Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

After a near century following the classic reports of Flexner (1910), Rose-Welch (1915) and Goldmark (1923) that laid the foundations for higher education in health, we find ourselves today challenged to keep pace with the revolution in health professional education and desperately seeking reform to meet the demands of educating future physicians, nurses and public health professionals in a global world. In 2010, the independent Commission on Education of Health Professionals for the 21st Century was launched with the aim of focusing globally on the field, identifying gaps and opportunities, and offering recommendations for reform published in Lancet. The Institute of Medicine (IOM) Global Forum on Innovation in Health Professional Education has launched activities that are inspired by the Lancet report and the Future of Nursing report to explore promising, scientifically based innovation in health professional education and to cultivate new ideas through multi-disciplinary collaboratives that are undertaking the recommendations.

Does gender matter in these issues? Dr. Afaf I. Meleis takes a hard look at gender inequity as a global phenomenon that manifests itself in different forms (see Meleis & Glickman, Nursing Outlook, 2012, v. 60, issue 5 supplement: “Empowering expatriate nurses: Challenges and opportunities – A commentary”, p. S24 – S26). She speaks passionately about linking some of the issues in nursing with global issues that affect women in general, including health professional inequalities in the workplace and educational change needed.

Afaf I. Meleis, Dean and Professor at the University of Pennsylvania School of Nursing, speaks to the issues of gender inequity and nursing.

Click here for the Lancet report.

“Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.”

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN

Afaf I. MeleisAfaf I. Meleis, PhD, DrPS (hon), FAAN

Margaret Bond Simon Dean of Nursing

Professor of Nursing and Sociology

University of Pennsylvania School of Nursing



Question 1. Are there opportunities and forces that promote or hinder the changes in the occupational structure that dominate healthcare systems?

There are. The pyramid view of the health care system reclines at the base and physicians at the apex. It’s being challenged, but it still continues to be the norm in our country and actually globally, and that’s definitely a hindrance. There are lots of indicators though that this is being challenged and challenged well. One is the Lancet report – the title is “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.” It’s a global report challenging the current way by which we are educating nurses, physicians and public health folks. The recommendations of that report speak to the urgent need for a new era in education which transcends the silos. It breaks barriers between the professions – those three important professions – and calls for creating curricula that are more integrated, that could lead to more teams functioning after they graduate. Instead of waiting for them to form teams after they graduate, they teach them ahead of time in teams so that they can graduate and continue to do what they learned in school.

And so, as a follow-up to this Lancet report, IOM (Institute of Medicine) took that really seriously and developed a three year commitment to a global forum for innovative education programs lead by inter-professional principles. Some of these things are going to break not only the silos, but that pyramid view. So that is the first challenge.

The second challenge is to this hierarchical approach – created by the advanced preparation of nurses, allowing them to take on more responsibilities. So that pyramid is being challenged by the Lancet report, but it is also challenged by preparing nurses – graduating nurses – who are well prepared with knowledge, evidence and research, that allows them to have a wider scope of practice and to have the evidence behind it. I believe that nurses are better educated in science and systems. And it gives them the tools and the power to become partners and challenge that pyramid approach.

The third challenge to the status quo is the more informed consumer. Consumers are far more informed now. They expect to be part of the decision-making and they will not want that somebody makes the decision for them nor will they accept that pyramid approach.

So, I think these things provide the framework that promotes a more egalitarian relationship and as such, we know that the egalitarian relationship actually affects the kind of care that’s provided and the outcomes for patients.


Question 2. In the past, nurses distanced themselves from gender inequity and feminism.  Could you speak to why you connect gender inequity with inequities that nurses face?

Excellent question! I think it has been disconnected in the past and I think we really are not going to make a difference and move forward unless we connect some of the issues. Since the nursing workforce is still made up of 90 percent women (and we are trying to change that situation, definitely, by recruiting more men in nursing), but since it is 90 percent women, has been in the past, we should not and cannot separate the situation of women in the world from that of nurses. Putting nurses’ issues within the context of inequalities due to gender provides us with a platform to understand, to explain, to interpret how nurses’ options and how the opportunities manifest themselves – and how the obstacles, why they have obstacles in front of them.

Women, I think we know, have been treated as objects, as helpers, as caregivers, and as such they are expected to be altruistic, they are expected to be giving, they are expected to be sacrificing without expecting compensation. That’s really our history. Many women are sacrificing wives, sacrificing mothers in the world, and what they do – my research when I studied women in different parts of the world – they expect to be rewarded in their old age by their children. That is their reward. So they sacrifice all their lives but they know it’s going to happen later on – that they are going to be rewarded. They expect this delayed reward by family when they become the respected matriarch, whom others then sacrifice for.

The analogy between women and nurses’ situation is partially similar. Nursing grew from a sacrificing war model as well as a church model: nurses as caregivers in wars and as nuns were expected to be compassionate caregivers. They are altruistic and they expect no immediate reward other than the reward of just really caring for others, and that should bring that intrinsic wonderful feeling. Compensation in monetary terms was not the main consideration – they were taught not to really expect immediate rewards and compensation, financially, as an immediate reward. So nursing and mothering as a calling, not as careers really required little compensation other than the intrinsic reward from the act of giving to others. So here are some of the similarities that prevented nurses from being compensated appropriately.

Now, while women as mothers may get their rewards later on in life and nuns after they go to heaven, they expect to get those rewards, nurses may end their lives with little reserved savings to support them – and with actually the lack of valuation because of the little compensation they are given, because, I think societies tend to value people who are well compensated. As we carry the analogy further, we can understand why nurses’ work is valued – just as mothers’ work is very much valued. I think caring all over the world is very valued – there is intrinsic value in it – but the value does not translate into more regulated hours, to more respect, to better compensation equal to the effort – and to more power and to more autonomy. So it doesn’t translate to these things – it just translates to “yes, we love caring people and we value caring.”

Now, give nurses, as we give women more power, give them better compensation, give them more autonomy, and some of that translates to their ability to do even better work in supporting the patients and in making a difference in society, making a difference in the health care system. It gives them the potential of having a voice, and it gives them the potential with that power to be able to effect the changes that they believe should happen in the health care system and society.

I really think very strongly that gender inequity in work or life has the same properties and the same consequences, whether it is for women or for nurses. So why not use the example of nursing to change gender inequity? And why not use gender inequity in general as a platform for inequities that nurses experience? I think by linking them we have more voice and we are empowering a larger group of people. And we’re going to make a difference in policies and make a difference in patient care.

Question 3. How would you characterize the current situation in nursing?

We need to change the metaphors that describe nursing and differentiate nursing from medicine. The metaphor is that nursing is soft, compassionate, caring, historical, and “touchy”; and the metaphor for medicine is hard evidence of science. I do like the nursing metaphor. It should continue to be compassionate caring and giving, but it should also be attached to the metaphor that it is hard evidence, scientific, and it is a career. And I think that sums up where nursing is now. There is such an amazing momentum now that nurses must take advantage of with health care reform and with all the reports that are coming out. It’s the best time for nursing and we have to take advantage of that time to move forward.

By empowering nurses and by allowing their voices to come forth on the policy table – we  are a very large body of people and we are very large in the world – we really could become such an amazing force in improving the quality of care in the world and increasing access to health care. At the same time we use that power to empower women, and if you empower women then you empower families, you empower communities, and you empower society. Maybe that will bring us some peace in the world.