those nurses do is entirely independent practice. Beyond hospital settings, people misunderstand the scope of nursing practice and its critical importance to medical staffing, said Paula Hafeman, chief nursing executive for the Hospital Sisters Health System’s Eastern District of Wisconsin.

She said the public is particularly ill-informed about advanced practice providers, people who often begin in nursing and move on through specialized education and clinical training to become key elements of medical staffs within health systems. Nurses working as advanced practice providers include nurse practitioners, clinical nurse specialists, certified nurse anesthetists and certified nurse midwives. While many people assume that “medical staff” means physician, in most health systems, advanced practice providers make up a third or more of the medical staff. Hafeman said that in states with significant rural areas, these providers are critical, yet they’ve traditionally been left out of important decision making.

“In those rural health communities, they are the only caregiver,” she said. “They’re the medical staff provider, yet they didn’t have a voice at the table and still don’t in many organizations and communities.”

Bryan, who has developed vast clinical experience in psychiatric and addiction issues, particularly in underserved areas, echoes the frustration of being left out of decisions and public conversations despite having direct, boots-on-the-ground perspective. She also said that when she is interviewed by journalists, questions most often focus on interactions with patients, rather than the science, economics and protocols in her areas of care.

“Nurses are highly trained and qualified health care providers who are trained in science- and evidence-based practice,” she said. “When I get interviewed, it’s often … ‘What did the patient feel like?’ rather than, ‘Tell me about the neurobiology of substance use disorders.”

Cultural constraints within nursing

Some of that misunderstanding comes from nursing itself and cultural issues that often prompt people to stay in the background. Hafeman points to her experiences with nurses referring to themselves as introverts and emphasizing patients over themselves.

“Nurses overall are caregivers at heart, and so they care about patients,” she said. “Humility-wise, they are very humble people. They are not people that go out and look for praise for the work they do.”

Garrett also struggles to help some nursing faculty and providers to see themselves as the critical part of the health care system that they are.

“I feel like nursing has a humility to it, and then it has its path, its history — its gendered history — and its history of subordination to medicine that it’s a push to get (nurses) to say, ‘Yeah, I am an expert on community care, and I can take that interview.’”

The concept of authority in medicine resonates particularly strongly for Mason, whose interviews with journalists revealed that even when reporters did contact nurses as sources, they often faced pushback from editors, who viewed physicians as the “real” authorities on health care. This default to authority is an ethics issue throughout journalism, so it’s not surprising to see it play out in this context.

And it relates to a final element of nursing culture that leaves them out of news: respect for nurses within their own health care systems. Mason said that in her experience, public relations and communications staff are not like Garrett, actively trying to get nurses’ stories told. They’re more often the problem than the solution, failing to understand nursing roles and responding to media requests accordingly.

May said she believes these communicators are falling victim to two important trends she sees: lionizing the work of physicians and an increasingly techno-centric framing of health care. She recounted talking to a friend who almost died in her hospital but was saved by a surgeon using leading-edge technology. Yet this friend also pointed to nurses as essential.

“He said, ‘The physicians saved my life, but the nurses gave me my life back,’” May said. “It’s the human-to-human work that is what nurses know and can do, but it’s very difficult to describe and it’s not sexy. We haven’t done a good job of figuring out how to put it in terms when it’s all about the technology or it’s all about the quick save.”

Training nurses and connecting journalists

One of the key pieces to solving the dearth of nurses in news coverage, these experts argued, is improving training and helping nurses see how they can be a bigger part of the public conversation on health care. The first step is simple and pragmatic, Mason said: “This is getting nurses to realize when a journalist calls, they may be on deadline. You’ve got to respond right away instead of waiting for a week and hoping that maybe you’ll get up your nerve to call back.”

Beyond that, Hafeman said, including public-facing work as part of nursing education and reward structures within health systems is essential. She said serving on community boards, doing interviews with reporters and penning op-eds can help nurses grow as leaders, and their organizations should back them in those efforts. Hospital Sisters Health System has a professional development effort that rewards nurses for these public engagement efforts. About 30% of her RNs participate now, and Hafeman said she would dearly like to see that number grow.

She said she also sees herself growing more proactive in directing others within her system to better understand and represent nurses.

“I can work with my communications department and say, ‘The next time the media calls, and they want to do a story, let’s get an advanced practice provider to do the story,’” she said. “We don’t do that. We give them a (physician), or we give them an executive. That’s on us.”

Woodhull Revisited and other experts’ efforts to address this issue come at a ripe moment in journalism, as multiple organizations have addressed the invisibility of women in journalism overall. Noted science writer Ed Yong wrote persuasively in The Atlantic about his two-year effort to upend the gender imbalance in his stories, providing a roadmap for other journalists to follow. The BBC saw measurable improvements when it committed to leveling the gender playing field on its broadcasts. And a Bloomberg News reporter went viral when he tweeted about using women as sources half the time, “something I’ve failed at miserably in the past.”

For her part, May is at work on an experimental training program called “First 60” for nursing students. It focuses on the first 60 seconds of interaction between nurse and patient because that is when people make judgments about credibility and trustworthiness ­— what May calls “authentic professional presence.” May turned to a colleague in the Department of Theater and Drama to develop the novel curriculum, finding that acting students are trained in capturing an audience quickly and convincingly and can help nursing students learn to relay their authenticity with the same speed and success.

May said she thinks the curriculum also can help nurses better relate to journalists, something she’s had to work at herself.

“I reflected on all the times when I talked to journalists, and how sometimes I got in there with the grabby lines early, and other times I wandered around like a true academic in the weeds,” she said.

Mason applauds these kinds of training efforts and anything that helps nurses prepare for opportunities to add their expertise in public settings, yet she notes nothing will change until reporters, producers and editors open their minds to how that expertise will enrich storytelling. When she decided to replicate the Woodhull study, she expected that key trends like more and better education for nurses and the expanding roles of advance practice providers would have translated to more nurses in news. The results shocked her.

“We’re not saying things have gotten worse. We’re saying things have not changed. And even that, in this day and age, is appalling.”

Kathleen Bartzen Culver is James E. Burgess Chair in Journalism Ethics and Director of the Center for Journalism Ethics at the University of Wisconsin-Madison.