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June 2021
A special supplement in partnership with WISH
The future of nursingTHE FUTURE OF FEATURE
NURSING
Foreword
It
is lamentable that it has taken the highest levels, where nurses can and do anthropogenic climate change pose.
a pandemic for the world to see provide essential direction. Nurses are trusted and can create societal
nurses’ value to society, in terms This collection of BMJ articles explores transformations at scale on behalf of the
of health and wealth. The World the evidence available to inform individual planet by speaking boldly and truthfully.
Health Assembly designated nurses, the profession, and policy makers as This collection starts a conversation that we
2020 as International Year of the Nurse and they reinvent nursing for a post-covid world, hope encourages a bold vision of the future
Midwife. However, many events planned to including practicable recommendations for of the profession because nurses hold many
showcase nursing did not go ahead because ways forward. The collection, including open of the solutions right now to strengthen our
nurses worldwide had key roles responding access fees, is funded by the World Innovation health systems for a post-covid world.
to covid-19. Summit for Health, a part of the Qatar
Yet the ensuing media coverage has Foundation. The BMJ peer reviewed, edited, Signed by
given the public unique insight into the and made the decisions to publish the work. Elizabeth Iro (co-chair), Chief Nursing Officer, World
Health Organization. iroe@who.int
complexity of modern nursing beyond In addition to a scene setting introduction,
Howard Catton (co-chair), chief executive officer,
nostalgic stereotypes. Worldwide, we have articles focus on three crucial themes. Firstly, International Council of Nurses. catton@icn.ch
seen nurses caring for ventilated patients, deep rooted gender based inequalities in the
using technology to help families say goodbye workforce. Some 90% of the world’s nurses Panellists
to dying loved ones, leading and delivering are women. Retention of the current workforce Patricia Davidson, Former Dean and Adjunct Professor,
testing and vaccination services, and holding and recruitment of more nurses, including Johns Hopkins School of Nursing, Baltimore, Maryland,
governments to account by protesting for more men, requires sustained investment USA. pdavidson@jhu.edu
personal protective equipment. and policy action in nursing education, Michele Rumsey , Director, WHO Collaborating Centre
for Nursing, Midwifery & Health Development, Sydney,
Nurses are often the first healthcare leadership, and jobs. Australia. Michele.Rumsey@uts.edu.au
professional a patient sees; many times Secondly, the profession must transition Mary Nandili Ishepe, Director of Nursing Services,
they are the only ones. Without nurses, the as digital technologies such as artificial Ministry of Health, Kenya. mnandili@yahoo.co.uk
sustainable development goals and universal intelligence become faster ingrained in Thomas Kearns, executive director, Faculty of Nursing
health coverage are but mere aspiration. society, health systems, and healthcare. and Midwifery, Royal College of Surgeons in Ireland.
thomaskearns@rcsi.com
The profession globally faces huge, How can nursing keep evolving to provide
Sally Thorne, Professor, School of Nursing, University
evolving challenges, including substantial compassionate care in a digital world?
of British Columbia, Vancouver, Canada. sally.thorne@
and worsening workforce shortages, chronic And thirdly, the profession has a crucial ubc.ca
underinvestment, poor status and pay, and role in increasing its advocacy to minimise David Miller, Director of Safety and Quality of Al-Ahli
under-representation in decision making at the considerable harms to health that Hospital, Doha, Qatar. millerd@ahlihospital.com
the bmj | BMJ 2021 iTHE FUTURE OF NURSING
1 How to reposition the nursing profession for a post-covid age
Howard Catton, Elizabeth Iro
5 How to attain gender equality in nursing—an essay
Thomas Kearns, Paul Mahon
9 How the nursing profession should adapt for a digital future
Richard G Booth, Gillian Strudwick, Susan McBride, Siobhán O’Connor, Ana Laura Solano López
BMJ 2021
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or any information in it whether based on contract, tort, or otherwise. Ishepe Nandili, Thomas Keans, Michele Rumsey and Sally Thorne. Richard Hurley and Kamran Abbasi were the lead editors for The BMJ.
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prior permission, in writing, of The BMJ.THE FUTURE OF NURSING
How to reposition the nursing profession for a
post-covid age
The pandemic has laid bare the need to invest in nursing for global health and economic security.
Howard Catton and Elizabeth Iro outline how the profession must transform to maximize its
effect on patient care and outcomes
T
he effectiveness of healthcare is world now faces. The current context, and partners and financiers around the
inextricably linked to the state of increased understanding of the state of world8 12 to address the chronic nursing
the nursing profession. The sec- nursing in the world, provides lessons that shortages that can limit service delivery
ond report of the Independent prompt consideration of nursing’s role and and undermine patient care.10 It is also
Panel for Pandemic Prepared- the form the profession should take in the clear that investment is needed to support
ness and Response said, “The world was future. nurses who are struggling to cope mentally
not prepared, and must do better,” arguing But these considerations must be viewed and physically with the consequences of the
that “the covid-19 pandemic must be a cat- within a wider global context that includes pandemic and exhausted from the demands
alyst for fundamental and systemic change gender equity4 5 and climate change6 as of working under extreme pressure over a
in preparedness for future such events, drivers of a new public health policy debate. prolonged period.3 13 14
from the local community right through to And to reach universal health coverage by Despite disruption of planned activities
the highest international levels.”1 2030 nurses must radically reframe their because of the pandemic, 2020 raised the
Frailties in healthcare systems, exposed relationship with digital technology.7 profile of nurses and nursing work around
by the covid-19 pandemic, reinforce the A bold vision of the profession can the world. The global media focused
urgent need for all governments to invest stimulate investment for the fundamentally on overcrowded hospitals, inadequate
heavily in nursing to bring about such changed healthcare services needed in protective equipment for the workforce, and
fundamental change.2 3 the decades after the pandemic. Streng desperate personal stories of dedication
In crisis situations, seizing opportunities thening nurse education and leadership and compassion—and the world clapped
to reflect, learn, and grow is critical. Coun and including a nursing voice in all deci in support. The past year has taught us
tries have an opportunity to address the sions about the future of health systems that applause is not enough. It is essential
weaknesses that have been revealed in and policies, will be essential if we are and urgent to invest in and protect all those
their healthcare systems and to ensure to create more equitable services and who safeguard our health and security. The
healthcare is available to everyone. The better outcomes for patients and their year 2021 is fittingly designated the year of
nursing profession must plan its next steps communities.8 health and care workers with the campaign
carefully to respond to the challenges the slogan, “Invest. Protect. Together.”15
Year of the nurse, year of the pandemic
The 72nd World Health Assembly desig- Nurses in top level leadership
KEY MESSAGES nated 2020 as the international year of the The pandemic has exposed the public to
• N urses should be leaders in the nurse and the midwife.9 In April 2020 the the realities of nursing: nurses’ advanced
design of healthcare systems, not just World Health Organization, in partnership clinical skills, the complexity of their work,
in delivery of care with the International Council of Nurses, and their commitment to patient care. The
• Health should be considered in every (ICN), and the global Nursing Now cam- public has also seen nursing’s frailties: too
government policy, with senior nurses paign published The State of the World’s few nurses with the right skills and in the
present at the top of all health system Nursing 2020. This report detailed the right place, insufficient plans to deal with
organizations and government depart- dimensions of the global nursing work- a pandemic, and in many countries a lack
ments force and provided evidence based policy of nursing leadership at government level
options to strengthen nursing education, to provide much needed direction.8 10 16 17
• Governments should lead implemen-
tation of globally endorsed strategies jobs, and leadership.10 Although nurses take on leadership at all
as appropriate for their health work- Activities were planned worldwide levels, globally nursing is least represented
force and nursing professions throughout 2020 to raise the profile of at the highest level in governments and
the nursing and midwifery professions, ministries of health.8 During the pandemic
• C ountries should adopt long term showing their important contributions to it has been normal to see chief medical
workforce plans, striving for self-suf-
population health, achieving universal officers speaking alongside government
ficiency in the supply of their health
health coverage, and society. However, ministers but rare to see chief nursing
workforces, including nurses
many were put on hold as nurses responded officers doing the same. The State of the
• Investment in nursing jobs, educa- to the covid-19 pandemic. It was hoped that World’s Nursing 2020 indicated that only
tion, leadership, and service delivery the advocacy for the nursing role, coupled 70% of countries have a government
should be viewed as an investment in with a compelling case for investment in chief nursing officer position 8; an ICN
every citizen’s safety, security, and nursing, would encourage a new generation assessment found even fewer countries
peace into the profession11 and mobilise strategic had a position with appropriate authority.18
the bmj | BMJ 2021;373:n1105 | doi: 10.1136/bmj.n1105 1THE FUTURE OF NURSING
For health to be a central tenet of all the new nurses we need. ICN has called an aspect of nursing that is important
policy making, nursing leaders must take on governments to make available dedi to people, particularly when they are
their seats at tables in every arena where cated additional “health education and struggling to deal with complex, long term,
health systems and health policy decisions retraining opportunity” funding to support and terminal illnesses.28 Compassion is a
are directed and driven. Senior nurses education providers to increase capacity key aspect of healing29 and can affect the
have roles as enablers of health not just and to support people who have lost jobs to delivery of quality health outcomes.29
in health ministries, but in organizations move into the health and care workforce.22 Nursing with compassion places people
and institutions tackling matters that at the centre of care, 30 but nursing is
affect health, including education, the Nurse migration much more than this: it is both an art and
environment, and the economy. For The inequitable state of the global sup- a science, requiring intelligence, skill,
government and industry leaders to ply of nurses and migration has left many knowledge, and, most importantly, high
recognize the value of nursing input across countries with too few nurses.16 Almost quality education.
multiple sectors, nurses at all levels must 90% of the six million shortfalls in nursing The pandemic has highlighted the need
continue to engage in informed dialogue occurs in low and middle income countries. for countries to increase investments in the
and debate on a range of global challenges. About one in eight, or 3.7 million, nurses health workforce, including nursing. The
WHO Global Strategic Directions for are working in countries that are not where economic and social value placed on what
Nursing and Midwifery (2021-2025) they were born or trained.8 In high income nurses do is deeply rooted in gender norms,
will be presented for consideration at countries, foreign born or foreign trained including pervasive gender segregation of
the 74th World Health Assembly in May nursing staff comprise 15% of the nursing the nursing profession.5 The challenges
2021. It includes policy options to tackle workforce, compared with less than 2% in surrounding workforce planning during
current challenges and strengthen nursing lower income countries, many of which can the covid-19 pandemic have highlighted an
leadership.19 Implementation would create ill afford to lose nurses. urgent need for fair pay,31 decent and safe
stronger and resilient health systems better ICN’s migration report16 underscored the working conditions, and gender equity in
prepared for future adversities. importance of having data on international health leadership opportunities.8 32 These
mobility and migration by nurses and types of expenditures should be considered
Global shortage of nurses advocated for transparency in terms of integral to national health security.33
The State of the World’s Nursing 2020 pre- each country’s reliance on international As the demand for health services and
sented data from 191 countries. In 2018 nurses. The WHO global code of practice nursing care continues to grow, having the
there were almost 28 million nursing per- on the international recruitment of health right number of nurses with the right skills
sonnel; more than 19 million were classi- personnel is widely recognized as the in every country in the world is an equity
fied as “professional nurses.”8 Nine out of universal ethical framework that links and health security imperative. Strategies
10 nurses globally are female, and one in the international recruitment of health to retain nurses and midwives, especially in
six countries have fewer young nurses than workers and the strengthening of health rural, remote, and other underserved areas,
nurses expected to retire within the next 10 systems.23 are critical.34
years.8 In addition to full implementation of
These 28 million nurses translate to a the code24 ICN advocates that countries Delivering and leading services
global nurse density of 36.9 per 10 000 employing nurses from abroad follow Nurses’ clinical skills span a wide spectrum
population. This figure masks vast ethical recruitment principles; ensure of health service delivery, including public
disparities in the distribution of nurses working conditions are compatible with health, health promotion, community care
around the world. For example, there are 10 individual nurses’ qualifications, skills, (tackling the social determinants of health),
times more nurses per 10 000 population and experience; and provide family primary healthcare, hospital care, infec-
in the Americas than in the African region friendly contracts that allow nurses the tion prevention and control, antimicrobial
(83.4 v 8.7/10 000). In short, some of the freedom to return home or bring their resistance, mental healthcare, emergency
poorest countries in the world have the families with them. care, and care in humanitarian and disas-
fewest nurses.8 Nurse leaders should position them ter settings.8 Nurses not only care for the
The report highlighted a current global selves in government ministries, to lead sick, they promote health and wellbeing.
shortage of six million nursing jobs. 8 A changes that build in education and In some parts of the world nurses are often
further 4.7 million nurses will be needed recruitment to foster greater self-sufficiency the first, and sometimes only, healthcare
to replace those expected to retire over by making nursing a more desirable and workers that people have access to. After
the next decade. 8 Other analyses have valued career choice. patients have had medical interventions,
identified a “covid-19 effect,” related to the often using high-tech equipment in hospi-
mass traumatisation of the global nursing Valuing nursing tals, nurses’ clinical competency is crucial
workforce,16 19 which could result in up to Nurses are valued especially for “being because every member of the healthcare
10% of nurses (2-3 million) leaving their there” for the patient and their loved ones team is equally responsible and must pro-
jobs once the pandemic work is done.20 during life’s most challenging moments.25 vide an equally high level of care.35
In effect, much of the current nursing This has continued throughout the pan- In many countries, nursing professionals
workforce could need to be replaced in the demic, with nurses often standing in for have the main responsibility for immuni
next decade, a gap that requires urgent loved ones while patients died, provid- sation programmes, and in some coun
action. ing comfort and compassion in their last tries they are entirely responsible. With
Up to 255 million people have lost their moments.26 27 the covid-19 pandemic, nurses are
jobs during the pandemic,21 creating a Traditionally, this kind of care and participating in what will be the biggest
pool of potential candidates to become compassion is associated with love, 25 immunisation event in history, with
2 doi: 10.1136/bmj.n1105 | BMJ 2021;373:n1105 | the bmjTHE FUTURE OF NURSING
billions of doses administered in diverse Competing interests:. We have read and understood Lancet Public Health 2020;5:e475-83. doi:10.1016/
BMJ policy on declaration of interests and have no S2468-2667(20)30164-X
locations worldwide. Many challenges
relevant interests to declare. 14 World Health Organization. COVID-19: Occupational
are becoming evident, including supply health and safety for health workers. 2020. https://
chains, distribution problems, training, Provenance and peer review: Commissioned; www.who.int/publications/i/item/WHO-2019-nCoV-
externally peer reviewed. HCW_advice-2021.1
health education of the general public,
This article is part of a series commissioned by The 15 Campbell J, Koca F. Financing and protection for the
availability of facilities and equipment for BMJ for the World Innovation Summit for Health health and care workforce.Bull World Health Organ
immunisation, the number of available (WISH). The BMJ peer reviewed, edited, and made 2021. doi:10.2471/BLT.20.284380
vaccinators, misinformation, mistrust, and the decisions to publish. The series, including open 16 Buchan J. Covid-19 and the international
access fees, is funded by WISH. supply of nurses: report for the International
vaccine hesitancy.36 Coordinating valued Council of Nurses, 2020. https://www.icn.ch/
and trusted nurse professionals to deliver Howard Catton, chief executive1
system/files/documents/2020-07/COVID19_
on this task will move us closer to ending Elizabeth Iro, chief nursing officer2 internationalsupplyofnurses_Report_FINAL.pdf
1
International Council of Nurses, Geneva, Switzerland 17 Jackson D, Bradbury-Jones C, Baptiste D, et al. Life
the acute phase of this pandemic.
2 in the pandemic: Some reflections on nursing in the
At the clinical level, advanced nurse World Health Organization, Geneva, Switzerland
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catton@icn.ch 18 International Council of Nurses. Where are we at the
cost effective care close to people’s homes,8
start of 2020 the year of the nurse and the midwife?
and these sorts of services can help to Government chief nursing officer (GCNO) positions.
reshape the healthcare of the future.37 ICN Briefing, 2020. https://www.icn.ch/system/files/
Advanced nurse practitioners create a huge This is an Open Access article distributed under
documents/2020-01/ICN%20briefing_GCNO_ENG.
pdf
opportunity to develop and grow strong the terms of the Creative Commons Attribution IGO 19 WHO global strategic directions for nursing and
health systems. They have a leading role License (https://creativecommons.org/licenses/ midwifery 2021-2025. Draft 1. 2021. https://
to play in the prevention and containment by-nc/3.0/igo/), which permits use, distribution, and cdn.who.int/media/docs/default-source/health-
reproduction for non-commercial purposes in any workforce/who_strategic-directions-for-nursing-and-
of diseases, as well as in providing first medium, provided the original work is properly cited. midwifery-2021-2025.pdf?sfvrsn=a5ffe81f_5&dow
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workforce. ICN, 2021.
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THE FUTURE OF FEATURE
NURSING
How to attain gender equality in nursing—an essay
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
T
he covid-19 pandemic shows The reasons for this are unclear but may gendered and inaccurate representations of
that where, when, how, and to include cultural perceptions of the role of men nursing and male nurses limit the public’s
whom care is delivered has never and women in society, the status of nursing perception and affect the recruitment and
been more diverse. In today’s itself, or the pay and conditions of nurses. retention of men.3 19
healthcare, the people delivering For example, a higher proportion of male Men in the profession have also experienced
care must be similarly diverse, for the benefit nurses in some countries may reflect societal stigmatization and have been disparately
of the profession, its practitioners, and perceptions of the role of women, and vice positioned as being both dominant and
patients.1-3 Yet around 90% of the world’s versa. Further research into this area may dominated, victimized and valorized, and
nurses are women.4 Calls are being made, as provide useful insights into gender equity for of benefiting from the hidden advantages
they have before, to examine ways to promote all. of status shield and status bonus that their
the profession among men to tackle this gender affords.20 21
imbalance.1 5 Why are men under-represented? Studies show that adverse stereotypes
Nursing is an inherently human experience: Contrary to the common perception that male affect male nurses’ physical and emotional
it is done for humans, by humans, and as nurses are a relatively recent phenomenon, wellbeing, resulting in depression,
humans, and in human experience no one men in nursing can be traced to 1600BC (box demotivation, and in some cases their exit
gender claims primacy. Men have had, and 1).16 History speaks of military and religious from the profession.19 The perpetuation of
continue to have, a valuable contribution to orders such as the Parabalani (“those who such stereotypes and gender based labels
make to nursing, not simply because they are disregard their lives”)—a group of men who injures the profession, preserves segregation,
male but because they are human. Men enter cared for people with leprosy in Alexandria and stifles the pursuance of gender equality
the profession for the same reason as women— in AD416, or St Camillus de Lellis, who in for all.1 6 22 Moreover, they compound the
to care for people. AD1535 vowed to care for sick and dying shortage of nurses, limit diversity in the
people. 5 12 The Maltese cross, a symbol workplace, and deny patients of both genders
Huge shortage of humanitarianism worn by the Knights a holistic caring environment.1 5 23
Nurses are often the first, and sometimes the Hospitaller in 1099, was subsequently
only, healthcare provider that a patient sees,6 adopted by the Nightingale School of Nursing What can be done?
making them well positioned to respond to in London.14 Increasing the number of men in nursing is
healthcare challenges at every level. One of By the mid-1800s as men fought and died seen as difficult because of the erroneous
the key challenges affecting the achievement during the Crimean, American civil, and perception that nursing is a female-only
of the sustainable development goals of health other wars, more women became nurses. In profession, sexist stereotypes of the male
and wellbeing,7 is the worldwide shortage of the years after the introduction of the epochal nurse being less masculine,11 13 16 and nurses’
nurses. Recruiting more men is essential to Nightingale reforms, men were increasingly undervalued status and pay. Solutions are as
tackle this shortage. excluded from formal nurse education and complex as the genesis of the 200 year decline
The world faces a deficit of 13.5 million eventually were barred from the English of men in nursing. There is no quick fix, and
nurses in the next decade.4 8 In its first report general register.2 5 11 14 15 17 change requires political, sociocultural, and
on the state of the world’s nursing, 6 the Combined with the gender based division of professional action. Although some solutions
World Health Organization estimated that an labor, and Victorian righteousness regarding will be universal, ultimately each country and
additional six million nurses will be needed by the place of women in society,14-16 18 the culture will have to determine what works best
2030. This is a 20% increase from the current feminization of caring within the hierarchical for them. Nurse leaders and politicians should
total global nursing stock of 27.9 million. In male dominated medical model meant men offer long term, strategic solutions beyond
addition, the burden of anticipated retirement wishing to do the dirty “women’s work” were mere marketing campaigns.3
over the next decade means that 4.7 million classified as deviant, undesirable, or unable
new nurses must be recruited just to maintain to get a “real man’s” job. As caring became Better public understanding
current staffing levels.4 It is too early to say devalued, more men were forced to find That is not to say that marketing is not needed.
what effect the covid-19 pandemic will have occupations with better pay so they could Indeed, given the publicity afforded to the
on intention to join the profession, but initial provide for their families.16 profession during the pandemic, now is an
estimates are that at least a further 10% will The decline of the male nurse is a complex ideal time to set aside the nostalgic view of
leave.9 Data to monitor the effect of covid-19 product of cultural, historical, economic, nursing3 and capitalize on a contemporary
on recruitment and retention of nurses will be and political factors. In modern times, the civic conception of caring, competence, and
vital. move from the hospital based apprenticeship capability throughout clinical settings from
Recent changes in society, healthcare model of education to the tertiary setting has community to critical care.
globally, and nursing have seen more men helped establish nursing as a profession. The public has seen nurses caring for
entering the profession. In general, their But rising entry requirements have not been ventilated patients, using tablet computers
number varies across regions (table 1) and accompanied by a corresponding increase in so that family members could say goodbye
remains stubbornly low in some countries remuneration, making nursing a less attractive to loved ones, leading covid testing centres,
and clinical specialties such as obstetrics.10 career option for men and women. In addition, and innovating in practice. We have heard
the bmj | BMJ 2021;373: n1232 | doi: 10.1136/bmj.n1232 5THE FUTURE OF NURSING
Table 1 | Percentage of male nurses worldwide* in terms of access to a place on the program
Region Regional mean (%) Range among countries (%) but also with financial support to facilitate
African region 38 8–90 the uptake of that place. As countries seek to
American region 11 2–24 increase the number of nursing graduates,
Eastern Mediterranean region 26 9–56 consideration could also be given to a specific
European region 11 0–32 allocation of places to male applicants to
South-east Asia region 18 0–62 show that men are both missing and needed
Western-Pacific region 18 2–40
in nursing.17 Many male nurse societies were
*National Health Workforce Data Portal (https://apps.who.int/nhwaportal/Home/Index). Year of data varies by country from
2009 to 2019 established in the mid-1800s, and such
social supports, including the provision of
male role models, will help retain men in the
stories of nurses’ adaptability, resilience, profile of nursing, and this momentum must profession.
determination, camaraderie, and composure. be maintained. As part of this, we must
We have seen them hold patients’ hands and de-gender and revalue caring1 by attaining a More financial investment
hold governments to account while fighting gender balance and by continuing to advocate WHO recommends that nursing education
for proper personal protective equipment. for better pay and conditions for nurses.25 be considered a science subject.6 Therefore,
This has given the public a better insight Better recruitment nursing should be afforded the status, pay,
into the art and science of caring in modern Men enter and stay in nursing for many of and benefits of other science and technology
healthcare, which we can build on to attract the same reasons as women, and ultimately, professions. For example, a senior staff nurse
more men, and women, to the profession. they do so to care for patients.24 Therefore, (a nurse with over 20 years’ experience) in
Neither patients nor the public fully recruitment strategies that dispel the myths Ireland earns just under €50 000 (£43 000;
understand the complexity of nurses’ work.3 surrounding the male nurse while promoting $61 000) in base pay a year whereas a
Highlighting nurses’ roles across domains the inherent values of nursing are needed.10 pharmacist earns the same after seven years
of practice, registration status, and stage We can look to countries with higher and up to €67 000 after 13 years.26
of career could promote a more realistic percentages of male nurses for direction. Adequate pay and acceptable working
understanding, not just of men in nursing For men becoming nurses mid-career, conditions,6 mobility, and opportunity for
but of nursing itself.24 Campaigns such as graduate entry should be an option—not just personal and professional advancement must
Nursing Now have raised the status and
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 nurses11 12
• AD416-18: The Theodosian codes refer to the Parabolani—a group of 500 poor men who cared for the lepers of Alexandria5 12
• 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 fire13-15
• 1099: Knight Hospitallers of St John of Jerusalem founded to care for sick and injured pilgrims en route to and from the Holy Land13 15
• 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 Europe5 14 16
• 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
activity14 16
• 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
education2 17
• 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.5 11 14 15 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 counterparts5 15
• 1937: Society of Registered Male Nurses founded
• 1950s: Men begin to be recognized in nursing in the US, Czechoslovakia, the UK,2 14 and towards the 1970s, in Denmark and Sweden15
• 1971: American Assembly for Men in Nursing founded
6 doi: 10.1136/bmj.n1232 | BMJ 2021;373:n1232 | the bmjTHE FUTURE OF FEATURE
NURSING
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Journal of Nursing and Midwifery. 2003;2:34-9.
early years to higher education levels, 6 a profession for all through robust policy that
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programming may negatively portray nursing leadership. 13 Smallheer B, Morgan B, Stern R. A historical look
and male nurses. We must robustly voice at men’s involvement in nursing and leadership in
Competing interests: We have read and understood GAPNA. Geriatr Nurs 2020;41:52-3. doi:10.1016/j.
our objection to any outdated overtures that BMJ policy on declaration of interests and declare that gerinurse.2020.01.003
disenfranchise the profession and the people we have no competing interests. 14 Evans J. Men nurses: a historical and feminist
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THE FUTURE OF NURSING
How the nursing profession should adapt for a
digital future
Transformation into a digitally enabled profession will maximize the benefits to patient care, write
Richard Booth and colleagues
D
igital technologies increasingly instance, telehealth programs where that supports nurses to champion and
affect nursing globally. Exam- nurses provide daily monitoring, coaching, lead digital health initiatives. Globally,
ples include the growing pres- and triage of patients with several chronic uncertainty remains regarding the next
ence of artificial intelligence diseases have helped reduce emergency steps the nursing profession should take
(AI) and robotic systems; department admissions.2 Mobile devices, to increase and optimize its use of digital
society’s reliance on mobile, internet, and in particular smartphones and health technology. This challenge is exacerbated
social media; and increasing dependence applications, are enabling nurses to offer by the global diversity of the profession,
on telehealth and other virtual models of remote advice on pain management to including unequal access to resources such
care, particularly in response to the covid- adolescent patients with cancer3 4 and as technological infrastructure maturity
19 pandemic. supplement aspects of nursing education and expertise. Huge differences exist
Despite substantial advances to date, by providing innovative pedagogical among countries and regions of the world
challenges in nursing’s use of digital solutions for content delivery and remote in terms of the digitalization of healthcare
technology persist. A perennial concern is learning opportunities.5 processes, access to internet connectivity,
that nurses have generally not kept pace The development and application to and transparency of health information
with rapid changes in digital technologies nursing of systems based on AI are still processes.
and their impact on society. This limits the in their infancy. But preliminary evidence
potential benefits they bring to nursing suggests virtual chatbots could play a Selected technologies: benefits and challenges
practice and patient care. To respond part in streamlining communication with The nursing literature contains many analy-
to these challenges and prepare for the patients, and robots could increase the ses of digital technologies used to support
future, nursing must begin immediate emotional and social support patients or extend the profession, including practice
transformation into a digitally enabled receive from nurses, while acknowledging (eg, hospital information systems, elec-
profession that can respond to the complex inherent challenges such as data privacy, tronic health records, monitoring systems,
global challenges facing health systems ethics, and cost effectiveness.6 decision support, telehealth); education
and society. (eg, e-Learning, virtual reality, serious
Many exemplars show how digital Challenges persist games); and, rehabilitative and personal-
technologies already bring benefit to Digital technologies may, however, be ized healthcare approaches (eg, assistive
nursing practice and education. 1 For viewed as a distraction from, or an unwel- devices sensors, ambient assisted living).1
come intrusion into, the hands-on caring Table 1 summarizes the potential benefits,
role and therapeutic relationships that challenges, and implications of emerging
KEY MESSAGES nurses have with patients and families.7 innovations to practice.
This purported incompatibility with tra- The table is not exhaustive, but the
• Nursing must accelerate the trans- ditional nursing ideals, such as compas- diversity of topics researched shows
formation to a digitally enabled pro- sionate care, may explain some nurses’ the profession recognizes the value and
fession by investing in informatics reluctance to adopt digital approaches to challenges of digital technologies. Given
education, research, and practice healthcare.8 9 In addition, nursing’s history the evidence, for the profession to make
• Nurses should upskill in data science was as structurally subordinate to other further progress we recommend five areas
and other digital health topics to healthcare disciplines,10 and the profes- for focused and immediate action. These
ensure emerging technologies such sion is still cementing its relationship and recommendations should be qualified in
as AI are developed appropriately and leadership in health systems. light of regional context and professional
safe for nursing practice and patient The specialty of nursing informatics background owing to global heterogeneity
care has long advocated for the integration of in nursing and the inclusion of digital
• N ursing must invest in and lead technology to support the profession, but it technologies into healthcare.
digital health developments and col- has comparatively few practitioners globally.
laborate with others to develop and Nursing informaticians are predominantly Reform nursing education
deliver digital tools that patients and based in the United States, where the We must urgently create educational oppor-
the public need discipline seems to have originated, but tunities at undergraduate and graduate
• Nurses should champion informatics many other countries and regions are levels in informatics, digital health, co-
across all areas of professional prac- expanding their digital nursing workforce design, implementation science, and data
tice, create leadership opportunities and involvement with informatics.11 12 science.39 These should include opportuni-
in digital health, and inform health Slow progress in some areas has been ties to work with and learn from computing,
policy in this area due to a lack of leadership and investment engineering, and other interdisciplinary
the bmj | BMJ 2021;373:n1190 | doi: 10.1136/bmj.n1190 9You can also read
