The future of nursing - The BMJ

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The future of nursing - The BMJ
June 2021
A special supplement in partnership with WISH

            The future of nursing


             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.
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.
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.
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.
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.
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.
   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
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.

the bmj | BMJ 2021                                                                                                                                           i

                                                                                 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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   be liable for any loss, injury, or damage resulting from the use of The BMJ
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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

             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                                                                                                1

   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 bmj

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;               
                                                         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.
and trusted nurse professionals to deliver               Howard Catton, chief executive1
on this task will move us closer to ending               Elizabeth Iro, chief nursing officer2                             internationalsupplyofnurses_Report_FINAL.pdf
                                                          International Council of Nurses, Geneva, Switzerland        17   Jackson D, Bradbury-Jones C, Baptiste D, et al. Life
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practitioners worldwide provide quality,                 Correspondence to: H Catton                                       doi:10.1111/jocn.15257
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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.
Advanced nurse practitioners create a huge               This is an Open Access article distributed under
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 (                    midwifery 2021-2025. Draft 1. 2021. https://
to play in the prevention and containment                by-nc/3.0/igo/), which permits use, distribution, and   
                                                         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
contact and long term care, while benefiting                                                                               nload=true
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35 Hetland B, Lindroth H, Guttormson J, Chlan          38 Fore HH, Gurría JÁ. Primary health care on the road to      Cite this as: BMJ 2021;373:n1105
   LL. 2020—the year that needed the nurse:               universal health coverage. 2019 monitoring report.

4                                                                                                                 doi: 10.1136/bmj.n1105 | BMJ 2021;373:n1105 | the bmj

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

             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                                                                                                   5

 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 ( 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 bmj

underpin and be highlighted in recruitment                   To increase the number of men in nursing,                 8    Petges N, Sabio C. Perceptions of male students in a
                                                                                                                            baccalaureate nursing program: a qualitative study.
and retention initiatives.                                it is important to highlight to men their                         Nurse Educ Pract 2020;48:102872. doi:10.1016/j.
                                                          historical past and their potential future                        nepr.2020.102872
Confrontation of stereotypes                              in a rewarding, contemporary career with                     9    International Council of Nurses. Mass trauma
                                                          myriad clinical, academic, and professional                       experienced by the global nursing workforce. ICN Covid
Stereotypical assumptions must be challenged
                                                                                                                            update 13 Jan 2021.
at school and societal level in careers                   development opportunities. The profession                         files/inline-files/ICN%20COVID19%20update%20
guidance, mainstream and social media,                    must continue to lobby governments to move                        report%20FINAL.pdf
and popular culture so that boys know                     beyond mere platitudes and actually provide                  10   Twomey JC, Meadus R. Men nurses in Atlantic
                                                                                                                            Canada. J Men’s Stud 2016;24:78-88.
that nursing is a valid career option.3 19 27-29          parity of pay and esteem. We must portray to                      doi:10.1177/1060826515624414
This will require greater intersectoral and               the public the true scope and complexity of                  11   Mahon P, Cowman S. The male nurse: a historical and
cross government collaboration from the                   our professional practice,3 and we must build                     contemporary analysis of the literature. All Ireland
                                                                                                                            Journal of Nursing and Midwifery. 2003;2:34-9.
early years to higher education levels, 6                 a profession for all through robust policy that
                                                                                                                       12   Wilson B. A history of men in American nursing. Nebr
and for broadcasters to consider how their                focuses on education, jobs, practice, and                         Nurse 2003;(Sept-Nov):15-6.
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
within it.                                                                                                                  perspective. J Adv Nurs 2004;47:321-8. doi:10.1111/
                                                          Provenance and peer review: Commissioned;                         j.1365-2648.2004.03096.x
  We must also promote professional                       externally peer reviewed.                                    15   Clementson R. Men in nursing. Nurs J
acceptance and challenge stereotypes and                  This article is part of a series commissioned by The BMJ          (Manila) 2008;(12):37-43.
assumptions in the profession itself—such                 for the World Innovation Summit for Health (WISH).           16   Mackintosh C. A historical study of men in nursing.
as those in relation to male nurses’ sexuality,           The BMJ peer reviewed, edited, and made the decision              J Adv Nurs 1997;26:232-6. doi:10.1046/j.1365-
                                                          to publish. The series, including open access fees, is            2648.1997.1997026232.x
ability to care, or reasons for entering the              funded by WISH.                                              17   Cottingham M. The missing and needed male nurse:
profession. For example, the literature often                                                                               DIScursive hybridization in professional nursing texts.
refers to the “hidden advantage” of male                  Thomas Kearns, executive director1                                Gend Work Organ 2019;26:197-213. doi:10.1111/
nurses and the over-representation of men                 Paul Mahon, operational lead2                                18   Hase S. The role of the man in nursing. Aust Nurses
in leadership positions without examining                 1
                                                           Faculty of Nursing and Midwifery, Royal College of               J 1977;7:52-3, 80.
broadly why this is so.                                   Surgeons in Ireland, Dublin, Ireland                         19   Rabie T, Rossouw L, Machobane BF. Exploring
                                                           Centre for Nursing and Midwifery Advancement,                    occupational gender-role stereotypes of male nurses:
  Although there may be many individual and                                                                                 A South African study. Int J Nurs Pract 2020:e12890.
                                                          Faculty of Nursing and Midwifery, Royal College of
institutional reasons for this “glass elevator,”          Surgeons in Ireland, Dublin, Ireland                              doi:10.1111/ijn.12890
including conscious and unconscious bias,                 Correspondence to: P Mahon
                                                                                                                       20   Santos M, Amâncio L. Gender and nursing in Portugal:
hegemonic masculinity, explicit or tacit                                                                                    the focus on men’s double status of dominant and
                                                                                                    dominated. Int J Iberian Stud 2019;32:159-72.
discrimination, continuity of employment,                                                                                   doi:10.1386/ijis_00003_1
organizational gendering practices, or the                                                                             21   Cottingham M, Erickson R, Diefendorff J. Examining
personal and professional characteristics of                                                                                men’s status shield and status bonus: how gender
                                                                                                                            frames the emotional labor and job satisfaction of
the individual nurse,17 30 31 such discussion             This is an Open Access article distributed in accordance          nurses. Sex Roles 2015;72:377-89. doi:10.1007/
conflates the problem of attracting men to                with the Creative Commons Attribution Non Commercial              s11199-014-0419-z
the profession with the career progression                (CC BY-NC 4.0) license, which permits others to              22   All Party Parliamentary Group on Global Health. Triple
                                                          distribute, remix, adapt, build upon this work non-               impact: how developing nursing will improve health,
of all nurses. Indeed, examining ways to
                                                          commercially, and license their derivative works on               promote gender equality and support economic
empower all nurses thorough initiatives such              different terms, provided the original work is properly           growth. All Party Parliamentary Group on Global
as the International Council of Nurses’ global            cited and the use is non-commercial. See: http://                 Health, 2016.
nurse consultants initiative will help improve                       23   Younas A, Sundus A, Zeb H, Sommer J. A mixed
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health, promote gender equality, and support                                                                                challenges during nursing education and
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a history that is somewhat lost to the last 200           2   Bonair J, Philipsen N. Men in nursing: addressing             Nurs 2016;72:1155-68. doi:10.1111/jan.12905
                                                              the nursing workforce shortage and our history. Md       25   International Council of Nurses. ICN says nurses’ pay
years and the often misquoted preface of                      Nurse 2009;10:19.                                             and safety are gender issues at the United Nations
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“every woman is a nurse.” Less well quoted,                   public perceptions of nursing: a systematic review            event. Press release, 22 Mar 2021. https://www.icn.
however, is her full contention that “While it                and narrative synthesis of the international research         ch/sites/default/files/inline-files/WS_09_CSW65_
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the contrary, that the very elements of nursing               supply of nurses: Report for the International Council        the public service stability agreements 2013-2020
                                                              of Nurses. International Council of Nurses, 2020.             (The Lansdowne Road Agreements). 2020. https://
are all but unknown.”                                     5   Arif S, Khokhar S. A historical glance: challenges for
  The consequences of the lack of men                         male nurses. J Pak Med Assoc 2017;67:1889-94.                 consolidated-pay-scales.pdf
in nursing can be considered in terms of                  6   World Health Organization. State of the world’s          27   N’Gbichi C, Ziraba AK, Wambui DW, et al. “If there
                                                              nursing 2020: investing in education, jobs and                are no female nurses to attend to me, I will just go
the effect on male nurses themselves, the
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profession as a whole, and on the patients                7   Jensen L, ed. The sustainable development goals               Kenya. BMC Pregnancy Childbirth 2019;19:332.
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the bmj | BMJ 2021;373: n1232 | doi: 10.1136/bmj.n1232                                                                                                                          7

28 Kalemba J. ‘Being called sisters’: masculinities               Res Public Health 2020;17:4959. doi:10.3390/                            the context of gender in Turkey. J Nurs Manag 2021.
   and black male nurses in South Africa. Gend                    ijerph17144959                                                          doi:10.1111/jonm.13266
   Work Organ 2019;27:647-63. doi:10.1111/                     30 Brown C, Jones L. The gender structure of the nursing hierarchy:     32 ICN Certified global nurse consultants. https://www.icn.
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29 Dos Santos L. Male nursing practitioners and nursing           doi:10.1111/j.1468-0432.2004.00218.x
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   experience, social stigma, and social bias. Int J Environ      still work: a descriptive and cross-sectional study in     

8                                                                                                                                   doi: 10.1136/bmj.n1232 | BMJ 2021;373:n1232 | the bmj

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

              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                                                                                               9
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