how the status quo is maintained through subtle action and omissions in recruitment literature

1. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
1
WHAT YOU SEE IS WHAT YOU GET: HOW THE MEDIA MIGHT
INFLUENCE THE REPRESENTATION OF GENDER IN NURSING
Barbara Hastings-Asatourian
MSc, BNurs, Cert Ed (FE) RN, RM, RHV, NDN Cert
Director of Community and Learning Disability Nursing Studies
School of Nursing
Eccles Campus
University of Salford
Peel House
Albert Street
Eccles
M30 ONN
Requests for offprints to the author at the above address.

2. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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Introduction
This paper considers some of the issues surrounding the representation of gender in
nursing, one of the themes addressed in the writer’s larger study (Hastings-Asatourian
1996), and seeks to demonstrate how there have been very few changes in the
representation of gender in nursing over the last 20 years. It begins by examining the
general literature related to gender theory from a historical perspective, then provides a
précis of the categories of gender display used by Goffman (1976). This is used as a
basis for the consideration of the representation of men and women recruited and selected
for nursing at one former NHS college. The writer argues that the way gender is
represented in the Department of Health promotional literature may perpetuate the
comparatively poor recruitment of men into nursing, and then the disproportionate
representation of men in higher management positions in nursing.
Biological versus cultural determinism
The most basic division of labour appears to be founded on sex and gender. Tiger and
Fox (1972) argued for biological determinism asserting that genetics predispose to certain
behaviours and that because genetic adaptations are very slow, males are still
‘programmed’ to aggression and dominance, and females into caring and mothering.
They proposed that any attempt to abolish gender roles would contradict nature.
Murdoch (1949) argued that biological differences, such as men’s strength and women’s
childbearing function, determine gender roles. Parsons believed that childbearing
motivates the social behaviour of a woman’s relationship to her children and her
‘expressive’ role of relieving tension and providing love and understanding. Conversely
he believed that the male has an instrumental breadwinner role, characterised by
achievement and competition. Parsons (1955) argued that both roles are needed to

3. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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complement each other and serve to maintain family integrity. He maintained that
successful families depended on a clear sexual division of labour.
Alternatively, cultural determinists (Friedl 1975, Oakley 1981, Sydie 1987) believe, that
human cultures ‘owe their creation to human inventiveness rather than invincible
biological forces’. They cite evidence refuting the claim that some tasks are exclusively
gendered. Oakley (1981) does not believe that biological factors obstruct woman’s
employment, insisting that women’s roles are a cultural construction. She maintains that
gender role stereotyping begins at birth and progresses through the whole of life.
Sharp (1976) notably commented firstly that upbringing prepares women for femininity,
secondly that their education reinforces the sex divisions through school organisations
and thirdly that the curriculum teaches them ‘skills’ suitable for women’s work, in which
they encounter some measure of discrimination throughout all parts of the occupational
structure.
Stereotyping in the workplace
The Equal Opportunities Commission (1994) highlighted gender stereotypes in relation to
the world of work in general as falling into two categories:
• Sex differences (abilities, physical and temperamental characteristics)
• The concept of “men’s work” and “women’s work”
Some common generalisations used in selection have included:
• Slight physique
• Work too boring for men
• Caring is women’s work
• Work is too dirty/demanding/heavy/ responsible for women

4. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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• Women are not as mobile as men
• Young women are only interested in short term work
• Domestic responsibilities would interfere with work
The Equal Opportunities Commission provides evidence that when a selection decision
has been based on a general impression such as poor performance at interview or
“wouldn’t fit in here”, conscious or unconscious unfair discrimination has been enabled.
(HMSO 1994) Jenkins (1986), in considering how recruitment in the labour market in
general is regulated, maintained that there is a social construction of the labour market.
His focus was firstly on the indirect discriminatory processes operational within
organisations, and secondly on the difficulty and ambiguity involved in attempting to
predict performance at work during selection processes. Jenkins affirms that recruiters
tend to fall back on stereotypical criteria for their decisions.
Closed Organisations and Gatekeepers
In Weberian terms nursing is a closed organisation which limits the admission of
‘outsiders’ (Weber 1968 Vol. 1). The Equal Opportunities Commission has found that an
organisation may exercise discrimination through personnel who are not officially
designated recruiters, selectors or managers. These are the ‘gatekeepers’ working
anywhere where they have access to the general public, or to the mechanics of
recruitment or selection. They may intentionally or unintentionally operate
discriminatory barriers. The Equal Opportunities Commission recommends proper
training of these personnel. (HMSO 1994)

5. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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Indirect Discrimination
In large organisations a Weberian Model of selection is frequently adopted. In theory
such a model uses technical competence criteria such as qualifications, skill, experience
and achievement. In practice, however many such objective criteria are not necessary for
the job, and therefore exclude workers in certain categories. Size, strength and ability to
travel between locations are three examples of how criteria could be used to obtain a
predominantly male or predominantly female workforce. Inherently adopting such
stereotyping in the selection process is therefore a form of indirect discrimination.
(Braham, Rhodes and Pearn 1981) Advertising which uses images representative of these
criteria is consequently an extension of indirect discrimination.
Theories of Perpetuation of the Status Quo in Nursing
Almost as far back as the introduction of the Race Relations and Equal Opportunities
Acts, Baroness Seear (1979) stated that a management concerned to introduce a general
equal opportunities policy, must check its formal procedures, and must discover, by a
process of questioning, what the real reasons are for the perpetuation of discrimination.
She asserted that words would not be translated into deeds unless the management of
equal opportunity was the responsibility of a senior manager with real influence and
sufficient time. The marketing of a position should also be the responsibility of that
senior person, in order to ensure equality of representation in the advertisement.
A much later example of the influence of senior managers can be found in Smith’s
investigation into the emotional labour of nursing. Smith (1992) observed that even
when regional and institutional differences are taken into account, most trainee nurses are
white, middle class females aged between 18 and 21. She claims that this in turn affects

6. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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the work and training of nurses as well as others’ expectations of them and their own
prospects. Smith notes that the hospital in which her research took place initially used a
prospectus containing images of young white women and no men. Because of the huge
number of applications in her chosen ‘City’ Hospital, the nurse recruiters could be very
specific in their requirements for students to ‘fit in’ with the hospital. This may have
been consciously or unconsciously expressed through the advertising prospectus and
reinforced in several other ways. Firstly Smith found that entry criteria included five
GCE equivalents at a time when the national requirement was only two. Secondly
candidates were selected on their past involvement with people, traditionally more likely
to be women. Thirdly the ‘City’ Hospital had a requirement for ‘articulate student nurses
who would understand clinical medicine and be acceptable to the medical staff of a
teaching hospital’. The recruiter at City confirmed that these criteria made it more likely
for recruits to fall not only into the female category but also into the white middle class
category.
There has apparently been only a minor development in the marketing of nursing since
Smith’s observations of the 1980’s. Male representation in nursing is evidently on the
increase (Austin 1977, London 1987, Hastings-Asatourian 1996) and there also continues
to be a disproportionate number of men in top management positions. (Dingwall 1977,
Hardy 1986, Equal Opportunities Commission 1991). Men represent only 1 in 10 of the
recruits into nursing, yet by the time management level is reached the number is 1:1
(Salvage 1985, Marrow 1990, Brownhill and Marshall 1994). In nurse education, the
disproportion was even more marked a decade ago, prior to the transfer of Nurse
Education into Universities. In 1987 there were 159 Directors of Nurse Education in
England, 92 (57.8%) of whom were male (Hospitals and Health Services Year Book

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1987). The writer does not believe that this situation has improved since then but this
requires further research. In their sample Davis and Rosser (1986) found that it took the
women with no career breaks an average of 6.1 years longer to reach management than
men . The NHSME (1994 ), acknowledged this inequality and set their eighth goal to
monitor the trend and to ensure that men and women have equal access to management
positions.
Over the last century nursing has been dominated in number by women, as medicine has
by men. The writer found that of the 1724 recruits studied in the two cohorts from 1994-
1995, 1479 (85.8%) of them were female and 245 (14.2%) were male (Hastings-
Asatourian 1996). Although earlier advertising campaigns contributed to that recruitment
position (Cottingham 1987, Vousden 1989), it may have also continued to influence the
selection process. Hastings-Asatourian (1996) found that of the 245 men who were
recruited, 106 (43%) were rejected at the shortlisting stage. This contrasted dramatically
with the picture for women, where, of the 1479 applicants, 312 (21%) were rejected. At
this stage it suggests that behaviour change is needed at the level of the recruiters and
selectors to alter their perceptions of what makes an acceptable candidate for nursing.
Austin (1977), in identifying the feminine image of general nursing, spoke of the
custodial, authoritarian tradition of the mental health nurse, attracting stereotypically
masculine characteristics. An additional consideration may also be the image of nursing,
namely that men also frequently report having to withstand taunts regarding either being
gay or effeminate. (Barkley and Kohler 1992)

8. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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In an American study of potential male recruits into nursing, Thompson (1989) found
discrimination in both recruitment literature and careers information about nursing. The
General Whitley Council National Agreement (Section13.5a) clearly states that adverts
which imply that particular jobs are suitable for only one sex through pictures or wording
are not permissible. Although attempts have been made to redress such discrimination in
the UK through advertising campaigns (1989, 1997), the latest Department of Health
literature is still guilty of perpetuating some of the old stereotypes. (DOH 1994 & 1996)
Gender Display
Goffman (1976) offered a theory as to why this might be in his work on gender display
in advertisements. He claimed “Advertisers do not create the ritualised expressions they
employ…(they) conventionalise our conventions, stylise what is already a stylisation,
make frivolous use of what is already something considerably cut off from contextual
controls. Their hype is hyper-ritualisation”. He suggests that the images used in
marketing are internalised by the consumers and reproduced, giving a situation where
“what you see is what you get”. So for nursing, whilst ‘hands-on’ care is marketed as a
predominantly female activity it will remain so, and while it remains so it will continue to
be marketed as such.
Goffman rejects the concept of biological determinism in favour of constructionism. He
does not believe that biological differences have much social consequence. He maintains
that behaviour is gendered and is manifest in face to face interaction. He claims “natural
expressions are commercials performed to sell a version of the world under conditions no
less questionable and treacherous than the ones that advertisers face”. Using illustrations
of an exaggerated form of gender display or hyper-ritualisation, Goffman presented his

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advertisements in a sequence, which formed an ‘instructed reading’. He defined six
categories of gender display in his findings from 1976:
• Relative size
• Feminine touch
• Function ranking
• Family
• Ritualisation of subordination
• Licensed withdrawal
These categories will now be considered in turn.
In his ‘relative size’ category, men are usually portrayed as bigger than women are.
Taller women are exceptional, and usually portrayed as belonging to a higher social class.
Some images are symbolised: a picture of a male hand is big and muscular, whereas a
female hand is small, pale, non-muscular and manicured.
‘Feminine touch’ is portrayed as light and gentle stroking, in contrast to men’s form
grasp. Women are also portrayed touching themselves more than men.
Goffman’s third category, ‘function ranking’ portrays the man in charge of any joint
undertaking. Women are often put into playful or childlike roles where the men are more
serious. Men seen doing housework are usually cast as objects of ridicule.

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In his ‘family’ category, the man is usually positioned at the centre of family portraits or
his superiority is symbolised by gestures. Goffman illustrates how the woman is there to
support the man.
‘Ritualisation of subordination’, category five, is illustrated in physical lowering of a
person, in the dame way animals show gestures of deference. Women in Goffman’s
sample are shown lying on floors and on furniture. It also illustrates women lowering
only their head, averting their eyes and looking coy, symbolically accepting
subordination. Smiling behaviour is explained as ritualistic mollification by women of
men. ‘Body clowning’ contrasts with more restrained and serious maleness. In mock-
assault games, men squeeze women, tease them and lift them up. Women utilise the arms
of men to enter their protective custody, referred to as ‘arm lock’ or ‘shoulder hold’.
Men are also shown to take a woman’s hand like a child’s.
The sixth and final category is ‘licensed withdrawal’. This represents psychological
leave taking, and is signified by gestures of shyness, such as hiding behind hands,
cuddling up to a man and playing with fingers, each symbolic of a dissociation or lack of
involvement. Head and eye-aversion illustrate concealed feelings, as does the withdrawal
of gaze from the scene.
As a preliminary exercise in pictorial analysis, the writer engaged in a small replication of
Goffman’s study using contemporary women’s journals (Hastings-Asatourian 1995).
Surprisingly, 19 years after Goffman’s study, a fairly arbitrary sample of advertisements
in women’s journals resulted in very similar representation, showing women rarely in
positions of power, except in sexual activity. Any seriousness in women is portrayed as
distance and detachment, in sharp contrast to men, who are most frequently observed as

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involved in their work. It appeared from this exercise that advertising in 1995 continued
to ‘hyper-ritualise’ gender roles.
Application to Nurse Recruitment Literature
This led the writer to look more closely at the representation of gender roles in the
marketing of nursing, for a possible explanation of present inequalities. The following
section therefore addresses the relationship between Goffman’s theories and the nurse
recruitment literature for England (DOH 1994 &1996). It examines eight coloured A4
sized pictures and 28 smaller ones. In the 1994 edition three of the A4 images depict
men as nurses. In the 1996 edition there are four A4 pictures of men in nursing.
Although this shows a move towards more equal representation numerically, the fourth
picture is in the mental health branch, which already has fewer problems recruiting men
than the other branches. The picture is in the elderly mental health section. Whereas the
1994 picture shows a woman in an armchair talking with a female nurse, the 1996 picture
has replaced the female nurse with an untypical, smiling male, who is positioned at the
same level as the client, maintaining very close body position and eye contact.
In the 1994 edition, the first A4 size picture representing a male nurse is a mental health
nurse apparently counselling a young woman. This image shows the male mental health
nurse in this picture attending very carefully and fixing his gaze on the client. The
corresponding picture in the 1996 edition has been replaced. The replacement shows a
male client and a male nurse, sitting together at a table set up with pottery activities, with
the nurse, identifiable by his name badge, engaged in an evidently serious conversation.
These pictures are both very serious representations of men at work on the one hand, in
accordance with Goffman’s finding that men at work are rarely portrayed in advertising

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as smiling. Yet they are exceptionally showing intense listening and closeness, which
are usually associated with traditional images of ‘women’s work’. Mental health
nursing, however, has historically attracted more men than adult (general) nursing has,
often estimated at 50% of the total, and it may well be that images like this have played
an important enabling role to that effect. The writer believes images like this, but with
the addition of ‘hands-on’ nursing for men, should also become more of the norm for
more representative marketing of the other branches of nursing. The Department of
Health advertising campaign of 1987 powerfully demonstrated that the double-page
advertisements featuring men in nursing produced 50% more response from men than
any other advertisement in the series, giving evidence of effective specific targeting for
emulation in future campaigns.
The next A4 size picture of a male nurse is the same in both the 1994 and 1996 editions
of the publication. It illustrates a male Paediatric orthopaedic community nurse. He is in
the child’s home attending to traction. In contrast with the mental health pictures there is
no eye contact between the nurse and patient or family in this picture. The nurse is
engaged in the serious business of attending to technical equipment.
The next A4 image of a male nurse in both publications depicts a nurse helping a disabled
person to use a computer, again there is no eye contact evident between nurse and patient,
and again the nurse is in a serious role, engaging in a technical activity. Neither is
smiling. The nurse is standing and so his ‘relative size’ is superior to the patient.
The other five A4 pictures (four in the 1996 edition) interestingly illustrate women
involved in ‘traditional’ adult and children’s nursing roles at home and in hospital.

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• The first shows a female District Nursing Sister supporting self care of a young male
patient. She is on the floor next to his armchair, on her knees, with her arm resting on
his leg. She is wearing surgical gloves in an unmistakable ‘hands-on’ nursing role, in
close proximity to the patient.
• The second depicts a young female nurse sitting at the bedside of an elderly male
surgical patient discussing some documentation with him and his partner. This image
illustrates physical closeness, intense inter-personal communication and eye contact.
She is positioned at the same level as the patient.
• The third in the 1994 edition has been described at the beginning of this section
• The next presents a young female nurse on a Paediatric ward engaged in direct
‘hands-on’ care of an infant who has a tracheostomy and appears to have a line for
total parenteral nutrition. She seems to be monitoring the child’s temperature, leaning
in towards the child, touching the child’s arm, looking directly at the child, and
apparently also engaging the child’s carer / visitor in the process.
• The final A4 size picture displays two females transferring a disabled male patient to
or from a wheelchair using a hoist, both holding the client’s legs as if to steady his
movement. However, neither of the women is smiling in this picture, which
disagrees with Goffman’s ‘ritualisation of subordination’ category, and their ‘relative
size’ is taller than the client. Nevertheless this extent of physical contact is not seen
in any of the pictures of men in nursing roles.

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There are 28 more smaller pictures, 27 common to both 1994 and 1996 editions, and one
change. The 1994 edition had a picture of three young women talking together, with the
caption “young people with mental health problems also need the skills of the mental
health nurse”. The 1996 edition shows three younger boy children with the caption
“Children playing in a Child and Adolescent Unit”.
• Of the 28 smaller pictures, ten have images of male nurses within them.
• Twenty-five of the smaller pictures have images of female nurses within them.
• Ten pictures show direct physical care being carried out by female nurses.
• Men are consistently shown as talking in mental health or learning disability roles.
• As students the men are three times shown observing the practice of a qualified
female nurse, without joining in. In one the male student is standing, while the ward
sister is on her knees at the side of the patient’s armchair. His ‘relative size’ is
superior. One picture shows the male nurse sitting on a level with the qualified
nurse/sister. In the child branch section there is one picture of women students
observing the health visitor assessing an infant’s progress, and one of a staff nurse
showing a nurse how a medication can be taken. On the following page two nurses,
one male and one female, are sitting on the floor with an infant. The female nurse is
close and playing Connect Four. The male nurse is further away and observing.
• Two smaller pictures of men show them as managers or senior nurses at meetings.
No women are pictured in this way. This accords with Goffman’s ‘function ranking’
category mirroring the top-heavy representation of men in the higher paid, higher
status positions in nursing.

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Furthermore the images analysed in this paper perpetuate the stereotypes of men being
more technical and serious, affirming Goffman’s ‘ritualisation of subordination’ category.
Men are still being represented as less suited to the traditional caring roles of the family
category and more suited either to custodial or to managerial roles. There is stark contrast
between the pictures of men and women in nursing. Women adult (general) nurses in this
publication show much more touching and smiling with patients and relatives than men
do. Men are better represented in the promotion material for mental health nursing, and
are only there seen to engage in more eye contact, than in adult and child health pictures.
Men are now more in evidence in recruitment material than Smith (1992) reports, but the
image of traditional ‘hands-on’ caring work for women and ‘hands-off’ for men is still
particularly evident in the recruitment literature.
Recommendations and Conclusion
Equality of access is part of the writer’s life philosophy. As gender equality constitutes
part of the societal dimension of health (Ewles and Simnett 1995), then inequalities in
gender representation in nursing must therefore be indicative of societal health
breakdown. Consequently, each organisation and each individual working in a health
promoting profession has a responsibility to improve the health of society by addressing
these inequalities. Promoting equality of access to those health-promoting professions
themselves is undeniably a wise initiative.
Inequalities in health can be approached from a number of perspectives, individual, group
and structural. A combination of health promoting activities is required. As a

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framework the writer has taken two of the four paradigms of a model of health promotion
to illustrate this theory (Naidoo and Wills 1994). The ‘radical humanist’ approach
utilises the collective efforts of a group of campaigners for equality who, in seeking
change, strive to influence policy from below, by seeking out evidence of inequality and
presenting this evidence to local and national policy makers. This paper, for example,
could be viewed as part of such a strategy. It seeks to effect change from the bottom up.
Conversely the ‘radical structuralist’ approach operates from the top down and would
require an enforced change in nursing recruitment policy by the Department of Health.
New material, carefully selected to avoid the old stereotypes, could then be distributed to
recruiters nation-wide. The two approaches, because they are not in conflict, would
impact upon each other. Information from the Department of Health with more balanced
representation of gender, coupled with nurse led initiatives, are more effective in
changing behaviour and attitudes than one approach alone. Reinforcement by the mass
media will then bring about changes in the behaviour and attitudes of the recruiter and
also the beliefs of the potential recruit, improvement in the recruitment of men into
nursing being the ultimate goal.

17. © Barbara Hastings-Asatourian, University of Salford, UK, 1998
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