Glass ceilings, class ceilings and sticky floors

Why are many nurses in general practice struggling in their jobs? Dr Helen Anderson speaks out about the findings of new research that brings together some alarming findings.

Nursing in general practice is under threat – in our new research, myself and my colleagues Professor Joy Adamson and Louise Brady identified important issues impacting retention and wellbeing of nurses working in general practice.

In the new GenRet Study¹ we found that long-standing, deep-seated issues such as poor pay, terms and conditions, lack of professional respect and parity of esteem, weak leadership and support from professional organisations, and a lack of a seat at the decision-making table, left nurses vulnerable and led to tipping points which made them unhappy and want to quit. In a second paper from the study² we explore why these issues are so difficult to resolve.

Deep-seated issues

We often hear that employers would like to pay nurses in general practice in line with their level of skill and knowledge, but there’s just not enough money in general practice. This doesn’t explain, however, why many nurses in general practice have never been paid appropriately over decades, even in times when there has been much more money in general practice. I know one GP who didn’t want to pay nurses in his employment more than a Band 6 equivalent as his wife was a nurse and he didn’t think she they should be paid more than her. At a recent discussion on pay and conditions, one GPN reported being told that her GP employers would not be able to feed their children if she had a pay rise!

Our study also revealed that nurses experienced being ignored or discounted at meetings and that the goodwill nurses gave their practices was often not reciprocated (eg, if they asked for accommodations for caring or health issues).

I’m often asked why nurses in general practice don’t simply just leave. One reason is because they value the patient care they provide and their professional identity supports putting patients first, sometimes to their own detriment. But there are also more complex cultural and structural reasons which leave nurses vulnerable.

Glass ceilings and sticky floors

So, what are these reasons? We found they often had to take work close to home and which fitted social hours due to caring and other responsibilities. Consequently, they couldn’t just take their labour elsewhere.

Nurses experienced a ‘sticky floor’³ which refers to the limited opportunities offered by low status, poorly paid work and personal circumstances which make it difficult for nurses to move workplaces. Even if they did look for work elsewhere, our study indicates that they were worried they may be treated even worse at other practices.

They also experienced a ‘glass ceiling’ (Punshon et al, 2019)⁴ which is the exclusion of nurses from higher status and strategic level work and consequently remuneration.

Working-class women’s work

Many of the issues experienced were contributed to by nursing being seen as ‘women’s work’, with nursing in general practice being associated with women’s and children’s health and what are  sometimes considered ‘softer skills’ such as developing therapeutic relationships. Howe (1977)⁵ calls this ‘pink collar’ work which lacks economic reward. This was also reflected in poor conditions such as lack of maternity and sick pay beyond statuary entitlements and these issues disproportionately affect women.

Social class also played a part with nurses being perceived as ‘less than’ and being ‘doers’ rather than  leaders. This was felt to be both deliberate and at the same time so embedded that it was hardly noticeable. GPs automatically assumed leadership while nurses were often socialised to ‘stay in their lane’. This was thought to be the result of socialisation within medicine and nursing and related to social class, with different exposure to things like private education and other life experiences, hindering opportunity.

In our study, even when nurses were able to get a seat at decision-making tables, they were often ignored or discounted due to perceptions about nursing based on deeply held notions of hierarchy and ownership. Snee and Goswami (2020)⁶ describe nurses as experiencing a ‘class ceiling’ that prevents meaningful social mobility and in which they are perceived in a particular way because they are nurses.

Intersection with culture, race, ethnicity and age

Culture, race and ethnicity also combined with gender and social class to impact on retention and wellbeing. Some nurses left general practice due to experiences of racism, lack of career progression – which disproportionally affects people from global majority backgrounds – and cultural differences which could lead to lack of understanding of what a supportive working environment looked like.

Ageism also played a part in the challenges experienced. More experienced nurses felt they were being replaced by cheaper alternatives and felt pushed out and unsupported. Some more junior members of the nursing team did not always respect experienced older nurses.

Economic, cultural and social capital

In our recent paper, to help us understand these issues, we used Bourdieu’s concept of ‘capital’ to make sense of the professional predicament of nurses in general practice.⁷ Bourdieu described three kinds of capital which are often shared unequally and are used to maintain power. Economic capital is pay and other income, wealth and financial assets. Cultural capital is made up of things like education, respect (including professional respect), confidence and knowing how to behave in certain circumstances and access to culture (eg, books, music). Social capital refers to connections and social networks people have.

We argue that nurses lack or – just as importantly – are perceived to lack, these forms of capital and this makes it very difficult to shift the power balance. Indeed, these forms of power can be leveraged to maintain the status quo and to intimidate. For example, in our study one nurse told us a GP she worked with would play classical music in his consultation room and then ask nurses questions about that music, assuming that they wouldn’t know the answer, which was felt to be demeaning and intimidating.

Addressing the challenge

So how do we address these complex cultural and structural issues? They are difficult to change and need recognition, and action, at a societal level if they are going to be meaningfully addressed.

In the first instance, it is important to recognise what is going on and to call it out. It then requires systematic bottom-up and top-down work from both nursing leadership and grass roots nursing to press these issues into the public consciousness.

Pressure can then be put on wider healthcare leadership to consider the needs of nurses in general practice for the benefit of patient care. Then we can we start to address these deep seated cultural and structural issues in a more meaningful way.

Dr Helen Anderson is a registered nurse and research fellow at the University of York

References

1 Anderson H, Brady L, Adamson J. Exploring the relationship between cultural and structural workforce issues and retention of nurses in general practice (GenRet): a qualitative interview study. BMC Prim Care. 2025;26:114. https://doi.org/10.1186/s12875-025-02813-1

2 Anderson, H., Brady, L. & Adamson, J. “I’m a bit middle class, a bit working class, a bit white and a bit Caribbean” – the retention of nurses in general practice and the intersection of professional and societal level cultural and structural issues: a qualitative interview study. BMC Health Serv Res 25, 1339 (2025). https://doi.org/10.1186/s12913-025-13420-2

3 Berheide CW. Women Still ‘Stuck’ in Low-Level Jobs. Women in Public Service: A Bulletin of the Center for Women in Government. 1992;3;1–4.

4 Punshon G, Maclaine K, Trevatt P, Radford M, Shanley O, Leary A. Nursing pay by gender distribution in the UK – does the glass escalator still exist? Int J Nurs Stud. 2019;93:21–9.

5 Howe LK. Pink collar workers: inside the world of women’s work. New York: McGraw-Hill; 1977.

6 Snee H, Goswami H. Who cares?? Social mobility and the ‘class ceiling’ in nursing. Sociol Res Online. 2020;26(3):562–80. https://doi.org/10.1177/1360780420971657

7 Bourdieu P. The forms of capital. In The sociology of economic life. Ed Granovetter, M and Swedberg, R. Routledge. 2018:pp. 78–92.