CHAPTER 12. The gendered culture of nursing
• understood and appreciated the historical development of feminist thinking on concepts such as nursing work and science
• examined the role that gender plays in defining the world of nursing work
• developed greater insight into how the healthcare system and health professionals are impacted upon by the issue of gender
• briefly explored the influence that feminisms have had on the discipline of nursing
• understood how feminist theory has influenced nursing research, and
• considered the debate about the relative advantages and disadvantages that gender provides for nurses.
In order to consider a range of gender issues—which are of interest and relevance to nurses all over the world—this chapter will consider the gendered nature of nursing work. This will involve discussion about the nature of women who provide the majority of the nursing workforce. It will also require some analysis of the nature of nursing work, as it is performed by women and men. Inherent in this discussion will be consideration of the role of science in determining views of the concept of ‘woman’, as well as the work women undertake. The chapter will also consider briefly the influence of the feminisms on nursing, and the influence of nurses and nursing on feminism. Finally, the chapter will examine the increasing role played by men in nursing, a gender issue of utmost importance for the future of nursing. It should be noted that there will be an extensive exploration of substantial volumes of literature that reflect classical thinking and debate over almost 20 years, but which remains relevant to the concepts presented here.
THE GENDERED NATURE OF NURSING WORK
A consideration of the gendered nature of nursing work must examine the concept of woman, since the majority of nurses are women. Whatever views are held regarding women will influence perception of women’s work—in this case, nursing work. Perspectives on women are influenced by ‘scientific’ views about the nature of women, although it might also be argued that perspectives on women influence beliefs about the nature of science.
There is a considerable volume of literature that demonstrates a range of approaches and various viewpoints on woman as object and subject. Women can be examined from sociological, psychological, biological, philosophical or political perspectives—and other viewpoints as well. Many of these viewpoints feature devaluation of women, as any examination of the concepts of essentialism, biologism, naturalism or universalism will demonstrate. In an insightful work, Grosz (1990) suggests that all of these terms, which argue the nature of women (and men, incidentally), do fix and define the limits, because they ‘are commonly used in patriarchal discourses to justify women’s social subordination and their secondary positions relative to men in patriarchal society’ (Grosz 1990:333). In their work, both David, 2000 and Gherardi, 1994 argue the similar point that ‘masculinity and femininity are symbolic universes of meaning socially and historically constructed’.
Gherardi suggests also that the way we ‘do gender’ in our work ‘helps to diminish or increase the inequality of the sexes: we use ceremonial work to recognize the difference of gender, and remedial work socially to construct the “fairness” of gender relationships’ (Gherardi 1994:592). Ceci (2004) asserts that genders are identified by specific traits, virtues and behaviours that place us as either feminine or masculine—that is, identifiable and named as such. There is no question that in nursing each gender experiences ‘cross-over’, necessitating the management of dual presence in what are essentially separate symbolic contexts.
There are problems with constructing a ‘universal feminism’, since allowance must be made for difference and diversity between women, just as there is between women and men. What is worthy of exploration are some of the views about women and nurses within a medical and health professions context, because these views are influenced by the concepts mentioned above. The issue of how women are constructed by science is also relevant here (Kane & Thomas 2000).
Feminist literature argues that the masculinity of science is an image that has been perpetuated for centuries. This image creation is affected by textbook representations, curriculum organisation, classroom behaviour, and stereotypical beliefs and attitudes. It distorts science, yet scientific method has not been successful in filtering out patriarchal bias in the scientific construction of women. In the early 1990s, Lather wrote with clarity regarding this. She says:
The claim of positivistic researchers that their method is sufficient protection against ideological incursion is debunked by feminist critiques of the conceptual and methodological orientations that reflect and reinforce sex-based inequality. Hence the construction of women brings into question that which has passed for knowledge in the human sciences (Lather 1991:17).
The masculinity of science is only an illusion (albeit a powerful one), not an intrinsic part of its nature. Science is a social construct, and ‘its development is inextricably linked with social relations, not least the relations between men and women’ (Kelly 1985:76). This leads, of course, to using male as the norm and female as the referent, a strategy that has been exposed and rejected in a wide range of disciplines, including psychology, sociology, psychiatry, medicine, education and biology. As long ago as the 1970s, it was pointed out that ‘male’ medicine misunderstood the female body, and these debates have now extended to cover all aspects of women’s health, not just those of childbirth and reproduction.
In nursing and medicine, the presence of increasing numbers of women at all levels of authority indicates a modicum of success in producing women-friendly services and conditions. This has come about only because women have been forced to reclaim their healing role, which was given a boost by the knowledge and insights in the classic treatise written by Ehrenreich and English (1979), documenting the exclusion of women-as-healers from professionalised, modern medicine. There has long been ‘increasing institutional awareness of the deficiencies and sexism of specific institutional practices’ (Evans 1997:42). This has had both positive and negative effects. For the latter, it has resulted in some feminists ‘beating up’ on nurses, thus earning the title of ‘anti-nurse’. This is:
… predicated on the belief that nurses willingly capitulate to male (and/or medical dominance), thereby making it difficult for ‘real feminists’ to achieve their goals. This … ‘complicity hypothesis’ … sees nurses as compliant with patriarchal demands to remain oppressed (Buchanan 1997:82).
Using this argument, nurses can be viewed as either the embodiment of the ‘ideal’ or ‘good woman’ (David, 2000 and Fealy, 2004:653), conforming to masculine desires, or as the ‘bad mother’, ‘thwarting women in their endeavours and assisting the medical profession in torturing women patients’ (Buchanan 1997:82). In some ways this analysis, awareness and critique could be viewed as hostile criticism; however, it provides us with alternative views and insights that can be growth enhancing for women and nurses should we objectively and critically consider all perspectives.
Published studies over the last decade or so indicate that we do not need feminists to ‘beat up’ on nurses—nurses do that very well to each other, whether they are feminists or not (Briles, 1994 and David, 2000). Horizontal violence has long been recognised by a range of authors, who suggest that nurses’ self-hate and dislike of other nurses (which is very common in oppressed groups) is demonstrated by the lack of cohesion in nursing groups, as well as the phenomenon of ‘eating our young’ (Bent KN, 1993, Kitson, 2004 and Roberts, 2000). This concept arose out of the original work of Freire (2007) in his now classical book Pedagogy of the Oppressed (first published in 1968), which highlighted the relationship between the coloniser and the colonised, its power and its powerlessness. From these insights, we can conjecture that the systematic oppression of women will assist nurses to recognise the oppressive structures in which they practise, which:
… includes recognising that nurses are placed in a culture that does not value their attributes, rather than ‘blaming’ them for ranking lower on self-esteem and higher in submissiveness in job-trait studies than do people in other occupations. Nurses must no longer assume that they are inherently inferior to the systems that surround them (Bent 1993:298).
Awareness of the social construction of women and nursing and its oppressive nature may change the way nurses relate to each other, and even refrain from ‘horizontal violence’. As David makes clear:
Nurses will never be able to expunge gender politics without first developing an understanding of how many use self-deception and how that action perpetuates nursing’s professional mediocrity, limits freedom of thought and action, and preserves nurses’ borderline status (David 2000:85).
This brings us to the work of nursing.
THE WORK OF NURSING
The role and function of nursing cannot be separated from those who undertake this activity. Literature published in the last two decades indicates that there are particular views held about women and nursing that create the definitions of women’s work and nursing work, and, by implication, men’s work (David, 2000, Fealy, 2004 and Meadus, 2000). Cheek and Rudge point out that:
… the low status of nursing and the way in which the work of nurses is devalued, especially when compared to other health professionals, can at least in part be explained by its gendered nature (Cheek & Rudge 1995:312).
Labelling nursing as ‘women’s work’ creates a deterrent that ‘inhibits recruitment of men into the profession and aids promotion of the sex imbalance in the nursing workforce’ (Meadus 2000:9). Nursing is thus viewed as a natural extension of the female role, valuing nurturance, caring, support, care and concern (Bent 1993, Brykczynska, 1997 and Evans, 1997). These characteristics have been described as encompassing a ‘tyranny of niceness’ (Street 1995). Nevertheless, researchers have found that these characteristics are selectively eliminated during the educational and socialisation process (Doering 1992). For example, Treacy noted that current ‘nurse training’ endorses ‘compliance, passivity and ladylike behaviour, but it negatively sanctions other female traits such as intuition, empathy, and emotional expression’ (Treacy 1989:88).
The descriptors ‘compliance, passivity and ladylike behaviour’ are words which, it could be argued, are suggestive of ‘powerlessness’ and ‘intuitiveness, empathy and emotional expression’, and are often viewed as unscientific and hence unacceptable in the world of science. The social construction of women as emotional beings is also used to undermine their credibility as nurses (Ceci 2004). As David (2000:86) also points out: ‘the gender dialectic is still so fundamental to gender politics that it permeates the traditions of nursing, such as the belief that nursing is woman’s work’.
Because of this, it could be argued that women and nurses steer towards nursing as a career, while men are relatively inhibited from entering the nursing profession. According to Evans (2004:321), the ‘ideological designation of nursing as women’s work has excluded, limited, and conversely, advanced the careers of men in nursing’. The issue of male advantage will be addressed later in this chapter.
Evans (1997) notes that nineteenth century science and rationality perceived the ‘feminine’ as an abstraction, which assisted in marginalising women within institutional practices. Women, as we have seen, were constructed as hysterical and intellectually inferior, while men were expected to conform to the stereotype of masculine behaviour. Thus, ‘the “soft” feminine and the “hard” masculine then received institutional recognition and confirmation in particular practices’ (Evans 1997:39). Feminists have sought to demonstrate the disjunction between supposed institutional objectivity and actual institutional practice. Specifically, the institution of medicine, for example, defines its values as non-gendered, while in practice they are deeply gendered (Evans 1997). This has been exposed in many areas—for example, in the management of childbirth and women’s sexuality (Erturk 2004).
Because the values that dominate our health system are so pervasive and reflect the values of society at large, ‘it is a struggle for nurses to remain aligned to the person rather than the institution’ (Huntington 1996:170). This creates difficulties in nursing work, as the dominant discourses that shape health, illness and perceptions of what it is to be a woman (and a man, incidentally) can disadvantage the individual. As Huntington (1996:170) points out: ‘we have been left with only male language to explain the fundamentally female practice of healing bodies’. The only solution to this problem is to develop an alternative discourse to that constructed and dominated by orthodox scientific discourse characteristics of the medical world.
Clearly too, the feminist literature has challenged the cultural code of organisations, designed around masculinity and femininity, which suggests that ‘gender is deeply embedded in the design and functioning of organisations’ (Davies 1995:44). These workplaces are socially constructed, as is the position of ‘nurse’ (David 2000), neither of which are gender-neutral, and operate on masculine values for their legitimation and affirmation (Gherardi 1994). Nurses therefore find it difficult to function within such gendered organisations, and frequently resort to ‘blaming the victims’, who are usually other nurses struggling with their day-to-day functioning within a hostile environment. Alternatively, they may adopt a victim mentality, rather than recognising the dysfunctionality of their workplaces (Kitson 2004). Thus:
[W]omen, in a very important sense, cannot be ‘at home’ in the public world—it is constructed in such a way that assumes home is somewhere else, somewhere far away and different (Davies 1995:62).
However, Kane and Thomas (2000) remind us that nursing has historically provided a haven for women who seek to control their lives within a professional context, although there are significant limits to what can be achieved. In fact, David (2000) suggests that this is delusion, because power does not belong to women in a male-dominated system (see also Paliadelis, 2005, Paliadelis, 2008 and Paliadelis et al., 2007).
As we continue our searching of pertinent literature, we find a range of other historical scholarly work that demonstrates the further weakening of nursing’s value. For example, Gamarnikow (1978) linked nursing to domesticity; Treacy (1989) suggested that the invisibility of nurses’ contribution to care reflected the invisibility of much of the work contribution of women in society. Other scholars have pointed out that the sexual division of labour in the home disadvantages women in the workplace, which creates enormous stress for working women, and, in this case, nurses. This taps into the work of feminist scientists who have ‘identified “women’s work” the “caring professions”, “unpaid domestic labour”, “the double shift” and other manifestations of the apparently “natural” social division of labour’ (Evans 1997:59).
It has been pointed out by many scholars that caring itself is a gendered construct, since notions of professional caring are derived from traditional concepts of caring as a feminine obligation (Caffrey and Caffrey, 1994, Ekstrom, 1999, Falk Rafael, 1996, Paliadelis et al., 2007 and Wuest, 1997). Caring in nursing has in the past been constructed as an inherently feminine pastime, and traditionally has received little social or economic recognition; it has been perceived as women’s work, as unintellectual, unskilled and emotional, and thus likely to perpetuate gender exploitation (Bubeck, 1995, Ceci, 2004 and Henderson, 2001). It was long believed that the work nurses undertake in order to provide care does not require any particular skill or knowledge; it has been viewed as a quality that women possess ‘naturally’ (Falk Rafael, 1998, Henderson, 2001 and Zebroski, 2001).
However, this view has been challenged. For example, Meadus (2000) cites research that demonstrates that men enter nursing because of their desire to care for others, thus challenging the stereotype that only women nurses care. He also notes that such men run the risk of being perceived as ‘gay’ because of this role violation. This viewpoint is challenged by Bubeck (1995:114), as she notes that ‘part of the practice of care is to focus on the needs of the other, to become attentive, to be selfless’. By the construction of masculinity, caring is very difficult for men; they also escape from the care burden through the ‘public/private’ split in responsibilities of women and men (Tronto 1999).
Nursing’s detractors have long promoted the idea that nurses are ‘doers’ rather than ‘thinkers’; that is, nurses do not need to ‘think’ to do nursing, as long as they can ‘do’ certain tasks. This has resulted in an anti-intellectual bias, which creates the perception that the ‘intelligent nurse was not a good practical nurse’ (Fealy 2004:652), a myth that then threatens the academic preparation of nurses (Liaschenko & Peter 2004). This has, in no small measure, led to a significant devaluation of nursing, assisted by the unequal power relations that characterise the position of nursing vis-a-vis medicine (David 2000). For many years, this view was used to justify the low-level education provided to nurses prior to their entry into the higher education system.
That caring is assumed not to require knowledge is not without practical consequence. The replacement of registered nurses with less skilled personnel could be considered less of a reflection of economic rationalism than a reflection of the idea that caring is unskilled activity intrinsic to domesticity and womanhood. To engender nurse caring as feminine, therefore positioning it as innately instinctive to women, is to deny the advanced knowledge and skills that lie within the therapeutic caring acts of nurses. Despite the fact that ‘emotional labour’ is a vital and necessary part of the nursing labour process, it ‘tends to be marginalized as a skill that a predominantly female nursing workforce would naturally possess’ (Bolton 2000:580).
The concept of emotional labour is derived from the work of Hothschild (1983) who suggested that stress occurs to those involved, as they need to repeatedly suppress their felt emotions while they express contradictory feelings. This dissonance creates emotional deadening and distancing from authentic feeling. Emotional labour can be conceived as a ‘gift in the form of authentic caring behaviour’ (Bolton 2000:586), which truly reflects the state of ‘being a nurse’ or acting out the social construction of the ‘ideal nurse’ (Mazhindu 2003:249). The fact that it is under-theorised and not appreciated is of serious concern (Henderson 2001).
Emotion work can be hard labour, because it requires containment of emotions and/or denial of feelings. Relief measures are sought to cope with this continuous labouring. Relief can be found in ‘backstage regions’, such as the nurses’ station, where profound irritation with patients or emotional anguish can be expressed, where nurses can ‘drop their public mask’ and express their true feelings (Weir & Waddington 2008). As Fineman (1993:21) indicates, ‘off-stage settings are not emotion-free ports’. Here, implicit feeling rules can come into play; colleagues can express emotion to a degree that will be cathartic for them, but will also maintain organisational order.
Despite the fact that it is now acknowledged that emotional labour occurs in organisations, and that employers have expectations about what sort of emotion one should feel in particular contexts, emotion work tends to be privatised and moved out of the realm of organisational responsibility (Boyle, 2002a, Boyle, 2002b and Martinez-Indigo et al., 2007). Emotional labour work involves remaining continually vigilant and sensitive to the environment, constantly noting and responding to others’ emotional states, alleviating resultant distress, and assisting those who are ‘inappropriately emotional’ to regain their stability (Lupton 1998). The fact that this creates workplace stress for nurses is rarely acknowledged (McVicar, 2003 and Mann and Cowburn, 2005).
Emotional labour work can be emotionally and physically demanding, but requires interpersonal and intrapersonal skills and competencies that are not acknowledged (McQueen, 2004, Myerson, 2000 and Nicolson, 1996). They assert that this lack of acknowledgment occurs for three reasons. First, emotion work remains largely invisible. Second, it requires the development of awareness and of a vocabulary to describe this work as a competency. Third, this work is predominantly done by women. Women tend to be more involved in the caring and service industries than men (as in nursing), and also perform much of the ‘backstage’ or behind-the-scenes work (Goffman 1959). While this work may be perceived as trivial, it is usually of a supportive nature, enhancing the intellectual capability or productivity of organisations (Lupton 1998).
This is not to say that men do not ‘do’ emotional labour; some do. However, management is still predominantly done by men, and their power to demand emotional labour from both women and men is maintained by management, although it is ‘often constructed as (non)emotions’ (Hearn 1993:161). As an antidote, Boyle’s (2002a) research on emotional labour and masculinities, given that males are not viewed to have a primary ‘caring’ role, when what is defined as emotionally acceptable in the workplace, and how this impacts on views of masculinity, have a ‘lose–lose’ predicament.
It is important not to forget the value of relationships that nurses develop with their patients, with relatives and carers, all of whom remain part of using the self in caring mode, often critical to recovery, and which can be very demanding. Sandelowski makes the point that those who engender nursing as female:
… inadvertently minimise or deny nursing its record of expertise and innovation within technology, the primary roles nurses have played in the deployment of technology and the power and remuneration that comes with technological knowledge and skills in a high-technology culture (Sandelowski 1997:172).
Traditional expectations that surround caring as a feminine and nursing activity involve subjugation of the self and selfless devotion to duty (Caffrey & Caffrey 1994). In some circumstances nurses may experience feelings of powerlessness and eventually burn out, as a result of suppression of their own feelings and needs (Demerouti et al 2000). Others suggest that emotional labour is an integral part of caring in nursing (Henderson, 2001 and Weir and Waddington, 2008). For an excellent and comprehensive analysis of caring, refer to Chapter 6 of this text.
THE INFLUENCE OF FEMINISMS ON THE DISCIPLINE OF NURSING
‘The feminisms’ refers to the variety of theoretical approaches to the advocacy of equal rights for women, accompanied by a commitment to improving the position of women in society. They are informed by a range of theoretical propositions, which include liberal feminism, socialist feminism, postmodern feminism, postcolonial feminism (Rancine 2003), feminist ethics (Peter et al 2004) and other forms.
This chapter has developed the argument, derived from decades of literature, that women and nurses are devalued in general, notwithstanding that gains have been made in recent years. Feminist nurses, and others, have provided feminist analyses of their clinical practice, their educational understandings and their research. It is most notable that the feminisms have been promoted more by nursing scholars than practitioners, which has led to some uneasiness between the two groups. This may have arisen because the feminisms have an ‘image’ problem due to stereotypical views of what constitutes a feminist.
In reality, the feminisms are political perspectives, which seek to balance societal power, to gain equalities and autonomies for women of all races, classes, ethnicities, ages, disabilities, sexualities and professional status (Peter et al 2004). These feminisms offer the opportunity for nurses to recognise and analyse the unequal power relations that have been discussed earlier in this chapter, and to develop a raised consciousness about gender issues (Dendaas, 2004, Meadus, 2000 and Valentine, 2001). Feminist analyses have been extended to clinical practice to examine nursing and healthcare contexts, particularly ‘managed care’ from the ‘feminist philosophical assumption that “the personal is political”’ (Georges & McGuire 2004:11).
It is noteworthy that the feminisms have been eschewed by a large number of women, particularly younger women (Baumgardner & Richards 2003). This may be partly attributed to (mis)understandings of the meaning of feminism. Those who seek to denigrate feminism and what it can offer suggest that feminists are ‘man-haters’ and therefore separatists; a number of other jaundiced and inaccurate epithets are hurled at them. Nevertheless, the literature also suggests that Generation Y women may believe that feminism is passé ‘because it worked’ (Wynter 2006). The argument runs that the successes of feminism must sow the seeds of its failure to be seen as relevant for adults of the present generation. Jayatilaka (2001) likens feminism to fluoride, suggesting that ‘feminism is like fluoride—we scarcely notice we have it—it is simply in the water’. And the new generation of women can take advantage of the gains of their fore-mothers, but ‘do’ their feminism in different ways.
In reality, one can espouse feminist philosophy or be driven from a feminist perspective while celebrating womanhood, whatever individualistic form it takes. Thus, women can enjoy male company and be interested in fashion, and enjoy their youth and femininity.
The key point is that feminism can be individually practised, which includes making choices about life. This can range, for example, from career choice and relationship definition, to shaving whatever parts of our body we wish, wearing nail polish and make-up, and even enjoying relationships with males. Feminism is thus about taking control of one’s life, respecting one’s womanhood as well as men; feminists can (and do) enjoy male company. The radical left of the 1970s view was that all men were rapists and perpetrators of violence. The reality is that some are, but the majority are not. So adopting a feminist perspective does not mean rejecting relationships with men; there can be (and often is) a natural and harmonious coexistence between women and men.
There is a strong view that women of Generation X and Y, in failing to identify with feminism, are rejecting the radical feminist notion of what it means to be a feminist. As Jayatilaka (2001) notes, such women might be identified as feminist if they were recognised as doing it in their own way. Rockler-Gladen (2007) suggests that this is ‘third wave feminism’, developed in the 1990s, which ‘focuses more on the individual empowerment of women and less on activism’. Essentially, this means that there is greater emphasis on using personal empowerment as a way to begin social change. It is this approach that is criticised by other feminists who believe that personal empowerment is unlikely to foster social change. Third wave feminism has also been identified as ‘postfeminism’—a concept explored in a study by Aronson (2003). She found that, while younger women are more ambivalent about supporting feminism, they are supporters, and may, under the right conditions, become the drivers for the next wave of the feminist movement.