Written by Dr Elaine Maxwell (@maxewele) & Professor June Girvin (@ProfJuneG) 

From the moment of our birth we are all exposed to the cultural codes of ‘masculinity’ and ‘femininity’; codes developed over years of observations and assumptions of how men and women think, feel, and operate and these codes have created our broad societal norms and expectations. These gender divisions are fundamental to the organisation of all areas of social life (Davies 1995) from the family to the workplace. Nursing is strongly established as a feminine profession, regardless of the sex of the practitioner.  It is the nature of nursing work that is gendered, not the individual nurse.

The first nursing school in the world was for men only and was established as far back as 250 B.C. in India, where only men were considered ‘pure’ enough to become nurses (Vallano, 2011).  The  long history of men being involved in nursing continued to 330 A.D. in the Byzantine Empire (Bullough, 1994), and men were also caring for the sick and injured during the Crusades in the 11th century, as part of the Knights of St John.  Post the fifteenth century enlightenment, and the emergence of empirical science, the identification of ‘male’ and ‘female’ roles in society became increasingly apparent, consolidating into well-established gender expectations by  the 19^th century and continuing into the 20^th.

As medical science developed post-enlightenment it became the preserve of the educated male until well into the 20^th century, leaving behind the caring and serving roles for women to take on.  Through their monopoly over diagnosis and prescription, doctors decided who should be treated and what should be done to them.  Nurses’ roles were limited to assisting their medical superiors and to maintaining a hygienic and comfortable environment for their charges who in turn had little knowledge of or authority over what was happening to them. Gamarnikow (1978) has argued that by the Victorian era doctor-nurse-patient relationships could be equated with husband-wife-child relationships. Florence Nightingale pragmatically accepted this hierarchy and was largely responsible for the 19^th century ‘feminisation’ of nursing into the caring, female dominated profession that is still prevalent in contemporary society (Masters, 2009).

In 1966 David Bakan developed the notions of ‘agency’ and ‘communion’ in his book The Duality of Human Existence: Isolation and Communion in Western Man. He argued that humans engage in both actions - agency focusing on goal completion, and communion on sustaining social relationships.  Bakan suggested that ‘agency’ was a masculine trait and ‘communion’ a feminine one. This assertion was later somewhat supported by empirical evidence showing that while men and women possess both agency and communion, a higher sense of agency is more common in men and a higher sense of communion is more common in women -although this may well be a product of socialisation rather than an innate quality. In addition, whilst both are important, society places less value on communion than on agency.

This distinction is apparent in healthcare, where medical staff have traditionally focused on goal based activities such as diagnosis and treatment interventions (agency) while nurses focus on the supportive, social relationships that sustain patients through these medical actions (communion). A recent example of the power of this distinction is Nursing’s reaction to criticism in the Francis report into Mid Staffordshire NHS Foundation Trust. There was an immediate move to increase its focus on communion  - to celebrate compassion, seen by some as the ultimate expression of communion.  English nursing leadership launched the strategy ‘Compassion in Practice’ which, although it did mention one agency attribute (competence), became a clarion call for caring and compassion as the defining attributes of nursing, neatly re-emphasising Nightingale’s ‘feminisation of nursing’.

It is not surprising given this background that attempts to increase the status of nursing have focused on emphasising the ‘agency’, or technical aspects. This is illustrated by a desire for nurses to ‘work at the top of their licence’ demonstrated by undertaking more technical activity and delegating the lower status ‘communion’ to unregistered staff and nursing associates. In gender terms, to take on work that is seen as belonging to the higher status, masculine gendered profession.  An action, no matter how useful in workforce terms, that does nothing to raise the status of nursing and may well lead tore-emphasising it as low -level activity belonging to, yes, a female - gendered profession.

Nursing will have to work hard to change this.  Given the deeply embedded nature of the issues associated with being a feminine gendered profession, these will not be ameliorated by simply increasing the number of men entering nursing - welcome though this is – or by becoming a substitute for junior medical staff. Nursing needs to embrace its own notions of agency and communion.The question is, do we even know what they are?

Davies, C. (1995) Gender and the professional predicament in nursing. McGraw-Hill Education

Bakan, D. (1966) The duality of human experience Beacon:Boston

Bullough, V. L. (1994) ‘Men, women and nursing history’ Journal of Professional Nursing, 10 (3),127

https://www.professionalnursing.org/article/8755-7223(94)90002-7/fulltext

Gamarnikow, E., 1978. Sexual division of labour: the case of nursing in Kuhn, A. and Wolpe, A. (eds) Feminism and materialism: Women and modes of production Routledge: Oxon

Vallano, A.T. (2011) Your Career in Nursing   Chicago, Kaplan Publishing.