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Nursing Professionalization, Gender Equality, and the
Welfare State: Identifying Macro-Level Factors That
Advance Nursing Professionalization
by
Virginia Gunn
A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Graduate Department of Nursing Science
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
© Copyright by Virginia Gunn 2019
ii
Nursing Professionalization, Gender Equality, and the
Welfare State: Identifying Macro-Level Factors That Advance
Nursing Professionalization
Virginia Gunn
Doctor of Philosophy
Graduate Department of Nursing Science
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
2019
Abstract
Nursing professionalization has important benefits for the nursing workforce, patients,
and health systems. Given the large number of associated goals, the process is ongoing
and of continuous relevance to all countries where nursing is practiced. Although the
body of research focusing on this topic is vast, the macro-level structural determinants of
this process are currently less understood. The objectives of this thesis were to examine
the effects of (a) welfare state and gender regimes and (b) measures of education, health,
family, labour market, and gender policies on nursing professionalization in high-income
countries.
The literature review conducted synthesised health and socio-political studies, bringing
attention to key links between nursing professionalization and welfare state policies. The
empirical analysis consisted of two studies, the first one focused on the welfare state and
the second one on gender equality, both using a time-series, cross-sectional design and
iii
fixed-effects linear regression models. The analysis covered 16 years and 22 countries.
The findings suggest that both the average regulated nurse and the nurse graduate ratios
differ among welfare state and gender regimes. In addition, the following policy
measures were found to be predictive of (a) the regulated nurse ratio: total government
expenditure on education, total and public health care spending, length of paid paternity
leave, female share of tertiary education graduates, female share of employment in
managerial positions, gender wage gap, and female share of seats in national parliaments;
and of (b) the nurse graduate ratio: total government expenditure on education, total
health care spending, length of both paid maternity and paid paternity leaves, female
share of employment in managerial positions, gender wage gap, female share of seats in
national parliaments, and female labour force participation rate.
This study’s findings could add to existing upstream advocacy efforts to strengthen
nursing and the nursing workforce through healthy public policy.
iv
Acknowledgments
This dissertation would not have been possible without the constant support and
encouragement of a number of amazing people and the funding received from the Lawrence
S. Bloomberg Faculty of Nursing and the Dalla Lana School of Public Health.
First and foremost, I would like to express my sincere gratitude to my supervisor Dr. Carles
Muntaner, for all the support and guidance throughout the doctoral program. Carles, you
have been a source of inspiration ever since my master studies, opening up to me the world
of social inequalities in health, politics, welfare state, gender, and global health research.
With tact and kindness, you guided my learning over the years, generously sharing your
expertise and wealth of knowledge on a broad range of topics, cultivating my scientific
curiosity and encouraging me to engage in meaningful research. A big heartfelt thank you to
my dissertation committee members Mike Villeneuve, Dr. Montse Gea-Sánchez, and Dr.
Haejoo Chung for your insightful feedback, expert advice, tactful guidance, and great
support during this process. Despite being busy with your numerous professional
projects, you always made time to share positive reinforcements and keep me motivated.
To my internal and external examiners, Dr. Elizabeth Peter and Dr. Sanna Salanterä,
thank you for your insightful questions and constructive feedback. Dr. Edwin Ng, I am
very grateful to you for providing valuable direction and support with data imputation,
analysis, and results interpretation. Your remarkable talent to break down complex statistical
approaches into concrete, clear steps motivated and facilitated my learning of advanced
statistical methods and the completion of the empirical analysis.
I would like to thank my professors, mentors, and colleagues at the University of Toronto.
Dr. Denise Gastaldo, Dr. Debora Nitkin, Dr. Elizabeth Peter, Dr. Martine Putts, and Dr. Anne
Tourangeau; your guidance and advice during the program were very helpful and much
appreciated. Patricia Patchet-Golubev, the skills I learned from you over the years helped me
become a much better writer, making it easier to communicate my ideas; I cannot thank you
enough for it. Dr. Uttam Bajwa, Dr. Erica Di Ruggiero, and my colleagues in the
Collaborative Doctoral Program in Global Health at the Dalla Lana School of Public Health,
v
thank you for providing me with so many diverse opportunities to learn about global health.
My colleagues and friends, Debbie Finn, Maria Kristiina Guglielmin, Somayeh Faghanipour,
Vida Ghodraty Jabloo, Matthew Wong, and Rozina Somani, thank you for you
encouragement and generosity in sharing insights and resources. My friends and colleagues
at Peel Public Health, your support and encouragement in the beginning stages of my
doctoral degree were much appreciated.
Thank you to my wonderful family. Mom and Dad, you raised me to care about others, be
strong, and not give up easily. Your unwavering love, self-sacrifice, and incredible
generosity motivated me to work hard to achieve my dreams. Mom, your belief in and
valuing of education were contagious, instilling in me a life-long love of learning. My
incredible sisters, Dorina and Adriana, thank you for always watching out for me and for
being so supportive and ready to help over the years. Thank you also to my brothers-in-law,
Mihai and Petre, and to my nieces Cristina, Stefania, and Ileana for your love and
thoughtfulness. My parents-in-law, Ted and Louise, thank you for caring about my work,
encouraging me in it, and for taking such good care of us. I would also like to thank my dear
friend Patricia Donnelly. Patricia, I would not have applied to, and graduated from, this
program if it weren’t for your ongoing support, reassurance, insights, and motivation. My
family away from home, Alina, Sorin, Cristina, Ovidiu, and your beautiful children, my
godsons and goddaughters, thank you for being in my life and for supporting me in so many
ways.
Last, but not least, my dearest husband, Kenneth Gunn, I cannot thank you enough for being
my biggest supporter in this exciting and challenging adventure. You cheer me on when I
need encouragement, you instill confidence when I lack it, you fuel my body with mouth-
watering meals and my mind with intellectually stimulating conversations, and you skillfully
share your knowledge and abilities, inspiring me to learn more and do more.
vi
Table of Contents
Abstract .................................................................................................................................... ii
Acknowledgments .................................................................................................................. iv
Table of Contents ................................................................................................................... vi
List of Tables ........................................................................................................................... x
List of Figures ........................................................................................................................ xii
List of Appendices ................................................................................................................ xiii
Abbreviations ....................................................................................................................... xiv
Chapter 1. Introduction ......................................................................................................... 1
Overview of Dissertation ...................................................................................................... 1
Background ........................................................................................................................... 2
Rationale ............................................................................................................................... 6
Theoretical Foundation and Conceptual Model Proposed .................................................... 8
Study Questions and Hypotheses ........................................................................................ 12
Methodology Used to Answer the Research Questions ...................................................... 13
Chapter 2. Literature Review .............................................................................................. 15
Abstract ............................................................................................................................... 15
Introduction ......................................................................................................................... 16
Background ......................................................................................................................... 16
2.1 Current Approaches to the Study of Nursing Professionalization 17
2.2 Review Rationale and Goals 20
Methods ............................................................................................................................... 21
Findings ............................................................................................................................... 22
2.3 Nursing Professionalization Relevance 22
2.4. Nursing Professionalization and Welfare State Policies 26
Discussion and Implications ............................................................................................... 32
vii
Conclusion ........................................................................................................................... 35
Statement of Contributions by Others ................................................................................. 36
Chapter 3. Methods .............................................................................................................. 37
Study Sample ...................................................................................................................... 37
Data Sources ........................................................................................................................ 38
3.1 OECD 38
3.2 World Bank 39
3.3 ILOSTAT 40
3.4 LIS Cross-National DATA CENTER in Luxembourg 40
3.5 United Nations 40
3.6 World Economic Forum 40
Outcome, Explanatory, and Control Variables ................................................................... 41
3.7 Outcome Variables 41
3.8 Explanatory Variables 43
3.9 Control Variables 60
3.10 Variables Used in the Imputation Process 62
Analysis Approach .............................................................................................................. 64
3.11 Regression Model Specification 64
3.13 Testing Regression Assumptions and Regression Diagnostics 68
Handling of Missing Data ................................................................................................... 69
Study Limitations ................................................................................................................ 70
Chapter 4. Nursing Professionalization and the Welfare State Empirical Analysis ...... 74
Abstract ............................................................................................................................... 74
Introduction ......................................................................................................................... 75
Background ......................................................................................................................... 76
Study Aims .......................................................................................................................... 79
Design ................................................................................................................................. 80
Sample/Participants ............................................................................................................. 80
Data Collection .................................................................................................................... 80
4.1 Outcome Variables 80
4.2 Explanatory Variables 81
4.3 Control Variables 81
viii
Ethical Considerations ........................................................................................................ 86
Data Analysis ...................................................................................................................... 86
Validity and Reliability/Rigour ........................................................................................... 88
Results ................................................................................................................................. 88
4.4 Descriptive Summary 88
4.5 Regression Models 94
Discussion ......................................................................................................................... 100
Limitations ........................................................................................................................ 102
Conclusion ......................................................................................................................... 103
Statement of Contributions by Others ............................................................................... 105
Chapter 5. Nursing Professionalization and Gender Regimes Empirical Analysis ...... 106
Abstract ............................................................................................................................. 106
Introduction ....................................................................................................................... 109
5.1 Study Approach and Rationale 110
Background ....................................................................................................................... 111
5.2 Gender, Feminism, and Nursing Development 111
5.3 Arguments against Nursing Professionalization 112
5.4 Ongoing Challenges to Comparative Nursing Workforce Studies 113
5.5 Gender Equality in Education, the Labour Market, and Politics 115
5.6 Theoretical Location 116
Study Objectives ............................................................................................................... 117
Design and Sample ............................................................................................................ 118
Variables ........................................................................................................................... 119
5.7 Outcome Variables 119
5.8 Explanatory and Control Variables 120
5.9 Data Collection 125
Data Analysis .................................................................................................................... 125
Results ............................................................................................................................... 128
5.10 Descriptive Summary 128
5.11 Regression Models 138
Discussion and Implications ............................................................................................. 143
5.12 Summary of Findings 143
ix
5.13 Potential Explanatory Mechanisms 143
Strengths and Limitations ................................................................................................. 145
Conclusion and Recommendations ................................................................................... 147
Statement of Contributions by Others ............................................................................... 149
Chapter 6. Conclusion ........................................................................................................ 150
Key Findings ..................................................................................................................... 150
6.1 Manuscript 1. Literature Review 150
6.2 Manuscript 2. Nursing Professionalization and the Welfare State Empirical
Analysis 152
6.3 Manuscript 3. Nursing Professionalization and Gender Regimes Empirical
Analysis 152
Revised Conceptual Model ............................................................................................... 154
Discussion: Significance of the Findings and Thesis Contributions ................................. 154
6.4 Manuscript 1. Literature Review 154
6.5 Manuscript 2. Nursing Professionalization and the Welfare State Empirical
Analysis 155
6.6 Manuscript 3. Nursing Professionalization and Gender Regimes Empirical
Analysis 160
Study Limitations .............................................................................................................. 165
Implications and Recommendations ................................................................................. 168
6.7 Implications for Education 168
6.8 Implications for Policy Development 170
6.9 Implications for the Global Nursing Community 172
6.10 Recommendations for Research 174
Conclusion ......................................................................................................................... 178
References ............................................................................................................................ 179
Appendix 1. List of Countries Included in the Empirical Analysis ................................ 226
Appendix 2. Conceptual Definitions .................................................................................. 227
Appendix 3. Data Sources .................................................................................................. 231
Appendix 4. Copyright Acknowledgments ....................................................................... 237
x
List of Tables
Table 1. Key characteristics of welfare state regimes and the list of representative countries
for each regime included in this study ...................................................................... 44
Table 2. Key characteristics of gender policy models, used as proxy for gender regimes, and
the list of representative countries for each regime included in this study ............... 54
Table 3. Outcome and explanatory variables - rationale, measurement, and data source
(welfare state analysis) ............................................................................................. 83
Table 4. Means; total, between- and within-country SDs; and minimum and maximum values
for the outcome and explanatory variables, 2000-2015, 22 countries (welfare state
analysis) .................................................................................................................... 89
Table 5. Pairwise correlation matrix for the outcome and explanatory—including control—
variables in 22 countries, 2000-2015 (welfare state analysis) .................................. 91
Table 6. PW-PCSE models of welfare state regimes on regulated nurse-to-population and
nurse graduate-to-population ratios in 22 high-income countries, 2000-2015
(welfare state analysis) ............................................................................................. 96
Table 7. Individual PW-PCSE models of welfare state measures of health, education, family,
and labour market policy on regulated nurse-to-population and nurse graduate-to-
population ratios in 22 high-income countries, 2000-2015 (welfare state analysis) 98
Table 8. Outcome, explanatory, and control variables - rationale, measurement, and data
source (gender regime analysis) ............................................................................. 121
Table 9. Means; total, between- and within-country SDs; and minimum and maximum values
for the outcome and explanatory variables 22 countries, 2000-2015 (gender regime
analysis) .................................................................................................................. 129
Table 10. Minimum and maximum values for the outcome variables 22 countries, 2000-2015
................................................................................................................................ 131
Table 11. Pairwise correlation matrix for the outcome and explanatory—including control—
variables in 22 countries, 2000-2015 (gender regime analysis) ............................. 133
xi
Table 12. PW-PCSE models of gender regimes on regulated nurse-to-population and nurse
graduate-to-population ratios in 22 high-income countries, 2000-2015 (gender
regime analysis) ...................................................................................................... 140
Table 13. Individual PW-PCSE models of measures of gender equality in education, the
labour market, and politics on regulated nurse-to-population and nurse graduate-to-
population ratios in 22 high-income countries, 2000-2015 (gender regime analysis)
................................................................................................................................ 141
xii
List of Figures
Figure 1. Conceptual model .................................................................................................... 11
Figure 2. Trends in the regulated nurse-to-population ratio in 22 countries, 2000-2015, before
imputation ............................................................................................................... 136
Figure 3. Trends in the nurse graduate-to-population ratio in 22 countries, 2000-2015, before
imputation ............................................................................................................... 137
Figure 4. Revised conceptual model ..................................................................................... 153
xiii
List of Appendices
Appendix 1. List of countries included in the empirical analysis ......................................... 226
Appendix 2. Conceptual definitions ..................................................................................... 227
Appendix 3. Data sources ..................................................................................................... 231
Appendix 4. Copyright acknowledgments ............................................................................ 231
xiv
Abbreviations
AR (1) First-Order Autoregressiveness
b Unstandardized Coefficient
β Standardized (or Semi-Standardized) Coefficient
CNA Canadian Nurses Association
df Degrees of Freedom
GDP Gross Domestic Product
ICN International Council of Nurses
ILO International Labour Organization
ILOSTAT International Labour Organization Statistics Database
IOM Institute of Medicine
LIS Luxembourg Income Study
OECD Organisation for Economic Co-operation and Development
PPP Purchasing Power Parity
PW-PCSE Prais-Winsten Regression with Panel-Corrected Standard Errors
R2 Coefficient of Determination
rho Common Autoregressive Term
RNAO Registered Nurses' Association of Ontario
SD Standard Deviation
SE b Unstandardized Coefficient Standard Error
t T-scores
U.K. United Kingdom
xv
UN United Nations
U.S. United States
WHO World Health Organization
1
Chapter 1. Introduction
Overview of Dissertation
This thesis is divided into six chapters. Chapter 1 provides some relevant background
information and the rationale for conducting this research. In addition, it briefly describes
the theoretical foundation guiding the study and presents the proposed conceptual
framework. The study’s overall goal, objectives, research questions , hypotheses, and
methodology used to answer the research questions are also included.
Chapter 2 describes the literature review conducted for this thesis and synthesizes its key
findings in the form of a manuscript that has been published in the journal Nursing
Inquiry.
Chapter 3 contains the methodological details concerning the analyses conducted for this
study, including sample description, data sources, data collection, explanatory/outcome
variables, estimation techniques, post-validation tests, and the strategy used to replace
missing data.
Chapters 4 describes the empirical analysis conducted to examine the effect of welfare
state regimes and of several measures of education, health, family, and labour market
policies on indicators of nursing professionalization, together with the findings from this
analysis. This manuscript has been submitted for publication to the Journal for Advanced
Nursing.
Chapter 5 focuses on the empirical analysis conducted to investigate the effects of gender
regimes and measures of gender equality policies on indicators of nursing
professionalization. This manuscript has been submitted for publication to the Journal of
International Nursing Studies. Chapters 4 and 5 also contain some brief literature review
sections that summarize and build on the literature review included in Chapter 2, adding,
2
however, other studies that rationalise the analyses and lay the foundation for the results
by explaining potential mechanisms of interaction.
Chapter 6 presents a general discussion highlighting the thesis’ overall contributions to
this field of research, key findings, a revised conceptual framework, together with a
review of research limitations and relevant implications for the nursing profession.
Background
No broadly acknowledged definitions of nursing professionalization exist. This concept is
usually described as a process used by nursing to reach professional status through a mixture
of strategies that: (a) ensure nursing education is offered through higher education
programmes (Smith, 2009) and/or enforce university education as a requirement for
professional registration (Keogh, 1997), (b) establish and harmonize both professional
standards and specialized knowledge, and create a code of ethics, (c) endorse professional
autonomy and involvement in health care decision-making, and (d) expand the size, role, and
influence of professional associations (Keogh, 1997).
The process of nursing professionalization impacts a wide range of characteristics of the
nursing workforce, such as educational attainment, competencies, roles and responsibilities,
role autonomy, participation in decision-making, compensation, working conditions, and
social status (Black, 2013). Thus, nursing professionalization is directly linked to improved
educational attainment (both before and during admittance into nursing schools); extended
roles, responsibilities, and professional competencies; enhanced autonomy in practice;
increased involvement in decision-making; higher financial rewards; better working
conditions; and higher social status (Black, 2013; Gebbie, 2009).
Besides its benefits for the nursing workforce, nursing professionalization has favourable
effects on patient outcomes as related to nurses’ increased education levels (Aiken,
Cimiotti, et al., 2011; Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken et al., 2014;
Covell, 2011; Rafferty, 2018; Tourangeau, Cranley, & Jeffs, 2006; West, Mays, Rafferty,
Rowan, & Sanderson, 2009). In addition, nurses’ enhanced autonomy, ability to operate
3
at their full scope of practice, and participation in decision-making are linked to increased
and more equitable access to care (Aiken, Cheung, & Olds, 2009; Canadian Nurses
Association [CNA], 2009; Horrocks, Anderson, & Salisbury, 2002; Institute of Medicine
[IOM], 2011), higher patient satisfaction (Aiken, Clarke, Sloane, Lake, & Cheney, 2008),
and reduced health care costs (Browne, Birch, & Thabane, 2012; Eibner, Hussey,
Ridgely, & McGlynn, 2009; Health Council of Canada, 2013; Horrocks et al., 2002;
Hussey, Eibner, Ridgely, & McGlynn, 2009; Stiefel & Nolan, 2012).
The advantages of nursing professionalization, however, are not always recognized
(Bradshaw, 2017; Herdman, 2001; Rutty, 1998; Yam, 2004); there are a number of
arguments that may be raised against professionalization, including the accentuation of
occupational closure (Limoges, 2007; McPake et al., 2013; Rhéaume, 2003; Waters,
1989), bureaucratization (Bail, Cook, Gardner, & Grealish, 2009), the replacement of
nurses with less expensive but also less qualified staff (Chapman, 1998; Jacob, McKenna,
& D'Amore, 2015; Trossman, 2005), and increased financial resources and time required
to train nursing human resources (Adams, 2003; Mingo, 2008; Schwarz & Leibold, 2014;
Squires, 2007; Squires & Beltrán-Sánchez, 2011; Villeneuve & MacDonald, 2006). This
thesis is based on the idea that the advantages of professionalization (R. Davies, 2008;
Trim, 2014), summarized earlier and described in more detail in Chapter 2, far outweigh
its potential disadvantages, making nursing professionalization a worthy endeavour.
Through a comprehensive review of the literature in this field, I identified an existing
knowledge gap, as described next. Given the significance of nursing professionalization
for the nursing workforce, patients—both individuals and populations—and health
systems, a very large body of nursing research has examined this process or various
aspects related to it. As a result, valuable insights have been gained through the study of
both context and micro-level determinants of nursing professionalization. Such research
has examined topics including: nurses’ attitudes toward professionalization (Brooks &
Rafferty, 2010; Herdman, 2001; Kinnear, 1994; Shohani & Zamanzadeh, 2017), the
development and power of professional organizations (Adams, 2003; Coburn, 1994;
Ghadirian, Salsali, & Cheraghi, 2014; Liu, 2011; Rhéaume, 1988), professional
4
hierarchies, resistance from the medical profession, inherent power struggles (Brooks &
Rafferty, 2010; Cash, 1997; Coburn, 1994; Kinnear, 1994; Liu, 2011; Peter, 2001),
nurses’ participation in political advocacy (Adams & Bourgeault, 2004; MacDonald,
Edwards, Davies, Marck, & Guernsey, 2012; Patton, Zalon, & Ludwick, 2014b),
bureaucracy (Bail et al., 2009; Hall, 1968; Ryder, 2000; Villeneuve & MacDonald,
2006), and task fragmentation (Brannon, 1994; Coburn, 1994; Liu, 2011).
The influence of other contextual factors on professionalization and/or the evolution of
nursing has also been explored in nursing and social research. Such factors include
religion (D'Antonio, Fairman, & Whelan, 2013; Kreutzer, 2008; Marshall & Wall, 1999;
Nelson, 1997a; Wall, 2007), increased upfront costs to the health system associated with
professionalization (Adams, 2003; Brooks & Rafferty, 2010; Squires & Beltrán-Sánchez,
2011; Starc, Pahor, & Ilic, 2012), patriarchal structures (Ashley, 1976; David, 2000;
Hearn, 1982; Witz, 1992), feminism, feminist ethics, socio-cultural norms (Adams &
Bourgeault, 2004; Aranda, 2017; D'Antonio, 2004; Kane & Thomas, 2000; Lopez, 2006;
Lunardi, Peter, & Gastaldo, 2002; Maresh, 1986; Peter, Lunardi, & Macfarlane, 2004;
Rafferty, 1996; Roberts & Group, 1995; Speedy, 1985; Summers, 1988; Treiber & Jones,
2015), gender roles, gender hierarchies (Choperena & Fairman, 2018; Coburn, 1994; C.
Davies, 1995, 1996; Galbany-Estragues & Comas-d'Argemir, 2017; Hoffmann, 1991;
Peter & Martin, 2007), the public image of nursing (Black, 2013; Gordon, 2005;
Summers & Summers, 2014), social positioning (Price, McGillis Hall, Angus, & Peter,
2013), organizational context of work in health care systems (Liaschenko & Peter, 2004;
Molina-Mula, Peter, Gallo-Estrada, & Perello-Campaner, 2018; Rankin & Campbell,
2006), and the practical/vocational nature of nursing (Gardner, 2008; Yam, 2004).
Various gender aspects relevant to professionalization—with potential implications for
practitioners’ education, role autonomy, and professional development—have also been
considered in studies of other occupations in which women represent the majority, such
as midwifery (Adams & Bourgeault, 2004; Bourgeault, Benoit, & Davis-Floyd, 2004),
dental hygiene (Adams, 2003, 2005), and occupational therapy (Evertsson & Lindqvist,
2005).
5
Furthermore, significant contributions have been made by nursing history scholars, who
have examined past events to understand nurses and nursing’s current position in the
health care field and in society (Black, 2013; Boschma, 2014; Breda, 2009; Buchan,
2000; CNA, 2013a; D'Antonio et al., 2013; C. Davies, 2000; Hallett, 2010; Limoges,
2007; Nelson, 2003; Nelson & Gordon, 2004, 2006; Nelson & Wall, 2010; Rafferty,
1996, 2014b; Rankin & Campbell, 2006; Ryten, 1997; Summers, 2000; Wall & Rafferty,
2013).
In comparison, fewer studies have scrutinized the influence of national policies and other
structural factors on the development of the nursing profession and its evolution towards
professionalization (Jacobs, 2007; Oguisso, de Freitas, Squires, & Bonini, 2016; Squires,
2007; Squires & Beltrán-Sánchez, 2011; Van den Heede & Aiken, 2013). Such research
focuses on the intricate links between policy and certain aspects of professionalization,
including education (Aiken et al., 2009; Rafferty, 1996); retention and recruitment
(Buchan, 2000; McGillis Hall et al., 2013); legislation and regulatory bodies (Benton,
Pérez-Raya, González-Jurado, & Rodríguez-López, 2015; Duncan, Thorne, & Rodney,
2015); clinical practice guiding principles (Bail et al., 2009; Registered Nurses'
Association of Ontario [RNAO], 2010); professional growth (Mirr Jansen & Zwygart-
Stauffacher, 2010; Pavolini & Kuhlmann, 2016); and density of practitioners, staffing
levels, and skill mix (Lane, Antunes, Kingma, & Weller, 2010; Van den Heede & Aiken,
2013; World Health Organization [WHO], 2017). Other studies, preoccupied with the
link between nursing, power, and politics, have been conducted to examine ways to
increase nurses’ participation in politics and policy development in order to advance
nursing and improve care and/or access to care (Antrobus & Kitson, 1999; Baer, 1997;
Brown, 1996; Bryant, 2012; Coloma-Moya, 2006; Feldman & Lewenson, 2000;
Freshwater, 2017; Gebbie, Wakefield, & Kerfoot, 2000; Katriina et al., 2013; Limoges,
2007; Lyttle, 2011; Mason, Gardner, Hopkins Outlaw, & O'Grady, 2016; O'Neill Hewlett
& Bleich, 2009; Rafferty, 2008).
6
Rationale
To increase the understanding of factors influencing nursing professionalization, I
decided to focus on macro-level determinants, such as country-level policies and other
structural factors. The rationale for this direction is twofold. First, both health and health
care are influenced by broad socio-economic and political factors guiding the allocation
of resources in a society (Bambra, Fox, & Scott-Samuel, 2005; Muntaner, 2002;
Muntaner & Lynch, 1999; Muntaner, Lynch, Hillemeier, & Lee, 2002; Navarro & Shi,
2001). Thus, given that health, health care, and nursing are closely related, a thorough
understanding of determinants of nursing professionalization would require the study of
such macro-policies and structural factors. The political nature of care work and care
ethics, and the need for careful consideration of power issues in its analysis, was
suggested by other theorists who point out the inherent distributive conflicts related to the
allocation of both care resources and responsibility for caring work (Held, 2005; Tronto,
2013, 2015). Closely related, the importance of considering higher-level, structural
determinants when studying professionalization has been previously acknowledged by
researchers who caution that a sole focus on typical features of professionalization such
as education level, knowledge base, and autonomy makes it easy to overlook the role of
power in this process (Johnson, 1972; Limoges, 2007; Yam, 2004).
Second, given that the majority of practitioners in nursing are female, gender factors and
feminist implications significantly affect nursing (Boschma, 1997; Cash, 1997; David,
2000; C. Davies, 1995; Liaschenko & Peter, 2004; Lunardi et al., 2002; Meerabeau,
2005; Melchior, 2004; Rafferty, 1996; Reverby, 2014) and carry significant weight in the
process of professionalization without, however, being sufficiently understood yet
(Adams & Bourgeault, 2004; Meerabeau, 2005; Squires, 2007; Wall, 2010). As a
consequence, in this thesis, I examine the macro-level determinants of nursing
professionalization through the use of both welfare state and gender regime frameworks.
This approach builds upon previous strategies utilized to study this process, adding to an
emerging field of research that looks outside of nursing to gain insight into its
development, with the hope of identifying high-level structural factors that can be utilized to
strengthen our profession through increasing professionalization levels.
7
The extent of the positive effects associated with nursing professionalization for nurses,
patients, and the larger health care system (R. Davies, 2008; Trim, 2014) justifies efforts to
expand our understanding of this process and its determinants. This study is the first to
investigate and compare the relationship between nursing professionalization and public
policies in different welfare state and gender regimes. The findings could support the
development of country-level policies that enable, maintain, and enhance nursing
professionalization. For instance, the extent and sustainability of the nursing workforce could
be influenced by national policies that safeguard the allocation of planned and consistent
funding for education—including health workforce training—and by policies that support
investments in health care—especially public—systems. Policies that legislate minimum
educational requirements for admission to, and graduation from, nursing schools, together
with extended scopes of practice, should enhance patient outcomes and enable health system
savings through efficient resource utilization. Gender egalitarian policies within the family
environment should stimulate the fair division of paid and unpaid work among males and
females. Similarly, such policies promoting gender equality in areas such as education,
income, and politics could facilitate nurses’ access to advanced education, enable their
continued participation in the labour market, and support their efforts to participate in
political activism in order to further their profession.
Consequently, this study’s findings should benefit advocacy efforts carried out by both
nurses and professional organizations to advance the nursing profession. In addition, given
this study’s comparative analysis of nursing across 22 countries, it should be of interest to
nursing professionals in a variety of national and international contexts. Finally, this study
should kindle interest in learning more about the long-term impacts of welfare state and
gender equality policies on the professionalization of nursing, thus moving this field of
research forward. In the long run, expanding our knowledge of the ways in which to
strengthen both nursing and the nursing workforce should increase the sustainability of
nursing human resources, thus, addressing ongoing health system workforce challenges
(Black, Rafferty, West, & Gough, 2004); it could also enhance patient outcomes, facilitate
8
improved access to health care, bring added system efficiencies, and, thus, add value to
health systems (Salmon & Maeda, 2016; WHO, 2016a).
The focus of this dissertation is on regulated nurses, namely licenced practical nurses and
registered nurses, including advanced practice nurses who practice nursing in a range of
public/private health care facilities and/or who are self-employed. Nursing care refers to the
care provided to both sick and healthy individuals of all ages, including families and
communities (International Council of Nurses [ICN], 2002). Care can be provided
individually or as part of a collaborative effort and includes health promotion and protection;
prevention of disease; and primary, acute, rehabilitative, chronic, and end-of-life care (ICN,
2002). Beyond providing direct care, nursing roles include education, advocacy, research,
policy analysis, and management (ICN, 2002).
Theoretical Foundation and Conceptual Model Proposed
To conduct this study, I selected a critical social theory perspective, guided by a few
theoretical frameworks. Specifically, I utilized Navarro’s political economy model, given its
potential to analyze health, social, and structural issues (Navarro et al., 2006; Navarro & Shi,
2001) and its focus on welfare regimes and the political forces shaping their development
(Muntaner et al., 2011). This theoretical approach explains how macro-structural factors such
as politics, the economy, and the balance of power between the government and other key
political actors affect the development of the welfare state, including the distribution of
resources in a society (Smith, Bambra, & Hill, 2016). This framework facilitates an analysis
of how politics and the welfare state affect the distribution of health, education, labour
market, family, and political resources among women and men, thus, potentially affecting the
development of nursing, an occupation with a high concentration of women practitioners.
A hybrid welfare state regime typology, reflective of both traditional (Esping-Andersen,
1990) and contemporary (Bambra, 2007; Eikemo & Bambra, 2008; Navarro et al., 2006;
Navarro & Shi, 2001) welfare state theory classifications, was used to assign countries to five
welfare regimes for the empirical analysis: Social Democratic, Christian Democratic,
9
Liberal, Authoritarian Conservative, and Confucian. This typology, summarized in Chapter
3, expands on the classification proposed by Navarro et al. (Navarro et al., 2006; Navarro &
Shi, 2001) by adding the Confucian category, proposed by Bambra and Eikemo (Bambra,
2007; Eikemo & Bambra, 2008). This classification was chosen because it is grounded in a
thorough consideration of the policies and politics influencing the welfare state. Higher
levels of welfare state spending on health and education sectors and more egalitarian policies,
supporting a more fair allocation of resources and opportunities among males and females,
characteristic of Social Democratic regimes (Bergqvist, Yngwe, & Lundberg, 2013), are
expected to positively influence the development of nursing, an occupation in which female
practitioners represent a majority. On the contrary, at the other end of the spectrum, low
investments in health and education, along with more pronounced patriarchy, characteristic
of Authoritarian Conservative regimes (Bergqvist et al., 2013), are likely to negatively
impact nursing and its practitioners.
The gender policy model employed, also outlined in Chapter 3, used as proxy for gender
regimes, is the one proposed by Korpi, Ferrarini, & Englund (2013), due to its focus on
family policies impacting gender equality. This model was used to allocate countries to three
categories: Earner-carer, Market-oriented, and Traditional family. Countries in the Earner-
carer category are typically known as having higher levels of gender equality due to a mix of
family policies that facilitate women’s access to education and paid jobs (Korpi et al., 2013),
thus, potentially favouring occupations like nursing, with a female-majority base. In contrast,
given that the Traditional family grouping is known for low levels of gender equality, as
derived from low levels of labour force participation accompanied by low economic power
(Korpi et al., 2013), the development of nursing in such countries is expected to be
negatively impacted.
Upon reviewing the theoretical and empirical nursing, health, social, and political literature
investigating nursing professionalization, gender equality, and the welfare state, I decided on
a conceptual model that links together key macro-level, structural factors outside of nursing
that influence the process of professionalization. The model, illustrated in Figure 1, proposes
that nursing professionalization is influenced by both welfare state and gender regimes, as
10
well as by specific welfare state policies—education, health, labour market, and family—and
gender equality policies regulating education, the labour market, and political representation.
Details about the possible mechanisms of interaction between these concepts are provided in
Chapter 2 - Findings section, Chapter 3 - Explanatory Variables section, Chapter 4, and
Chapter 5 – Background and Discussion sections. The model also acknowledges that the
welfare state and gender equality are, in turn, influenced by country-specific political,
historical, and socio-cultural contexts as well as by international influences; however, testing
these relationships was outside the scope of this study.
11
Figure 1. Conceptual model
12
Study Questions and Hypotheses
Statement of Purpose: This study acknowledges the close links between nursing
professionalization, the welfare state, and gender equality, examining them in relationship to
each other. The overall goal of the study was to gain a better understanding of which
structural, macro-level factors could play a role in increasing professionalization levels.
Study Objective: To examine the effect of welfare state and gender regimes and that of
several measures of welfare state and gender policies on nursing professionalization
indicators.
Research Questions: Four research questions were addressed, grouped into two
categories, according to their focus on the welfare state or on gender regimes.
Welfare State Regimes
What is the effect of welfare state regimes on nursing professionalization
indicators in high-income countries?
What is the effect of education, health, family, and labour market welfare state
policies on nursing professionalization indicators in high-income countries?
Gender Regimes
What is the effect of gender regimes on nursing professionalization indicators
in high-income countries?
What is the effect of gender equality policies in education, the labour market,
and politics on nursing professionalization indicators in high-income countries?
Research Hypotheses: Four research hypotheses were formulated and, similar to the
research questions, grouped into two categories, according to their focus on the welfare
state or on gender regimes.
13
Welfare State Regimes
Average nursing professionalization indicators in high-income countries differ
among welfare states, being the highest in Social Democratic regimes, given
their increased health spending and more gender equality policies, and the
lowest in Authoritarian Conservative regimes, as related to lower levels of
health spending and increased patriarchy.
Increased generosity in welfare state spending, as well as universal,
redistributive strategies, along with gender equality policies, reflected in
measures of education, health, family, and labour market policies, are expected
to be positively associated with nursing professionalization indicators.
Gender Regimes
Average nursing professionalization indicators in high-income countries differ
among gender regimes, being the highest in Earner-carer regimes, given their
higher levels of gender equality, and the lowest in Traditional family regimes,
as related to increased patriarchy.
Public policies that promote gender equality in education, the labour market,
and politics, as illustrated by measures of gender equality in these fields, are
expected to be positively associated with nursing professionalization
indicators.
Methodology Used to Answer the Research Questions
A literature review and two empirical studies, the first one focused on the welfare state and
the second one on gender regimes were conducted to address this study’s objective and
research questions. The literature review consisted of a comprehensive critical review of the
nursing, health, socio-economic, and political literature. The empirical studies employed a
time-series, cross-sectional, comparative study design. Fixed-effects linear regression
models and Prais-Winsten regressions with panel-corrected standard errors, including a first-
order autocorrelation correction, were utilized to examine the effect of welfare state and
14
gender regimes, and that of welfare state and gender equality policies, on nursing
professionalization indicators. Data were gathered from open access, secondary sources and,
given the existence of missing observations, a multiple imputation strategy was devised and
implemented.
The analysis covered 16 years and 22 high-income countries, members of the Organisation
for Economic Co-operation and Development (OECD): Australia, Austria, Belgium,
Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, Netherlands,
New Zealand, Norway, Portugal, South Korea, Spain, Sweden, Switzerland, United Kingdom
(U.K.), and the United States (U.S.). For the 2018 fiscal year, countries categorized by the
World Bank as high-income had a gross national income per capita of $12,056 (U.S. dollars)
or more (The World Bank, 2019).
For the welfare state analysis, countries were allocated to welfare state regimes as follows:
(a) Social Democratic — Austria, Denmark, Finland, Norway, and Sweden; (b) Christian
Democratic — Belgium, France, Germany, Italy, Netherlands, and Switzerland; (c) Liberal -
Australia, Canada, Ireland, New Zealand, U.K., and the U.S.; (d) Authoritarian Conservative
— Greece, Portugal, and Spain; and (e) Confucian — Japan and South Korea. For the gender
regime analysis, countries were divided into three clusters, as follows: (a) Earner-carer —
Denmark, Finland, Norway, and Sweden; (b) Market-oriented — Australia, Canada,
Ireland, Japan, New Zealand, South Korea, Switzerland, U.K. and the U.S.; and (c)
Traditional family — Austria, Belgium, France, Germany, Greece, Italy, Netherlands,
Portugal, and Spain.
15
Chapter 2. Literature Review
Gunn, V., Muntaner, C., Villeneuve, M., Chung, H., & Gea-Sanchez, M. (2019). Nursing
professionalization and welfare state policies: A critical review of structural factors
influencing the development of nursing and the nursing workforce. Nursing Inquiry, 26(1),
e12263. doi:10.1111/nin.12263
This manuscript was first published in the Nursing Inquiry journal, in the Early View
category on September 2, 2018. The numbering of headings has been reformatted for
inclusion in this thesis, to fit the overall chapter numbering patterns, and a number of minor
edits have been made, including the addition of a number of references previously excluded
from the version submitted for publication due to space limitations.
Abstract
Nursing professionalization is both ongoing and global, being significant not only for the
nursing workforce but also for patients and health care systems. For this reason, it is
important to have an in-depth understanding of this process and the factors that could
affect it. This literature review utilizes a welfare state approach to examine macro-level
structural determinants of nursing professionalization, addressing a previously identified
gap in this literature, and synthesises research on the relevance of studying nursing
professionalization. The use of a welfare state framework facilitates the understanding
that the wider social, economic, and political system exercises significant power over the
distribution of resources in a society, providing a glimpse into the complex politics of
health and health care. The findings shed light on structural factors outside of nursing, such
as country-level education, health, labour market, and gender policies that could impact the
process of professionalization and thus, could be utilized to strengthen nursing through
facilitating increased professionalization levels. Addressing gender inequalities and other
structural determinants of nursing professionalization could contribute to achieving health
equity and could benefit health systems through enhanced availability, skill-level, and
https://doi.org/10.1111/nin.12263
16
sustainability of nursing human resources, improved and efficient access to care, improved
patient outcomes, and cost savings.
Keywords: critical review, nursing professionalization, nursing human resources, patient and
health system outcomes, welfare state, health equity, gender inequalities, politics of health.
Introduction
Nursing professionalization, resulting in the setting of professional standards and nursing
competencies, impacts people’s lives around the world and has significant repercussions on
the nursing workforce (Palese et al., 2014). The WHO highlights the key role played by
health human resources in the successful operation of health care systems, suggesting that
enhancing health workforce performance should be a priority (2015). Given that nursing is
an integral part of the health care system and that nurses represent the largest group of health
care professionals in most countries, many attempts to increase effectiveness and efficiency
in health care delivery target nursing and the nursing human resources (Willis, Carryer,
Harvey, Pearson, & Henderson, 2017). This literature review addresses a gap in the nursing
literature. It synthesises structural, macro-level factors linked to nursing professionalization
and suggests new ways to study this process through the use of a welfare state perspective.
Background
Professionalization is referred to as the process undertaken by occupations to gain expertise
(Abbott, 1988), autonomy (Freidson, 1974), professional recognition (Neal & Morgan,
2000), prestige, higher social status, income (Freidson, 1974), and power (Coburn, 1994). No
widely recognized definitions of nursing professionalization exist. This concept refers to the
process employed by nursing to achieve professional status through a combination of
strategies that: (a) move nursing education into higher education (Smith, 2009) and mandate
university education as an entry-to-practice requirement (Keogh, 1997), (b) create
professional standards, specialized knowledge, and a code of ethics, (c) promote professional
autonomy and involvement in health care decision-making, and (d) strengthen professional
associations (Keogh, 1997). Such strategies have mixed effects. Although they ensure a
17
certain training standard for practitioners, they could also constitute a closure mechanism that
could potentially restrict access to nursing to certain social classes who possess the required
time and financial resources.
Similarly to professionalization, there is no unique definition of nursing professionalism,
reflecting varied perspectives and interpretations across time and geographical location
(Monrouxe & Rees, 2017). A concise explanation refers to professionalism as a combination
of practices, behaviours, attitudes, and communication techniques that demonstrate core
values of nursing and that include the application of altruism, caring, excellence, ethics,
respect, and accountability (Charania, Ferguson, Bay, & Freeland, 2017). Given existing
similarities among nursing professionalization and professionalism and despite their
significant differences, these terms are sometimes used interchangeably in the literature
(Evetts, 2013). For this reason, this review’s search terms included professionalism to ensure
that studies referring to professionalization but using the term professionalism are reviewed.
Nevertheless, the focus of the review is limited to studies focused on the professionalization
process.
2.1 Current Approaches to the Study of Nursing
Professionalization
A preliminary scoping review we conducted increased our understanding of existing
approaches to the study of factors influencing nursing professionalization. Key relevant
findings are synthesised next.
A large body of literature examined micro-factors influencing the development of the
nursing profession, including: the inconsistent interest in professionalization among
nurses (Kinnear, 1994), the strength of professional associations (Stahlke Wall, 2018),
nurses involvement in political advocacy (Adams, 2003), task fragmentation (Coburn,
1994), and medical opposition (Liu, 2011). Numerous other studies investigated factors
affecting nursing’s development (CNA, 2013a; D'Antonio et al., 2013; Siles, Solano-Ruiz,
Fernández de Freitas, & Oguisso, 2010). Such work focused on education,
18
recruitment/retention, working conditions, decision-making, and workforce sustainability
(Aiken et al., 2014; Benner, Sutphen, Leonard, & Day, 2010; Büscher, Sivertsen, & White,
2010; WHO, 2010a). However, only a small subset of such research has specifically
investigated the links between these elements and the process of professionalization.
Nursing has a high concentration of women practitioners; although it is suggested that gender
implications should be considered when studying professionalization (Adams, 2003; P. G.
Clark, 1998; Hearn, 1982; Huppatz, 2012; Meerabeau, 2005), given this process’ typically
taken for granted gender-neutrality, its gendered character is not always acknowledged or
addressed (Kuhlmann & Bourgeault, 2008; Wall, 2010). Despite steadily increasing rates,
men continue to constitute a minority in nursing. The reasons why fewer males than females
pursue nursing are multiple and complex (MacWilliams, Schmidt, & Bleich, 2013; Mullan &
Harrison, 2008; Villeneuve, 1994). Central to the study of professionalization is the
understanding of ways to eliminate such barriers and close the gender gap in nursing, thus,
keeping pace with other professions once known for their gendered workforce (MacWilliams
et al., 2013). Existing gender bias could deter many males from pursuing nursing (Liu & Li,
2017; Meadus, 2000; Mullan & Harrison, 2008), thereby robbing the profession of the many
strengths and benefits that males could bring to it. Further, given that gender bias is often
associated with nursing’s difficulties to obtain more social and financial recognition, the
elimination of such bias could benefit both males and females in nursing and, especially, the
nursing profession (Sullivan, 2002).
Despite an emphasis on gender in the context of occupations with a predominant female
membership, the pathways through which gender impacts the process of professionalization
are not yet completely understood (Squires, 2007). Various studies emphasised the role of
sociocultural norms/attitudes and organizational context in the continuous undervaluing of
women’s work in society (Black, 2013; Evertsson & Lindqvist, 2005; Riska & Wegar, 1993),
including the underappreciation of occupations with a female majority, such as nursing
(Carpenter, 1993; Choperena & Fairman, 2018; Yam, 2004). Lack of appreciation for
women’s work has been linked to financial and social devaluing of work that involves
caring (Limoges, 2007; Mandel & Semyonov, 2005), often associated with emotion and self-
19
sacrifice (Treiber & Jones, 2015) and branded as a woman’s quality rather than as a
requirement for health organizations (Apesoa-Varano, 2016; Goodman, 2016), expected of
both the women and men working there (Boschma, 1997). The analysis of the socially
constructed care/cure or emotional/technical dichotomy, which compares the caring work
performed by nurses with the curing work completed by physicians (Barnard & Sandelowski,
2001; Caffrey & Caffrey, 1994; Sandelowski, 1997, 2000; Sullivan & Deanne, 1994; Treiber
& Jones, 2015) and that of the lack of recognition of caring work in organizational policies
and practices (Galbany-Estragues & Comas-d'Argemir, 2017) brings further insight to the
understanding of differences in public recognition, autonomy, and power among health care
professionals.
The negative portrayals of nursing by the media are also linked to the belittling of nursing
work (Gordon, 2005; Summers & Summers, 2014). Further, although the development of
nursing has been uniquely shaped by contextual factors (Nelson & Wall, 2010), religion has
been recognized as a common and profound influencer of European and North American
nursing (Marshall & Wall, 1999; Nelson, 1997b; Rafferty, 1996). Thus, differing religious
values and practices, including the concept of taking care of the sick as a tradition of self-
sacrifice and vocation, influenced not only the development of nursing and the path to
professionalization but the lives and social recognition of its practitioners (Baker, Guest,
Jorgenson, Crosby, & Boyd, 2012; CNA, 2013a; Gardner, 2008; Rafferty, 1996).
Relatively fewer nursing studies considered the role of national policies in influencing
nursing professionalization (Oguisso et al., 2016; Squires, 2007; Squires & Beltrán-Sánchez,
2011). Insightful work has been done to investigate the links between policy and particular
aspects related to professionalization such as regulation (Benton et al., 2015; Duncan et al.,
2015), education (Aiken et al., 2009; Blaauw, Ditlopo, & Rispel, 2015; Duncan, Thorne, Van
Neste-Kenny, & Tate, 2011), practice guidelines (Bail et al., 2009; Kleinpell et al., 2014;
RNAO, 2010; Stahlke Wall, 2018), professional development (Mirr Jansen & Zwygart-
Stauffacher, 2010; Pavolini & Kuhlmann, 2016), and density of practitioners and staffing
levels (Buchan, 2000; Lane et al., 2010; Tourangeau et al., 2006). Other structural elements
such as: (a) increased time/financial investments associated with professionalization, and
20
financial constraints favouring lower wages instead of the higher pay associated with
professionalization (Adams, 2003), (b) medical dominance (Coburn, 1988), (c) power
imbalances, patriarchal structures, gender hierarchies, and inequalities within the health care
field (Galbany-Estragues & Comas-d'Argemir, 2017; Maresh, 1986) have been similarly
highlighted as impacting nursing professionalization.
2.2 Review Rationale and Goals
A gap in the nursing literature on professionalization has been previously identified by
researchers who argued that the impact of political and socioeconomic factors on nursing is
strong, however, there is insufficient scholarship studying the influence of political structures
on its development (Duncan et al., 2015; Jacobs, 2007; Van den Heede & Aiken, 2013).
Similarly, a case study analyzing the professionalization of nursing in Mexico concluded
that, although the state plays a significant role in the process, one that is larger than that
played by nurses, who rely on the often limited economic and political resources available to
them, the role is not well understood (Squires, 2007). The preliminary scoping review we
conducted confirmed this gap and, given the powerful role of macro-level determinants
and the limited understanding on ways they could affect nursing professionalization, we
performed this review.
The review builds upon existing approaches to the study of nursing professionalization,
placing emphasis on structural factors through the use of a welfare state framework. The
study of the welfare state offers insightful perspectives into the distribution of resources
in a society, often reflective of class and gender inequalities, thus offering an excellent
context for understanding how the generosity and structure of different welfare state
policies could impact different population or occupational groups, in this case nursing.
Since politics is involved in the distribution of scarce resources (Navarro & Shi, 2001),
recognizing the political character of health and health care, is a prerequisite to
successfully influencing health human resources policy in support of nursing
professionalization. The specific goals of this review are two prong: first, to synthesise
research on the relevance of studying nursing professionalization and second, to shed
21
light on structural factors such as welfare state policies that could impact nursing
professionalization.
Methods
A critical review of the literature was conducted to identify key studies at the intersection of
nursing professionalization and the welfare state. Targeting nursing, sociological, and
political research, the electronic databases searched included: CINAHL, Web of Science,
Scopus, Gender Studies, Sociological Abstracts, Worldwide Political Science Abstracts,
Medline, and Embase. The subject headings and keywords used included short and long
versions and related forms of: nursing professionalization, nursing professionalism,
professionalization, professionalism, academization, nursing profession, welfare state,
welfare regime, welfare state policy, gender, gender policy, and gender regime. Search terms
were used both separately and combined, using the Boolean operators OR and AND. Titles,
abstracts, and keywords were reviewed for relevance. Reference lists and sources of grey
literature were also reviewed to identify relevant resources that have not been indexed
according to the search terms used.
The upper date limit of the review is January 2018 and, to eliminate the risk of missing
relevant seminal studies, no lower date limit filter was set. Only studies in English were
included, which, when studying nursing in a global context, is a clear limitation since a
large subset of potentially relevant studies could be, thus, missed. We addressed this
limitation and adopted a global perspective by including: (a) studies prepared by large
international organizations, (b) cross-national comparative research, (c) studies focused on
specific countries, as well as (d) systematic reviews and other type of reviews. Thus, of the
131 studies included, four were prepared by large international organizations such as the ICN
and the WHO. A comparative approach was used in 26 studies that focused on continents
(e.g. Europe, Asia, America, and Africa), geographical regions (e.g. Latin America, East
Asia, South Asia, sub-Saharan Africa, Western Europe, Australasia) or countries in certain
income categories. Seven systematic and other types of reviews with an international focus,
as well as 21 theoretical articles were also included. Other studies focused on specific
countries or were written by researchers in those countries, such as: Australia and New
22
Zealand (6), Brazil (1), Canada (15), France (1), Germany (4), Greece (1), Japan (1), Mexico
(2), Norway (1), Poland (1), Spain (2), Sri Lanka (1), Russia (1), South Africa (3), Sweden
(1), UK (11), and the US (21).
Findings
2.3 Nursing Professionalization Relevance
2.3.1 Nursing Workforce
Professionalization impacts a wide-range of nursing human resources characteristics,
including educational attainment, competencies, roles/responsibilities, autonomy,
participation in decision-making, compensation, working conditions, and social status
(Black, 2013). Thus, nursing professionalization is positively linked to increased educational
achievement (both before and after program admission), expanded roles/responsibilities and
the attaining of additional professional competencies, increased role autonomy, higher levels
of participation in decision-making, improved financial compensation, enhanced working
conditions, and elevated social status (Black, 2013). Professionalization might have mixed
effects with regard to nursing shortages. In the long term, it could contribute to alleviating
shortages (Palese et al., 2014) however, without eliminating them. This is attributed to higher
levels of professional satisfaction enjoyed by university-prepared nurses, making them less
likely to leave the profession (R. Davies, 2008). Further, in a globalized knowledge economy
(Castles, Leibfried, Lewis, Obinger, & Pierson, 2010) and in an era focused on higher
education, more potential candidates might be attracted to nursing. In addition, in 2011 the
IOM suggested that a larger pool of university-prepared nurses increases the likelihood that
some will pursue graduate education, thus contributing to solving the shortage of nursing
faculty, limiting the number of admitted students (2011). However, nursing
professionalization does not eliminate shortages, especially since significant time/financial
investments are required for professionalization at both individual and societal levels.
Furthermore, professionalization enhances nursing’s visibility. The establishment of
standardized entry-to-practice education requirements reinforces that nurses require skills
23
and knowledge, not only vocation and sacrifice (Yam, 2004) and that nurses’ contribution to
the health care system is significant (IOM, 2015). Increased autonomy and involvement in
decision-making increase nurses’ voice and impact on health care services and policy design
(Trim, 2014). In addition, professionalization contributes to the development of institutional
infrastructure for both nurses and women in general. The availability of graduate degrees in
nursing facilitates the development of nurses as academics and researchers, who will
contribute to the training of new generations and the creation of nursing-specific knowledge
(IOM, 2011). Additionally, the existence of university-level education for a majority-female
occupation empowers women by providing them with added choices (Squires, 2007).
2.3.2 Individual, Organizational, and Health System Outcomes
Besides its impact on the nursing workforce, professionalization influences individual,
organizational, and system outcomes. In the context of health care reform aimed at
improving individual/population health and patients’ experience of care, as well as reducing
health care costs (Stiefel & Nolan, 2012), nursing is considered a significant driver of better
health, better care, and better value (Health Council of Canada, 2013). A strong link exists
between nurses’ education levels and patient outcomes, as has been shown in research that
associates the hiring of degree-prepared nurses with reduced mortality rates (Aiken et al.,
2003; Tourangeau et al., 2006), decreased preventable death rates among acute patients
(Aiken, Sloane, et al., 2011), decreased failure-to-rescue rates, shorter hospital length-of-stay
(Aiken et al., 2003), lower nosocomial infections rates (Covell, 2011), and overall
improvements in patient outcomes (West et al., 2009).
Such findings are not unexpected, given that a meta-analysis of 139 studies concluded that
university-prepared nurses score higher than diploma-prepared nurses on a range of
indicators, including knowledge, communication, problem-solving, and teaching skills
(Johnson, 1988). Similar studies showed that degree-prepared nurses develop additional
competencies on topics such as health policy, leadership, system thinking, funding, quality
improvement (IOM, 2011) and substantially higher levels of research skills that, in turn,
support evidence-informed practices (Kovner, Brewer, Yingrengreung, & Fairchild, 2010).
Not surprisingly, increasingly complex health problems reinforce the need for health care
24
human resources with high levels of educational achievement (Frenk et al., 2010; IOM,
2011).
Next, increased autonomy for nursing practice (Boyle, 2004) and environments characterized
by participation in decision-making (Aiken et al., 2008) have also been shown to be
positively linked to improved care quality and patient satisfaction. Several studies revealed a
strong link between advanced practice nurses being able to function to their full scope-of-
practice and significant cost savings in direct health care costs (Browne et al., 2012) as well
as increased access to both general (Aiken et al., 2009) and primary health care (Horrocks et
al., 2002) along with a reduction in wait times (CNA, 2009). In turn, enhanced access to
primary care together with nurses’ involvement in health policy and nurse-led health clinics
are associated with the advancement of health equity (IOM, 2011). A growing body of
evidence employs economic arguments to show that inadequate investments in nurse staffing
and skill mix practices based solely on cost savings are linked to an increase in adverse
outcomes, leading ultimately to avoidable health care system and societal costs (Buchan,
2000; Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006), showing once more the
significance of systematically planned investments in nursing human resources (Sermeus et
al., 2011). Equally important is to ensure that the substantial evidence showing the positive
impact of higher levels of nursing education, as well as experience, and expertise on patient
outcomes is not ignored and that nurses are not replaced with less trained workers in efforts
to cut costs.
2.3.3 Nursing Professionalization—Global, Ongoing, and Dynamic
The move toward professionalization is global, having spread from North America to
Europe, Australasia, and, most recently, to South America (Palese et al., 2014). While
nursing has gained professional status in some countries, in others it is still considered a
semi-profession and for this reason, the debate about the status of nursing as a profession is
ongoing (Liu, 2011). Further, given that the educational system for health care professionals
is intricately linked to both local and global contexts (Frenk et al., 2010), the process of
professionalization is invariably affected by international trends (Oguisso et al., 2016). For
instance, the Bologna process, fast-tracked the integration of nursing education into higher
25
education, accelerating and harmonising the process of nursing professionalization among
European Union member countries (R. Davies, 2008).
The view that professionalization is a milestone in the evolution of nursing, which, once
complete, creates room for other nursing achievements (Nelson, 1997b) has gradually
evolved towards recognizing its enduring character. Recent scholarship regards this process
as ongoing, remaining continually relevant to all countries in which nursing is practiced
because of the large number of related goals, including to: (a) move nursing education to
higher education, (b) mandate university-level education for registered nurses entering the
profession, (c) increase the number of nurses holding university degrees, (d) enhance
professional standards/competencies, (e) enhance autonomy, (f) enhance nurses’ participation
in decision-making, (g) increase the number of nurses in advanced practice roles, and (h)
create more professional organizations (Baumann & Blythe, 2008). Provided that there are
various stages and goals involved in the process of achieving, maintaining, and enhancing
professionalization, and that there can be both progress and regress (Pavolini & Kuhlmann,
2016) in its evolution, given insistent movements to bring down entry-to-practice
requirements (Bradshaw, 2017), this is a very dynamic and non-linear process (Andrews &
Wærness, 2011).
2.3.4 Opposition to Nursing Professionalization
The long-term benefits of professionalization are not recognized unanimously. Thus, this
process has been often critiqued in the sociological literature (Herdman, 2001) and, even
though professionalization is mostly perceived as positive by nurses, polarizing and
ambivalent perspectives exist among them with regard to its purpose (Yam, 2004). Further,
while the majority of other professionals recognize without hesitation that more education
leads to improved performance, in nursing, this acknowledgement is still debated (Rafferty,
2014a). Similarly, statements of criticism and mistrust addressed at the university-prepared
nurse are not uncommon (Bradshaw, 2017), a puzzling attitude, given that other
professionals are admired and respected for their academic training and achievement (Rutty,
1998).
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Key arguments against professionalization include the fear that higher wages resulting from
increased educational requirements will lead to the replacement of nurses with a cheaper and
less qualified labour force (Chapman, 1998). It is also anticipated that the added
requirements associated with professionalization could accentuate occupational closure
(Waters, 1989), increase bureaucratization (Bail et al., 2009), and escalate financial/time
investments required at both individual and institutional levels (Squires & Beltrán-Sánchez,
2011).
Professionalization, as long as it does not create unnecessary obstacles to entry, nor does it
promote practice monopolies (Starr, 1982), should protect the interests of patients and
populations through: a) the promotion of quality, professional standards, and accountability,
and b) the expansion of health services coverage and improved health equity, enabled by a
sustainable and well-educated global nursing workforce. This review is based on the
assumption that professionalization benefits both the nursing profession and patients and,
thus, is a goal worth pursuing.
2.4. Nursing Professionalization and Welfare State Policies
The findings of this review, synthesised next, suggest that there are numerous links between
nursing professionalization and structural factors such as welfare state policies, emphasizing
the need for a new approach to the study of professionalization, through the use of a welfare
state framework. Such a perspective enables the understanding that both health and health
care are political, and that the political context has to be acknowledged and addressed to
meaningfully influence health policy (Bambra, Fox, & Scott-Samuels, 2005; Navarro and
Shi, 2001).
Common definitions of the welfare state refer to it as a combination of services, benefits,
insurance, and subsidies funded or provided by the state and supported through social
transfers, meant to provide citizen protection against social risks; such services include
education, health care, housing, pensions, transportation, social assistance, and worker,
consumer, and environmental protection policies (Castles et al., 2010). These definitions,
however, fail to reflect the complexity of the welfare state, including the potential negative
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implications of some of its social policies and their effect on class structures (Esping-
Andersen, 1990).
Esping-Andersen, a well-known theorist in this field, adopted a more comprehensive
approach to this topic (1990). He used a political economy perspective to show that social
policies influence employment and social structure, and, thus, in addition to positive
influences such as facilitating social transfers and welfare services, the welfare state could
have detrimental societal influences through the creation and/or maintenance of socio-
economic hierarchies (1990). Such hierarchies and distributive conflicts are reflective of
class and gender inequalities and result from the set of rules, beliefs, and values that guide
the organization of welfare services and social transfers in society, which are likely to mirror
the interests and beliefs of dominant classes (Korpi, 2010).
A number of welfare state typologies exist, reflective of both traditional and contemporary
welfare state theories. Such typologies are used to group countries into distinct clusters,
based on factors such as decommodification, social stratification, and the relative roles
played by the state, the market, the family, and the voluntary sector in the provision of
welfare (Esping-Andersen, 1990). Numerous welfare state studies are dedicated to
classifying and comparing high-income countries in Western, Central, and Northern Europe,
North-America, East-Asia, and Australasia (Esping-Andersen, 1990; Huber & Stephens,
2005; Korpi, 2000). In addition, a growing body of research is devoted to examining welfares
state typologies and their labour markets in middle- and low-income countries in Latin
America, East and South Asia, Africa, and Eastern Europe (Haejoo Chung, Muntaner,
Benach, & EMCONET Network, 2010; Cook, 2007; Mesa-Lago, 2009; Muntaner, Chung,
Benach, & Ng, 2012; Wood & Gough, 2006).
2.4.1 Education Policies
Professionalization is intertwined with educational achievement, given that the attainment of
university education is often considered a criterion for obtaining professional status. The
education system, in turn, is an integral part of the welfare system (Busemeyer & Nikolai,
2010). Given that the government allows members of certain occupations to set and enforce
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standards for educational achievement (Timmons, 2010) and that facilitating the provision of
such education falls often within the realm of the government, the state controls which
occupations benefit from higher education and subsequently, from higher incomes. Available
funding structures for higher education could impact levels of professionalization differently,
for example, accelerating nursing professionalization in Australia and slowing it down in the
UK (Francis & Humphreys, 1999). Further state interference in the education sector is
illustrated through recent developments in neoliberal societies that led to the reorganization
of expert knowledge and expertise in order to support efficiency agendas, thus transforming
the role of professions through an added political dimension (Foth & Holmes, 2017).
2.4.2 Health Care Policies
The link between nurses, as main providers of health care, and the welfare state is clear,
gi