In line with previous research, the primary care nurses who participated in this study reported that patients could be heavily influenced by controversial health stories from various forms of mass media such as the Internet, print media and television [3, 30, 31]. This not only impacted on patients’ judgments about some healthcare practices, but also impinged on primary care nurses’ workloads as they reported having to spend an increasing amount of time discussing the latest news stories with patients, especially when controversies occurred. With the increasing availability of unregulated information and the drive for open-access journal articles online, a wide spectrum of health literature, which varies in accuracy, complexity and quality, is available to the public. This, coupled with the patient choice agenda in healthcare, empowers individuals to form decisions themselves [32, 33]. An emerging issue, then, that needs to be addressed is: should healthcare professionals embrace the increasing task of engaging and aiding patients with the appraisal of self-sourced health information? Research suggests that people who use the Internet to source health information need more help from healthcare professionals with interpreting and understanding reports to be able to make choices themselves [34, 35]. Nurses are centrally positioned to help advance patients’ knowledge and decision-making about health information, and, in turn, to help improve their health outcomes [36, 37]. However, in an age where people experience an overload of information from mass media channels, providing this support to patients appears to be taking its toll on primary care nurses’ workloads. If healthcare professionals are to effectively support patients in deciphering media stories, they not only need to be up-to-date with accurate information and evidence-based practices, but they also need to feel confident in their own abilities to appraise and contextualise mass media reports. Of some concern is the finding that media reports were often cited as primary care nurses’ first point of contact with new or controversial health information due to time pressure, easy access and a lag in dissemination from official channels. Previous research has also found that nurses use mass media as a source of evidence . In view of this, healthcare professionals should be encouraged and given time to access and engage with original research (which media stories are often based on) so that they are able to appraise the primary source of information. While critically appraising evidence is an important aspiration for healthcare professionals, research suggests nurses are often unable to find the time, and sometimes lack the skills, to do so [24, 38–40]. Therefore, we encourage official channels such as the Department of Health and Primary Care Trusts along with academic researchers to work towards more rapid and effective dissemination and engagement of evidence summaries and statements to staff working at the frontline of healthcare services. These summaries and statements can be easily consumed by both healthcare professionals and their patients. It has been suggested that social media such as Twitter and online forums, which are being increasingly used by official agencies, can prove essential aspects of communication strategies if used effectively . Social media can also provide valuable opportunities for intra-professional communication within healthcare , which will enable nurses to gain accurate, real-time updates. We also encourage healthcare professionals to make use of existing official resources, such as the 'Behind the Headlines’ section of the NHS Inform website, which provides unbiased up-to-date quality-assured health information (http://www.nhsinform.co.uk/behind-the-headlines.aspx).
Tabloid newspapers, found to produce lower quality, less-informed health stories in greater frequency than broadsheet newspapers , were reported as a common source of health information for lower socio-economic patient groups. Alarmist news stories that present public health risks can have a negative impact on audience’s behaviour . Our findings suggested that nurses believed these groups of patients may need more support in making judgments and decisions about care. Alternatively, patients from high socio-economic groups, who were viewed by these nurses as educated, and who appeared to have researched and deliberated on a number of online information sources, would frequently challenge and decide not to follow recommended practice. One explanation proposed is that people’s socio-cultural group identities can also lead to biases in decision-making, as individuals align their views with specific media messages that are congruent with their identities but that do not necessarily support the objective evidence . Therefore, being more educated does not imply that decision-making will result in the most informed conclusion. To the contrary, researchers in the US  found that people who are more likely to spend time deliberating on their decisions about the health risks of the human papilloma virus vaccine (a health topic that became highly politicised in a number of States) did not all reach the most informed conclusion. Instead, their views became more polarised to opposite extremes, depending on their cultural identities and political persuasions, as opposed to aligning with the scientific evidence.
Mass media can play a role in the social amplification of health risks, too [46, 47], whereby experts assess practices or treatments as relatively low risk but they take on social and political identities fuelled by the media, which amplifies their risk disproportionately . In our study, primary care nurses often referred to the MMR controversy played out in the media as having a significant negative impact on vaccination uptake; the repercussions of which are being felt a decade later with recent measles outbreaks in parts of the UK.
It is important to note that while the media can influence the public in the formation of social-level judgments, studies have shown that people often rely on interpersonal channels such as social networks, family and friends to help shape their perceptions of health risks [49, 50]. However, some research indicates that, especially during high levels of publicity, health stories in the media can be more influential than interpersonal sources . This indicates that providing accurate and up-to-date information to counterbalance inaccuracies in media stories may assist health professionals to confidently discuss and share best evidence with patients, while taking account of their personal views and preferences.
In our findings, primary care nurses were aware of the common pitfalls of mass media reporting, but sympathised with patients about the alarmist and fear-evoking nature of some news reports. They too recalled times in their own careers when media reports contributed to a loss in their confidence and trust towards certain healthcare practices and treatments. The finding that the media can directly influence primary care nurses’ own perceptions of health risks has scarcely been reported. Although healthcare professionals are expected to use critical appraisal skills to interpret health information, it has been acknowledged that emotions can override analytical reasoning . All of the participants who took part in our study were female, with over three quarters being mothers, and some discussed being torn by strong maternal and emotional instincts when confronted with an influx of media stories reporting on unsafe treatments for children. Emotional stories were discussed as being more powerful and engaging than dry facts and figures. In the psychological literature, emotion is widely considered to play a core role in decision-making, as people form judgments not only from what they think but also from what they feel . Dual processing theory  proposes that there are two systems at work in the formation of judgments and decisions. The intuitive system is fast-acting, automatic, emotion- and intuition-based, heuristic-forming, experiential and unconscious, while the deliberative system is slower-acting, cognitive, rational, logical, analytical and conscious. In evidence-based medicine, there is a strong reliance on rational, critical and scientific inquiry, which aligns with deliberative thinking and with patients being encouraged to use deliberative and analytical processes to appraise options . Within the wider literature, the importance of using intuitive and experience-based tacit forms of knowledge in decision-making is recognised [55–58], with evidence of people using both intuitive and deliberative thinking to arrive at a decision . Although there may be some valid arguments for incorporating intuitive thinking into nursing practice, there are risks associated with it and this should not be at the expense of delivering safe and effective healthcare and advice .
Our findings indicate that in an age that is characterised by a growing availability of information, primary care nurses felt they had little support to expand their own media literacy skills and to engage and develop these skills in their patients. While media literacy is still a relatively new field of inquiry, a recent review on its effectiveness reported positive outcome effects on: media knowledge; criticism; perceived realism; influence; behavioural beliefs; attitudes; self-efficacy; and behaviour . Media literacy training would provide an overarching and more critical understanding of the way in which media messages are produced and framed. Providing more educational training and resources, aimed at developing deliberative thinking, will not provide a 'magic bullet’ solution to eradicating the negative influences of media reporting, as judgement and decision-making is also affected by other personal, socio-cultural, and political factors (discussed above). However, the fundamental goal of media literacy is to maintain critical autonomy in relation to all media . Therefore, providing individuals with the critical and analytical tools to better decipher media messages will help to: ameliorate uninformed decision-making; empower to promote better self-management of patients; instill more confidence in health professionals to trust best evidence guidelines during health controversies; and facilitate more meaningful and effective conversations between patients and healthcare professionals about their health concerns and choices. On a final note, although this paper primarily focused on the potential negative influences of mass media on patients and health professionals, it is important to recognise that responsible, well-informed media reporting can be an asset [9, 11, 62]. Effective mass media communication can deliver important messages, facilitate public engagement in health sciences, support better decision-making in health matters and help to save lives .
Strengths and limitations
So far, little research has been carried out on primary care nurses’ experiences of how mass media can affect their daily practices and perceptions about the healthcare that they provide to their patients. This study used qualitative interviews to provide descriptive, detailed data on the subjective experiences and views of primary care nurses. Qualitative methods are recommended when a topic is relatively unexplored, as was the case in our study, and can provide contextually bound in-depth accounts. However, it is important to recognise that qualitative methods are limited in their generalisability. Another potential limitation of this research is that the health visitors and practice nurses who took part in this study were self-selected and may represent a highly engaged group within their professions. There are also some potential differences between the roles and settings of health visitors and practice nurses, as health visitors would primarily carry out house visits and focus on child health and practice nurses would usually be situated in doctors’ practices or health centres working with a wider cross-section of the public. These contextual differences could alter the relationships that health visitors and practice nurses have with their patients but in relation to media influences this did not seem to be the case from analysing their accounts. It is also important to note that the age of the data (collected in 2008/2009) is likely to present a somewhat dated picture of how more contemporary forms of media, such as Facebook, Twitter, blogs etc. operate within the healthcare environment today.