Nursing Professionalization, Gender Equality, and the ......Virginia Gunn Doctor of Philosophy Graduate Department of Nursing Science Lawrence S. Bloomberg Faculty of Nursing University

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