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Where Are the Nurses, the Women, and the Equity Lens?

A Critique of the 2025 Patient Safety across the Health and Care Landscape.

Patient safety is one of the most urgent and enduring priorities in health and care for the United Kingdom in 2025. It is, in fact, the bedrock of quality healthcare. Yet, in today’s Review of Patient Safety Across the Health and Care Landscape (2025), there is glaring omissions that I cannot let go unchallenged, the absence of nursing voices, women, and that equity analysis we are all asked to consider then developing strategy. I am therefore curious as to who is shaping this safety narrative, and wondering does it matter?

I will start with nursing. Why is the RCN not listed as one of the Royal Colleges contributing? Nursing is described as a safety critical profession. Nurses are the largest professional workforce in healthcare. We are at the bedside, in homes, in communities, and leading systems. We monitor vital signs, catch early signs of deterioration, prevent errors, advocate for patients, de-escalate crises, and hold continuity where fragmentation reigns. And we lead on safety and quality within systems. We are not an “optional extra” in patient safety. Yet, I am not able to see the nursing voice or nursing knowledge contribution within this review.

Secondly, and even more troubling: where are the women? Given that 90% of nurses are women, and the majority of the health and social care workforce is female, this question matters deeply. When women, and professions largely composed of women are absent from leadership conversations about safety, the resulting strategies risk being partial, skewed, or even unsafe. Remember we had this is COVID when those making the high-level decisions were not representative of all of the population.

The Patient Safety Review sets out to assess the current patient safety landscape and provide recommendations for structural improvements across the NHS and wider health and care system. On the surface, it presents a well intentioned,systemic view and integrates patient safety and patient experience. As with the NHS 10 Year Plan Fit for the Future it is leveraging Artificial Intelligence (AI), improving complaint handling, and is focussing on amplifying the patient voice. But a closer, gender transformative analysis reveals troubling disparities which make me wonder about what sort of equity thinking that has informed the recommendations to improve quality and safety across the system.

1. Nursing Absence from Key Contributions

The Royal College of Nursing (RCN) is conspicuously missing from the list of professional contributors. In contrast, a multitude of other Royal Colleges of are named. This exclusion is not benign. It symbolically and practically marginalises the profession most embedded in day-to-day safety practices. Maybe the RCN was

consulted and not listed, a common issue for nursing leaders, and an issue itself.

2. Gender Imbalance Among Expert Voices

Of the fourteen named “experts in safety” contributing to the review, are only five are women? And of those is only one, Donna Ockenden, an expert in nursing and midwifery? There may be more women, I do not know all of those involved, but there are definitely more male than female expert views in this report. Given that safety events often disproportionately affect women (as patients) and more of the staff involved in health and social care are women, I wonder if this imbalance matters more than optics? I believe that it does because representation shapes the questions asked, the assumptions made, and the solutions proposed.

3. Advisory Board Demographics

Does the Review’s advisory board comprise twenty men and nine women? Again, maybe this is not accurate number but there is definitely an underrepresentation of the very people (nurses and female healthcare professionals) most involved in operationalising safety. This is not only statistically troubling, it suggests that gender and profession have not been considered as critical dimensions in understanding patient safety. Was there a Gender Equality and Social Inclusion (GESI) assessment?

Does it Matter?

Yes, this matters. If we are to reduce harm and improve care, we must draw on the full diversity of experience, expertise, and voice at all levels, whether defining the issues or designing the solutions. Having a lack of diversity in the design thinking is what got us to this problem in the first place. Again, I quote Andre Lorde, “The

master’s tools will never dismantle the master’s house.” The gendered and professional imbalance in this Review speaks to a broader systemic issue, the consistent undervaluing of nursing knowledge and female leadership in safety critical discourse. This discourse matters as this is where it is decided what matters most.

I am curious about three points.

1. Nursing is a Safety-Critical Profession

The Review itself refers to improving data-sharing, enhancing analytics, and reducing paperwork burdens. These are sensible aims. But look at the examples provided of non useful safety issues: fire safety training for GPs, end of consultation forms for psychiatrists. No mention of the nurses, nor the good things that could be spread, early warning scores nurses escalate, the infection prevention protocols we lead, the way we prevent harm and falls, or the families we support through crises and so prevent complaints. Where is the data from the daily safety work of nursing mentioned in this new approach?

If we ignore these frontline contributions, we risk designing systems that created the problem in the first place, what in global health we call structural violence, We risk creating a system that works for boards and dashboards, but fails at a human level, on wards and in people’s homes. Safety is not just a technical problem, it is a deeply human, relational practice. People need to feel safe and as well as be safe. Again, in mental health this is often the issue behind the challenges faced. Nurses hold safety at a personal and system level and build the equitable and the moral architecture of a safe place, which is often invisible to others until it is missing.

2. Gendered Impact of Safety Failures

Patient safety events are not gender neutral. Women form the majority of carers, both unpaid and professional providing care. Women are more likely to experience diagnostic overshadowing, under treatment of pain, and dismissal of symptoms. The statistics in the report point to some racist stereotypes towards pain experiences but does not delve into equity. Equity is the least mentioned aspect of quality within the whole review. Omitting women’s voices in shaping safety policy thus compounds systemic inequity. It is disappointing that such an important quality based report has no gender and equality impact assessment (GESI) within it. Maybe because the expert voices where not aware of the need for such a critical lens on such work.

A gender-transformative approach to this Review would ask:

 How does gender affect the types of safety risks experienced?

 Who is burdened with the emotional labour of unsafe systems?

 Whose expertise is recognised and rewarded in shaping solutions?

The Review does not ask these questions. Should it? I think so, and so I am asking them myself.

3. Patient Experience and Advocacy

The Review recommends integrating patient safety with patient experience under a new directorate within DHSC and aligning Healthwatch with this work. This is promising, particularly if done well. But again, I am curious, who will make this happen as near to the patient as possible?

The answer is perhaps nurses. We are the ones who translate complaint data into care changes, who sit with distressed patients and reestablish trust, who mediate between systems and individuals daily. Who do what metaphorically can be termed the ‘domestic work of safety,’ sit on committees, manage relationships and resources, monitor what is going on, make adaptations within systems, but never get the publication, the podium, the position of power. Maybe this is why we are not named in this Review. We are still invisible.

To create truly safe and person-centred care, we must not only amplify patient voices, as is advocated by this Review, but also support the voices of those who hear and respond to them every day.

Towards a More Equitable Safety Landscape

This Review represents an important step in reshaping patient safety for the next decade. But I worry that it also reflects an outdated paradigm, one in which safety is something done to patients, by policymakers and technology, now AI, rather than with people. It did not have the choir of contributions that would make safety and equity seen in multiple ways. The Review perhaps sees safety mostly through a medical lens and machine metaphor. This misses out those who are already acting on safety and most trusted to do so. To address this, I wonder if a gender- transformative approach for the Review could look like this:

 Naming nursing as a safety critical profession in the body of the report.

 Including the RCN and nursing academics in evidence-gathering.

 Ensuring gender balance in advisory and expert panels.

 Recognising the unique safety risks experienced by women patients and professionals.

 Valuing relational, embodied, and experiential knowledge as vital safety intelligence as well as artificial intelligence.

I say this because having been in the system for more than 40 years I see safety and improving safety as more than merely metrics. It is about how we and those we care for and design systems for, make meaning of what is happening to us, how we form relationships, build trust, and create presence. It is about whose expertise is counted and whose lives are protected. To omit nursing, and to overlook gender is to build safety policy on the partial truths that got us to the unsafe place in the first place.

Where are the Nurses? And where are the Women? Where is Equity?

Not in the Review. We are in hospitals and homes, in clinics and communities. We are holding patients to ensure safety, noticing early warning signs, filling gaps in systems and forming systems to improve quality. But we are not, it seems, in this Review, at least not in the way we could be.

If we are serious about safety, we must be serious about equity, visibility, and voice.

That means recognising nursing as central, not peripheral. That means understanding safety through a gendered lens too. That means asking not only what goes wrong, but who is left out of the conversation, and at what cost, and why.

Equity is not an end point; it is part of the design. A GESI lens is needed on quality if we are to change the safety discourse and stop designing the system that gives us exactly what is designed to do (the old quality adage we learnt from Deming).

We need nurses and women so that we are asking the right questions and listening to the right voices, only then will we design and deliver safe care and systems that work.

Dr Marion Lynch RN RMN Global Health Consultant and Gender Activist.

https://assets.publishing.service.gov.uk/media/6867c25510d550c668de3b2a/dhsc-review-of_patient-safety-across-the-health-and-care-landscape.pdf

Nurses as a 21st-Century Profession:

How to be Human

Dr Marion Lynch

Introduction

A nurse sits at the bedside of a patient living last days with myeloma. On one side of her chair, the monitor scrolls an endless stream of numbers, oxygen saturation, heart rate. Algorithms decide what to show and what the numbers say. On the other side, she notices the patient’s hand tremble slightly when he reaches for his water. She leans forward, catching his eyes, steadying the glass, and in that gesture communicates presence, reassurance, and artful nursing care.

This scene captures the paradox of nursing in the 21st century, and my memories of being a newly qualified general nurse on a haematology ward in Oxford the 1980s. Back then, the machines were background noise, sometimes soothing, sometimes shouting for attention, but the focus was on the person in front of me. Today in 2025 it is maybe different, maybe the same. This balance of human and non human interaction is however more than I initially trained for. This need led to my thinkinig on how to human in a non human system (Lynch 2025), and this Art of Nursing movement.

Nurses now work in health systems saturated with technology, globalised by policy, and shaped by relentless pressures toward efficiency. Yet the heart of our work remains profoundly human: being present, noticing absences, and responding with empathy. I am wondering what does it mean to be a nurse when there is demand for both patient data and patient dignity?

Charles Kenny (2021) reminds us that things are getting better, the arc of global progress is real: life expectancy has risen, child mortality has plummeted, literacy has expanded. The progress towards the Sustainable Development Goals, although not fast enough, is forward. None of this progress could have occurred without us nurses, who have historically been both implementers of public health advances and the people we see and speak up the uneven distribution of health, wealth and privilege. At the same time as this unequal rise in health and opportunity across the world, the fourth industrial revolution is bringing the world artificial intelligence. For nursing this has resulted in contemporary developments in artificial intelligence and digital health technologies that in turn demand new configurations of nursing practice (Ronquillo et al., 2021).

I suggest that nurses must claim their place as leaders in shaping the future of health care by harmonising what I have have named  as artful intelligence™️. This includes the irreplaceable human capacities of empathy, presence, judgment, creativity, and hope (Loaiza & Rigobon, 2020),  and the art of nursing so needed in times of crisis but so invisible in policy documents, and misunderstood in politician speeches about vocation, care and and other gendered tropes linked to less pay, less voice, and less power. The artful intelligence approach in nursing may be the balancing weight accompanying the computational power of artificial intelligence. If we hold both in equal measure, maybe nurses can ensure that technological progress amplifies rather than erases the relational and ethical dimensions of care.

My thinking unfolds in six parts: (1) nursing within the frame of global progress, (2) the dual identity of nursing as both science and art, (3) the interplay of artificial and artful intelligence™️, (4) ethics and equity in digital health, (5) professional identity and agency, and (6) future directions for a harmonised profession.

Nursing in a Century of Global Progress

When Charles Kenny (2021) opens Your World, Better with the tragic life and early deaths of Louis XIV’s children, and the paintings that show this family as a unit of care, he makes a startling point: even the wealthiest families of the 17th century endured losses that modern medicine has largely prevented. In other more positive royal accounts (to be continued in the Highness of Health Series I am writing), there are stories of Queens taking it upon themselves to innoculate their children against Smallpox in a time where mistrust of such actions prevented lives being saved. (A moment here perhaps for nursers to relfect on current vaccine hesitency. Today, in 2025, far fewer parents bury their children. Infant and maternal mortality have declined dramatically, life expectancy has nearly doubled in many world regions, and vaccines have turned once deadly illnesses into rare events. However, misinformation and removal of global health finding is putting this progress at risk, and so needing nurses to notice the impact of these individual and collective omissions in public health progress, and act as one.

The gains, Kenny argues, are not accidents of history but the product of collective action of people.  evidence that progress is possible, uneven, but they are real and that uniting people for a common good brings good. A note of caution that such collective calls for public good are not universal drivers and the differing approaches to nursing evolution in neo liberal and collective societies means a global phosophical lenses is needed as well as a practical workforce one.

Nursing has been an agent in this public health transformation. The eradication of smallpox (with the Queen’s help), the control of measles ( which is currently not so good), and the dramatic reduction in deaths from pneumonia and diarrheoa depended not only on scientific discovery but also on nurses’ relentless efforts to deliver vaccines, teach sanitation practices, and sustain patients through recovery (World Health Organization [WHO], 2019). In hospitals and communities, we nurses have made this happen: the hands and voices through which public health becomes personal health and people trust their nurse to help them get well or be well in whatever context they are.

Kenny (2021) reminds us that all all is fair, and progress is never universal. Millions still live without reliable access to clean water, adequate food, or affordable health care. The WHO / Unicef report (2025) states that only 50% of healthcare facilities in the poorest countires have basic WASH, waste and reliable electricity services. My own global health work made this so clear to me when, on an evaluation visit to rural health posts in Zambia, the requested powerpoint presentation was impossible as there was no power.

Nurses stand at these dual front lines of progress and lack of progress, working in rural clinics without broadband access, improvising treatments when supplies run out, and advocating for patients left behind by uneven global systems. Nursing, in this sense, has always embodied the paradox of progress: it is both a marker of how far we have come and a reminder of how far we have yet to go.

The 21st century now adds new layers to our global story. Migration, climate change, and pandemics reveal how interconnected health truly is. The COVID-19 crisis demonstrated both the fragility of health systems and the indispensable role of nurses as the largest group of health professionals worldwide (International Council of Nurses [ICN], 2025). In Kenny’s terms, “billions of people have been part of solutions” (2021, p. 9), and we nurses are counted among those billions, not only as caregivers but also as the innovators, educators, and advocates for equity. As nurses we are the agitators at the edge of policy changes but rarely get the limelight for the work we do and the difference we make.

The story of global progress therefore shows nurses as successful in some ways, but so silenced in others, and so sets the stage for reimagining nursing as a 21st-century profession. If the last century was about scaling sanitation, vaccines, and maternal care, this century requires scaling the non human in health and nursing, artificial intelligence, digital health, digital competencies, ethical governance, and the human side. artful intelligence™️. Hanlon (2011) called the move from the fourth wave of public health, i.e. telling people what to do about their health (run more, eat less, do not smoke) to the fifth wave of public health as a shift to addressing the wider culture that enables health, this includes the arts and also how the world views what it is to be healthy. In this wave culture will take more of a role in helping us be healthy, and define what that is too.

As health systems in some of the world start to move away from telling people how to behave to be healthy and instead start shaping society so people can be healthy (perhaps the neighbourhood approaches bering advocated in the UK as part of the NHS Fit for the Future Plan (NHS, 2025), there is a accompanyinh shift away from bio medical approaches. This may shift thinking on personal responsibility and blame to social determinants of health, neighbourhood approaches and collective cultural community approaches to health making. Or it may be about getting people healthly enough to get into work and earn money rather than cost money. Nurses are never passive bystanders, we are part of this future and we are therefore at the balancing point between building on our agency or being pushed into ambivalance because of how we are seen, not heard and unvalued. I choose action over ambivalace which is why I act and develop this work. We as a collective of wise innovative nueses are ensuring that the benefits of progress are distributed fairly and that its human meaning is never lost. This is possible as long as we are here to do this, there in places of power (or here on the website) to share this, and that what we do is seen as effective. Wer need to show, tell and provwhy the art of nursing matters.

The Dual Identity of Nursing; Science and Art

Consider the image of a nurse adjusting an infusion pump while simultaneously noting the hesitation in a patient’s voice. One action is technical, measurable, and easily documented in an electronic health record; the other is relational, subtle, and invisible to most systems. This juxtaposition illustrates what Barbara Carper (1978) named the patterns of knowing in nursing: empirical, ethical, personal, and aesthetic. Together, these ways of knowing remind us that nursing has always been more than technical proficiency, a task, or a semi professional which is how it was still being framed in 1995.

The scientific dimension of nursing is undeniable. Evidence based protocols, pharmacological knowledge, and infection-control practices sustain safe and effective care, degree educated nurses save more lives. All the evidence is there to support the economic agruement for desgree qualified nurses and high quality nursing. We as nurses are trained in systematic assessment, diagnosis, and intervention, a knowledge base that is testable, replicable, and essential for accountability, and we measure what can be counted, and potentially miss what matters but cannt be counted. I recall always being told, if it is not written down it did not happen. I do not think I have ever written down the sympathetic presence shown when the person in front of me is broken with grief, or the matching of my calm 4x4 breathing for a person too scared to take another breath on their own. Our ways of counting only count some of what we do. what can currently be counted is the part of nursing that aligns most easily with the technological age, where algorithms and predictive analytics can support clinical reasoning (Ronquillo et al., 2021).

But there is also the art. Jean Watson (2008) describes nursing as the philosophy and science of caring, where presence, empathy, and compassion are as vital as medications or procedures. The artistry of nursing lies in sensing what is unspoken: the pause before a patient answers, the absence of laughter in a child’s play, that 1000 yard state that any nurse who has worked in a trauma informed way can see in a child’s eyes, the grief folded into silence hidden behind a forced smile. These are acts of noticing that cannot be reduced to metrics, yet they often make the difference between good nursing care and poor nursing care, they make the difference to the tone we take, the words we use, the time between the silences that say so much. People do not feel cared for if they do not feel connected to. Nurses know that healing is the recovery of the body, the restoration of dignity and the return to one’s life. Tghis aspect of human may be possible through an AI bot, as it has been possible through a screen, I am both glass of water on my desk half full and half empty on this.

As nurses we inhabit the dual roles of scientist and artist, technician and companion, evidence gatherer and storyteller. The Art of Nursing webinar content and stories, and the poems in the resource section of this website are testiment to that, Our authority rests precisely in our ability to hold both and to translate the rigor of data (and sometimes the metaphorical rigormortis of more paperwork into compassionate action.

The challenge of the 21st century is that technology risks amplifying one side at the expense of the other. Artificial intelligence can process data faster and more accurately than any human, but it cannot offer that sympathetic presence, remember when someone said that they did not know what the nurse did, ‘she was just there’. Digital health tools can chart symptoms, but they cannot sit quietly holding that suffering. Without attention to the aesthetic and ethical dimensions, nursing risks being reduced to “what can be measured” (Krick et al., 2020), and what can be recorded as ‘there’. The relational aspect between two people, maybe described as not here or there, and so not so easily measured using the metrics that currently matter. Does it matter?

I beliece so an that the dual identity of nursing must be protected and amplified if the human in the non human healthcare is to survive. As we turn toward artificial intelligence, the question becomes: how do we preserve and elevate artful intelligence™️ alongside the scientific?

Artificial + Artful Intelligence™️ in Nursing

Artificial intelligence (AI) has entered nursing  in the same way as it has entered other areas of life. Like the new electricity. Policy frameworks such as the NHS Fit for the Future Plan (NHS, 2025) predict  automated documentation, predictive risk scores, and therapeutic chatbots as solutions to workforce shortages and efficiency pressures (Buchanan et al., 2021). In theory, these tools we liberate us nurses from routine tasks and allow more time for human connection and the automation or augmentation of work may free up nurses to do the human elements so needed. Maybe that ‘being there’ aspect of relational presence. However, the introduction of AI does not simply add new capacity to care; it reconfigures what counts as knowledge, what is valued as labour, and who gets to decide what is right or true.

The promise of such time saving processes is seductive in an economic way, and as we know money talks and this is where the power is. The issue of the power in the future of nursing thinking is scary. As AI can detect sepsis hours earlier than clinicians, predict patient deterioration from subtle biometric shifts, and generate care recommendations based on population-level data (Koo et al., 2024) will it replace some of what we do, and be welcomed as the time saving solution it is, and at what cost?

Most AI systems have been designed without nurse input, leading to tools misaligned with practice realities and inattentive to relational care (Zhou et al., 2021). When algorithms structure decision-making, the invisible work of presence, empathy, and advocacy risks being removed, irrelivant to the role of a nurse. If care becomes what machines can contribute and calculate, then what remains of the art of nursing, the hearing a silence, sensing a shift, making moments safe by what Bell Madden’s poem in the resources section shows as ‘sorted’. It’s okay Jennie is here may bring the same trust and relief if Jennie is not Jennie and human in all senses of the word.

Here, the concept of artful intelligence™️ becomes critical. This builds on what  Loaiza and Rigobon (2020) identify as the five domains that cannot be replicated by machines: empathy, presence, judgment, creativity, and hope. These are core to nursing’s professional identity. AI may simulate empathy, offering warm phrases in response to patient queries, but it cannot feel with patients. It cannot sense the tremor in a hand, the fatigue in a parent’s eyes, or the moral weight of a decision that the end of life symptom management medication package now needs to be opended. Or can this be via an algorithm and resolved by a bot? And if so, how would this be decided and discussed?

Zohny et al. (2025) have demonstrated how large language models can mimic four physician–patient communication styles: paternalistic, informative, interpretive, and deliberative. For nursing, the lesson is double edged. On one hand, AI can help patients articulate preferences and practice dialogues, potentially empowering them before clinical encounters. On the other hand, the persuasive power of AI risks manipulation, reinforcing biases rather than fostering autonomy. Nurses, long attuned to relational ethics, are uniquely positioned to mediate these tensions,  to ensure that communication remains value sensitive and person centred. If the AI bot is programmed for paternalistic there will be one way of speking about dealth, if it is programmed for interpretative there will be another. I wonder whether last words and last rites are so reduced.

A vignette makes this tangible. A nurse in an oncology ward uses an AI tool to flag elevated infection risk in a patient receiving chemotherapy. The algorithm predicts with striking accuracy, but it is the nurse who contextualises the alert, explaining gently to the family why neutropenia matters and offering reassurance that vigilance does not mean there should be fear, we as nurses are aware of everything that is going on around the person. As Gaye Poole in the webinar on Novel Nurses so wonderfully said, we as nurses are nosy. Maybe AI can be viewed as nosy too, over and above the noisy monitors defining what is happening. The machine informs; the nurse interprets, translates, and sustains that relationship.

In this sense, the future of nursing is not about nurses resisting AI but about embedding artful intelligence™️ into its deployment and keeping the human elements of nursing where non human cannot help . Nurses must therefore be the co-designers of any AI care, ensuring that technology augments rather than undermines the relational, ethical, and imaginative heart of practice. This is a challenge as nurses and AI engineers speak different languages. Clare Su-Yeon Park’s poem In the Twilight zone; between AI and nursing ( in the resources section) highlights the issues we face. The task ahead for us nurses is not therefore to choose between artful and artificial intelligence, but to harmonise them into a profession that remains both scientifically rigorous and profoundly human, and ethical.

Ethics, Equity, and the Unfinished Conversation

The integration of AI into nursing is not occurring in a vacuum. Algorithms are built on data sets that carry the biases of the societies that produced them. As Peirce, Smith, and Kolotylo (2020) caution, electronic health records and machine learning outputs are not morally neutral; they embed histories of injustice, including racial disparities in diagnosis and treatment. I attempted to create some images of nurse leaders using AI for a presentation. I gave up as with each specific request I got a more and more unrepresentive image that become less and less like the leaders I know looking image. If we as nurses uncritically adopt such tools, we risk amplifying inequities rather than reducing them. Social justice is part of being a nurse, it is not as evident as direct nursing care, but it is there, here and there. 

Kenny (2021) reminds us that progress is real but is uneven. While child mortality has fallen globally, five million children under five still die each year from preventable causes. Universal health coverage remains elusive for millions. The efforts to address this have been hampered by global politics and cuts to health care where the funds are needed most. The digital divide adds a new layer: hospitals in urban centres may boast AI-driven decision support, the  huge AI investment promised by Trump and Starmer in September 2025 is useless while rural clinics lack broadband to upload vital signs.  In this landscape, technology may widen rather than bridge gaps but the relational aspect of nursing, the trust built wihtin that community will prevail.

Nurses, grounded in the ethics of care, are well positioned to surface these inequities. If we are heard and if what we say matters. Consider my experience in Zambia. The clinic lacks reliable internet, rendering AI decision-support tools unusable. Instead, the nurse needs to draw on experiential judgment, community knowledge, and trust built with families to guide care. 

The ethical challenge, then, is not only whether AI works but also for whom, under what conditions, and at what cost. Transparency, accountability, and distributive justice must be part of nursing’s engagement with digital health. If AI systems cannot explain their reasoning, or if they are deployed only in wealthy settings, they risk betraying the very ethos of nursing: to advocate for those most vulnerable.

In this unfinished nursing of the future conversation, artful intelligence™️ is not something aligned to old tropes of caring and nice quiet kind nurses, it is the human compass to where we need to be. Empathy, judgment, and presence guide nurses in asking hard questions about fairness and access. As Kenny (2021) insists, progress requires intentional effort and nurses need to now be intentionally artfully intelligent as well as harness artifical intelligence. For nursing, this effort means ensuring that such technological innovation does not take away our focus on equity, and that the humanity of care remains visible even in an algorithm led non human system.

Professional Identity and Agency

For much of our history, nursing has been cast in the shadow of medicine, essential but subordinate, technical but undervalued. Particularly worrying is the gender inequity in leadership posts in nursing, and the continued gendered concept to nursing. Whilst these words of Davies are from 1995, they resonate with much of the current power battles influecning the future of nursing.

“..there is a sense in which nursing is not a an adjunct to a gendered concept of profession, Nursing is an activity, in other words, that enables medicine to present itself as masculine/rational and to gain power and privilege of doing so. It has clearly had the first bite of the cherry in defining its work and… We get closer to the matter of recognizing that (nursing) is trying to put a conceptual framework around just those aspects of the work of health and healing that are ‘left over’ after medicine has imposed as essentially masculine vision.” (Davies 1995; p61).

I find that there are still many who see nursing as such, mostrly those who have not needed nursing and not been in nursing. In the 21st century, this framing is dangerous to patients and unhelpful to our profession. Nurses are still the largest group of health professionals worldwide, often the first and last point of contact for patients, and increasingly recognised as leaders in interprofessional teams (ICN, 2025). Yet as digital health expands, there is a risk that professional identity could be pushed backwards and narrowed to what algorithms can measure and delegate, and what other health professions deem that they need from nurses. If that happenes nurses will be deskilled in their cognitive processes, mis skilled due to biased algorithms, and unskilled because we will never feel have learnt what we need to do if it is something AI can do.

To mitigate this risk we need to expand our professional agency and resist such narrowing. We and other health professionals need to tell the “hidden stories” of our work, more than the stories of work left undone. We need to tell of the improvisations, negotiations, and moral labour that do not fit easily into metrics set for measuring quality and the tasks set out for nursing in NHS Fit for the Future (NHS, 2025). For nurses, these stories are the quiet advocacy for a patient waiting too long for care, the careful calibration of a gentle smile and humour to ease a child’s fear, the courage to challenge a physician’s decision when it conflicts with observed patient values, and loud activism for gender equity, patient safety and professional respect. These acts are  invisible to AI and constitute our profession’s ethical backbone. They are not invisible if we look at nursing in other ways than ‘adjunct to medicine’, there are other wider way of viewing nurses’ ways of knowing.

Carper (1978) reminds us that professional identity is not only about competence but also about self-awareness. Nurses continually navigate tensions between autonomy and hierarchy, between algorithmic recommendations and lived patient realities and consider weighing up both sides all of the time. To claim agency in this forthcoming context where AI is everywhere means weighing up both sides again, and refusing to be reduced to data entry clerks for machines or passive recipients of an algorithmic authority. It means positioning nursing knowledge, empirical, ethical, aesthetic, and personal, within all developments of care. Whilst I imagine an image of an ethical bathbone, I am also now seeing large nursing elbows coming into view.

Kenny’s (2021) broader argument about progress resonates here: societies evolve when professions step into leadership, aligning their expertise with the arc of human betterment and explore boundaries and scope of their practice. Nurses can do the same for the evolution of nursing. This evolutionary stage is that of boundary maintainence and inter-professional negotiation and will require ongoing negotiation within the healthcare system and against emerging roles such as digital health and AI. Key traits in this phase of any professional evolution are the expansion of scope of practice and resistance to role dilution or deskilling. So we as the nursing profession are not alone here, it is how all professions evolve.

One tangible aspect of this evolution is the need to be active in engineering AI. As Clare Su-Yeon Park has shown in her poem, the mismatch of language is shown by the responses; thw work on nursing and AI is “too philosophical” from the AI engineers, and seen as “too technical” from the nurses. As nursing has reached this professional evolution stage we need to now embed ourselves in AI design, governance, and evaluation so that we can ensure that nursing knowledge shapes rather than merely adapts to digital futures. By advocating for patient-centred outcomes and the need for artful intelligence™️ as much as efficiency metrics, we can hold systems accountable to values as well as numbers and build a shared language.

In this light, no professional identity is or has ever been static, and nursing identity needs to now evolve. Nurses in the 21st century must claim our dual role as designers of health systems that include AI, and the providers of and guardians of relational care. Our agency lies in harmonising technological innovation with artful intelligence™️, ensuring that progress serves not only efficiency and the utalitarian view of what we do, but also equity and human dignity and emancipatory view too.

Future Directions: Harmonising Artful and Artificial

What, then, does the future of nursing look like in a century shaped by both exponential technology growth and widening inequities? It looks bright and bleak to me. I always see both sides. I am a mental health nurse after all!. To make the bright outshine the bleak I believe we need three things.

First, education must prepare nurses as digitally literate, ethically reflective and able to embody  the human aspects of nursing that humans need. However, not on its own. Scoping reviews warn that AI in nursing education often emphasises technical skill at the expense of relational practice (Buchanan et al., 2021). Nursing curricula should therefore integrate training in digital tools with sustained engagement in humanities and arts-based methods, preserving empathy and creativity alongside computation. This is called diological literacy and needs to be named and supported alongside digital literacy. This is where the art of nursing movement and the concept of artful intelligence TM can help.

Second, governance structures need to include nurses at every stage of AI design and deployment. Excluding them, as the current trends suggest, results in tools misaligned with practice realities and inattentive to patient-centred outcomes (Zhou et al., 2021). Nurses’ proximity to patients makes us indispensable in evaluating whether technologies enhance or erode care. We need to avoid wasting time and money and expertise, and the waste in the system will be seen when work arounds appear to allow patients and nurses to get around the AI. We have all seen these work arounds with technology when it has not been tested with the nurses who are supposed to use it, and benefit from it first.

Third, metrics of progress must shift. Efficiency cannot be the only outcome. As Kenny (2021) reminds us, global improvement is measured not only in wealth or survival but in dignity, opportunity, and shared wellbeing. For nursing, this means developing indicators that capture relational outcomes,  trust, comfort, presence, alongside clinical effectiveness, efficiency and all the economic models of quality that can be counted. This is the challenge for the social return on investment meaasures and accounting for nurses’ worth. Whether this is more than ‘staff wellbeing’ and more than ‘more nurses’ remains to be seen

Return to the opening vignette but 40 years ago. This was me as a nurse at a bedside, one hand steadying a glass of water, the other monitoring a monitor, not an AI-generated one, just one with numbers I needed to read out of the corner of my eye.  This was a side room when the machine was there as a prop and prompt as this was the final part of this man’s life. Let’s call him Mr Smith. Becasue that was his name. I still remember him because he was the first person to die with me when I was also in charge of the ward and had other pressing priorities too. This  memory of being torn between being there and being somewhere else distills for me the essence of 21st-century nursing. We need to have the capacity to hold responsibility, technology and humanity in unison whatever century we are in, whatever monitor is there.  I know, because later his wife told me, that it made a difference to both of them that I was there. Not the monitor, the human. 

I am suggesting that nursing’s future depends on harmonising artificial and artful intelligence™️. Global progress, as Kenny (2021) reminds us, has transformed health outcomes, but inequities across the world remain, and may well be getting worse. Nurses, as agents  of this progress, must ensure that digital tools do not deepen the current structural violence and social divides. Carper’s (1978) patterns of knowing and Watson’s (2008) philosophy of caring remind us that nursing is irreducibly both science and art. AI promises efficiency, but it cannot replace empathy, presence, or hope. I hope. Our professional identity, long marked by invisibility, must now be reasserted in design rooms, policy debates, and ethical governance. Those elbows I mentioned. Education, leadership, and advocacy will be key to embedding relational outcomes alongside clinical ones.

If the 20th century belonged to antibiotics, vaccines, and sanitation, (Hanlon 2011), the 21st will belong to data, algorithms, and digital platforms, and culture, and maybe the new profession of nursing. I hope so, but as I was always reminded in senior health management meetings, hope os not a plan.

We as nurses will not be replaced, completely, but we do need to be redefined. Nurses will be and do what we have always been and done: bridge art and science, human and non human care, and maybe have the artful intelligence counted and be counted as more than just being there. How will this happen?

Artful intelligence™️ now it is named, (and trade marked as I have often found my thinking and work when given freely has been taken and made not free) needs to be considered as a professional resource. In an era when machines can calculate risks and suggest treatments, it is the uniquely human capacities of empathy, judgment, and hope (not as a plan but as a position in life) that distinguish nursing and will enable nurses to flourish. These are essential for navigating ethical ambiguity, service complexity  and sustaining patient trust so needed and wanted.

Kenny’s optimism offers a closing reminder that progress is not inevitable but possible if enough people contribute. “Billions of people have been part of solutions” (2021, p. 9). This speaks to me of collective action and positive assett based approaches to being healthy. Among those billions, nurses have always been and must continue to be central in communities. We are millions. At the last count I think it was 10 million.  The 21st-century nurse needs to perhaps advocate  for both artificial and artful intelligence™️. This Art of Nursing movement works is one way of helping us to do so.

References

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