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Feature The Future of Nursing

How to attain gender equality in nursing—an essay

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1232 (Published 14 June 2021) Cite this as: BMJ 2021;373:n1232

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  1. Thomas Kearns, executive director1,
  2. Paul Mahon, operational lead2
  1. 1Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
  2. 2Centre for Nursing and Midwifery Advancement, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
  1. Correspondence to: P Mahon pmahon{at}rcsi.ie

Tackling stereotypes and assumptions that deter men from nursing is essential to meet the growing shortage of nurses and improve diversity, say Thomas Kearns and Paul Mahon

The covid-19 pandemic shows that where, when, how, and to whom care is delivered has never been more diverse. In today’s healthcare, the people delivering care must be similarly diverse, for the benefit of the profession, its practitioners, and patients.123 Yet around 90% of the world’s nurses are women.4 Calls are being made, as they have before, to examine ways to promote the profession among men to tackle this imbalance.15

Nursing is an inherently human experience: it is done for humans, by humans, and as humans, and in human experience no one gender claims primacy. Men have had, and continue to have, a valuable contribution to make to nursing, not simply because they are male but because they are human. Men enter the profession for the same reason as women—to care for people.

Huge shortage

Nurses are often the first, and sometimes the only, healthcare provider that a patient sees,6 making them well positioned to respond to healthcare challenges at every level. One of the key challenges affecting the achievement of the sustainable development goals of health and wellbeing,7 is the worldwide shortage of nurses. Recruiting more men is essential to tackle this shortage.

The world faces a deficit of 13.5 million nurses in the next decade.48 In its first report on the state of the world’s nursing,6 the World Health Organization estimated that an additional six million nurses will be needed by 2030. This is a 20% increase from the current total global nursing stock of 27.9 million. In addition, the burden of anticipated retirement over the next decade means that 4.7 million new nurses must be recruited just to maintain current staffing levels.4 It is too early to say what effect the covid-19 pandemic will have on intention to join the profession, but initial estimates are that at least a further 10% will leave.9 Data to monitor the effect of covid-19 on recruitment and retention of nurses will be vital.

Recent changes in society, healthcare globally, and nursing have seen more men entering the profession. In general, their number varies across regions (table 1) and remains stubbornly low in some countries and clinical specialties such as obstetrics.10 The reasons for this are unclear but may include cultural perceptions of the role of men and women in society, the status of nursing itself, or the pay and conditions of nurses. For example, a higher proportion of male nurses in some countries may reflect societal perceptions of the role of women, and vice versa. Further research into this area may provide useful insights into gender equity for all.

Table 1

Percentage of male nurses worldwide*

View this table:

Why are men under-represented?

Contrary to the common perception that male nurses are a relatively recent phenomenon, men in nursing can be traced to 1600BC (box 1).16 History speaks of military and religious orders such as the Parabalani (“those who disregard their lives”)—a group of men who cared for people with leprosy in Alexandria in AD416, or St Camillus de Lellis, who in AD1535 vowed to care for sick and dying people.512 The Maltese cross, a symbol of humanitarianism worn by the Knights Hospitaller in 1099, was subsequently adopted by the Nightingale School of Nursing in London.14

Box 1

Brief history of men in nursing

  • 250BC: First nursing school in the world started in India. Only men were considered “pure” enough to become nurses1112

  • AD416-18: The Theodosian codes refer to the Parabolani—a group of 500 poor men who cared for the lepers of Alexandria512

  • 1095: Order of the Brothers of St Anthony founded (merged with the Knights of Malta in 1775) to care for people inflicted with the medieval disease of St Anthony’s fire131415

  • 1099: Knight Hospitallers of St John of Jerusalem founded to care for sick and injured pilgrims en route to and from the Holy Land1315

  • 1119: Order of Saint Lazarus of Jerusalem founded

  • 1180: Order of the Hospitallers of the Holy Spirit and the Brotherhood of the Holy Spirit founded

  • 1192: Order of Brothers of the German House of Saint Mary in Jerusalem, or the Teutonic Knights, founded

  • 1334: The Beghards (renamed Alexian Brothers after Saint Alexis in 1469) cared for the poor, the lepers, and the “morons and lunatics” of Europe51416

  • 1535: St John of God began studying under the monks of St Jerome and cared for the ill and mistreated

  • 1585: St Camillus de Lellis became a priest and established a religious order, vowing to care for the sick and dying even with danger to his own life

  • 1600s–1700s: Protestant reformation led to the closure of monasteries and convents across Europe resulting in a loss of records of organized nursing activity1416

  • 1780s: Nurse James Durham (or Derham) became the first African American in the United States to practise medicine12

  • 1850–1950s: War began to alter nursing, and the role of men within it

  • 1859: Florence Nightingale publishes Notes on Nursing, suggesting “every woman is a nurse”

  • 1861–65: American civil war: more women became nurses in civilian life12

  • 1877: St John Ambulance Association founded (derived from the Knight Hospitallers)

  • 1884: The Male Nurses (Temperance) Cooperation founded

  • 1892: The Male Nurses Mutual Benefit Association founded

  • 1888−1914: Alexian Brothers and other orders built hospitals throughout Chicago, Connecticut, Massachusetts, Missouri, New York, and Pennsylvania. Increasingly, men became nurses at their own social peril, experiencing discrimination, pay inequality, role erosion, and exclusion from formal nurse education217

  • 1914–18: American men were prohibited from practising in the US Army Nursing Corps

  • 1919: The Nurses Act in England barred men from entering the general register.5111415 Internationally, men found it difficult to access formal training and where they did, their training was shorter and lacked the curricular content of their female counterparts515

  • 1937: Society of Registered Male Nurses founded

  • 1950s: Men begin to be recognized in nursing in the US, Czechoslovakia, the UK,214 and towards the 1970s, in Denmark and Sweden15

  • 1971: American Assembly for Men in Nursing founded

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By the mid-1800s as men fought and died during the Crimean, American civil, and other wars, more women became nurses. In the years after the introduction of the epochal Nightingale reforms, men were increasingly excluded from formal nurse education and eventually were barred from the English general register.2511141517

Combined with the gender based division of labor, and Victorian righteousness regarding the place of women in society,14151618 the feminization of caring within the hierarchical male dominated medical model meant men wishing to do the dirty “women’s work” were classified as deviant, undesirable, or unable to get a “real man’s” job. As caring became devalued, more men were forced to find occupations with better pay so they could provide for their families.16

The decline of the male nurse is a complex product of cultural, historical, economic, and political factors. In modern times, the move from the hospital based apprenticeship model of education to the tertiary setting has helped establish nursing as a profession. But rising entry requirements have not been accompanied by a corresponding increase in remuneration, making nursing a less attractive career option for men and women. In addition, gendered and inaccurate representations of nursing and male nurses limit the public’s perception and affect the recruitment and retention of men.319

Men in the profession have also experienced stigmatization and have been disparately positioned as being both dominant and dominated, victimized and valorized, and of benefiting from the hidden advantages of status shield and status bonus that their gender affords.2021

Studies show that adverse stereotypes affect male nurses’ physical and emotional wellbeing, resulting in depression, demotivation, and in some cases their exit from the profession.19 The perpetuation of such stereotypes and gender based labels injures the profession, preserves segregation, and stifles the pursuance of gender equality for all.1622 Moreover, they compound the shortage of nurses, limit diversity in the workplace, and deny patients of both genders a holistic caring environment.1523

What can be done?

Increasing the number of men in nursing is seen as difficult because of the erroneous perception that nursing is a female-only profession, sexist stereotypes of the male nurse being less masculine,111316 and nurses’ undervalued status and pay. Solutions are as complex as the genesis of the 200 year decline of men in nursing. There is no quick fix, and change requires political, sociocultural, and professional action. Although some solutions will be universal, ultimately each country and culture will have to determine what works best for them. Nurse leaders and politicians should offer long term, strategic solutions beyond mere marketing campaigns.3

Better public understanding

That is not to say that marketing is not needed. Indeed, given the publicity afforded to the profession during the pandemic, now is an ideal time to set aside the nostalgic view of nursing3 and capitalize on a contemporary civic conception of caring, competence, and capability throughout clinical settings from community to critical care.

The public has seen nurses caring for ventilated patients, using tablet computers so that family members could say goodbye to loved ones, leading covid testing centres, and innovating in practice. We have heard stories of nurses’ adaptability, resilience, determination, camaraderie, and composure. We have seen them hold patients’ hands and hold governments to account while fighting for proper personal protective equipment. This has given the public a better insight into the art and science of caring in modern healthcare, which we can build on to attract more men, and women, to the profession.

Neither patients nor the public fully understand the complexity of nurses’ work.3 Highlighting nurses’ roles across domains of practice, registration status, and stage of career could promote a more realistic understanding, not just of men in nursing but of nursing itself.24 Campaigns such as Nursing Now have raised the status and profile of nursing, and this momentum must be maintained. As part of this, we must de-gender and revalue caring1 by attaining a gender balance and by continuing to advocate for better pay and conditions for nurses.25

Better recruitment

Men enter and stay in nursing for many of the same reasons as women, and ultimately, they do so to care for patients.24 Therefore, recruitment strategies that dispel the myths surrounding the male nurse while promoting the inherent values of nursing are needed.10 We can look to countries with higher percentages of male nurses for direction.

For men becoming nurses mid-career, graduate entry should be an option—not just in terms of access to a place on the program but also with financial support to facilitate the uptake of that place. As countries seek to increase the number of nursing graduates, consideration could also be given to a specific allocation of places to male applicants to show that men are both missing and needed in nursing.17 Many male nurse societies were established in the mid-1800s, and such social supports, including the provision of male role models, will help retain men in the profession.

More financial investment

WHO recommends that nursing education be considered a science subject.6 Therefore, nursing should be afforded the status, pay, and benefits of other science and technology professions. For example, a senior staff nurse (a nurse with over 20 years’ experience) in Ireland earns just under €50 000 (£43 000; $61 000) in base pay a year whereas a pharmacist earns the same after seven years and up to €67 000 after 13 years.26

Adequate pay and acceptable working conditions,6 mobility, and opportunity for personal and professional advancement must underpin and be highlighted in recruitment and retention initiatives.

Confrontation of stereotypes

Stereotypical assumptions must be challenged at school and societal level in careers guidance, mainstream and social media, and popular culture so that boys know that nursing is a valid career option.319272829 This will require greater intersectoral and cross government collaboration from the early years to higher education levels,6 and for broadcasters to consider how their programming may negatively portray nursing and male nurses. We must robustly voice our objection to any outdated overtures that disenfranchise the profession and the people within it.

We must also promote professional acceptance and challenge stereotypes and assumptions in the profession itself—such as those in relation to male nurses’ sexuality, ability to care, or reasons for entering the profession. For example, the literature often refers to the “hidden advantage” of male nurses and the over-representation of men in leadership positions without examining broadly why this is so.

Although there may be many individual and institutional reasons for this “glass elevator,” including conscious and unconscious bias, hegemonic masculinity, explicit or tacit discrimination, continuity of employment, organizational gendering practices, or the personal and professional characteristics of the individual nurse,173031 such discussion conflates the problem of attracting men to the profession with the career progression of all nurses. Indeed, examining ways to empower all nurses thorough initiatives such as the International Council of Nurses’ global nurse consultants initiative will help improve health, promote gender equality, and support economic growth.32

Continuing men’s long history in nursing

Men have a rich and varied history in nursing, a history that is somewhat lost to the last 200 years and the often misquoted preface of Florence Nightingale’s Notes on Nursing that “every woman is a nurse.” Less well quoted, however, is her full contention that “While it has been said and written scores of times, that every woman makes a good nurse I believe, on the contrary, that the very elements of nursing are all but unknown.”

The consequences of the lack of men in nursing can be considered in terms of the effect on male nurses themselves, the profession as a whole, and on the patients that nurses serve.

To increase the number of men in nursing, it is important to highlight to men their historical past and their potential future in a rewarding, contemporary career with myriad clinical, academic, and professional development opportunities. The profession must continue to lobby governments to move beyond mere platitudes and actually provide parity of pay and esteem. We must portray to the public the true scope and complexity of our professional practice,3 and we must build a profession for all through robust policy that focuses on education, jobs, practice, and leadership.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decision to publish. The series, including open access fees, is funded by WISH.

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References

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