key: cord-0901962-r0pmjy12
authors: Boulton, Maggie; Garnett, Anna; Webster, Fiona
title: A Foucauldian discourse analysis of media reporting on the nurse‐as‐hero during COVID‐19
date: 2021-11-02
journal: Nurs Inq
DOI: 10.1111/nin.12471
sha: 723b2459b6fadf308e37fa8d58ea81358ddc37c5
doc_id: 901962
cord_uid: r0pmjy12

This study uses a Foucauldian discourse analysis to explore media reporting on the role of nurses as being consistently positioned ‘heroes’ during COVID‐19. In so doing, it highlights multiple intersecting discourses at play, with the caring discourse acting as a central one in negatively impacting nurses' ability to advocate for safe working conditions during a public health emergency. Drawing on media reports during the outbreak of COVID‐19 in Ontario, Canada in the spring of 2020 and on historical information from SARS, this study seeks to establish caring as a discourse and examine if the caring discourse impedes nurses' ability to protect themselves from harm. The results of this analysis explicate how public media discourses that position nurses as caring, sacrificial and heroic may have impacted their ability to maintain their personal safety as a result of the expectations put upon the nursing profession.

We selected a FDA due to its emphasis on the material (or 'realworld') effects of discourse (Foucault, 1971 ). An FDA is concerned with asking, 'how' and 'why' questions regarding behaviours and beliefs rather than seeking any kind of universal truth, (Springer & Clinton, 2015) . The primary purposes of an FDA are to expose what is taken-for granted, such as societal norms or that which is generally accepted to be true by a large proportion of society (Bicchieri et al., 2018) , to delineate how these norms are in fact the tools of those who are in power (such as hospital administrators), and to offer an alternative to the dominant discourse (Cheek & Porter, 1997) . For

Foucault, normalization has occurred through the processes of capitalism and is associated with standardization of behaviour (Foucault, 2008) . These norms represent an optimal state and are directed towards a specific result and are prescriptive in nature (Foucault, 2008) . Norms can be utilized and perpetuated by those who wield power, albeit perhaps unknowingly as an assumption, while simultaneously allowing for the identification of behaviours that do not support the norms (i.e., the abnormal) (Kelly, 2019) .

A discourse is 'a common set of assumptions that are typically taken for granted, invisible, or assumed' (Cheek, 2004 (Cheek, , p. 1142 . Put in another way, a discourse is both a composite of and a repository for societal norms. These norms establish patterns that can shape both behaviours and expectations about the subjects of the discourse (Mills, 1997) , and legitimize certain modes of knowledge, such as scientific or intuitive knowledge (Hook, 2001) . Following Foucault, an FDA allows for an historical examination of discourse within a specified timeframe and context, acting as a means to examine the durability and persistence of the discourse (Foucault, 1972a) .

Establishing methods for an FDA can be challenging, due in part to the fact that Foucault changed his approach with each publication (Mills, 2003; Powers, 2013) . Following the work of Rawlinson (1987) and Powers (2013) , the following FDA methods were chosen to demonstrate completeness of analysis: problematization, the establishment of the archive, genealogy, history of the present, discontinuity, exclusion, discipline and circulation of the discourse (Boulton et al., 2020) . In this paper we present on our findings related to problematization, genealogy, history of the present and discipline.

The research question was developed using problematization.

Problematization allows researchers to look at why certain things have potentially become a problem (Foucault, 1990) . In this study, the ways that caring might impact the conceptualization and act of nursing itself was problematized using a gendered lens. Our use of a gendered lens was ultimately rooted in the values of the Victorian Era, as our genealogy traced the professionalization of the nursing profession to that time. However, we did not exclusively apply a gendered lens to our analysis; to do so would have been beyond the scope of this study.

Next, the historical usage of the term was traced using the specific lens created during the problematization process. This process is known as conducting a genealogy. The genealogy traces the construction of institutions and practices that have been created as a result of specific struggles, events and exercises of power (Garland, 2014) . Foucault called the culmination of the genealogy a 'history of the present', which demonstrates how the seemingly unquestionable current political and social climate of the discourse has actually been historically constructed (Roberts, 2017) . While our archive focuses on Ontario, Canada, the genealogy will focus on the caring discourse in a North American and European context, as the two developed in tandem (Reverby, 1987) .

The construction of the archive forms the basis of the pursuant analysis. The archive sets the limits for what can and cannot be said within the discourse via the context of the statement and the speaker of the statement (Mills, 1997) . The speakers (or authors) of the texts under analysis of the archive are positioned to be viewed as authorities on the subject, or as someone who would necessarily know or represent the 'truth' (Foucault, 1972b) . The authority of the speaker is assumed, thereby adding weight to the veracity of the statement.

In reality, the speaker's positionality is often supported by a wide range of institutional and textual sources (Mills, 2003) . The resulting analysis is intended to critically examine the positionality of the authors in the archive and place it in a wider context.

The archive for this study was established by conducting a focused search in three of Canada's major newspapers for articles related to nurses and COVID-19: The Toronto Star, The Globe and Mail and the National Post. All three report on rapidly developing situations and offer real-time quotes from the individuals and institutions at play. These specific newspapers were selected because they are widely read and easily accessed.

The search itself was limited to a three-month period, from 1 March 2020 to 1 June 2020, as this correlates roughly with the beginning of the pandemic in Canada. Nexus Uni, a database built specifically for newspaper searches was used to conduct our search.

The search terms included: nurse*, COVID-19 or coronavirus, work or job and Ontario. An Excel spreadsheet was created to record and subsequently categorize the themes noted during the review of the articles.

There was an original return of 559 articles. The titles and bodies of the articles were briefly scanned for issues related to safety, work refusal, caring, nursing care, nurses, hospitals, long-term care and frontline or healthcare workers. Articles addressing these issues were set aside for a more in-depth review. At that point, duplicates were identified and articles that did not meet our inclusion criteria were excluded. Our inclusion criteria included any articles that made reference to safety, work refusal, caring, nurses, hospitals, or healthcare workers. Our exclusion criteria included birth and death notices, anything that was not reporting on the situation in Ontario, or summaries of the daily news. There was an original return of 559 articles, 50 of which were ultimately included in the analysis. A complete list of articles included in the final analysis can be found in the 'Supporting Information' section. The articles were read using the technique of 'making strange', which entails attempting to view as an outsider with no knowledge of the underlying assumptions and knowledge that guides our capacity for making inferences during communication events (Gee, 2011) . The articles were then evaluated in relation to the research question (Kuper et al., 2013) . Story arcs, the use of quotes and specific language were noted. Any themes that were identified during the process of 'making strange' were noted and placed on an Excel spreadsheet alongside any potentially important quotes and details.

The articles were then read a third and fourth time, two and three weeks later respectively, to ensure consistency of approach and to re-analyse the archive for additional themes or discourses.

This process of moving back and forth between text and analysis numerous times is consistent with the methods of discourse analysis (Kuper et al., 2013) . Throughout the article review process, attention was also paid to disciplinary power. Disciplinary power works to create changes in conduct, attitudes and habits to cultivate specific skills or ways of thinking (Holmes & Gastaldo, 2002) .

Presentation of our genealogy precedes our discussion of analysis of the archive. This will provide historical context and a brief examination of the underlying, gendered construction of both the nursing and medical professions. We began our analysis in the Victorian Era, with the works of Florence Nightingale. This timeframe was selected as it is considered by many to be the advent of the professionalization of nursing in the Western context (Adams, 2016; Beck et al., 2013; McDonald, 2014; Reverby, 1987) . Before Nightingale, any woman could claim to be a nurse, as at that time it was believed that women innately knew how to care for the ill (Lewenson, 1993) . This belief may have been prevalent at that time because women were considered to be the traditional caretakers in the family. For example, if there was a sick relative, it was the women in the household who assumed care of the ill; nursing thereby became a logical extension of this role (Reverby, 1987) . While women were assumed to naturally act as nurses, it was also assumed that males were more suited to act as physicians (Hawkins, 2010) . It is upon these foundations of the gendered division of labour that our analysis rests. This analytic approach is in alignment with the idea that professions can be rooted in gendered stereotypes, resulting in a gendered construction of the profession, in spite of the fact that these professions remain open to any gender or sex (Acker, 1990; Davies, 1996; Le Blanc, 2016; Schneider, 2016) . Family medicine for example is now comprised of more women than men; nevertheless, aspects of the discipline remain tied to masculine ideals (Davies, 2003; Nye, 1997) .

In the Victorian era, the discourse of caring permeated ideas about woman's role in the home. In the early days of professional nursing, it was simply assumed that nurses would be innately caring as a result of their gender (Dahlke & Wall, 2017; Dunlop, 1986) . The notion of caring included the idea that self-sacrifice and altruism were desirable traits in a nurse (Dahlke & Wall, 2017; Reverby, 1987; Roberts & Group, 1995) . As a result, sacrifice and altruism were core concepts of the profession from its very earliest days (Dahlke & Wall, 2017; Reverby, 1987; Tierney et al., 2019) . Walker and Holmes (2008) wrote that nurses took on a 'sacrificial' role in the early days, both towards the physician and the patient. This notion of sacrifice was therefore embedded into the conceptualization of the profession during these early days.

Linked closely to this notion of caring is the idea that gender can be associated with function or specific attributes. The professionalization of the nursing profession during the Victoria Era is closely linked to ideas of biological (or gendered) essentialism (DeFrancis, 2005; Mosedale, 1978) . These ideas were mirrored in the organization of Victorian society. Victorian middle-and upper-class society was organized around the idea that women were the caretakers of the home (known as 'the private sphere') and men were to keep charge of any worldly affairs that took place outside of the home, including paid work (known as 'the public sphere') (Cordea, 2013; Hawkins, 2010) . This resulted in socially constructed, gendered ideas about what activities both women and men excelled in (Walker & Holmes, 2008) . One element of home care was the presence of a female caregiver, typically a family member (Hawkins, 2010) . It could therefore be said that the hospital nurse was used as a means to simulate the home environment in the clinical environment, with nurses playing the role of mother to the patients (Hawkins, 2010) . This had the added effect of reinforcing the patriarchal hierarchy inside the hospital, as at that time all physicians were male, were in charge of the nurses and ultimately made all decisions related to patient care (Hawkins, 2010) . They still arguably hold more power than nurses in any clinical setting, regardless of whether or not individual nurses are men or women (Davies, 2003; Nye, 1997) .

The result was an explicit gendered division of labour between physicians and nurses. The gender normative organization of the Victorian era resulted in an historical formulation of specifically feminine, sacrificial behaviour, linked to ideas related to morality, respectability and motherhood (Dahlke & Wall, 2017; Hawkins, 2010; Van Nistelrooij & Leget, 2017) . Nurses were not trained to 'care'

because it was assumed that they automatically could as a result of their gender (Anthony & Landeen, 2009; Dahlke & Wall, 2017) . This is reflected in some of the attributes associated with the nursing profession at that time (such as tenderness, nurturing, morality, selfsacrifice and devotion to duty), identified by nursing reformers and government bureaucrats across North America and Europe as essential characteristics of a nurse (S. Gordon & Nelson, 2006) . The presumed female duty to provide care, rooted historically in biological essentialism, was therefore already entrenched in societal gender norms and roles, and this association was simply carried forward into the profession of nursing. The gendered origins of the nursing profession helped to ensure that these concepts were not sex-specific, but instead were mapped onto the profession as a whole (Hallam, 1998) . Subservience and deference to the physician remained an essential attribute of the nurse through the 1950s and 1960s (Peplau, 1999) , further consolidating the power differentials between physician and nurse. With the emergence of feminist theory in the 1970s, nursing as a profession was sometimes denigrated due to the subservient role nurses were expected to take to physicians (Roberts & Group, 1995) . Gender essentialism was taken up by some feminist theorists such as Gilligan (1982) and Noddings (1984) . Both Noddings and Gilligan believed caring was integral to the female sex, bringing gender essentialism to the forefront yet again. This type of feminism was often referred to as 'maternal feminism'. This formulation of caring as a feminine trait was presented in a positive manner; however, linking biology with specific attributes and gender may result in misattributing behaviour to biology instead of environment (Herd et al., 2021) . Around the same time, nursing theorists such as Jean Watson (1979) and Madeleine Leininger (1978) developed theories of caring that concentrated on caring as the defining attribute of the nursing profession. By the 1980s, caring was positioned as intrinsic to the nursing profession by many theorists (Meleis, 2012; Paley, 2002; Traynor, 2019) . In fact, Dunlop (1986) noted that the emergent caring theories of the 1980s could be linked back to the concept of love in the private domain of the Victorian Era.

The linkages between caring and gender were established outside of nursing theory but remained problematic as they did nothing to reformulate the profession outside of its gendered origins.

The influence of caring theory and the discourse of caring remains linked to the profession of nursing in subtle but important ways. For example, the expectation that nurses sacrifice themselves for their patients and the healthcare system remains an oft-unspoken but recognizable element of the nursing profession (see Beard, 1999; Ciezar-Andersen & King-Shier, 2021; Emerson, 2017; Goodolf, 2018; Langtree et al., 2020; Mohammed et al., 2021; Moradi et al., 2020; Pask, 2005; Rickett, 2010; Traynor, 2019; Valiani, 2013) . Caring theorists in the nursing field point to sacrifice as a meaningful and important component of the nursing process (Helin & Lindström, 2003; Watson, n.d.; Watson et al., 2019) . Nurse participants in Fitzgerald and van Hooft (2000) study identified sacrifice as a precursor to 'love' in nursing. As demonstrated in the genealogy, the emphasis on certain traits such as caring and sacrifice is intertwined with the ideal of the feminine. Justice Archie Campbell was established for the official provincial inquiry post-SARS. In the commission's final published report, the inquiry team found that safety concerns of nurses were routinely dismissed (Campbell, 2006a; Registered Nurses' Association of Ontario, 2003) .

Nurses felt they were expected to do as they were told by management, reported being shouted at and belittled by hospital administrators when they raised concerns about their safety, were asked to reuse masks, claimed they were refused access to masks by hospital administrators, and were told by management that if they did not like the working conditions, they should not be in the profession (Campbell, 2006a (Campbell, , 2006b . Some nurses surveyed by the committee reported that they felt that the budget was given greater priority than nurse welfare (Campbell, 2006a) . Nurses reported higher levels of burnout, stress and greater levels of decreased job satisfaction than physicians after their experiences in SARS (Tolomiczenko et al., 2005) .

Media representations at that time also promoted the 'healthcare heroes' trope, which was often presented in spite of direct opposition to the feelings and experiences of nurses themselves (McGillis Hall et al., 2003) .

The Commission found that physicians were not always subject to the same rules as nurses. For example, they found that nurses reported that physicians often needed to be reminded to wear their PPE by nurses, at times refused to wear PPE or follow other safety protocols, had their opinions taken over the advice of bedside nurses, and management who tended to take physicians' concerns related to safety more seriously than nurses' (Campbell, 2006a) . At the same time, existing power differentials between nurses and physicians meant that nurses felt constrained in their ability to ask physicians to follow infection control procedures (Amaratunga et al., 2010) . Nurses reported that they expressed their concerns about lack of appropriate PPE to senior physicians and others in positions of authority at that time but were nonetheless expected to come in when they were symptomatic and pressured to work overtime and double shifts (Registered Nurses' Association of Ontario, 2003) .

The genealogy and history of the present demonstrate the persistent nature of these discourses in relation to the nursing profession, indicating that this relationship is an historical one. Our genealogy has identified the linkage in the literature between caring and acts of sacrifice and our history of the present has demonstrated that there can be differences in how physicians and nurses are treated during emergencies. We will now move onto the analysis of the archive.

In addition to the genealogy presented above, we identified four dominant themes in our analysis of the archive. These were: (1) dismissed concerns for safety, (2) fear of retribution, (3) caring nurses versus expert doctors and (4) discipline.

The majority of the included articles focused on the debate surrounding the level of PPE required to maintain individual safety from COVID-19. There were numerous comparisons to the SARS outbreak in a multitude of the articles. Very few these articles were positioned from the standpoint of nurses themselves. For much of March and April 2020, it was reported that nurses who were actively treating COVID-19 patients were denied the use of N95s (National Post, 2020a, 2020b). The reasons for this lack of access were ostensibly related not only to issues of supply, but to the presumed nature of the transmission of the virus at that time. Initially (i.e.,

March and April 2020), infectious disease physicians at the provincial level advised the province to stop requiring the use of airborne precautions for the disease, not only because the scientific evidence suggested droplet transmission, but also to conserve sparse resources (The Toronto Star, 2020c; Ward, 2020). Physicians specializing in infectious diseases employed by the hospitals made it clear in some of the articles included in the archive that allowing healthcare workers access to N95s was an unnecessary expenditure (at best) and a waste of resources (at worst), particularly when the supply chain was questionable (Weeks, 2020a (Weeks, , 2020b . Speculation existed around whether or not the policy of Public Health Ontario to downgrade from requiring the use of N95s was based on scientific fact or related to issues with supply Cribb, 2020; The Toronto Star, 2020a , 2020b . In addition, staff in one facility were told not to wear surgical masks in the halls as it might scare the residents of a long-term care home even though PPE was available to them (LTCH) (McLean & Welsh, 2020) . The supply issues and disagreements among healthcare staff regarding the appropriate level of PPE are reminiscent of the experiences of nurses during SARS as described by Paterson and Tyshenko (2010) . The rationales provided to nurses as to why they did not need N95s was formally attributed to emerging science in these articles, but could alternatively be interpreted as supportive of the informal, historically based expectation that nurses had a duty to sacrifice themselves for their patients.

Active withholding of PPE led some nurses to report a sense of mistrust between nursing staff and management (McKinley, 2020;

The Toronto Star, 2020a). A nurse who requested anonymity stated that she had heard managers telling staff, 'This is what you signed up for' in response to a request for PPE (Cribb, 2020) . One nurse stated that she felt that their entire worth had been reduced to 'two masks and a brown paper bag' (Ferguson, 2020) . It was also reported that staff who did not belong to unions feared being fired for work refusals or complaining (The Toronto Star, 2020b). This fear of retribution was a common theme reported in many of the articles and aligns with Foucault's formulation of discipline (Foucault, 1995) . For Foucault, discipline is a tool that is used to maintain power relations over the subjects of the discourse via disciplinary coercion (Foucault, 1980) . Disciplinary coercion is intended to evoke a desired response through correction. There were a few examples of this type of coercion reported in the archive. It was rumoured that one nurse who posted a video clip to her Facebook account asking the public for PPE donations was going to be fired as a result of the video (DiManno, 2020). The same newspaper put in a request to the hospital to interview front-line workers, and the hospital declined to allow the interviews. One unnamed nurse provided a reporter from The Toronto Star internal memos from her hospital regarding the re-use of N95 masks (Warren, 2020) . Some nurses interviewed explicitly stated that they preferred to remain anonymous as they were concerned about the potential for retribution Cribb, 2020; DiManno, 2020; Ferguson, 2020; Li, 2020; Warren, 2020) . The indication is that this fear of retribution effectively silenced some nurses from speaking publicly about their worries related to keeping themselves safe.

In many newspaper accounts, nurses were portrayed as passively providing emotional work such as providing comfort to a patient, whereas physicians were often depicted as active, conducting research, making decisions and performing medical procedures. In one article, intensive care unit (ICU) nurses were described as the 'emotional conduits' between families and COVID-19 patients . ICU nurses are some of the most highly technically trained nurses in the field of nursing, yet they were rarely portrayed as such in the archive. There was only one instance where a nurse was described as monitoring vital signs, the ventilator, medications, IV, as well as ensuring the patient's comfort (Ogilvie, 2020) . Other articles described nurses as speaking very lovingly of those that they are caring for and expressing discomfort with the ways that the bodies are treated following death by COVID-19 (Welsh, 2020) . A nurse quoted in The National Post (2020), talks about having to stop herself from hugging patients and cites the importance of maintaining the 'humane' side of nursing. Nurses were described as holding hands of those who died, and a family member notes the staff's love and concern for residents. One story describes a nurse as 'gently' putting a thermometer in the ear of a mourner at a funeral (Orms, 2020) .

Another article discusses a nurse employed at a long-term care home, finishing her shift in spite of the fact that she was symptomatic for COVID-19, because she knew there was no one else to do the work (Li, 2020) . There was no description of how the disease might affect her personally, or whether she had any health conditions or family at home to care for; it was simply a testament to this nurse's desire to care for other people by putting their well-being ahead of her own.

On the other hand, physicians were primarily described as performing technically sophisticated work or procedures that required great skill and expertise. For example, one article detailed a physician as intubating patients at the start of their shift (Yang & Ogilvie, 2020 ).

Doctors were also described as frequently checking scientific BOULTON ET AL. | 5 of 12 literature and drawing attention to provincial websites outlining safe procedures for intubation and providing guidance on patient care.

One physician's role was described as interpreting scientific literature into policy at the hospital, with no references to patient care or interaction (National Post, 2020) . Another physician noted an online site dedicated to help guide healthcare workers at the bedside through cell phone technology; this information overlooked the reality that many healthcare facilities prohibit nurses from carrying cell phones while working (Yang & Ogilvie, 2020) . Physicians were quoted on explaining how mechanical ventilation works, when in fact ventilators are most often maintained by ICU nurses.

Overall, the archive depicted a stark contrast between physicians and nurses work, even though their skill sets often overlap. Physicians often appeared detached from the caring process or from patient care altogether. Nurses were depicted as being absent from the research and scientific processes involved in medical care. Again, we see here some of the historical ideas and images about the caring and sacrificial nurse emerging in stories of the present day.

The CNO governs documentation, administration and the behaviour of nurses by ensuring that nurses follow their Code of Conduct Evidence from the archive suggests there were a number of instances where nurses were threatened with disciplinary action or retribution if they refused to wear surgical masks (as opposed to N95 masks). As discussed previously, discipline was used as a threat against nurses for noncompliance in numerous instances in the archive. In addition, nurses were quoted as being scared of retribution within the workplace for speaking with the media or sharing their stories and in many of the articles nurses requested to speak anonymously when being openly critical of the healthcare system.

The discourses of 'nurse-as-hero' and 'nurse-as-sacrifice' are not disparate. Discourses routinely co-exist with one another (Powers, 2013) . The discourse of 'nurse-as-hero' during has been discussed by other authors (Brophy et al., 2021; Cox, 2020; Einboden, 2020; J. M. Gordon et al., 2021; Mohammed et al., 2021) . Mohammed et al. (2021) concluded that the nurse-as-hero discourse was positioned as a reward for nurses and as a convenient means to ignore the lack of support that nurses receive from their places of work, managers and the government. Cox (2020) posits that a focus on heroism can detract from valuable conversations about the professional obligations of healthcare workers. Our study has added to these findings by identifying the durable historical nature of this discourse and placing it within the broader discourse of caring. In addition, we have focused on the sacrificial aspect of this particular discourse, which can be related back to the hero discourse via the imagery of war (Rahimi, 2005) or to the caring discourse via the discourse of femininity (Hallam, 1998) .

Caring is a malleable concept that can be defined in multiple ways and remains a divisive concept among nurses themselves (Cook & Peden, 2017; Paley, 2001) . By positioning caring as a central tenet of nursing, an opportunity exists to constantly redefine the purpose and job of nurses due to the lack of clarity in the meaning. This lack of specificity creates a space for the emergence of multiple forms of knowledge about nurses, such as the idea that nurses are innately nurturing and sacrificial. A recent meta-analysis of the concept of caring in the nursing literature found that caring is a cross-disciplinary concept that some nurses felt was currently poorly defined in nursing theories and philosophies (Sebrant & Jong, 2021) . The authors recognized that caring requires the full support of healthcare organizations and inclusion into the curriculum and practice of all healthcare professionals (Sebrant & Jong, 2021) . Given the complexity of the integration and interpretation of caring, characterizing it as the foundation of the profession should be considered carefully.

The safety issues identified by many of the nurse interviews contained within the archive have been identified by other researchers as issues that caused nurses in Ontario significant distress during the early stages of the COVID-19 outbreak in 2020 (Brophy et al., 2021) . Brophy et al. (2021) found that healthcare workers felt they had received inadequate protection, were failed by the government, and felt as if they were unable to exercise their own agency.

The authors concluded that healthcare workers were essentially sacrificed to maintain a functional healthcare system. In addition, nurses who initially raised questions around the transmission mechanisms of the virus (i.e., airborne vs. droplet) were ultimately supported by numerous studies (Brophy et al., 2021; Centers for Disease Control and Prevention, 2021; Greenhalgh et al., 2021; World Health Organization, 2020) .

The practice of sacrificing the health and well-being of nurses in Ontario is not a new one. Valiani (2013, p. 1) wrote that the sacrifice of nurses is an 'under-recognized but regular practice in Ontario', and is not limited to public health emergencies. The healthcare system is dependent on the idea that nurses will do whatever it takes to be caring, which ultimately may result in acts of sacrifice on behalf of the nurse (Dahlke & Wall, 2017) . Valiani calls this the cycle of sacrifice in nursing, and suggests that it functions via specific mechanisms, such as understaffing and overwork. According to Valiani, the results are burnout, stress, nurses who opt to take stress leave, or who leave the profession altogether (Valiani, 2013) . It should therefore come as no surprise that the number of nurses who considered resigning from nursing rose once the SARS outbreak in Ontario was declared over (Mavromichalis, 2003) . Related, a survey conducted by the Registered Nurses' Association of Ontario mirrored Mavromichalis' finding. The report suggested that up to 15.6% of nurses will exit the profession by the end of 2021, which is approximately three times higher than the typical loss rate (Registered Nurses' Association of Ontario, 2021). A more recent article reported that new nurses are choosing to leave the profession after only working in the profession for a number of months (Favaro et al., 2021) . The same article interviewed a nurse who stated that the expectation of being a 'hero' made her feel constrained in discussing 'how exhausted she really was' (Favaro et al., 2021) . The routine sacrifice of nurses therefore has real-world implications not only for nurses but for the healthcare system as a whole. The expectation that nurses work in unsafe conditions has led not only to burnout, but to a mass exodus. It is perhaps cynical to point out that instead of addressing the existing problems within the healthcare system the current provincial government has instead decided to fund educational opportunities for future nurses (Alberga, 2021) .

This action merely supports the cycle of sacrifice that has become embedded into the nursing profession.

As demonstrated in this study, media accounts can serve as one source for the perpetuation and reinforcement of these norms. The media is often positioned as an objective source of information, but other researchers have found that social norms can be projected through journalists. For example, multiple studies have demonstrated the detrimental effects of the media on body image (M. K. Gordon, 2008; Hamilton et al., 2007; Milkie, 1999; Tiggemann, 2006; Tiggemann & McGill, 2004) . Gunther et al. (2006) found that the media played a role in the perpetuation of perceived peer norms. The positioning of the media as a 'neutral' source of information coupled with the findings of previous research on the media's role in the perpetuation of social norms ties into Foucault's contention that knowledge, truth-telling and power are inextricably linked (Foucault, 2000) and they can be used as a means to exert political influence or authority (Foucault, 2001) . The circulation of the caring discourse bolsters the position of hospital administrators and managers by potentially reinforcing their attitudes around the necessary sacrifice of nurses.

The perpetuation of these norms in the media may therefore act as a means to reflect what society believes nurses should be, rather than what they necessarily are. Whilst issues related to body image and issues related to nursing are quite disparate in terms of subject matter, the means to perpetuate these norms via the media are similar. Nurses may either compare themselves or be compared by others to the images perpetuated by journalists. While most journalists strive to be objective, the objectivity of the media can be exceedingly challenging and in some quarters is no longer considered to be an achievable goal (Weber, 2016) . The Foucauldian interlinking of power, truth-telling and knowledge means that the perceived neutrality of the media places them in the position of societal 'truth-tellers', ultimately placing journalists in a position of authority.

Their writings serve as a vehicle to reproduce social norms by presenting an image of nurses that is ultimately comforting and already known to the reader.

The findings of this study reflect the tendency of media outlets to reproduce the portrayal of nurses as unskilled helpers to physicians, obfuscating their technical knowledge and skill (Summers & Summers, 2015) . Media representations of nurses will often reproduce this idea of what nursing is, resulting in the perpetuation of the idea that nurses are inherently loving and sacrificial (S. Gordon & Nelson, 2006) . Our findings are also consistent with the findings of DeMarco and Roberts (2003) , who wrote that nurses were generally resistant to speak to the press or in public situations. The authors associated this reticence with 'institutionally imposed powerlessness' (DeMarco & Roberts, 2003, p. 113) , a learned behaviour that can result in a reluctance to assert oneself either publicly or in the workplace. S. Gordon and Nelson (2006) further support these findings, and assert that journalists turn to physicians, not nurses, for healthcare news. In addition, they found that nurses have reported being disciplined by their employers when they speak out about medical matters, but not if they spoke about caring, advocacy, or their humanistic role (S. Gordon & Nelson, 2006) . The discourse of caring therefore can act as a means to silence nurses from speaking out about issues that they are concerned about, due to a fear of retribution.

This potential silencing of nurses has real-world implications.

Nurses in Ontario are advised by their regulating body to advocate for quality work environments (College of Nurses of Ontario, 2017).

The CNO states that work refusal during COVID-19 is an ethical dilemma, requiring careful consideration on behalf of the nurse, as it may be perceived as patient abandonment (CNO, 2021) . Physicians were provided with options during COVID-19 to work remotely or to refuse work that may put them or their family members in harm's way (College of Physicians and Surgeons of Ontario, 2018, 2020). Nurses were advised to consider their ethical obligations around work refusal and were not provided by any means from the CNO to adjust their obligations to keep their family members safe (College of Nurses of Ontario, 2021). Dahlke and Wall (2017) hypothesize that the focus on caring may impede nurses from raising their concerns about certain workplace practices out of the fear that they might not be performing up to the ideal of caring.

This has placed nurses in a bind: if they wish to advocate for themselves, there is a recognition that they may face retribution from administrators, colleagues, or even the public. The evidence gathered from the archive suggests that many nurses were provided a space to speak in media accounts only if they were speaking about emotional labour. The discourse of caring therefore impacts the ways in which nurses express themselves publicly as well.

Our study examined current discourses related to nursing during a time of pandemic through a genealogical lens. The nurse-as-hero discourse is related to many other discourses, such as caring and its attendant emphasis on sacrifice that surrounded Victorian ideals of women's place in the home. Providing a historical context allows us to examine current ideas as they arose from past associations. In addition, instead of discussing discourses as an abstract concept, we have traced the material consequences of these discourses on nurses' ability to advocate for safe workplaces during public health emergencies. We linked the themes of caring, sacrifice, gender and safety in a way that demonstrates that caring is not a theoretical concern for nurses; it impacts nurses daily.

A limitation of the study may be related to the fact that we confined ourselves to national Canadian newspapers, with a particular focus on the province of Ontario, the most-populated province in Canada. However, it seems unlikely that the inter-related discourses we identified would have developed in any substantially different way across the provinces, with the probable exception of areas with large Indigenous populations or on Indigenous reserves.

The importance and breadth of this field of study means that there are many possible future directions for research. For example, future studies should include a systematic review of the literature surrounding some of the discourses that have arisen from the COVID-19 pandemic. Another area requiring further research is the issue of racialized identities and the discourse of caring given that the current research has identified the potential exclusion of racialized identities from the discourse of caring (Boulton et al., 2020; Einboden, 2020; Mohammed et al., 2021) . Further, a closer inspection of ethical issues would add important information, as would a more detailed gender analysis.

The association of sacrifice with the discourse of caring can be traced back to at least the Victorian Era, and this study demonstrates that sacrifice is still considered to be a 'caring' behaviour. The expectation that nurses should be caring may result in placing nurses in unsafe situations or asking nurses to compromise their sense of personal safety. As a result of the historically based conceptualization of nurses as sacrificial, nurses may feel compelled to conform to these unspoken social norms that, in turn, may pose safety risks to the nurse. Nurses operate under the auspices of autonomy and advocacy, but the discourse of caring has the potential to silence them through the co-optation of their right to speak by experts, their places of employment and regulatory bodies. Calling nurses 'healthcare heroes' creates potential for the reinforcement of the perpetual cycle of sacrifice as described by Valiani (2013) . By monitoring the behaviour of nurses and labelling advocacy as insubordination or unprofessional behaviour, nurses may be at risk of being formally disciplined or of being expelled from their own profession (College of Nurses of Ontario, 2018). In future, it is important to recognize that the work of humanizing healthcare needs to be applicable to all healthcare professions, regardless of professional designation or gender.

The authors declare that there are no conflict of interests.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://orcid.org/0000-0002-7049-1074

Anna Garnett https://orcid.org/0000-0001-7111-8602

Fiona Webster https://orcid.org/0000-0002-7318-7713

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