Literature review

The literature review presented here is divided into several sections. The first section examines gender segregation in health occupations, followed by a discussion about men’s choice of nursing as a career. Next we will explore the professional experiences of men in nursing, with a particular focus on their career progression and retainment. We will then analyse the participation of men in nursing education, which is the focus of the current project. While the theories and findings presented in the first section are not exclusively focused on the Nordic Region, we will incorporate studies conducted in the Nordic Region when relevant. The following section provides a Nordic perspective, including statistics from the Nordic countries, to provide background information for understanding the context of this study. Finally, we will present practices suggested by academic literature on the subject for increasing the proportion of men in nursing and discuss their effectiveness where applicable. Such practices provide the foundation for choosing and evaluating the measures discussed in this project.

Gender segregation on the labour market can manifest itself in two forms: horizontal and vertical segregation. Horizontal segregation occurs when one gender is overrepresented in a sector, leading to the underrepresentation of the other gender within that sector. By contrast, vertical segregation refers to the overrepresentation of one gender in terms of specific grades, levels of responsibility or positions within a sector (Bettio et al., 2009). Both vertical and horizontal segregation are significant issues in the health and social sectors globally. In the context of our project, horizontal segregation refers to the decisions made by men and women to pursue nursing education, a field in which women are traditionally overrepresented. Conversely, vertical segregation pertains to the differing career prospects for men and women within the nursing field. The following section will focus on horizontal segregation and men's career choices, followed by a section on vertical segregation in nursing. It is important to note that the literature discussed here addresses both types of gender segregation – horizontal and vertical – with a particular emphasis on horizontal segregation, which is the focus of our study. Additionally, while there is significant public interest in increasing the representation of women in male-overrepresented fields such as STEM, considerably less attention has been paid to the underrepresentation of men in Health, Education, Administration and Literacy (HEAL) occupations (Block et al., 2019).

Most health programmes and all nursing programmes in the Nordic countries remain strongly horizontally segregated, with a disproportionately high number of women pursuing care-related studies. Despite financial incentives for men in these fields and higher levels of gender equality in the Nordic Region, barriers to male participation in such programmes persist. Academic literature on the subject has identified several factors that may explain why men are less likely to choose nursing as a career.

Some of these issues include role conflict and feelings of exclusion (Blackley et al., 2019; O’Lynn et al., 2020). Nursing was described as “pink-collar work”, a term coined in the late 1970s, referring to jobs primarily providing care or personal services, typically held by women. That contrasts with blue-collar work, which involves physical labour or skilled trades traditionally performed by men, and white-collar work, which is associated with higher social and economic status. Historically, nursing, as a pink-collar job, was often viewed as less prestigious and less skilled than white-collar and blue-collar professions. In addition, nursing was viewed as applying women's "natural" nurturing and sacrificing tendencies, a perception which implies that involvement in nursing – whether as a caregiver, educator or researcher – is considered more of a gendered behaviour than a true profession (Burton, 2020). That may explain why male nurses may experience a conflict between their gender and occupational identities since women are overrepresented in nursing. Men might feel they are “transgressing traditional masculine norms while identifying with their nursing role” (Blackley et al., 2019). For example, in his research, Tom O’Connor (2015) studied how men accommodate their masculine identity with their career choice. He suggests that although men might attempt to distance themselves from the feminine caring narrative, they “display affinities with caring nurturance which they see as being essential to being nurses” (O’Connor, 2015, p. 206). They therefore rebrand the nursing profession by acknowledging that caring can also be a masculine trait and by doing so they also rebrand masculinity. 

Some of these issues include role conflict and feelings of exclusion (Blackley et al., 2019; O’Lynn et al., 2020). Nursing was described as “pink-collar work”, a term coined in the late 1970s, referring to jobs primarily providing care or personal services, typically held by women. That contrasts with blue-collar work, which involves physical labour or skilled trades traditionally performed by men, and white-collar work, which is associated with higher social and economic status. Historically, nursing, as a pink-collar job, was often viewed as less prestigious and less skilled than white-collar and blue-collar professions. In addition, nursing was viewed as applying women's "natural" nurturing and sacrificing tendencies, a perception which implies that involvement in nursing – whether as a caregiver, educator or researcher – is considered more of a gendered behaviour than a true profession (Burton, 2020). That may explain why male nurses may experience a conflict between their gender and occupational identities since women are overrepresented in nursing. Men might feel they are “transgressing traditional masculine norms while identifying with their nursing role” (Blackley et al., 2019). For example, in his research, Tom O’Connor (2015) studied how men accommodate their masculine identity with their career choice. He suggests that although men might attempt to distance themselves from the feminine caring narrative, they “display affinities with caring nurturance which they see as being essential to being nurses” (O’Connor, 2015, p. 206). They therefore rebrand the nursing profession by acknowledging that caring can also be a masculine trait and by doing so they also rebrand masculinity. 

While such role conflicts discourage men from choosing nursing as an occupation, family support and role models play an important part in overcoming those barriers (Juliff et al., 2017; O’Connor, 2015; O’Lynn et al., 2020). Specifically, personal relations with female nurses, either as friends, partners or family members, facilitate the decision to choose nursing as a career path (Juliff et al., 2017). 

Related to gender stereotypes and occupational choices, the popular image of nursing may contribute to a lower motivational drive to pursue nursing (Gill & Baker, 2021; Nordfjell & Nielsen, 2019). Gill and Baker (2021) note that although the nursing profession has developed greatly over time, media representations, at least in the United Kingdom, provide inaccurate portrayals of nurses that damage their societal perception, professional identity and status. Media representations often depict female nurses in a sexist manner or suggest that women have an intrinsic caring ability, while male nurses are generally portrayed negatively as being less compassionate, effeminate or sexually predatory (Gill & Baker, 2021). Clow et al. (2015) analysed the perceptions of male nurses by Canadian undergraduates using promotional marketing materials for nursing education programmes. Two of the posts were titled "Interested in a career in nursing?" showing either a female nurse or a male nurse, while a third version showed the same male nurse, referred to as the “manly nurse”, with the slogan "Are you man enough to be a nurse?" They found that participants perceived the manly nurse as less competent and more deviant. Clow et al. (2015) suggest that featuring a diverse range of individuals in advertisements rather than targeting specific sub-populations is a more effective way of advertising the nursing occupation. Similarly, the effects of societal perceptions are felt within the profession, as noted by nurses in Iceland, who observe that men might avoid nursing due to the stereotypical and feminised construct of caring (Þorsteinsdóttir & Heijstra, 2023).

Finally, although it could be suggested that pay levels might be a barrier to men choosing nursing, there is weak evidence for that in the literature on the subject. Studies suggest that job security, high employability and career advancement opportunities associated with nursing serve as motivators for men to become nurses (Hoffart et al., 2019). However, Hankins (2011) argued that, at least in the United States, the generally lower pay in nursing might discourage men from entering the profession if they see themselves as primary breadwinners (Hankins, 2011). However, it is not clear to what extent Hankins’ (2011) findings are relevant to the Nordic context. In addition, the question of which motivational factors play a role in individuals’ decision to pursue nursing and whether such factors differ by gender has also been at the centre of several studies and has not yet been answered conclusively. While some studies suggest that men, like women, enter the nursing profession due to the caring and altruistic aspect of the profession (Hoffart et al., 2019; Maurud et al., 2022), others suggest that external factors play a more significant role for men (Petges & Sabio, 2020). Such aspects involve, for example, employability and perceived job security (Petges & Sabio, 2020).

Overall, the findings regarding internal and external drivers for men and women choosing nursing are mixed. While there may be gender differences in those drivers, income levels alone cannot explain such differences and the evidence for male nurses in the Nordic Region is inconclusive (Maurud et al., 2022).

In 2019, the World Health Organization (WHO) published a report on gender and equity analysis in the global health and social sector, highlighting that "women deliver global health and men lead it, with men holding the majority of senior roles in health from the global to the community level" (World Health Organization, 2019). The report also emphasised that gender segregation is pervasive in society, particularly in the health and social sectors, where 70% of the long-term healthcare workforce is composed of women, yet a minority of women occupy leadership positions in health institutions (World Health Organization, 2019). The WHO reports that organisational gender segregation has its roots in gender essentialism, i.e. the belief that gender is a constitutive element of skills and working styles, and male primacy, meaning the ideology of a natural supremacy of men (World Health Organization, 2019).

The notion of the “glass ceiling” is often used to explain vertical gender segregation. However, Eagly and Carli (2007) prefer to use the metaphor of a labyrinth to describe the path of women through institutional barriers and tortuous organisational obstacles that separate them from leadership (Eagly & Carli, 2007). Accordingly, the World Health Organization notes that gender disparities in leadership primarily stem from power imbalances, gender stereotypes, discrimination and systemic structures that create opportunities for one gender to advance while others are marginalised (World Health Organization, 2019). In addition, men in female-overrepresented sectors tend to advance to leadership positions up a career ladder that Christine Williams (1995) termed a “glass escalator”. That describes preferential promotion of white, heterosexual men, even when they are underrepresented in a sector, over women. Such differential treatment also results in female nurses earning less than men. For example, in the United States and Germany, male nurses earn 15% to 30% more than female nurses, depending on the specific features of the different models (Dill & Frogner, 2024; Muench & Dietrich, 2019; Wilson et al., 2018).

It should be noted that from 2001 to 2017 most health occupations in the USA experienced a decline in gender earning gaps, except for nursing employees (Barry, 2021).

The findings of a recent systematic literature review corroborate that, demonstrating that in nursing, opportunities and promotions are frequently determined by gender rather than merit, which benefits men (Gauci et al., 2023). Though the glass escalator offers an appealing framework to explain vertical segregation that prevailed in female-overrepresented professions, Williams later refined the scope and applicability of her concept, noting that it assumed work stability, which was fading with neoliberal reforms, and that it failed to address a deeper intersectionality approach (2013).

In the healthcare sector, vertical segregation extends to other professions assuming a leadership position over the care workforce, including policy makers, doctors

Please note that while the WHO report refers to the proportion of male doctors globally, in the Nordic Region the proportion of female doctors in recent years has been comparable to that of men and the proportion of women enrolled in medicine programmes is now higher than that of men (Between 59% and 69% of all enrolled medical students in the Nordic countries in 2022 were women, see EUROSTAT table https://doi.org/10.2908/EDUC_UOE_ENRT03 )

and other chiefs at healthcare centres, who are mainly men, while directing nurses, care assistants, carriers and cleaners are mainly women (World Health Organization, 2019, p. 39). Studies from Sweden and Norway suggest that vertical segregation exists in the health sector, with more women, immigrants and persons with an ethnic minority background in precarious jobs and a majority of men in senior positions. For example, after healthcare reforms in 2007-2009 that privatised some elements of the healthcare sector in Sweden, more women had temporary jobs, since fixed-term employment is common within the private healthcare sector and more men entered chief positions in the healthcare sector (Kurvinen et al., 2020). Moreover, male nurses often climb quickly up the hierarchical ladder, assuming the role of supervisor or chief executive after graduating from nursing school (Öhman, 2009). Similarly, a Norwegian study from 2004 found that more than half of the male nurses in the study had a leadership position four to five years after completing training. After twenty years, 70% of men had a leadership position but that was only the case for 40% of women (Abrahamsen, 2004). The same findings regarding managerial position and earnings were also found in Norway for more recent cohorts of nursing graduates (Karlsen, 2012).

Maternal and feminine values are embedded in the nursing profession and its practices in many areas, as highlighted in several research papers (Bakken, 2004). That often does not align with the aspirations of many male nursing students regarding their future careers. As Runar Bakken (2004) notes, "the boys quickly gravitate towards the masculine sectors. Anaesthesia, surgery and emergency departments are such specialised areas where equipment, technology, professional language and tools are prominent. Tools and medical language contribute to making their competence explicit – demonstrating professionalism that excludes those who cannot master the tools and language" (p. 21). The fact that male nursing students seek out areas of healthcare related to medicine, as well as specialisations in addiction, psychiatry and management, is likely also connected to the desire expressed by many to have male colleagues (Svare, 2009).

It should be noted that while many male nurses quickly move into management or advanced practice roles, such men have successfully completed their education and remain in the nursing occupation, unlike many others. That suggests they are a relatively select group (Guy & van der Krogt, 2021). While vertical segregation emphasises the relative advantage that male nurses experience in their career, male nurses, as an underrepresented group, face unique challenges and barriers not experienced by their female counterparts, including stereotypes and gender discrimination (Blackley et al., 2019; Hoffart et al., 2019; Jamieson et al., 2019; Metzger et al., 2020). Such stereotypes suggest, for example, that male nurses are more likely to identify as gay or feminine (Harding, 2007; Kronsberg et al., 2018) or that men enter nursing due to a lack of success in medical school (Ashkenazi et al., 2017; Zysberg & Berry, 2005). Male nurses often face assumptions that they will pursue advanced practice roles and are frequently expected to assist with lifting heavy patients due to their physical strength, overshadowing their professional capabilities (Kronsberg et al., 2018; Mao et al., 2021).

Gender discrimination also affects male nurses, who may be denied employment in specific specialities. The literature on the subject highlights numerous discriminatory barriers faced by men in nursing, such as the reluctance to make nursing conferences and events gender-inclusive and the prevalent bias implying men do not belong in the profession. The generic use of the pronoun "she" for nurses persists, alongside support for legal actions to exclude men from obstetric and gynaecological settings. Other issues include tokenism and the depiction of male nurses as advancing their careers at the expense of their female counterparts (O’Lynn et al., 2020). Female patients are sometimes given a choice about whether they wish to receive care from male nurses but not from male physicians, leading male nurses to avoid high-touch care areas and gravitate towards management or high-tech specialities such as critical care and surgery (Whiteside & Butcher, 2015). Such challenges contribute to some male nurses leaving the profession, exacerbating the shortage of nurses and the gender imbalance in nursing (Younas et al., 2019). Those who stay more often face negative effects, including low self-esteem, reduced self-efficacy, depression and anxiety (Kronsberg et al., 2018).

Many studies have emphasised the need for policies and strategies to encourage men to pursue nursing education (Nordfjell & Nielsen, 2019; Younas et al., 2019). Nevertheless, a significant number of male nursing students in several Nordic countries drop out before completing their programmes (Nesje, 2023; Nordfjell & Nielsen, 2019). 

Men in nursing education face a variety of challenges that can hinder their academic performance and professional success. One significant barrier is the societal stigma associated with male nurses in a mainly female field. That stigma can lead to feelings of isolation and a lack of support from both peers and faculty, as many male nursing students report experiencing negative stereotypes that question their masculinity and suitability for caregiving roles (Blackley et al., 2019; O’Lynn et al., 2020; Twidwell et al., 2022). For example, Myklebust (2021) observed gender essentialism in the discourse of Norwegian nursing students. Both men and women evoked gendered nursing skills and described women “as more caring, empathetic, nicer and more sensitive than men and therefore more suitable to become nurses” (Myklebust, 2021, p. 330). Such stereotypes contribute to weakening the professional status of nurses by attributing their professional skill to natural, gender-specific skills of caring. Þorsteinsdóttir and Heijstra argue that as long as caring is perceived as feminine and professional advancement and assertiveness are viewed as masculine, a conflict exists between being a nurse and professionalism (Þorsteinsdóttir & Heijstra, 2023, p. 68). In addition, men also struggle to pull away from an orthodox masculinity rooted in male primacy towards more inclusive forms of masculinity and gender equality (Farstad & Stefansen, 2015). Male nursing students exhibited lower confidence in their career choice than female students and reported lower psychological support from the faculty than their female counterparts (Twidwell et al., 2022).

As stated, male nursing students encounter numerous challenges and barriers during their academic journey and many nursing programmes still exhibit a noticeable female bias (Younas et al., 2019). Male students report that teaching strategies often cater to female students and the curriculum frequently uses female-oriented language (Nordfjell & Nielsen, 2019; Younas et al., 2019). Furthermore, admissions practices may be biased against male applicants, with male students frequently questioned about their motivations for pursuing nursing, while such questions are less often directed at female students (Kronsberg et al., 2018). It was argued that there are strong assumptions that men do not need support, are hesitant to seek help and often advance more quickly in their nursing careers than their female peers (Guy & van der Krogt, 2021).

Additionally, male nursing students face discrimination during clinical rotations, often being excluded from more private situations despite needing to demonstrate competency in those areas for licensure exams (Nordfjell & Nielsen, 2019; Powers et al., 2018). They are sometimes denied opportunities to provide personal care to female patients and may be asked to leave patient rooms by other nurses without the patient themselves making such a request (Nordfjell & Nielsen, 2019; Petges & Sabio, 2020).

Interestingly, not all male nurses agreed that the nursing education process was biased. For example, Petges and Sabio (2020) interviewed male students enrolled at a university in the United States, where the nursing school was perceived as welcoming by male students despite gendered textbooks. Nonetheless, the need for more male peers, professors and mentors in nursing education has been highlighted in many studies, including those in the Nordic Region (Nordfjell & Nielsen, 2019; Petges & Sabio, 2020; Powers et al., 2018). Participants also expressed a desire to remove the label "male nurse" and simply be called "nurse." The request to avoid being singled out in front of others was echoed by male nurses in the Nordic context (Nordfjell & Nielsen, 2019)

In his concept analysis of the term "male nurse", Sasa (2019) argues against its use, claiming that it is perceived as unnecessary and unwelcoming by those it aims to represent. Men in the nursing profession generally prefer to be identified simply as "nurse" as the label "male nurse" perpetuates stereotypes and marginalises their role (Sasa, 2019).

In addition, while the focus of this report is on gender, such aspects are relevant to the broader question of inclusivity within the nursing profession and its educational processes. The literature highlights that students often experience discrimination and a lack of belonging (Metzger et al., 2020).

Such challenges contribute to significant psychological distress among male nursing students, leading to feelings of isolation, role strain and not belonging (Feng et al., 2019; Twidwell et al., 2022). Role strain occurs when male students are perceived as occupying a traditionally female role, causing stress (Folami, 2017; Sherrod, 1991). Psychological distress is a key factor in the higher attrition rates observed among male nursing students (Kronsberg et al., 2018; Moore et al., 2020). Although the lower number of male students in nursing programmes might exaggerate attrition rates, the issue remains significant, particularly for underrepresented groups. Male students cite gender bias and discrimination by faculty and staff as major factors contributing to their lack of success and higher dropout rates (Folami, 2017). Moreover, faculty support is crucial for student success and retention, underscoring the need for more inclusive and supportive educational environments (Guy & van der Krogt, 2021; Nordfjell & Nielsen, 2019; Powers et al., 2018).

In conclusion, we looked at various barriers and factors that discourage men from choosing a nursing education or careers in nursing. From gender roles, stereotypes and stigma associated with nursing to faster and easier careers for men in the medical career system, the literature review highlights multiple and surprisingly universal factors and barriers faced by men entering this career field. To further illustrate this phenomenon, Nordic statistics are presented and analysed in the next section.