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Nurse migration from India: a literature review

Affiliations.

• 1 Baylor University - Louise Herrington School of Nursing, 3700 Worth Street, Dallas, TX 75246, USA. Electronic address: [email protected].
• 2 Baylor University - Louise Herrington School of Nursing, 3700 Worth Street, Dallas, TX 75246, USA; Baylor University - Robbins College of Health and Human Sciences, One Bear Place #97303, Waco, TX 76798-7303, USA. Electronic address: [email protected].
• 3 Baylor University - Louise Herrington School of Nursing, 3700 Worth Street, Dallas, TX 75246, USA. Electronic address: [email protected].
• PMID: 26216005
• DOI: 10.1016/j.ijnurstu.2015.07.003

Background: A profound nursing shortage exists in India where nurses are increasingly outmigrating to practice nursing in surrounding countries and abroad. This is important globally because countries with the lowest nursing and healthcare workforce capacities have the poorest health outcomes.

Objective: This review sought to synthesize and unify the evidence about nurse migration from India and includes a look at nurse retention within India.

Design: A comprehensive literature review was performed to synthesize and unify both qualitative and quantitative research.

Data sources: Bibliographic databases searched included CINAHL, MEDLINE, PsycINFO, and EconLit using associated keywords for empirical and descriptive literature published between January 2004 and May 2014. Hand searches of the Nursing Journal of India from 2004 to February 2014 and the Journal of Nursing Research Society of India from its inception in 2007-February 2014 were also completed.

Review process: 29 studies were selected and analyzed for the review. Data were appraised for quality; reduced through sub-categorization; extracted; and coded into a framework. Thematic interpretation occurred through comparing and contrasting performed by multiple reviewers.

Results: Findings included an exponential growth in nurse recruitment efforts, nurse migration, and a concomitant growth in educational institutions within India with regional variations in nurse migration patterns. Decision-making factors for migration were based on working conditions, salience of family, and the desire for knowledge, skill, technology, adventure and personal enrichment. Challenges associated with migration included questionable recruiting practices, differing scopes of practice encountered after migration and experiences of racism and cultural differences. A shift toward a positive transformation of nursing status in India has resulted in an increased respect for individual nurses and the profession of nursing. This was attributed to the increased globalization of nursing.

Conclusions: Results from this review can be used to shape health policy and advocate for nursing reform in India. As India's healthcare infrastructure continues to evolve, effective programs to improve conditions for nurses and retain them in India are needed. Additionally, as the globalization of nurses increases, more research is needed to develop effective programs to aid in a smooth transition for nurses who migrate from India.

Keywords: Attrition; Brain drain; Emigration and immigration; India; Migration; Nurses; Racism; Recruitment; Retention; Work conditions.

Copyright © 2015 Elsevier Ltd. All rights reserved.

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Current Social Perception of and Value Attached to Nursing Professionals’ Competences: An Integrative Review

Margarita rodríguez-pérez.

1 Department of Nursing, University of Huelva, 21007 Huelva, Spain; se.uhu.fned@oragram (M.R.-P.); se.uhu.fned@anemjf (F.M.-N.)

Francisco Mena-Navarro

Abraham domínguez-pichardo.

2 Centro de Salud Bombero Etxaniz, Osakidetza, 48010 Bilbao, Spain; moc.liamg@51odrahcipmaharba

Cristina Teresa-Morales

Associated data.

Not applicable.

In order to develop nurses’ identities properly, they need to publicise their professional competences and make society aware of them. For that, this study was conducted to describe the competences that society currently attributes to nursing professionals and how nursing is valued in society. This review was based on the conceptual framework by Whittemore and Knafl. The literature search was conducted using PubMed, WOS, and CINAHL databases, and the search strategy was based on a combination of natural language and standardised keywords, with limits and criteria for inclusion, exclusion, and quality. The results of the studies were classified and coded in accordance with the competence groups of the professional profile described in the Tuning Educational Structures in Europe programme. Fourteen studies were selected. The most commonly reported competence groups were as follows: nursing practice and clinical decision making; and communication and interpersonal competences. Nursing is perceived as a healthcare profession dedicated to caring for individuals. Its other areas of competence and its capacity for leadership are not well known. In order to develop a professional identity, it is essential to raise awareness of the competences that make up this professional profile.

1. Introduction

A nurse’s professional identity (NPI) was described by Fargemoen as “the values and beliefs held by the nurse that guide her/his thinking, actions, and interaction with the patient” [ 1 ] (p. 437) that are considered to be inherent to professional development. The four key elements that make up NPI are the theoretical and practical knowledge that professional nurses must acquire; the definition of the professional role, setting out what nurses must know, do, think, and feel; the nurses’ own social and moral values, which cause them to behave in an expected, desirable manner; and the social image or representation of the profession, encompassing the prestige and value assigned to it by society [ 1 , 2 , 3 ].

Thus, the social or public image of the profession is a key component of professional identity. Generally speaking, nursing is recognised within society as a healthcare profession in its own right [ 4 ], whose essence lies in delivering care in close contact and developing ongoing relationships with patients, who are always vulnerable and completely or partially dependent [ 1 ]. The nursing profession is demanding, advocating for, and constructing a body of distinct, specific scientific knowledge that is produced and corroborated by its members [ 5 ]. This would provide a reasoned foundation for NPI to differentiate nursing from other professions and define its nature, characteristics, knowledge, and activities. However, it is very important that these aspects are made visible and highlighted within society so that the nursing profession is recognised for what it is. A number of studies highlight the fact that nursing professionals perceive patients as being unaware of and not understanding the role and tasks involved in nurses’ professional performance [ 6 , 7 ]. This lack of knowledge is even present among nursing students themselves, who, before starting the nursing degree, were not able to describe what nursing is or what nurses do [ 8 , 9 , 10 ]. As a result, nursing professionals are frequently mistaken for other healthcare workers [ 11 , 12 , 13 ] or defined by comparing healthcare workers with one other [ 14 ]. Therefore, it seems that the general public is unaware of the current academic, scientific, and professional situation of the profession, resulting in the profession often being misrepresented [ 4 , 15 ]. This may stem from the image that is sometimes portrayed in the media, the image of a secondary, passive, limited profession [ 6 ] that does not reflect its real competencies, thus rendering its competencies either invisible or unrecognised by society [ 16 ].

In the last decade, the nursing profession has evolved largely due to curriculum changes and the enactment of legislation aimed at structuring healthcare professions. In the United States, in 2021, the American Association of Colleges of Nurses established new guidelines for the purpose of shaping the education of nurses in a report entitled The Essentials: Core Competencies for Professional Nursing Education. This report lists 10 domains and their associated competencies, which are the essence of the nursing profession and practice [ 17 ]. In turn, in Europe, the Bologna declaration initiated a new competence-based training model developed through the Tuning Educational Structures in Europe programme in 1999 [ 18 ]. Both models describe curriculum outcomes in terms of competences, understood as the dynamic combination of attributes regarding knowledge, skills, attitudes, and responsibilities. As a result, nursing professions are defined by the set of competences that their professionals must possess. These programmes established the competencies that define the nursing profession by classifying them into five groups of competencies, as in the case of Europe, or into ten domains, as in the case of the United States [ 17 , 18 ]. Table 1 describes both classifications and identifies common areas between them.

Reference frameworks for the general descriptors of a bachelor’s degree programme in Nursing in Europe and in the United States.

Source: The authors, based on direct quotes from the following reports: Guidelines and Reference Points for the Design and Delivery of Degree Programmes in Nursing [ 18 ] (p. 7), and The Essentials: Core Competencies for Professional Nursing Education [ 17 ] (pp. 27–54).

This competence-based structure offers new guidance for understanding and learning nursing, and for current and future nursing professionals and students to work on their NPIs. It is therefore essential to gain an understanding of what is perceived about what nurses do and/or can do and the value that society places on the profession. Therefore, the aim of this study was to describe the competences that society currently attributes to nursing professionals and how nursing is valued in society.

2. Materials and Methods

Design: An integrative review was made. The stages followed in this review are based on the methodological framework developed by Whittemore and Knafl [ 19 ]: problem identification; rigorous search strategy; comprehensive evaluation; interpretation and critical analysis of selected data; synthesis and presentation of selected data.

Search Method: The databases explored were PubMed, WOS, and CINAHL. The search strategy was based on a combination of the following keywords: social perception/image/representation and nurse/nurses/nursing. The thesaurus of each database was selected for the search using standardised terms. Natural language keywords were used in the search by title and abstract. Details of the search strategies employed can be seen in Table 2 . The search was conducted in April and May 2021. Finally, key authors in the selected documents were identified, and the snowballing technique was used.

Search strategies.

a Only for Pubmed. b Only for Cinahl.

Inclusion and exclusion criteria: The search was limited to studies published between 2016 and 2021 in English, Spanish, and/or Portuguese. The inclusion criteria were as follows: articles whose object of study was the social image of nursing (IC1); original or review articles using a qualitative, quantitative, and/or mixed methodology (IC2).The exclusion criteria were as follows: articles using ahistorical methodology (EC1); studies with samples of nursing students in their second year and above or samples of professional nurses (EC2).The latter criterion was applied because first-year nursing students’ social image of the nursing profession remains intact. However, over time, their social image becomes self-image and is influenced by academic training and clinical placements.

Quality appraisal: The methodological quality of the studies was assessed using MMAT [ 20 ], an appraisal tool for qualitative, quantitative, and mixed methods studies and reviews. The templates for the different methodologies were reviewed independently by the researchers. A low methodological quality score was used as an exclusion criterion (EC3).

Data extraction and analysis: The data extraction and synthesis followed the steps set out by Whittemore and Knafl [ 19 ]. The researchers read the selected studies exhaustively. Using an analytical comparative framework, the results of the studies were classified and coded in accordance with the competence groups defined by the Tuning Programme, as described in the Introduction section. We believe that this coding is flexible and specific enough to define the competence profile of a nurse in any context.

Search outcomes: When the search limits were applied, 1423 articles were found, of which two were identified by searching for key authors using the snowballing technique. Once duplicates were removed, there was a total of 1085 articles remaining. In the review, we discarded studies whose titles did not expressly focus on the perception of nursing competencies. We then proceeded to read the abstracts of the 292 selected titles, applying the established inclusion and exclusion criteria. As a result, 206 were discarded because their objectives were not in line with our research objectives; a further 55 were discarded because they had used a historical method, were letters to the editor, reflection articles, or similar; and a further 16 were discarded because they sought to ascertain nurses’ perceptions of other professional or user groups on the subject. The 15 resulting documents were read in their entirety and were assessed using the MMAT tool. One of them scored poorly and was therefore discarded (see Figure 1 ).

Prisma flow diagram showing the article selection process.

3.1. Descriptive Analysis

Fourteen articles were included in the review, which, in methodological terms, were three reviews, four quantitative studies, five qualitative studies, and two mixed methods studies. Study samples included young individuals and university students (three); nursing students (five); professionals working with nurses in teams (one); and, the general public users of healthcare facilities (one). Finally, another study took news in the media as a source of information. Table 3 shows a summary of the studies included.

Summary of the studies included.

3.2. Qualitative Analysis

A number of studies detected widespread ignorance of nursing functions, activities, and roles, and an inability to differentiate them from those exercised by doctors [ 23 , 32 , 33 ]. However, other studies report that nursing is viewed as a health sciences profession [ 33 ] whose primary mission is to care or deliver care [ 22 , 28 , 33 , 34 ]. Care is understood as the delivery of help, assistance, and services to patients and sick people, for whom nurses should act as resources during their processes [ 22 , 26 , 34 ]. The findings on professional competences and social perception are shown below.

3.2.1. Professional Competences Perceived by Society

Some studies have described in great depth the skill sets or groups of competences that society attributes to and/or expects from the nursing profession. We classified their contributions into the five groups of the Tuning framework:

Knowledge and cognitive competences: they include the possession of sound, up-to-date knowledge, a willingness to engage in lifelong learning, and the development of critical thinking skills and emotional intelligence to enable engagement with patients without burnout [ 26 , 30 , 34 ]. Two studies identified a perception of nurses as less intellectually capable [ 22 ] or inclined more to being skilled than to being intelligent [ 24 ]. There is limited representation of nursing research and the ability to apply this research evidence to nursing practice. Čukljek [ 26 ] reported that the items “Research is vital to nursing as a profession” and “Nurses incorporate research findings in their clinical practice” were viewed as largely irrelevant by their sample, obtaining an average score below agree. In the sample in the study by Albar [ 34 ], only 46% answered agree in response to the research profile, and 33% affirmed that nursing practice is based on scientific evidence.

Nursing practice and clinical decision making: nursing practice was mentioned in all the studies reviewed, suggesting that nursing is viewed as a predominantly practical profession [ 32 ]. Nursing is understood as a profession that operates primarily in the clinical setting. There is a tendency to perceive the nursing profession as existing primarily within hospitals [ 28 , 33 , 34 ]. As a result, the hospital setting is the main symbol representing nursing, as it is viewed as the physical space in which most nurses deliver care [ 28 , 33 ]. Other symbols include the uniform or clothing that nurses tend to wear in hospitals [ 26 ] and the equipment and instruments they use on a daily basis: stethoscope, gloves, etc. [ 30 ]. Nursing students agreed with this relationship between nursing and the hospital as the main working environment. For instance, the first-year nursing students participating in the study by Čukljek [ 26 ] explained that nurses care for sick individuals at the hospital. In addition, the sample in the study by Yilmaz [ 27 ] saw themselves working as clinical nurses in surgical and paediatric departments, for example, rather than in areas such as education or teaching, administration, and management in the healthcare sector. Other settings, such as home care [ 24 , 28 ] and end-of-life care [ 22 ], were rarely mentioned in the studies. Regarding health prevention, promotion, and recovery, Albar [ 34 ] reported that 84% of their sample of first-year nursing students agreed that the role of nurses was associated with health prevention, 90% with health promotion, and 94% with recovery. The techniques described include healing wounds, monitoring vital signs, taking samples, administering medication and fluids, taking anthropometric measurements, providing basic care, controlling pain, and working with technology [ 22 , 24 , 28 , 32 , 34 ]. Regarding clinical decision making, the nursing profession is even presented as “providing medical care”, an undeniably vague nuance found in Elmorshedy [ 25 ]. In other studies, nursing is viewed as a subordinate profession that depends on, assists, or helps doctors [ 22 , 25 , 29 , 34 ], with some alluding to a lack of overall autonomy, and, more specifically, to a lack of decision-making autonomy, and others to a lesser degree of responsibility [ 22 , 34 ]. Despite this being the predominant stance, other studies contradicted perceptions of this subordinate position. In Pierroti [ 28 ], nurses are identified as doctors’ assistants due to the 24/7 clinical care provided by the group in comparison with the brief contact between doctors and patients. Girvin [ 23 ] detected two conflicting positions; on the one hand, nursing is viewed as an autonomous profession characterised by comprehensive roles, broad knowledge, and high visibility, while on the other hand, nurses are perceived as doctors’ helpers or apprentices. However, Glerean [ 22 ] found that nursing is viewed as a profession with a low level of autonomy, despite nurses being perceived as independent professionals. The sample in Čukljek [ 26 ] displayed high levels of disagreement with the item “Nurses do not follow physicians’ orders without questions”, echoing Albar [ 34 ], in which 36% of the sample of students agreed with the item “Nurses make decisions on care autonomously”. The most extreme contradiction can be found in the study by Sanz Vega [ 24 ], where 69.1% of the sample agreed completely or somewhat with the item “Nursing involves functions that do not require a doctor to be present”, and only 2.1% agreed that one of the conditions required to be a nurse was obedience. Meanwhile, 10.7% of the sample disagreed with the item “Nurses only perform activities on a doctor’s orders”, indicating that more than 89% agreed with this statement.

Professional values and the role of the nurse: the professional values with the greatest representation were having a vocation, inclination, drive, or enthusiasm for the profession, and responsibility [ 24 , 29 , 33 , 34 ]. On the other hand, other studies included flexibility to change, versatility to take on different roles, and ability to cope with occupational risks, death, and times of maximum demand [ 22 , 28 , 30 ]. After these, the most represented values were altruism; being humane, possessing human sensibilities, or being humanitarian; respect, tolerance, and open-mindedness; being committed or dedicated to the profession; being hard-working; and self-sacrifice [ 22 , 28 , 29 , 30 , 33 ]. Finally, values with less representation were fellowship and being supportive; professionalism; determination and trustworthiness; solidarity; honesty and compassion; and being disciplined, cautiousness, and meticulousness [ 22 , 28 , 30 , 33 ].

Communication and interpersonal competences: these included empathy, active listening, communication skills, friendliness, and ability to establish close interpersonal relationships with patients [ 22 , 28 , 30 , 34 ].

Leadership and team working: these include connecting with other members of the multidisciplinary team, being able to engage in collaborative work, efficiency, leadership or charisma, and good time management [ 29 , 30 ]. Competences related to education, teaching, research, and management are only sporadically mentioned among nursing students or any other type of sample and in review studies [ 24 , 28 , 34 ]. With regard to management, Elmorshedy [ 25 ] found that 68.9% of their sample answered disagree to the idea of nurses holding senior management positions, as they viewed them as lacking the necessary training and skills.

3.2.2. Prestige and Value Attached by Society

The sample in Pierroti [ 28 ] viewed nursing as an essential, vital profession for improving patients’ health, as nurses are responsible for providing all forms of care, corroborating the findings of a number of studies. In the review by Terry [ 12 ], nurses are acknowledged to have a significant impact on the general population. Equally, in Yilmaz [ 27 ], 66% of the participants evaluated nurses’ professional status very positively, while only 12.5% evaluated it negatively. The sample in Browne [ 30 ] also made a very positive professional evaluation of nurses. The image of nursing observed by Glerean [ 22 ] portrays a profession that is highly valued and needed by the population.

More specifically, the sample in Sanz Vega [ 24 ] displayed high levels of trust in nurses: 97% of users would welcome nurses into their homes, 76% trusted nurses to apply new techniques, and 50% trusted nurses to prescribe medication, although 71.3% would confirm the prescription with a doctor. In addition, in the study by Čukljek [ 26 ], first-year nursing students showed the highest levels of agreement on the following items: “Nurses act as resource persons for individuals with health problems”, and “The service given by nurses is as important as that given by physicians”.

Some studies compared evaluations of different healthcare professionals by nursing students, other healthcare professionals, users, and the general public. With some ambivalence, the sample in Pierroti [ 28 ] viewed nurses as equally important as doctors but said that doctors enjoyed greater prestige. In Terry [ 21 ], nurses are considered inferior to doctors or with a lower social status. Similarly, Glerean [ 22 ] showed that the nursing profession has low levels of recognition or social status. We identified the lowest level of social status in Elmorshedy [ 25 ], whose sample, university students and teachers, stated that they would be ashamed to have a nurse in their family.

According to the findings reported by Girvin [ 23 ], the nursing profession is sometimes not recommended by school career advisors or family members because it is not viewed as the ideal career. Conversely, in Sanz Vega [ 24 ], 73.4% of the respondents viewed the profession as a good occupation that they would recommend to their loved ones.

In consonance with Sánchez-Gras [ 31 ], and according to Girvin [ 23 ], nurses are generally portrayed in the press as professionals with a secondary role associated with another profession, with little responsibility, autonomy, or decision-making capacity. The nursing profession is conveyed as uninteresting, unchallenging, and lacking in creativity and responsibility, with few opportunities for growth or promotion, with a low academic level, low pay, and low social status. According to these studies, the image conveyed in the media centres around mistakes made by nursing professionals, errors with an impact on patients’ health, negligence, and even crimes committed by nurses [ 23 , 31 ]. In contrast, the sample in Sanz Vega [ 24 ] disagreed with the image of nursing portrayed by the media for failing to do justice to the profession’s social status or prestige. According to Girvin [ 23 ], websites belonging to official institutions and healthcare facilities reveal the dominance of medicine over the other healthcare professions. Nursing is barely represented: it is not even listed as a service or as one of 10 professions featured, unlike other professions such as medicine [ 23 ].

4. Discussion

Our findings suggest that nursing is perceived as a healthcare profession whose primary function is to provide care, which is consistent with other studies that also link nurses to care work [ 8 ] for the sick in hospital, administering medication [ 10 ], or performing patient hygiene [ 6 , 35 , 36 ]. To this end, society considers it vital, almost a prerequisite, that nurses possess high technical skills, thus perpetuating the classical view of healthcare, nursing care, the nursing profession, and the recipient of care. The social perception of nurses’ knowledge and cognitive competences is in line with American and European structures alike, although nursing research and the application of nursing evidence to nursing practice is considered to be of little to no relevance by society. Even though there is no doubt that nursing research has increased considerably, society still seems to be unaware of nurses’ research competence. This may be related to the image of the clinical nurse, dedicated to caring for sick people in the hospital. Areas such as health promotion, disease prevention, and assisting healthy individuals have not been reflected in society’s perception either, which echoes previous studies [ 8 ].

Even communication skills are reduced to interpersonal relations, which are established between nurses and patients in the care setting, ignoring other contexts such as interprofessional relations and communication through mass media, which are included in our profile. The competence to communicate in political contexts and to participate in health policies has not emerged. This is likely to be linked to the dependent role attributed to the profession. The limited involvement and visibility of nurses in these decision-making groups is increasingly evident and vindicated by professionals. In this regard, the International Council of Nurses states that it is critical to ensure that nurses have a say in the development and implementation of healthcare policies in order to ensure that these policies are effective in meeting the real needs of patients, families, and communities around the world. This aspect has been investigated by different authors, such as Benton, Al Maaitah [ 37 ]; Rasheed and Younas [ 38 ]; and, Cervera-Gasch and Mena-Tudela [ 39 ]; who have proposed interesting interventions to include this competence in the nursing colleges. However, in order to achieve this status, society needs to become aware of nurses’ real competences and value them.

Society identifies communicative values and competences, but relates them more to personal attributes than to professional competences. This view is confirmed by studies that identify the following professional values as qualities of nurses: being responsible and skilful [ 40 ]; compassionate and kind [ 13 ]; kind, patient, and affectionate [ 41 ]. This perception favours an out-dated view of the profession, tied to its historical background, thus downplaying the importance of professionalism. In addition, a number of healthcare managers and many nurse educators maintain a vocational style, which can lead to considerable differences between nursing education institutions in terms of the overall vision of nursing [ 42 ].

Leadership and team work competences coincide with some of the ideas presented in this review. Society perceives nurses as being able to work collaboratively with other professionals. At the same time, however, society places nurses in an inferior position to other team members. Although the value attributed to the nursing profession is similar to that of the medical profession, it is perceived as a secondary role associated with another profession, lacking the training and skills for team management, with few opportunities for growth or promotion, and with little responsibility, autonomy, or decision-making capacity. This vision is more prominent in certain cultural contexts where this lack of autonomy is understood as obedience, where nurses are perceived as simply following the doctor’s instructions [ 10 , 40 , 43 ]. The idea of being subordinated to the medical profession also influences the self-concept and professional identity of nurses [ 4 ] and their social perception. It is sometimes argued that the social prestige of nursing is poor because it is compared to other professions such as medicine [ 35 , 44 ], highlighting that choosing to study medicine as opposed to nursing is linked to the higher status of medicine [ 14 ]. Nevertheless, nurses’ knowledge, skills, and abilities, which underpin the profile defined in the aforementioned programmes, do equip them with the competences to work autonomously and independently. Authors have shown that nursing was considered to be as prestigious as the medical profession, ranking it higher in terms of the trust patients place in them [ 6 ]. It is important to note that, according to the annual Gallup report, nurses have been selected for the twentieth year running by the American population as the professionals they trust the most for their honesty and ethics. They were voted for by 81% of the sample, ranking ahead of doctors, teachers, pharmacists, and the military [ 45 ]. In addition, our findings suggest that the value that society places on nursing is positive, and it is perceived as an essential profession for improving people’s health.

The limitations of this integrative review include the methodological variability of the studies reviewed, which hindered the comparison of their results, and the wide range of territories covered, which produced conflicting results depending on the majority culture in the region of study.

5. Conclusions

The competences attributed by society to nursing professionals do not match the set of competences described in the professional profile of nurses. A lack of knowledge and a partial vision of nursing leave out essential aspects of the profession, such as nurses’ capacity for research and leadership, health policy planning, and health management. These aspects constrain the development of the profession and the creation of a professional identity, and therefore it is essential to make society aware of the real professional competencies of nurses.

This article provides a comparison between the competences defining the nursing profile as per the European and American frameworks, and the skills attributed by society to nurses and how society perceives them. It also provides the ideal framework for comparing reality and perceptions, enabling researchers to identify competence areas that are less known or valued by society in order to be able to address them.

Professional nurses must realise that the solution to the mismatches between the projected image, the perceived image, and reality must come from nurses themselves as a whole and in different contexts, such as faculties, professional associations, scientific associations, etc., focusing on the least known areas, such as research, teaching, and management. In particular, nurses need to take on and project their capacity for leadership to be able to participate fully in the development of health policies and health legislation. To this end, it appears to be essential that nurses follow the ICN guidelines and assume their role as health leaders. Nurses can do this by using traditional media and today’s wide array of social media, embracing and developing their own social media skills, which they could use to make their research results more visible, beyond professional circles. Finally, it is also essential to influence prospective students, e.g., through recruitment open days, and people who influence their choice of career, such as educators, career advisors, and parents, so that they can advise students with knowledge of the reality of the profession’s competences.

Author Contributions

Conceptualization, M.R.-P. and C.T.-M.; methodology, M.R.-P. and C.T.-M.; software, M.R.-P., C.T.-M. and A.D.-P.; formal analysis, M.R.-P. and C.T.-M.; investigation, M.R.-P., C.T.-M., F.M.-N. and A.D.-P.; resources, M.R.-P., C.T.-M., F.M.-N. and A.D.-P.; data curation, M.R.-P., C.T.-M., F.M.-N. and A.D.-P.; writing—original draft preparation, M.R.-P., C.T.-M. and A.D.-P.; writing—review and editing, M.R.-P. and C.T.-M.; visualization, F.M.-N.; supervision, M.R.-P. and C.T.-M.; project administration, M.R.-P. and C.T.-M. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Status of Nurses in India

Current situation analysis and strategies to improve.

Sharma, Suresh K. ,* ; Thakur, Kalpana; Rani Peter, Pastin Pushpa

College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Address for correspondence: Prof. Suresh K. Sharma, College of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand, India. E-mail: [email protected]

Received September 20, 2020

Received in revised form September 21, 2020

Accepted September 25, 2020

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

INTRODUCTION

The term status is slippery and difficult to define; however in this paper, “status” has been referred to an element of professional “honor” or recognition of nurses in society. The status of the nursing discipline is still viewed as lower-level subordinate, dirty and menial jobs in this country. It could be because of their projection as submissive females in subordination with physicians assisting them in caring and curing the patients without any autonomy. Although nurses are obtaining undergraduate and or postgraduate professional degrees to practice as a nurse in the country unfortunately, they are still socially socially viewed as servants in health-care delivery system. Nurses are continuously striving to achieve a higher status in this patricentric society, but still long journey is waiting a head to achieve honor and respect, which they deserve. Lack of social status, recognition, low pay, poor working conditions, lack of autonomy in practice, lack of recognition as a member of health-care team and exploitation has significantly contributed towards brain drain of nurses to the Western world. Nurses' shortage has been reported by the WHO worldwide and the latest Indian trends suggest shortage of more than two million nurses that give a nurse: Population ratio of 1.7:1000, which is 43% <recommended 03/1000 population.[ 1 , 2 ] In the recent past, a rapid surge has been recorded in the number of nursing training institutions in India, with approximately 1958 nursing institutes and 98,749 sanctioned seats for annual admissions in basic nursing programmes presently,[ 3 ] but still we lack nurses and the most probable reason could be the migration of nurses to western countries, as around 33,147 Indian nurses were working overseas in the year 2016.[ 4 ] It has been noted by many into the profession that Indian nurses work more enthusiastically in other countries as compared to their native land and that is surprising. Nurses settled and working as registered nurses (RN) in other countries shared that their hard work and diligence never get recognised and rewarded in India. Fear of unknown while moving to foreign country is always there and it is not an easy task to leave family and everything behind, but the prejudice attitude of health-care professionals and general public towards nurses ignite migration. India is facing dearth of nurses and their positions are filled by incompetent or untrained personnel, which causes negative portrayal of the professional image as well as compromised quality care for patients.[ 5 ] Draft to implement new initiatives and policies have been formulated many a times, but till now, no visible change occurred in managing escalating issues of nurses' struggle for their dignity and pride. This article is written with an intention to bring cognizance on challenges and issues faced by a 21 st -century nurse for getting the desired professional status in India. Authors also dispensed strategies that could be beneficial in restructuring and upliftment of nursing as a respectable job.

CURRENT STATUS OF NURSES IN INDIA

In a country where doctors are considered next to God but on the contrary, nurses who work hard day and night in a close proximity of sick handling all ups and down are just taken for granted. The history of formal training in nursing discipline had begun in 1867 and Indian nurses at that time faced discrimination to a great extent from British nurses as they were excluded from leadership and managerial roles. With no exaggeration, the situation of nurses in India has not changed so far; the only difference which we see now is nurses receive discrimination and humiliation from their own people and medical colleagues and clients. Research findings have clearly recommended that all patients must be taken care by registered and qualified nurse as it minimizes the chances of adverse events and medications error.[ 6 ] Unfortunately, there are many functional nursing homes and private health-care units where unqualified people are working as a nurse, and this puts patients in grave danger.

Modernisation has contributed nothing into nursing as it is not uncommon to get doctors who think that taking temperature, blood pressure and assisting in feeding, bathing along with other activities of daily living are the only few things which a nurse can do efficiently and this perception promotes the number of quacks who falsely represent nursing. Supreme Court's order had directed private hospitals in country regarding minimum pay of Rs. 20,000/-to a nurse working in <50 bedded health-care facility and working conditions should be near to nurses working in government hospitals.[ 7 ] Moreover, no noticeable changes came after this order because the implementation of such order in a country where nurses' worth are not considered more than a laborer or servant is onerous. Still, nurses are working on salary scale of Rs. 2000-10,000/-per month[ 5 ] and this is not the scenario in small health-care setup, but big corporate hospitals who are making huge profits also pay very less to nurses although they are willing to pay handsome salaries to physicians; it is considered that physicians treat patients which adds on to hospital income, but everyone shut their eyes to nurses who care 24 h day and night for patients from admission till discharge. Majority of the nurses working in India are females and their safety is an another area of concern and not much has been done to solve these issues related to workplace safety for nurses working in shift duties by both government and private sector even after a brutal rape of a nurse 'Aruna Shanbaug' by hospital ward boy in 1973. Little disappointing, but it is true that even after >40 years of this incident, scenario has not changed and every now and then, nurses are at the verge of violence by patients, attendants or relatives and co-workers. The nursing profession is a well-recognised and respected discipline in the Western world, where nurses are considered equivalent to doctors and other health care professionals in health-care team, and thus, they have significantly contributed in ensuring quality healthcare, however the situation is not the same in our country [ Figure 1 ].

Exceptional job done by nurses during this COVID-19 pandemic is highly appreciated by many be it the general public, physicians or hospitals' management and government. However in our opinion, it is all temporary because if we look for working hours and facilities during quarantine, nurses again faced discrimination and better facilities were given to doctors.[ 8 ] Nurses in India do not have voice and most of them are not assertive and lack confidence when it comes to talk about their rights as a RN and the one possible reason which we come across more often is that they feel ashamed to be called as a 'Nurse.' There are many nursing professionals who have opted nursing as a secondary choice after failure to reserve seat in the medical entrance and that is why have minimum acceptance for nursing and top of that stagnant carrier instead of higher qualifications make nurses unwilling to do much for their professional growth. Nurses who are working on a reputed position even do not want their children or relatives to be a nurse as this is still not accepted as a reputed profession such as doctors and engineers. Moreover, very few higher secondary school students are aware and interested to join nursing because this discipline lack in popularity and social recognition.[ 9 ] Although nursing is a profession based on scientific knowledge and skills, it is still overpowered as a nurturing and caring job for which only women are considered best. These stereotypes are deep-rooted and cause hindrance in professional growth. Reputed institutes in the country like PGIMER and AIIMS do not enroll male students into B.Sc., nursing programme and recent amendment of 80:20 between females and males nurses for AIIMS recruitment in 2019 has become a matter of debate in every other nursing conference or meeting, but no one listens and this also give rise to myth that nursing is a profession that belongs to submissive females. Most of the countries, including India, are already facing serious shortage of nurses and this phenomenon may further expand the gap in demand and supply of this category of workforce and tomorrow world may not find the sufficient number of motivated, capable and competent nurses for the smooth running of their hospitals. Nursing profession in our country lacks dynamic leaders and there are very few unsung leaders who are meticulously putting efforts to represent ignored issues and problems of nurses. There are numerous factors which are contributing to poor status of nurses in our country as illustrated in Table 1 .[ 10 , 11 , 12 ]

STRATEGIES TO IMPROVE STATUS OF NURSES IN INDIA

Appropriate status or professional recognition for nurse is not a one-man job and that is why it requires efforts on all levels with the planning and implementation of short and long-term goals. With the advancement in the number of nursing institutes and availability of seats, infrastructure facilities and skill training have been compromised to a great extent that raised serious concern on quality in nursing education and sanctity nursing degrees. Nursing training and education must be sound and should be entirely outcome-oriented based on desired clinical competencies. Nursing regulatory bodies and the health ministry of India need to take the lead for bringing change in the existing system, whether it is curriculum, licensing for RNs, or cadre structure for nurses. Nurse practitioner course has been started in few of the institutes, but neither there is any law to protect their practices nor separate job or cadre available for their deployment, which ultimately will add on to nurses' disappointment. License issuing system for become a RN in India is an another major area of concern because in the current scenario it is given to everyone who so ever passes nursing diploma or degree from the Indian Nursing Council recognised institutes, which again enhance the number of incompetent and unskilled nurses. Licensing system should be improvised with the provision of stagnant exit or licensing examination like America's National Council Licensure Examination for RNs exam and standardized skill assessment before nurses are considered eligible for getting their license to practice as RN or advanced nurse practitioner. Negative attitude of medical colleagues and fear of wrath by them should not stop nurse leaders to raise their voice. Provision of inter-disciplinary education is the best approach to create awareness among the medical fraternity about scope of nursing practice, a team working culture so that they can work collaboratively, contributing much more in quality care and overall professional growth. Solving an alarming issue of gender discrimination is a prerequisite for professional advancement because people working in a profession should be a clear representation of all sections of society and diversity in the professional discipline and this will also have its impact on quality care and health outcomes. It would not be wrong to mention that somehow status comes with money and nurses who are being paid well for their work will be more satisfied and have better social recognition. Therefore, strict amendments and provisions on minimum wages need to be established and practiced by all health-care organisations. Resolving all these issues with the different but unique approaches are important to promote status and establish recognition of nurses in the country.

Nurses need to work on broader horizon and should try to become an entrepreneur so that they can work in different areas with all their strengths to bring desired prestige and marked contribution in health-care outcomes. There are many areas where nurses need to focus their services and the first and foremost is 'nurse-led clinics' which is best for clients with chronic illnesses such as diabetes, hypertension and palliative care. Adjuvant nurse-led clinics along with physicians are successfully implemented in Western countries and we have enough data to support this but unable to implement because of endless reasons and we have tried to compile list of barriers and challenges in [ Table 1 ]. Tele-nursing, home-based care, independent nurse practitioners, clinical nurse specialist and expanded role of nurses are another area which can be further explored and nurses' role can be expanded in these areas. Surprisingly, nurses are totally missing in policymaking and at top-level administrative roles; there is no presence of nurses, especially in health directorates of centre or states and they are also not seen in governing body or institute of bodies in autonomous institutes like all AIIMS, PGIMER, JIPMER, etc., In spite of being the largest group of health-care workers in these institutes, they are being seriously marginalised and their voice is left unheard. Therefore, nurses should reflect their strong presence in policymaking and at ministerial positions to reiterate themselves properly and bring expected honor and acknowledgement. Nurses with doctorate degrees can also give their remarkable contribution towards professional development by doing evidence-based research, developing new theories or modifying existing theories and putting emphasis on required changes at both public and policy level. All areas of nursing, including education, training, administration, and research, require changes and reforms to incorporate best standards of practice. Sense of self-accomplishment or confidence comes with up-to-date knowledge, competency, well-formulated policies, and laws for practice; only then desired status can be achieved as well [ Table 2 ].[ 13 , 14 , 15 , 16 ]

Nurses are the head honchos and lifeline of health-care organisations but still lack recognition. Concern on this has been expressed by many, but till date, no strong recommendations and visible implementation of laws and policies are seen. Nurses need to take leadership and proceed to participate more at higher levels to bring a change in the existing scenario. Adaptation of nurses as a nurse practitioner would not be easy, but it will definitely bring the pride and honor which every nurse desire for. Collaborative working model of nurses and doctors with mutual respect would reflect positively on the health outcomes of the country.

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

Nursing & Midwifery Research Journal is a publication of Nursing Research Forum Society, National Institute of Nursing Education (NINE), Post-Graduate Institute of Medical Education and Research (PGIMER) Chandigarh. National Institute of Nursing Education – initially known as College of Nursing – established as a part of PGIMER, Chandigarhin 1964, is a prestigious institution known for providing academic excellence in nursing at graduate, post graduate and doctorate levels. The journal was started as an objective of National Institute of Nursing Education when it became a WHO Collaborative Centre. This journal is a functioning part of the Nursing Research Forum Society which was a pioneer society, established in 2004, with an agenda to promote nursing research activities throughout India. It is a double-blind peer-reviewed journal which covers all the specialities in the field of nursing relevant to India as well as abroad. The editorial board includes experts from prestigious institutions all over India.    Journal Highlights: • Rigorous peer review policy • Prestigious and renowned editorial board • Publication of well-established and a pioneering society • No article submission or processing charges

Submission Information: Submit your manuscripts at ( https://peerreview.sagepub.com/NMR ) after going through the Submission Guidelines tab.

Electronic Access: Nursing & Midwifery Research Journal is available electronically on SAGE Journals Online at http://journals.sagepub.com/home/NMR .

Nursing & Midwifery Research Journal is published by Nursing Research Forum Society, National Institute of Nursing Education (NINE), Post-Graduate Institute of Medical Education and Research (PGIMER) Chandigarh. This Journal is the official organ of the society and is a double-blind peer reviewed journal. It invites research-based articles, research briefs, letters to editor, etc. for publication. The journal considers articles from all nursing specialities including emergency, anaesthetic, midwife nursing, psychiatric nursing, community health nursing, surgical nursing, oncology nursing, paediatric nursing, cardiac care nursing, geriatric, gastroenterology, dermatology and women’s health nursing etc. with a primary scope relevant to especially India and secondarily from rest of the world. The aims of the journal are to:

 - Promote scientific query among nurses  - Publish quality research articles  - Highlight newer breakthroughs in different specialties of nursing

This Journal recommends that authors follow the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals formulated by the International Committee of Medical Journal Editors (ICMJE).

Nursing & Midwifery Research Journal (NMR) is hosted on Sage Peer Review; a web based online submission and peer review system. Please read the Manuscript Submission guidelines below, and then visit https://peerreview.sagepub.com/nmr to login and submit your article online.

Only manuscripts of sufficient quality that meet the aims and scope of Nursing & Midwifery Research Journal will be reviewed.

There are no fees payable to submit or publish in this Journal. Open Access options are available - see section 3.3 below.

As part of the submission process you will be required to warrant that you are submitting your original work, that you have the rights in the work, and that you have obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by you, that you are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere. Please see our guidelines on prior publication and note that Nursing & Midwifery Research Journal will consider submissions of papers that have been posted on preprint servers; please alert the Editorial Office when submitting (contact details are at the end of these guidelines) and include the DOI for the preprint in the designated field in the manuscript submission system. Authors should not post an updated version of their paper on the preprint server while it is being peer reviewed for possible publication in the Journal. If the article is accepted for publication, the author may re-use their work according to the Journal's author archiving policy.

If your paper is accepted, you must include a link on your preprint to the final version of your paper.

If you have any questions about publishing with Sage, please visit the Sage Journal Solutions Portal

1. What do we publish? 1.1 Aims & Scope 1.2 Article types 1.3 Writing your paper

2. Editorial policies 2.1 Peer review policy 2.2 Authorship 2.3 Acknowledgements 2.4 Funding 2.5 Declaration of conflicting interests 2.6 Research ethics and patient consent 2.7 Research data

3. Publishing policies 3.1 Publication ethics 3.2 Contributor’s publishing agreement 3.3 Open access and author archiving

4. Preparing your manuscript 4.1 Formatting  4.2 Artwork, figures and other graphics 4.3 Supplemental material 4.4 Reference style

5. Submitting your manuscript 5.1 ORCID 5.2 Information required for completing your submission 5.3 Permissions

6. On acceptance and publication 6.1 Sage Production 6.2 Online First publication 6.3 Access to your published article 6.4 Promoting your article

7. Further information

1. What do we publish?

1.1 Aims & Scope

Before submitting your manuscript to Nursing & Midwifery Research Journal , please ensure you have read the Aims & Scope .

1.2 Article types

The Journal considers the following kinds of articles for publication:

• Original articles
• Case studies
• Letter to the Editor

Guest editors are advised to provide minimum three months for the review process after the last date of submission.

1.3 Writing your paper

The Sage Author Gateway has some general advice and on  how to get published , plus links to further resources. Sage Author Services also offers authors a variety of ways to improve and enhance their article including English language editing, plagiarism detection, and video abstract and infographic preparation.

1.3.1 Make your article discoverable For information and guidance on how to make your article more discoverable, visit our Gateway page on How to Help Readers Find Your Article Online

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2.1 Peer review policy

  Nursing & Midwifery Research Journal adheres to a rigorous double-anonymize reviewing policy in which the identity of both the reviewer and author are always concealed from both parties.

The Editor or members of the Editorial Board may occasionally submit their own manuscripts for possible publication in the Journal. In these cases, the peer review process will be managed by alternative members of the Board and the submitting Editor/Board member will have no involvement in the decision-making process.

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Papers should only be submitted for consideration once consent is given by all contributing authors. Those submitting papers should carefully check that all those whose work contributed to the paper are acknowledged as contributing authors.

The list of authors should include all those who can legitimately claim authorship. This is all those who:

• Made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of data,
• Drafted the article or revised it critically for important intellectual content,
• Approved the version to be published,
• Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Authors should meet the conditions of all of the points above. When a large, multicentre group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript. These individuals should fully meet the criteria for authorship.

Acquisition of funding, collection of data, or general supervision of the research group alone does not constitute authorship, although all contributors who do not meet the criteria for authorship should be listed in the Acknowledgments section. Please refer to the International Committee of Medical Journal Editors (ICMJE) authorship guidelines for more information on authorship.

If the named authors for a manuscript change at any point between submission and acceptance , an Authorship Change Form must be completed and digitally signed by all authors (including any added or removed) . An addition of an author is only permitted following feedback raised during peer review. Completed forms can be uploaded at Revision Submission stage or emailed to the Journal Editorial Office contact (listed on the journal’s manuscript submission guidelines). All requests will be moderated by the Editor and/or Sage staff.

Important : Changes to the author by-line by adding or deleting authors are NOT permitted following acceptance of a paper .

Please note that AI chatbots, for example ChatGPT, should not be listed as authors. For more information see the policy on Use of ChatGPT and generative AI tools .

2.3 Acknowledgements

All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general support.

Any acknowledgements should appear first at the end of your article prior to your Declaration of Conflicting Interests (if applicable), any notes and your References.

2.3.1 Writing assistance Individuals who provided writing assistance, e.g. from a specialist communications company, do not qualify as authors and so should be included in the Acknowledgements section. Authors must disclose any writing assistance – including the individual’s name, company and level of input – and identify the entity that paid for this assistance. It is not necessary to disclose use of language polishing services.

2.4 Funding

Nursing & Midwifery Research Journal requires all authors to acknowledge their funding in a consistent fashion under a separate heading.  Please visit the Funding Acknowledgements page on the Sage Journal Author Gateway to confirm the format of the acknowledgment text in the event of funding, or state that: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 

2.5 Declaration of conflicting interests

It is the policy of Nursing & Midwifery Research Journal  to require a declaration of conflicting interests from all authors enabling a statement to be carried within the paginated pages of all published articles.

Please ensure that a ‘Declaration of Conflicting Interests’ statement is included at the end of your manuscript, after any acknowledgements and prior to the references. If no conflict exists, please state that ‘The Author(s) declare(s) that there is no conflict of interest’. For guidance on conflict of interest statements, please see the ICMJE recommendations here

2.6 Research ethics and patient consent

Medical research involving human subjects must be conducted according to the World Medical Association Declaration of Helsinki

Submitted manuscripts should conform to the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals , and all papers reporting animal and/or human studies must state in the methods section that the relevant ethics committee or institutional review board provided (or waived) approval. Please ensure that you have provided the full name and institution of the review committee, in addition to the approval number.

For research articles, authors are also required to state in the methods section whether participants provided informed consent and whether the consent was written or verbal.

Information on informed consent to report individual cases or case series should be included in the manuscript text. A statement is required regarding whether written informed consent for patient information and images to be published was provided by the patient(s) or a legally authorized representative. Please do not submit the patient’s actual written informed consent with your article, as this in itself breaches the patient’s confidentiality. The Journal requests that you confirm to us, in writing, that you have obtained written informed consent but the written consent itself should be held by the authors/investigators themselves, for example in a patient’s hospital record. The confirmatory letter may be uploaded with your submission as a separate file.

Please also refer to the ICMJE Recommendations for the Protection of Research Participants

2.7 Research Data

At Sage we are committed to facilitating openness, transparency and reproducibility of research. Where relevant, Nursing & Midwifery Research Journal encourages authors to share their research data in a suitable public repository subject to ethical considerations and where data is included, to add a data accessibility statement in their manuscript file. Authors should also follow data citation principles. For more information please visit the Sage Author Gateway , which includes information about Sage’s partnership with the data repository Figshare.

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Sage is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’ International Standards for Authors and view the Publication Ethics page on the Sage Author Gateway .

3.1.1 Plagiarism Nursing & Midwifery Research Journal and Sage take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of published articles. Equally, we seek to protect the reputation of the Journal against malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarized other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.

3.1.2 Prior publication If material has been previously published it is not generally acceptable for publication in a Sage journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the Sage Author Gateway or if in doubt, contact the Editor at the address given below.

3.2 Contributor’s publishing agreement

Before publication, Sage requires the author as the rights holder to sign a Journal Contributor’s Publishing Agreement. Sage’s Journal Contributor’s Publishing Agreement is an exclusive licence agreement which means that the author retains copyright in the work but grants Sage the sole and exclusive right and licence to publish for the full legal term of copyright. Exceptions may exist where an assignment of copyright is required or preferred by a proprietor other than Sage. In this case copyright in the work will be assigned from the author to the society. For more information please visit the Sage Author Gateway .

3.3 Open access and author archiving

Nursing & Midwifery Research Journal offers optional open access publishing via the Sage Choice programme and Open Access agreements, where authors can publish open access either discounted or free of charge depending on the agreement with Sage. Find out if your institution is participating by visiting Open Access Agreements at Sage . For more information on Open Access publishing options at Sage please visit Sage Open Access . For information on funding body compliance, and depositing your article in repositories, please visit Sage’s Author Archiving and Re-Use Guidelines and Publishing Policies .

4. Preparing your manuscript for submission

4.1 Formatting

The preferred format for your manuscript is Word. LaTeX files are also accepted. A LaTex template is available on the Manuscript Submission Guidelines page of our Author Gateway.

4.2 Artwork, figures and other graphics

For guidance on the preparation of illustrations, pictures and graphs in electronic format, please visit Sage’s Manuscript Submission Guidelines  

Figures supplied in colour will appear in colour online regardless of whether or not these illustrations are reproduced in colour in the printed version. For specifically requested colour reproduction in print, you will receive information regarding the costs from Sage after receipt of your accepted article.

4.3 Supplemental material

This Journal is able to host additional materials online (e.g. datasets, podcasts, videos, images etc) alongside the full-text of the article. For more information please refer to our guidelines on submitting supplemental files .

4.4 Reference style

Nursing & Midwifery Research Journal adheres to the Sage Vancouver reference style. View the Sage Vancouver guidelines to ensure your manuscript conforms to this reference style.

If you use EndNote to manage references, you can download the Sage Vancouver EndNote output file .

5. Submitting your manuscript

Manuscripts for Nursing & Midwifery Research Journal (NMR) is hosted on Sage Track Sage, a web-based online submission and peer review system. Visit https://peerreview.sagepub.com/nmr to login and submit your article online. 

As part of our commitment to ensuring an ethical, transparent and fair peer review process Sage is a supporting member of ORCID, the Open Researcher and Contributor ID . ORCID provides a unique and persistent digital identifier that distinguishes researchers from every other researcher, even those who share the same name, and, through integration in key research workflows such as manuscript and grant submission, supports automated linkages between researchers and their professional activities, ensuring that their work is recognized.

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• NATURE INDEX
• 19 August 2024

Gender bias might be working at level of whole disciplines

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A New Zealand data set shows that women in male-dominated fields, such as physics, scored better on researcher-evaluation metrics than did those in female-dominated disciplines. Credit: Leon Neal/Getty

Inequity between men and women in research funding and researcher performance evaluation has been firmly established as a problem in science policy for many years. But an emerging body of research is documenting a new piece of the puzzle, which some think has been hiding in plain sight: that whole research fields might be prone to gender bias.

“People just believe that there are some disciplines that are better than others,” says Alex James, a mathematician at the University of Canterbury in Christchurch, New Zealand, who led one the latest studies on the phenomenon. “And it turns out that ones that we think are a bit rubbish are all full of women.”

The study by James and her co-authors, published in eLife on 7 May 1 , found that, the more women there were in a field, the lower the overall grant-application success rate and evaluation of researcher quality, according to the analysis of data from more than 30 countries. It builds on other studies published in the past decade that have investigated the various ways in which sexism and other biases might be playing out across and between disciplines. But researchers are divided as to how surprising the latest findings are.

James and her colleagues looked at funding data from several organizations spanning tens of thousands of researchers and grant applicants in more than 40 disciplines. This included data from the previous three rounds of New Zealand’s Performance-Based Research Fund (PBRF), which evaluates the research quality of every academic in the country; ten years of data on grant-application success rates from the Australian Research Council (ARC); and similar data sets from the Canadian Institutes of Health Research (CIHR) and the European Institute for Gender Equality (EIGE), the latter of which collates data from government funders across the European Union, the United Kingdom, Turkey and Israel.

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Using statistical modelling, the study authors investigated the relationship between the gender balance of a researcher’s discipline and their PBRF score, accounting for factors such as the researcher’s age, institution and publication record. With the other data sets, the authors analysed the gender balance of a discipline alongside funding success rates.

The New Zealand data set revealed that researchers of any gender working in female-dominated disciplines, such as nursing or education, tended to receive lower scores in the PBRF than did those working in male-dominated disciplines, such as physics and philosophy. According to the modelling, men working in male-dominated disciplines scored an average of around 40 points, out of 700, more than did men working in female-dominated disciplines. Meanwhile, women working in a male-dominated field scored some 70 points more than did women in a female-dominated field.

The latest ARC data set, from 2019, revealed that, in the same discipline, women had a slightly higher success rate in securing grants than men did. But the difference in success rates between disciplines was pronounced. For example, the average success rate for both men and women in philosophy (male-dominated) was 22–23%, but in nursing (female-dominated), it was 17–18%. Similar patterns were observed in the CIHR and EIGE data.

This was not the case in the oldest ARC data set, from 2010. At that time, men were generally more likely than women to secure funding across disciplines, and the differences in success rates between male- and female-dominated fields were limited. For example, success rates in philosophy were 31–33%, similar to those of nursing, at 30–33%.

Disciplinary bias

The authors are not able to explain these patterns, but suggest several reasons. It could be that grant-application reviewers are biased against women or female-dominated disciplines, or, as previously male-dominated disciplines began to attract more women, the perception of the fields’ quality dropped.

James says that many people are aware of how the gender balance of a field alters how others perceive it, but this has not been documented until now.

Virginia Valian, a psychologist at Hunter College at the City University of New York, in New York City, was surprised by the findings suggesting that women benefit from working in male-dominated fields. Women “appear to be more devalued in fields in which they are the majority and, if anything, more valued in fields in which they are a minority. I do not think that this is generally the case,” she says. This effect could be down to of a particular quirk of the ARC data set analysed, she adds.

But Ebony McGee, who studies structural racism at Johns Hopkins University in Baltimore, Maryland, was not surprised by the findings.

“Female-dominated disciplines are facing marginalization in evaluation due to biases that say that work is not rigorous or valuable,” she says. Ideas around what constitutes valuable research originate from entrenched power structures usually developed by white, male, non-disabled people from wealthier social classes, she adds.

McGee argues that using data to highlight potential biases is not enough. “One has to dismantle the field and rebuild it with women and women of colour leading the effort, but people do not want to give up or share their power,” she says.

James and her colleagues are not the first to have looked at how gender and other biases might be related to disciplines. In 2019, researchers at the US National Institutes of Health suggested that Black scientists more often proposed research projects in fields that had lower success rates for funding 2 . Topic choice accounted for more than 20% of the funding gap between white and Black scientists when other variables that affect success, such as previous achievement, were controlled for.

And in 2015, researchers found that women were under-represented in fields in which success was perceived as requiring raw, innate talent — such as mathematics or philosophy — compared with disciplines in which people thought success could be gained through hard work 3 .

Rachael Murray, a biomedical scientist at the Queensland University of Technology in Brisbane, Australia, says that the studies in this area highlight the complexities involved. “We don’t yet fully understand where all the issues lie,” she says. She adds that institutions and funding bodies have an obligation to look thoroughly at their data — which are often not accessible to researchers — and identify problems that might need addressing.

Some of the organizations that were featured in the eLife study are taking action on the issue. An ARC spokesperson says that the agency is reviewing its grant-awarding mechanism, and will look at how to support “a strong and diverse workforce”. Research funders in Australia have previously made big moves to try to rectify gender bias. In 2022, the country’s main health- and medical-research funder, the National Health and Medical Research Council, overhauled its funding process, introducing quotas that specify that half of its grants will go to women , after an analysis found that men were disproportionately benefiting from the previous system.

In New Zealand, the study by James and her colleagues prompted discussions at the Ministry of Education, which administers the PBRF. Katrine Sutich, the general manager for tertiary and evidence policy at the ministry in Wellington, says an independent panel that reviewed the PBRF has met with the researchers and has taken their findings into account.

doi: https://doi.org/10.1038/d41586-024-02502-6

Nature Index’s news and supplement content is editorially independent of its publisher, Springer Nature. For more information about Nature Index, see the homepage .

James, A., Buelow, F., Gibson, L. & Brower, A. Preprint at eLife https://doi.org/10.7554/eLife.97613.2 (2024).

Hoppe, T. A. et al. Sci. Adv. 5 , eaaw7238 (2019).

Article   PubMed   Google Scholar  

Leslie, S.-J. et al. Science 347 , 262–265 (2015).

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