Women in health academia: Power dynamics in nursing, higher education and research.

Abstract

Power – or the wielding of power – is an in evitable and necessary component of the way organizations function. This is because power forms the basis of “getting things done”, “making a difference”, and achieving outcomes – the common goal of all organizations (Blake & Mouton, 1968; Vine, 2004). Power is further broken down into two types: “power to” or the ability to achieve objectives; and “power over” or the influence one has over the behaviours and actions of others (Hawks, 1991, p. 755). Nursing has been marked by examples of both types of power – with mixed results. For example, having the “power to” has allowed nurses to achieve a high level of social standing (Morgan, 2017) and to work effectively with patients and in multidisciplinary teams (Katriina et al., 2013). These outcomes have positive connotations. On the other hand, nursing has also been characterized by “power over” (Katriina et al., 2013, p. 580). For example, the predominantly female-dominated profession of nursing has experienced a long history of dominance by the predominantly male-dominated medical profession (Palmer & Short, 2014). One reason for this is the presumption that nurses have less knowledge when it comes to the diagnosis and treatment of the patient (de Raeve, 2002). Socialization of women and the medicalization of society are additional explanations for this “power over” relationship. Another reason lies with the notion of “rational authority”, where an obligation to obey exists when there is a good reason for action (e.g., the wellbeing of the patient) (May, 1993). The reality that extends from such power imbalance is that powerless nurses are less satisfied in their employment and less effective (Manojlovich, 2007; Manojlovich & Spence Laschinger, 2002), leading to issues when delivering optimal patient care. Whatever the driver, this power imbalance and the gender divide on which this power imbalance is built, creates a culture that has become largely self-perpetuating. Women are associated with nursing and nursing is associated with a position of lesser power, drawing a link between occupation, power, and gender. Even in nursing, the gender divide manifests as a power divide, with male nurses – who are largely a minority in the profession – far more likely to be promoted to senior positions and, consequently, paid more than their female colleagues (Brown, 2009). This further exacerbates perceptions of gender and power in the profession, yet others argue that males in nursing suffer double discrimination being nurses and “intruders” in others social interplay (Ross, 2017). This raises questions as to whether the notion of gender and power imbalance is limited to the conventional clinical context of the nursing profession? Or are these notions of imbalance challenged in, for example, settings where the medical profession has less influence in terms of rational authority? Settings known for deeper levels of thinking, such as academia? Interestingly, the academic sector – including the health disciplines – are likewise dominated by males. This is demonstrated by the gendered rates of career advancement (Carr, Gunn, Kaplan, Raj, & Freund, 2015) and remuneration (Jagsi et al., 2012), with the disparity exacerbated by the juggling of professional and personal lives by female staff (Buddeberg-Fischer et al., 2010). For example, academic medicine is heavily dominated by males, with the more senior the academic position, the less likely the incumbent will be female (Fitzpatrick, 2012). Research is likewise dominated by males, with less than a quarter of A grade researchers being female (European Commission, 2009). This disparity can have follow-on effects, resulting in potential bias (Penny, Jeffries, Grant, & Davies, 2014) for recruiting to research positions and specialities (Penny et al., 2014). Power imbalance, however, is about more than numbers alone – it is also about culture and perception. For example, a recent study by the University of New South Wales found that negative stereotypes had contributed to a partiality for male, English-speaking teachers, with this cohort subsequently receiving higher positive feedback from students (Crossley, Johnston, & Fan, 2019). Such stereotypes and partiality are shaped by and in turn shape, the prevailing culture. This raises significant concerns for the profession of nursing. As female dominated, with a history and culture of being dominated by others, the nursing profession often seems powerless to influence those in its own ranks to behave or act in ways that will achieve change. Exercising “power to” achieve objectives does not come easily. Nevertheless, the wielding of power to overcome the challenges is an essential means by which change in an organization – including academic organizations – occurs. Questions must be asked, then, of what can be done to address this situation. Research has demonstrated that when there is a lack of support in the workplace, female academics underperform (Smith & Gayles, 2018). Addressing female representation, advancement and involvement in health academia requires the creation of a more supportive work environment – which, in turn, will create a means of changing the culture that perpetuates power imbalances and gender gaps. For example, changing the work environment can be as straightforward as changing the workplace culture which supports female academics to address work/life demands (Athanasiou et al., 2016). Such changes will allow females, not only to be equally represented but also to be supported through their career development. This, in turn, will allow them to contribute to valuable research in key areas by converting their clinical experience to scholarly or research outcomes. Mentoring is another key strategy that helps to support women in their early career stages, improving recruitment, retention and advancement (Maas et al., 2006). While informal mentoring may be enjoyable to those involved, the most effective mentoring involves a structured and intense relationship between the mentor and mentee, supported by a commitment of resources, time and the right people (Brody et al., 2016; Cleary, Jackson, Sayers, & Lopez, 2017). Some research, however, has pointed to insufficient opportunities for mentoring for females in academia, with this situation acting as a barrier to career advancement (Blood et al., 2012; Sambunjak, Straus, & Marusic, 2006). To unravel the issues further, juxtapose the situation of nursing in Pakistan, where women in general and in nursing and nursing academia, are far less liberated than their colleagues in many overseas countries (Chauhan, 2014). Firstly, traditionally and today many young women cannot access schooling at primary and secondary levels, let alone university. There are more medical doctors than nurses; there is a huge status and image gap between the two professions (Chauhan, 2014). Nurses have been dominated by doctors in their nursing schools, on their nursing council and in government. Nurses constantly bemoan that doctors have a “power over” relationship; the Pakistan Nursing Council (PNC) has limited the intake numbers of males in nursing to 10% in mixed nursing schools; and in Punjab males are not employed in the public sector, not by legislation but by “power over” relationships in the female dominated hierarchy. In the profession itself there are multiple silos of dysfunctional organizations, professional and industrial, where power over each other dominates and has exacerbated professional corruption, lack of leadership and a floundering profession. The result is a nursing profession in chaos, in clinical settings and in nursing academia, with a strong “power under” relationship with medicine; a lowly self and public image of nursing; poor professional relationships with medicine; and suffering clinical outcomes (Gul, 2008). It seems that every family wants their child to do medicine and go overseas to become a success, few wish the same for nursing. The resultant brain drain and excess of doctors locally has led to them taking up senior government and political roles rather than addressing the healthcare issues, further enhancing their power in society and over nurses. The new Imran Khan government is redressing the power roles by driving a nursing expansion agenda (doubling numbers in 2 years and seven-fold by 2030) which is empowering nurses – the power to get things done. Appointing a nurse as President of PNC; creating a Chief Nursing position; inviting senior nurses to the decision table while the road map for nursing is rolled out’; tackling bullying and discrimination; allowing men the freedom to work and study in nursing, are some strategies (The News, 2019). Agreeing to expand university schools and increase faculty capacity also illustrates this move forward, such that the profession now has the opportunity to exercise “power to” and establish a stronger gender balance and equitable relationship. The final strategy for improving gender parity and addressing the power imbalance that can manifest from disparity is, quite simply, awareness. The study by the University of New South Wales (UNSW) (Crossley et al., 2019) highlighted the way bias can become a self-reinforcing mechanism for the creation of cultural norms. As the training ground for future leaders, universities should be acutely aware of such biases and the need to educate against these so as to reshape this culture. Efforts by UNSW to look beyond the over-arching results from student feedback and to consider its drivers and origins, showed a level of awareness that allowed such feedback to be better understood and used. This awareness, if applied more broadly in female participation in health academia, will allow for a reduction in bias that can only benefit all of society as a result. To achieve the level of power required to “get things done”, “make a difference”, or achieve outcomes in terms of scholarly contribution or research, it is important that the profession of nursing consider how to better support female colleagues to rise through the ranks in nursing. In developing countries this will be a huge challenge, but the scene is set in Pakistan for a rapid change which will need awareness raising campaigns, mentoring from the global profession, encouraging nurse academics who are sensitive and wise. This consideration includes unpacking the issues relates to the exercising of power over or in the profession itself, to raise awareness of what is needed to achieve wider, structural change. This work was partially supported by UTas funding awarded under the UTas Research Themes: Better Health Research Development Grant Scheme, supported by the Office of the Deputy Vice-Chancellor and FoH (C0025653). Authors declare that there is no conflict of interest.