Diminishment by Design: The Role of Class, Gender and Architecture in Shaping the Nursing Profession

ABSTRACT

This paper advances a critical, multidisciplinary argument that nursing's persistent subordination is not the result of historical accident, but of institutionalized power/knowledge asymmetries deliberately embedded within healthcare systems. Rather than offering an exhaustive literature review, this paper develops a theoretically informed synthesis of historical, spatial, feminist and policy scholarship. The analysis draws on comparative evidence from Canada, the United States, Australia and the United Kingdom, while also incorporating emerging insights from healthcare systems in Pakistan, Brazil, Sri Lanka, Turkey, Ireland, Finland, Portugal and New Zealand. The analysis traces how patriarchal norms, architectural arrangements, credentialing hierarchies and governance structures have systematically constrained nursing's authority, visibility and epistemic legitimacy, even amidst professionalization. To counter this structural injustice, the paper proposes six interlocking domains as foundations for genuine autonomy: clinical authority, governance integration, control over working conditions, spatial equity, independent advancement pathways and epistemic recognition. Each domain is situated within broader philosophical concerns about moral agency, institutional ethics and epistemic justice. Through critical synthesis across disciplines, the paper offers not only a conceptual critique but also a normative framework for reimagining healthcare design. It positions nursing as a full epistemic and strategic partner in leadership and system transformation, arguing that such recognition is both a professional necessity and a philosophical imperative for building just, resilient and inclusive health systems.

1. Professional Diminishment by Design: How Class, Gender and Architecture Shaped Nursing

This paper advances a critical, multidisciplinary argument that nursing's persistent subordination within healthcare systems is not an incidental byproduct of historical development, but the deliberate outcome of institutionalized power/knowledge asymmetries and socio‐spatial design. Grounded primarily in the Canadian context, the analysis draws on historical, spatial, feminist and policy scholarship to trace how patriarchal norms, architectural arrangements, credentialing hierarchies and governance structures have systematically constrained nursing's authority, visibility and epistemic legitimacy, even in the context of professionalization.

While Canada provides the analytical foundation, the argument is extended through comparative illustrations from the United Kingdom, Australia and the United States, countries with shared professional legacies but divergent governance models and reform trajectories. Additional insights are drawn from a range of healthcare systems, including Pakistan, Brazil, Sri Lanka, Turkey, Ireland, Finland, Portugal and New Zealand, to highlight how structural subordination manifests across diverse institutional and cultural contexts.

Additionally, the analysis is informed by critical social epistemology and feminist ethics, which interrogate how authority, knowledge and moral agency are distributed and constrained within institutional hierarchies. Fricker's (2007) concept of epistemic injustice foregrounds how nursing knowledge is routinely devalued, while Code's (1991, 2006) work on epistemic responsibility affirms the need to recognize nurses as situated knowers with legitimate epistemic authority. Sherwin (1992, 1998) feminist health ethics sharpens this critique by emphasizing the relational and institutional dimensions of moral agency, underscoring that genuine autonomy cannot exist within structurally subordinating systems.

Drawing selectively from historical analysis, spatial critique, feminist institutional theory and comparative health policy scholarship, this paper offers a theoretically informed synthesis rather than an exhaustive review. Its aim is to illuminate how institutional design has entrenched nursing's marginalization and to outline the philosophical and structural conditions necessary for its transformation. Autonomy, here, is not treated as a rhetorical ideal or professional privilege, but as a structural and epistemic imperative.

Despite expanded roles through education, licensure and professionalization, nursing continues to operate within systems that deny full authority and epistemic legitimacy. From surveillance‐driven architectural layouts and gendered divisions of labour to governance structures that exclude nurses from strategic decision‐making, healthcare systems reproduce structural injustice under the guise of reform.

Furthermore, credentialing mechanisms often reinforce dependency on physician oversight, privileging compliance over critical engagement and innovation.

To respond to these conditions, the paper traces nursing's historical evolution in Canada, from its roots in domestic and gendered labour to its current position within classed, racialized and bureaucratically regulated institutions. It then proposes a structural reimagination of nursing autonomy across six interlocking domains: clinical authority, governance integration, control over working conditions, spatial equity, independent advancement pathways and epistemic recognition. These domains are not simply policy levers; they are philosophical and institutional anchors for embedding nursing leadership into the fabric of healthcare systems.

Finally, the paper draws on multidisciplinary evidence and international comparisons to demonstrate that nursing autonomy is both possible and necessary. Case studies from the UK, Australia and beyond illustrate how reforms can reposition nurses as full epistemic and strategic agents in governance, innovation and care delivery. The argument concludes that realizing genuine autonomy demands more than symbolic inclusion, it requires the deliberate dismantling of institutionalized hierarchies and the creation of systems that recognize nurses as legitimate knowers, leaders and co‐architects of healthcare transformation.

1.1. From Domestic Labour to Professionalization

To uncover the roots of nursing's structural subordination, it is necessary to trace its historical positioning within intersecting structures of class, gender and institutional design. Synthesizing historical, architectural, sociological and feminist scholarship, it advances the central contention that nursing's marginalization is not a historical accident but the product of institutionalized power/knowledge asymmetries. The sources engaged are strategically chosen evidence to illustrate how institutional arrangements have systematically denied nursing epistemic legitimacy and positioned the profession as subordinate to medicine.

This structural subordination is further illustrated in the Canadian context, where scholars have shown that these constraints are not only epistemic but also deeply moral and relational. Despite being the backbone of healthcare, nursing has developed within systems deliberately designed to limit its authority, visibility and moral agency. Canadian scholars have underscored how these constraints are not only epistemic but also deeply moral and relational: nurses are often denied the ability to act as autonomous ethical agents within hierarchical institutions (Varcoe et al. 2012; Peter and Liaschenko 2013). Rooted in patriarchal norms, hierarchical credentialing, gendered labour ideologies and architectural exclusion, these systems have cast nursing primarily as a role of compliance rather than independent judgement (Graells‐Sans et al. 2025). In Fricker's (2007) terms, this represents a form of epistemic injustice: nursing knowledge is systematically discredited within institutional hierarchies.

The transition from domestic caregiving to a regulated profession reconstituted rather than resolved subordination. Early reforms provided credentials and training but embedded deference to medical authority as a professional virtue (Coburn 1988; Zelek and Phillips 2003). Hospital‐based programs modelled on Nightingale's approach emphasized obedience, moral discipline and service over critical enquiry (McPherson 2003; Paul 2005). Codes of conduct and the 1893 Nightingale Pledge institutionalized loyalty and moral virtue, formalizing an ethic of submission into professional identity (Storch and Kenny 2007). Sherwin (1992) feminist ethics of health helps explain how such norms undermine moral agency, requiring nurses to function as compliant auxiliaries rather than autonomous ethical actors.

In Canada, spatial and institutional controls reinforced these asymmetries. From the late 19th century, centralized nursing stations and segregated wards (Adams 2008) facilitated surveillance of nurses while excluding them from decision‐making arenas. Dormitory life under strict supervision extended institutional authority into nurses' personal lives (McPherson 2005; Wishart 2004), cultivating an identity defined by availability and virtue rather than epistemic authority or leadership. These spatial and social mechanisms parallel findings by Benoit et al. (2003), who illustrate how marginalized women, particularly Indigenous and racialized women, are structurally constrained through institutional spatial design. Such architectural and organizational choices reveal what Grosz (1994) and Massey (1999) describe as the material reproduction of hierarchy: space itself encoding and perpetuating power.

Race and class exclusions further entrenched structural injustice. In Canada and the United States, working‐class, Indigenous and racialized women were frequently barred from elite nursing programs or confined to segregated facilities (Stake‐Doucet 2023; Flynn 2009). In the United Kingdom, racialized exclusions curtailed mentorship and leadership pipelines (Bell 2023). These inequities were simultaneously social and spatial, restricting nurses' opportunities to claim epistemic legitimacy and reinforcing hierarchical dependency. Code's (1991) account of situated knowledge is particularly relevant here: the credibility of knowers is determined not by the quality of their insights but by their social positioning within unjust structures. Similarly, Peter and Liaschenko (2013) argue that institutional constraints erode moral identity and professional voice, while J. Rankin (2017) shows how health systems render nursing knowledge invisible through bureaucratic organization and discursive control.

Labour regimes added further constraints. In the United Kingdom, rigid shift structures curtailed nurses' autonomy over their work (Dall'ora 2019), while in the United States, hospital workflows centralized authority in physicians (Zborowsky et al. 2010). Even temporary expansions of nursing authority, during wartime (Toman 2005) or pandemics (Turner and Fernandez 2024), were quickly reversed, reinstating hierarchies once crises passed. In Canada, the shift to university‐based education enhanced professional recognition but left governance and executive power structures intact, sustaining asymmetries of power and knowledge (McPherson 2003). These structural dynamics impose what Pauly et al. (2009) describe as ‘constrained agency’, wherein nurses are expected to shoulder ethical responsibilities without institutional power, often resulting in moral distress (Varcoe et al. 2012).

For nursing to achieve true autonomy, reform must directly confront these institutionalized asymmetries and the structural injustices that underpin them. This requires embedding nurses into governance as epistemic equals, redesigning institutional space to reflect parity and creating independent leadership pathways that affirm nurses' moral agency as co‐architects of healthcare. Without such transformation, professionalization remains a paradox: conferring legitimacy while perpetuating subordination.

1.2. Gendered Foundations of Obedience

Beyond formal institutional policy, cultural expectations of femininity and moral servitude have long embedded obedience into nursing identity. This analysis advances the paper's central contention by showing how gendered norms have operated not as incidental cultural artifacts but as structural mechanisms of control. Drawing on historical, sociological and feminist scholarship, it illustrates how these expectations, reinforced across more than a century, produced institutionalized power/knowledge asymmetries that defined nursing as a profession of compliance rather than epistemic legitimacy. The works cited here were selected for their explanatory value in demonstrating how obedience was naturalized as a professional trait and continues to constrain moral agency.

In Western contexts, early nursing was framed as an extension of women's presumed moral duty and caregiving instincts (Purvis 2023). In the United States, these foundations anchored a professional identity in obedience, moral virtue and self‐denial rather than clinical authority (Drevdahl and Canales 2023). Faith‐based hospitals in North America reinforced this framing, casting nurses as ‘angels of mercy’ serving a spiritual mission (Vandenberg and Gallagher‐Cohoon 2021). In addition, secular programs mirrored these ideals, aligning nursing education with social norms that valorized feminine subservience (Walsh and Dillard‐Wright 2022). Nursing schools thus became sites of gender discipline, conditioning nurses into epistemic positions of servitude within patriarchal systems.

These legacies persist in subtler but no less powerful forms. In the United Kingdom, nurses who assert authority or disrupt hierarchical norms often face professional backlash (Salvage and White 2019). In Canada, advocates for systemic reform encounter similar resistance (Stake‐Doucet 2023). Advancement often hinges on compliance: those who align with institutional expectations of loyalty, silence and deference are rewarded, while critical voices are sidelined (MacDonnell and Buck‐McFadyen 2016). Here, obedience functions simultaneously as a disciplinary expectation and as a pathway to promotion, reproducing structural injustice under the guise of professional advancement.

Leadership norms replicate this paradox. In European contexts, women in nursing leadership roles are expected to balance authority with likability, preserving a collegial, service‐oriented image (Durand et al. 2022). In Brazil, some leaders reproduce the very norms that historically constrained the profession to maintain legitimacy within hierarchical systems (Bernardes, Cecilio, et al. 2020). These dynamics demonstrate how epistemic legitimacy remains tethered to conformity rather than to critical agency or epistemic responsibility (Code 1991).

In Canada, nursing continues to be framed as supportive labour rather than strategic expertise, shaped by decades of role construction, education and institutional messaging (MacMillan 2012). Breaking this cycle requires not only reimagining professional identity but also transforming evaluative systems that reward compliance while marginalizing dissent. J. M. Rankin and Campbell (2006) show how these institutional logics are encoded within regulatory frameworks that shape how nurses advance, or fail to, within Canadian health systems. Pauly et al. (2012) further highlight that constrained moral agency in such contexts often leads to moral distress, particularly when ethical responsibilities are disconnected from institutional power. As Sherwin (1992) emphasizes in her feminist ethics of health, genuine autonomy requires conditions that support relational moral agency rather than subordinating it to hierarchical authority. Leadership pipelines must therefore shift from privileging deference to affirming critical engagement as a marker of epistemic legitimacy (Lankshear et al. 2013).

International evidence underscores the stakes of this transformation. In Norway, Heldal et al. (2019) show that enabling nurses to speak and lead without fear of sanction is crucial to elevating the profession's moral agency. Furthermore, across systems, gendered assumptions about care and leadership continue to reproduce structural injustice, limiting innovation and autonomy (Burton 2020). Until these cultural and institutional foundations are dismantled, reforms will remain constrained, and nursing autonomy will remain structurally out of reach.

1.3. Spatial Control and Hospital Architecture

Often overlooked in analyses of power, space itself has played a critical role in reinforcing nursing's subordination. This subordination was not merely symbolic; it was spatially engineered. Hospital architecture and spatial organization functioned as mechanisms of institutionalized power/knowledge asymmetry, materially embedding nursing's subordinate role into the built environment. Drawing from architectural, historical and sociological scholarship, this analysis illustrates how spatial design operated simultaneously as a disciplinary apparatus and a cultural inscription, shaping professional roles and constraining moral agency.

Historical hospital layouts offer a striking example of how spatial arrangements entrenched nursing's subordination. In Western hospital design, particularly under the Nightingale model, centralized nurse stations emphasized surveillance and efficiency, ensuring nurses remained constantly visible to patients, physicians and administrators (Pachilova and Sailer 2022). In Canada, these spatial arrangements reinforced disciplinary control: nurses were placed in settings with little privacy or autonomy, their labour rendered perpetually observable and thus governable (Hammond 2005; Holmes 2001). The effect was not neutral; it cultivated a professional identity premised on availability, responsiveness and deference, rather than epistemic legitimacy or leadership.

Architectural segregation extended these asymmetries. In Canadian and UK hospitals, nurses were physically excluded from spaces where authority was exercised, physician offices, administrative suites and boardrooms (Conn et al. 2009). This spatial marginalization reinforced governance hierarchies in which nurses implemented but rarely influenced care decisions (Shariff 2014). As Code (1991) reminds us, epistemic responsibility requires access to the spaces where decisions are made; exclusion from such spaces not only denies nurses authority but systematically devalues their situated knowledge.

Hospital‐based training practices compounded this logic. In Canada, student nurses were confined to dormitories governed by curfews, codes of conduct and constant supervision (McPherson 2005). Such infrastructures regulated not only professional work but personal life, producing what Wishart (2004) describes as a mode of disciplined existence, an institutionalized way of life built on obedience, sacrifice and moral virtue. By structuring both professional and personal domains, these arrangements enacted what Sherwin (1992) would call a suppression of relational moral agency, positioning nurses as caregivers without reciprocal recognition of their ethical or epistemic authority.

Even as hospitals modernized, spatial hierarchies persisted. Nurses were clustered in task‐oriented areas such as nursing stations, supply rooms and break zones, while physicians and administrators occupied offices that signified and enacted authority (Conn et al. 2009). Thus, spatial arrangements functioned to conceal structural injustice, embedding unequal power and epistemic authority into routine professional life.

Race and class further shaped this spatial regime. In the United States, Rutland (2018) shows how racialized and working‐class nurses were disproportionately assigned to under‐resourced wards, restricting mentorship, visibility and career advancement. Similarly, comparative examples from postcolonial Portuguese‐speaking countries highlight how racialized labour structures persist in shaping nursing's subordinate positioning (de Pinho and Alberto 2022). These cases highlight how epistemic injustice intersects with racialized and classed exclusions, limiting who is permitted to be recognized as a knower within healthcare.

Contemporary research underscores the persistence of these dynamics. In Brazil, Bernardes, Gabriel, et al. (2020) demonstrate that nurses in large hospitals are positioned close to patients but excluded from strategic spaces where policy and leadership decisions occur. Across Europe and North America, architectural studies confirm that centralized nurse stations and segregated work zones continue to marginalize nursing voices while privileging medical and administrative authority (Pachilova and Sailer 2022; Conn et al. 2009; Shariff 2014). Moreover, historical analyses of Canadian hospitals reveal that these hierarchies were deliberately designed into healthcare architecture in the early 20th century (Adams 2008), and their legacies remain embedded in contemporary infrastructures.

The consequences are both epistemic and ethical. Nurses frequently develop ‘workarounds’ to navigate organizational structures that prioritize efficiency and compliance over autonomy (Debono et al. 2013). Yet such strategies highlight the resilience of practitioners rather than the justice of the system. As global leadership scholarship emphasizes, dismantling these divisions is not simply a technical matter of redesign but a philosophical imperative of epistemic justice and health equity (Salvage and White 2020). Achieving parity requires reimagining architecture and governance alike: creating interdisciplinary floor plans, restructuring decision‐making processes and ensuring nurses' physical and symbolic presence in spaces of authority. Without such intentional redesign, built environments will continue to reproduce institutionalized asymmetries, undermining nursing's epistemic legitimacy and moral agency.

1.4. Structural Illusion of Professionalization

While nurses gained credentials, they did not gain control. Professionalization has functioned less as a pathway to emancipation than as a mechanism of institutionalized power/knowledge asymmetry. Credentialing systems, far from dismantling hierarchies, have reinforced them by rewarding competence without conferring epistemic legitimacy or structural authority. The architecture of professionalization has thus converted recognition into regulation and visibility into control.

Credentialing and regulatory systems often prioritize compliance over autonomy, embedding nurses within governance frameworks that limit their organizational influence. In Canada, French and Emed (2009) note that while education and licensing elevated nursing's public profile, governance systems continued to subordinate nurses to medical authority. In Spain, Galao‐Malo (2025) shows how reforms framed as accountability failed to redistribute power, leaving nurses excluded from governance roles. In Aotearoa/New Zealand, Wiapo and Clark (2022) demonstrate that even Indigenous nursing leadership remains constrained within colonial structures that silence alternative epistemologies. As Code (1991) argues, epistemic responsibility requires both recognition and authority; denying nurses institutional access to decision‐making denies them the very conditions for responsible knowing. Across these contexts, advanced degrees and certifications have not disrupted hierarchies but have re‐inscribed them, producing a credentialed workforce denied moral agency in system‐level decision‐making.

The outcome is not genuine autonomy but professionalized subordination. In Canada, systems adopt the rhetoric of professionalism while preserving governance structures that exclude nurses from policymaking, budgeting and strategic leadership (French and Emed 2009). In the United Kingdom, entrenched medical dominance continues to block nursing influence over critical resource and policy decisions (Ominyi et al. 2025). In Finland, academic reforms raised standards without altering governance arrangements that privilege physician authority (Kanninen and Häggman‐Laitila 2021). Comparative evidence from Aotearoa/New Zealand underscores how credentialing regimes not only constrain nursing authority but also marginalize Indigenous epistemologies (Brockie et al. 2023). Collectively, this demonstrates how professionalization often masks structural injustice: visibility without voice, competence without control, participation without epistemic legitimacy.

Clinical autonomy illustrates this contradiction with particular clarity. In Canada, physicians retain overriding decision‐making power across care settings, reducing nurses' contributions to conditional input (J. M. Rankin and Campbell 2006). In the United States, authority remains centralized in medical hierarchies even when nursing expertise is crucial for workflow and safety (Sundean et al. 2017). In India, nurses' critical contributions in high‐acuity contexts are curtailed by physician dominance (Krupp et al. 2022). In Brazil, physician resistance undermines nursing‐led safety practices such as medication protocols (Rodrigues et al. 2020). In the Middle East, nurse‐led initiatives in infection control are often dismissed when they conflict with administrative or medical priorities (Fawaz et al. 2019). These examples expose the structural asymmetry between epistemic authority and professional responsibility: nurses bear accountability for safety yet are denied the authority to act independently.

Institutional rhetoric of empowerment further obscures these realities. In Europe, nursing is celebrated as the ‘backbone’ of healthcare, yet this symbolic recognition rarely disrupts entrenched hierarchies (Stievano et al. 2019). In Malta, symbolic participation is reframed as leadership, providing recognition without redistributing authority (Griscti et al. 2017). Such discourses constitute a form of epistemic injustice: they acknowledge nurses as participants while structurally denying them legitimacy as knowers and leaders.

The widening disjuncture between education and practice compounds these asymmetries. In South Korea, university programs emphasize critical thinking and leadership, but clinical settings reduce nurses to efficiency‐driven roles (Oh et al. 2025). In Australia, professional identity is shaped more by task execution than strategic engagement (Murray et al. 2018). In the United States, visibility through advanced education has not translated into governance authority (Sundean et al. 2017). In the United Kingdom, Hughes et al. (2015) argue that genuine autonomy requires redefining nursing expertise beyond technical proficiency towards systemic leadership. Sherwin (1992) reminds us that such reforms must be grounded in a feminist ethics of health, attentive to how relational practices of care are systematically devalued when authority is withheld. Across contexts, the same pattern emerges: professionalization confers credentials but denies epistemic legitimacy, producing a workforce praised rhetorically while structurally constrained by entrenched hierarchies.

1.5. Barriers to Leadership and Research

True leadership, however, requires more than titles; it demands epistemic legitimacy, authority in decision‐making and the dismantling of institutionalized power/knowledge asymmetries that confine nursing to the realm of labour rather than strategy. Exclusion from leadership and research is not an incidental gap, but a deliberate structural mechanism that preserves hierarchical subordination. Drawing on leadership studies, health policy analysis and feminist philosophy, this discussion illustrates how systemic designs constrain nurses' moral agency while denying them structural authority, ensuring that nursing knowledge remains undervalued and epistemically marginalized.

Nurses remain structurally excluded from shaping the very systems they sustain. In Pakistan, governance frameworks restrict nurses' influence over system design and policy development (Rasheed et al. 2020). In the United Kingdom, underrepresentation in research funding, policy councils and innovation governance curtails their ability to shape institutional priorities (Aspinall et al. 2023; Peckham et al. 2018). In England, advancement is tied to research productivity, yet nurses often lack equitable access to funding and protected time, effectively excluding them from senior roles (Heaton‐Shrestha et al. 2023). In Canada, most leadership roles are operational rather than strategic, tasked with executing priorities set elsewhere (Udod et al. 2020). Comparative evidence from Sri Lanka shows that advancement often rewards compliance with hierarchical norms rather than epistemic innovation (Pincha Baduge et al. 2024). These patterns exemplify what Code (1991) calls failures of epistemic responsibility: systems that exploit nurses' situated knowledge while systematically denying them legitimacy as knowers and leaders.

These exclusions extend into health policy, where institutional design actively reproduces structural injustice. In Canada and the MENA region, nurses remain underrepresented on decision‐making committees, regulatory boards and funding councils (Ben‐Ahmed and Bourgeault 2022). Even where included, evidence from the UK shows their roles are largely advisory, with little authority to reshape governance or redirect resources (Peckham et al. 2018). Such arrangements exemplify epistemic injustice in Fricker's sense: nurses' contributions are acknowledged symbolically yet denied institutional weight. They also reflect, as Sherwin (1992) argues in her feminist ethics of health, a broader ethical failure, reducing care work to compliance while excluding it from the relational and moral dimensions of governance.

The consequences of this exclusion are epistemic as well as practical. In Ireland, studies show that nurses' frontline expertise provides critical system intelligence and ethical insight, yet these contributions are persistently undervalued (Hussey and Kennedy 2016). In the United Kingdom, O'Hara et al. (2022) document how excluding nurses from policy design reduces them to implementers rather than co‐creators, perpetuating evidence gaps and undermining the moral legitimacy of health policy. By sidelining nursing perspectives, healthcare systems not only weaken reform capacity but also perpetuate institutionalized power/knowledge asymmetries, treating one of the profession's most sustained sources of knowledge as expendable.

Addressing these barriers requires more than leadership training or professional development; it requires systemic redesign. Evidence from the UK highlights the need to embed protected research time into clinical roles, integrate nurses as principal investigators on interdisciplinary grants and create leadership pipelines that connect clinical expertise to strategic governance rather than limiting advancement to operational oversight (Aspinall et al. 2024). These reforms are not merely technical adjustments but ethical imperatives. As Sherwin (1992) emphasizes, justice in health requires restructuring institutions so that care‐based expertise is granted authority in decision‐making. Without such deliberate redesign, nursing will remain trapped in a regime of epistemic injustice, recognized symbolically but denied structural authority and epistemic legitimacy.

1.6. Epistemic and Professional Autonomy: A Framework for Nursing‐Led Reform

Efforts to elevate nursing within health system reform require more than policy inclusion; they demand epistemic recognition. Despite longstanding calls for greater autonomy, nurses continue to operate within architectures that reproduce subordination: spatially, institutionally and epistemologically. To address these conditions, a six‐domain framework is proposed that articulates the dimensions of nursing autonomy necessary for equitable reform, while also identifying the epistemic gaps that current reform efforts systematically ignore.

The framework encompasses six interrelated domains: (1) spatial autonomy, (2) jurisdictional authority, (3) epistemic legitimacy, (4) institutional representation, (5) interprofessional parity and (6) reflexive leadership. Each domain reflects a distinct yet intersecting aspect of what it means for nurses to practice and to be recognized as knowledge‐producing, decision‐making professionals. Spatial autonomy refers not only to physical positioning within institutions but also to symbolic space in policymaking and governance. Jurisdictional authority centres on the ability to define, defend and expand the scope of nursing practice. Epistemic legitimacy recognizes the value of clinical, affective and relational knowledge forms, often dismissed as ‘soft’ or subordinate. Institutional representation addresses the absence of nursing voices in governance bodies. Interprofessional parity challenges hierarchies that privilege medicine's authority over care work. Finally, reflexive leadership speaks to the capacity for collective self‐governance and policy‐shaping from within the profession.

Yet these domains are not simply absent; they are actively negated in dominant reform discourses. Calls for ‘evidence‐based’ innovation often privilege data paradigms that align with biomedical, physician‐centred knowledge, excluding the forms of knowing that characterize nursing work. Reform proposals, even those invoking equity, fail to address the systemic erasure of nursing perspectives in both agenda‐setting and implementation. This epistemic exclusion renders nursing's knowledge not merely invisible but inaudible, unheard in the very forums where transformation is debated.

Bridging this gap requires more than inclusion; it demands a paradigmatic shift. Nursing must not only be present in reform spaces but be structurally positioned to shape their terms. The six‐domain framework offers not just a diagnostic tool, but a normative orientation for policy and organizational redesign. Without acknowledging and embedding these domains into reform processes, efforts will reproduce the very asymmetries they purport to dismantle.

1.7. Designing Autonomy Into the System: Global Insights for Structural Reform

To move nursing autonomy from rhetorical aspiration to institutional reality, it must be structurally embedded into the physical, cultural and governance architecture of healthcare systems. Professional recognition without systemic redesign is hollow; autonomy must be codified into decision‐making power, spatial inclusion, educational reform and leadership equity in ways that affirm both epistemic legitimacy and moral agency. Autonomy, in this sense, is not an individual possession but a structural condition: the ability to exercise clinical judgement, strategic insight and ethical decision‐making as part of an equitable redistribution of institutional authority.

Fricker's (2007) concept of epistemic injustice helps frame nursing's historical and ongoing marginalization as a denial of testimonial authority, where nurses' knowledge is excluded not because it lacks value, but because it is institutionally discounted. Code's (1991) notion of epistemic responsibility sharpens this further, highlighting how situated knowledge, produced through relational and embodied practice, is both morally and epistemically indispensable. Sherwin (1992) feminist ethics reinforces that autonomy is not reducible to choice or individual agency but requires institutional and collective conditions that recognize nurses as co‐constructors of healthcare ethics. Reform, therefore, must do more than add nurses to existing structures; it must transform those structures to cultivate spaces in which nursing knowledge is acknowledged as a legitimate and necessary foundation for ethical and effective care.

This transformation has clear operational implications. In the United States, genuine partnership requires nurses to hold voting seats on boards and system‐design committees, rather than occupying token advisory roles (George and Luhrsen 2014). Beauvais (2018) emphasizes that leadership authority must be accessible at all career stages, especially for historically marginalized groups. In Canada, spatial hierarchies persist in the architectural separation of boardrooms and nursing stations, encoding status differentials into everyday design (Conn et al. 2009). Similar spatial marginalization is documented in US hospitals, where nurses are placed on peripheries of care environments, reflecting deeper epistemic exclusions (Cai and Zimring 2019). Curricula further reinforce these hierarchies; in North America, nursing education often prioritizes technical efficiency over policy fluency or systems leadership, limiting nurses' capacity to influence reform (Gunn et al. 2019). By contrast, UK models exemplify how investment in nurse‐led research and education can reposition nursing as a source of innovation (Whitehouse et al. 2022), affirming the structural value of epistemic inclusion.

Comparative evidence across global contexts confirms these dynamics. In Colombia, nurses are increasingly recognized professionally but remain structurally excluded from governance (Bezuidenhout et al. 2009). In Aotearoa/New Zealand, Indigenous nurses face barriers to leadership despite visibility, reflecting colonial legacies of epistemic exclusion (Brockie et al. 2023). In Portugal and other European contexts, racialized and working‐class nurses remain underrepresented in leadership, with governance structures perpetuating inequity (de Pinho and Alberto 2022). Yet there are promising countermodels: Finland and the Netherlands have legally formalized nurses' rights to prescribe and manage care independently, codifying their epistemic authority (Kroezen et al. 2011). Sweden and Finland embed nurses in hospital boards and policy councils, supported by organizational cultures that emphasize interdisciplinary parity and public accountability (Torjesen et al. 2017; Höglund and Falkenström 2018). In China, nurses increasingly carry advanced responsibilities without corresponding authority, mobilizing expertise in practice while remaining epistemically invisible in policy (Xie et al. 2024).

Across these varied systems, three consistent enabling conditions emerge for nursing autonomy to be durable and institutionally embedded:

• 1.Governance integration: Nurses must have formal decision‐making power within boards, policy bodies and executive structures (Torjesen et al. 2017).
• 2.Legislative recognition of clinical authority: Autonomy must be backed by legal frameworks that authorize independent practice and leadership (World Health Organization [WHO] 2020).
• 3.Interprofessional epistemic respect: Cultural reform is necessary to recognize nurses as knowledge producers and ethical agents (Reeves et al. 2017).

Equity remains central to these reforms. In both Canada and the US, research emphasizes the importance of mentorship, transparent advancement metrics and structural representation for racialized, Indigenous and working‐class nurses (Stake‐Doucet 2023; Giordano et al. 2024). Without attention to these historic exclusions, reforms risk reinscribing old hierarchies under new guises. Code (1991) emphasis on situated knowledge is instructive here: without intentionally valuing diverse epistemologies, institutional reform remains incomplete.

Ultimately, the question is no longer whether autonomy is possible, but whether systems are willing to be redesigned to support it. If subordination has been historically designed into the infrastructure of healthcare, autonomy must be equally deliberately designed back in. This requires embedding nursing knowledge into governance, spatial design and education in ways that address epistemic injustice and affirm relational moral agency. Only by integrating structural change with epistemic justice can nurses be repositioned from subordinate labour to co‐architects of healthcare systems.

1.8. Reclaiming Nursing as a Knowledge Discipline

Bridging the gap between evidence and action in health reform requires more than new studies, it demands a radical shift in whose knowledge is recognized, whose insights are institutionalized, and how epistemic legitimacy is assigned within the architecture of care. Nursing, despite its central role in health systems, continues to be marginalized epistemically: its knowledge is often discounted, its contributions rendered invisible and its agents structurally excluded from governance and reform. The challenge is not merely one of absent data but of epistemic injustice, the systemic devaluation of knowledge grounded in feminized, relational and practice‐based domains.

Fricker (2007) identifies this exclusion as testimonial injustice, wherein voices are discredited based on social identity rather than epistemic merit. In nursing, this manifests in the dismissal of clinical insights as ‘soft’ or subordinate to physician‐led paradigms. Lorraine Code (1991) expands this critique through the notion of epistemic responsibility, arguing that knowledge produced in situated, relational contexts, like bedside care, is not only epistemically valuable but ethically indispensable. Susan Sherwin (1992) further clarifies that moral agency in healthcare is not individualistic, but relational and systemic: it is embedded in institutional structures that either enable or suppress the ethical voices of caregivers. Ignoring nursing knowledge is thus not just an epistemic failure, but a breach of moral and institutional accountability.

This injustice is structurally encoded across global contexts. In Brazil, nurses remain excluded from planning rooms and leadership suites, reinforcing spatial and symbolic hierarchies of authority (Cassiani et al. 2019). Governance frameworks treat them as operational labour, not strategic leaders, a pattern echoed in Sri Lanka, where promotion depends on hierarchical conformity over innovation or relational leadership (Pincha Baduge et al. 2024). In Finland, by contrast, institutional design allows nurses to exercise independent clinical judgement and lead in high‐acuity contexts, affirming their roles as epistemic and moral agents (Pursio et al. 2021). These examples, drawn from earlier discussions of autonomy, illustrate how institutional architecture can either obstruct or enable professional authority and underscore the need for justice‐oriented reform that integrates nursing knowledge into the core of system design.

Yet while the philosophical and practical arguments for nursing autonomy are increasingly clear, the empirical base that supports reform remains fragmented and epistemically constrained. In Spain and Portugal, for example, evidence of nursing leadership's benefits is largely limited to small‐scale case studies or qualitative reports, with limited policy translation (Sillero Sillero and Buil 2021; Rodrigues et al. 2020). In Turkey, findings that nurse leaders enhance team performance have failed to yield structural policy shifts (Aragon et al. 2020; Gürsoy et al. 2023). Australia presents observational data on spatial marginalization (Naccarella and Raggatt 2019), and Canada offers reform initiatives mostly confined to symbolic or pilot‐scale programs (Ben‐Ahmed and Bourgeault 2022). These studies, while valuable, are too often dismissed for lacking biomedical rigour, despite the relevance and insight they offer into systemic design.

Large‐scale reviews do offer more robust evidence. Meta‐analyses consistently show that nurse‐led models improve outcomes, enhance safety and strengthen interprofessional collaboration (Swiger et al. 2016; Wong et al. 2013). However, even these studies tend to privilege outcome metrics over the structural, cultural and epistemic conditions that make nursing leadership possible in the first place. The limitation is not only methodological but epistemological: dominant research paradigms continue to undervalue the kinds of knowledge nurses produce, knowledge grounded in relationship, responsiveness and embedded care.

This reveals a deeper problem: the knowledge infrastructure underpinning health reform remains biased towards biomedical, quantitative and managerial paradigms that systematically exclude practice‐based, relational and affective insights. As Code (1991) reminds us, such exclusions erode institutional responsibility. When situated knowledge is ignored, systems lose their capacity for ethically responsive governance. Sherwin (1992) feminist ethics underscores that health systems denying moral agency to caregivers cannot claim legitimacy. These failures are not merely academic; they shape policy, entrench inequity and reproduce the very hierarchies that reform efforts claim to dismantle.

What is needed, then, is not just more data, but a reimagined epistemological architecture: one that values diverse ways of knowing, centres relational ethics and legitimizes the knowledge produced through nursing practice. This includes supporting longitudinal and comparative research, elevating qualitative and mixed‐methods approaches and redefining validity to encompass insights grounded in care. Research frameworks must begin with the premise that nursing knowledge is structurally and morally essential, not secondary to other forms of expertise, but co‐constitutive of what effective, ethical and equitable care looks like.

Only by building a knowledge infrastructure that affirms nurses as full epistemic agents, producers of insight, shapers of policy and architects of ethical systems can healthcare move towards the structural justice it claims to seek. Bridging epistemic and evidence gaps is not simply a scholarly concern; it is a moral imperative at the heart of system reform.

1.9. Towards Structural Reversal: Embedding Nursing Autonomy

This paper has argued that nursing's persistent subordination is not an accidental byproduct of healthcare evolution but a deliberate outcome of institutionalized power/knowledge asymmetries. Drawing on historical, architectural, sociological and feminist scholarship, selected for their explanatory, it has demonstrated how patriarchal norms, spatial segregation, credentialing hierarchies and gendered labour expectations have systematically positioned nursing as subordinate to medicine.

The six interlocking domains of autonomy outlined here, clinical authority, governance integration, control over working conditions, spatial equity, independent advancement pathways and epistemic recognition, together form a structural and philosophical framework for dismantling these constraints. Each domain points not only to practical reforms but also to deeper questions of justice, recognition and moral agency. Global case studies confirm that autonomy is not a distant ideal but a realized possibility in systems that have deliberately restructured power, codified authority and recognized nurses as epistemically legitimate co‐architects of healthcare.

The evidence is clear: reform cannot remain rhetorical. Epistemic justice requires that autonomy be materially embedded in governance structures, spatial design, educational pathways and workforce policy. This entails legislating nursing authority, ensuring equitable representation in decision‐making, funding nurse‐led research and cultivating interprofessional cultures that treat nurses not as auxiliaries but as epistemic equals. These are not aspirational ideals but ethical imperatives to redress structural injustice and to create health systems capable of learning and acting inclusively.

What is at stake is not only professional recognition but epistemic justice: the right of nurses to be acknowledged as knowers, leaders and moral agents. As previously discussed, denying this legitimacy constitutes structural harm, limiting what health systems can know, imagine and achieve. Drawing on Fricker (2007) concept of epistemic injustice, Code (1991) notion of relational responsibility and Sherwin (1992, 1998) ethics of care, it becomes clear that excluding nursing knowledge is not merely a professional oversight but a structural failure of justice, epistemic, moral and institutional.

Nurses are not the silent infrastructure of healthcare. They are theorists, practitioners and moral actors whose situated knowledge is central to both care and transformation. Sherwin (1998) argues that justice in healthcare requires centreing the voices of those historically marginalized to build systems that are not only efficient but relationally and ethically just. Recognizing and structurally empowering this reality is not only a matter of professional justice but a philosophical imperative: to build health systems that are not merely clinically effective but also ethically grounded and epistemically inclusive. Until these cultural and institutional foundations are dismantled, reforms will remain constrained and nursing autonomy will remain structurally out of reach. Taken together, these global cases do not replace the Canadian context but sharpen its contours, illustrating how structural injustice, testimonial silencing and spatial marginalization operate internationally while reinforcing the urgency and applicability of the six‐domain reform framework in Canada.

Ethics Statement

This study did not involve human participants, animal subjects or any identifiable personal data. Therefore, ethical approval from an Institutional Review Board (IRB) or equivalent ethics committee was not required in accordance with the guidelines of the University of Saskatchewan.

Conflicts of Interest

The author declares no conflicts of interest.

Dunn, J. 2025. “Diminishment by Design: The Role of Class, Gender and Architecture in Shaping the Nursing Profession.” Nursing Philosophy 26: 1–12. 10.1111/nup.70042.

Data Availability Statement

This manuscript does not report any new empirical data. All sources referenced are publicly available and cited appropriately in the reference list. As such, there are no associated data sets to share.