Course Price  $24.00 Contact Hours  3 Instructions   Study the course, then take the test. You can also print the course and test questions and return later to take the test.

Quicklinks Print this course Take the test How to take a course

Taking the Lead

Women Stepping Forward in Healthcare

Nancy Evans, BS

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here.

No one would argue that America's healthcare system needs changing—and as soon as possible! Just ask Harvard's Regina Herzlinger (2007): "Our $2 trillion healthcare system is as large as the economy of China. And yet, despite all this spending, millions of people cannot get the care they need." More than 47 million Americans who have no health insurance. The uninsured include 9 million children, many of whom come from working families whose income is too high to qualify for Medicaid and too low to afford health insurance. Once every 30 seconds someone files for bankruptcy because of medical bills. Every year another 18,000 people die prematurely because they lack insurance (AARP, 2007).

Add women, change culture. Add women, change business. Add women, change politics. Add women, change everything! The White House Project, 2007

The need for healthcare is great and growing. Rates of cancer, asthma, diabetes, and other chronic health problems are rising among Americans of all ages. Obesity is a national epidemic, affecting nearly half of American children. Half of all pregnancies now end in the loss of the baby or the birth of a child with birth defects or chronic health problems (National Research Council, 2000). An estimated 12 million children under age 18 suffer from one or more learning, developmental, or behavioral disabilities.(Boyle et al., 1994).

More than 1 million Americans are infected with HIV/AIDS and 40,000 more are infected each year. Women, particularly women of color, are the fastest growing group infected with HIV/AIDS. The ranks of older Americans continue to swell as baby boomers reach retirement age, dramatically increasing the burden of Alzheimer's, which is projected to reach 7.7 million cases by 2030. Medicare is viewed by some as unsustainable and in need of "fixing."

Fundamental change in our healthcare system is long overdue. To ensure that the right changes are made—changes that will benefit all Americans, including women and families—women leaders must help make the decisions. The problem is the serious shortage of women leaders throughout the health professions—in practice, education, research and professional organizations. In the healthcare industry as in every other area of business, it's still lonely at the top for women.

A new study of thirteen industries in the United States (ZoomInfo, 2007) shows that women account for only 22% of healthcare CEOs. Surprisingly, however, that's a larger percentage than in any other area except the nonprofits. Women leaders are similarly under-represented in academic medicine: only 14 of the 125 U.S. medical schools have a woman as dean (AAMC, 2006). In social work, a profession dominated by women, research shows that men in social work are paid more and obtain managerial positions earlier and in greater numbers than their female counterparts (National Association of Social Workers, 2007).

The story is much the same in physical therapy (PT). Although 7 out of 10 physical therapists are women, only about 55% of the directors of accredited university PT programs are women. The odds are somewhat better in occupational therapy (OT). More than 90% of occupational therapists are women, and women account for 80% of directors of accredited university programs in OT. Nursing may be the only health profession in which women dominate both in the practice arena and in academic leadership (Women in Health Sciences, 2004).

The effect of this shortage of women leaders is most visible in the continuing neglect of women's health issues such as children's health, childcare, eldercare, family violence, and breast cancer and other women's cancers. Solving this shortage—bringing more women into positions of power and influence—will affect more than just "women's issues." Women's involvement will improve health policy and healthcare not only for women but also for their families and for society as a whole.

Women physicians, nurses, dentists, and other health professionals understand the day-to-day difficulties of dealing with our healthcare system both as providers and consumers. As providers, they treat more women patients because women use more health services than men. As consumers, women healthcare professionals use health services and, like most women, they make the majority of health decisions for their families. Who could be better qualified to bring women's values and perspectives to the healthcare agenda, to inform health policy, and to reform the healthcare system?

Half of today's medical students are women, and their numbers are growing. But sheer numbers of women in the ranks are not enough, as Janet Bickel, former director of the Women in Medicine Program at the Association of American Medical Colleges, explains:

At this point, ironically, the good news—the high numbers of women entering medical schools—actually obscures the bad news: that academic medicine still greatly favors the development of men.

She recommends that every department head "initiate a conversation with every woman and minority faculty in his/her department to learn what they need for their career progress and to encourage their development" (Bickel, 2003).

Women have always been the largest group of healthcare providers, but numbers alone have not been enough to make positive change. For example, the nation's 3.2 million nurses are the largest group of health professionals, yet healthcare policy is shaped primarily by male physicians, administrators, and the insurance and pharmaceutical industries. The number of women physicians has increased steadily since the 1970s, but most of are in patient care. Of the fifty most powerful physician executives named by Modern Physician Online (2006), only eight were women.

The need for more women leaders in nursing, in medicine, in academic institutions, in professional organizations, and in government has never been greater. When women's values, perspectives, and leadership become an integral part of health policy we will have a better chance to achieve humane healthcare that is accessible to all.

DEFINING LEADERSHIP

Good leadership is increasingly defined in terms of the qualities of a good coach or teacher rather than a highly authoritative person who merely tells others what to do. Alice Eagly, 2007

Leadership is a blend of personal characteristics, abilities, strategies, and circumstances that enable a leader to influence individuals and organizations to accomplish a goal. Although there is no single formula for becoming an effective leader, some common elements include self-confidence, courage, a clear vision of the goal and how to reach it, the ability to clearly communicate the vision/goal as well as strong personal commitment, and the ability to inspire trust and respect among followers.

Leadership differs from management in that leadership is a combination of personal qualities and abilities whereas management is a process. Leaders are more likely to be effective when they use the management process to achieve goals. Managers are more effective when their actions demonstrate leadership qualities, thereby earning the respect and trust of those they manage (Hamilton, 1996).

Types of Leaders

Leaders who derive their power from some official authority are called formal leaders. Leaders who gain their power without an official position of authority are called informal leaders. For example, President Woodrow Wilson was the formal leader of the United States during the early days of the women's suffrage movement. Elizabeth Cady Stanton and Susan B. Anthony were the informal leaders of that movement, which gained women the right to vote in 1920.

Styles of Leadership

Leaders lead in different ways, depending on their personal repertoire of skills and abilities, as well as on the context within which they function. The context includes societal values, organizational culture, the nature of the task to be accomplished, and the characteristics of their followers.

The traditional authoritarian style of leadership—the top-down directive approach—has largely been replaced with a more democratic/participative style, which involves such collaborative behaviors as consulting, discussing, cooperating, or negotiating. No one style is effective for all situations, however, so flexibility is important. For example, an authoritarian style may be the most effective in dealing with an emergency when decisions must be made and implemented quickly.

Rapid technological growth, increased diversity in the workforce, and growing complexity within organizations has led to changes in the way effective leadership is defined. Leadership researchers and theorists define good leadership as "future-oriented rather than present-oriented and as fostering followers' commitment and ability to contribute creatively to organizations" (Eagly, 2007). Political scientist James McGregor Burns (1978) described this type of leadership as transformational leadership.

Transformational leaders establish themselves as role models by gaining followers' trust and confidence. They establish the organization's goals, plan how to achieve the goals, and innovate. As Eagly (2007) explains, "Transformational leaders mentor and empower their subordinates and encourage them to develop their potential and thus to contribute more effectively to their organization."

Researchers also describe a more conventional type of leadership as transactional leadership, in which leaders establish exchange relationships with their followers or subordinates. After clarifying objectives and subordinates' responsibilities, transactional leaders reward those who meet objectives and correct them when they fail to meet objectives.

Another type of leadership, laissez-faire leadership—a hands-off approach—assumes that individuals are motivated by internal forces and are best left alone to accomplish their work. The leader provides no direction and little involvement. Although this style may be effective in small groups of motivated self-starters, it is generally not effective in highly structured organizations such as hospitals and other healthcare institutions.

WOMEN LEADERS IN HEALTHCARE

Leadership takes many forms in the healing professions. Examples of women in professional leadership positions include:

• The Director-General of the World Health Organization is Dr. Margaret Chan, only the second woman to lead this agency since its founding in 1948.
• Dr. Julie Gerberding heads the U.S. Centers for Disease Control and Prevention (CDC).
• Two of the world's top general medical journals, the British Medical Journal (BMJ) and the Journal of the American Medical Association (JAMA), have women editors (Drs. Fiona Godlee and Catherine DeAngelis, respectively).
• In 2006 the American Dental Association elected Kathleen S. Roth as president, the second woman to hold this office in the organization's 147-year history.
• Dr. Elvira Craig de Silva is president of the National Association of Social Workers.

Three nurses and five social workers serve in the U.S. Congress (Box 1), which is now led by the first woman Speaker of the House, Representative Nancy Pelosi (D-CA) . Many other women health professionals serve in elected and appointed office at the city and state levels of government.

Less visible in the policy arena but equally important are the leaders who bring about personal and institutional changes, for example, Barbara Staggers, director of adolescent medicine at Children's Hospital and Research Center in Oakland, California. Staggers also co-directs the hospital's health professions internship partnership, FACES for the Future. This three-year internship program partners with local colleges, universities, health academies, medical schools, and residency programs to introduce under-represented minority students to the health professions.

FACES helps students get into educational programs of their choice and prepares them with the personal skills needed to succeed there and later in their careers. More programs like this would help increase racial and ethnic diversity in the health professions. Staggers leads by example, serving as both role model and mentor for inner-city teens. "We must look back to see what kind of path we are blazing for young people to follow," Staggers cautions. "We could build legacies that are phenomenal but if we deny someone the right to pick up our mantle when we've done our work, what have we accomplished?" (Mills, 2001).

Emergency nurses Theresa Meyers, Dezra Eichhorn, and Cathie Guzzetta changed hospital policy on the issue of family presence during resuscitation and invasive procedures (Eichhorn et al., 2002). Based on years of experience in emergency and trauma nursing, these nurses saw a need to change the unwritten policy that banned family members from the bedside during cardiopulmonary resuscitation (CPR) or invasive procedures. They began discussions with physicians, some of whom were opposed to the idea, and with hospital administration.

Over time, it became clear that research evidence was needed to support the change. Existing research was limited but, serendipitously, the Emergency Nurses Association had produced an 84-page guideline on implementing family presence during CPR and invasive procedures. In addition, they worked with the hospital's nursing research consultant to survey family members of patients who had died in the emergency department to determine whether they would have preferred to be present during their loved one's CPR.

The results overwhelmingly confirmed what the nurses knew based on clinical experience: 8 out of 10 family members said they would have welcomed the opportunity to be with their loved one and believed it would have been helpful to them and to the patient (Meyers, Eichhorn, & Guzzetta, 1998).

Then there are leaders who reach out to their communities—women like Carmen Warner-Robbins. After two decades as an emergency department nurse, Warner-Robbins entered seminary in preparation for work as a medical missionary. Once ordained, she worked first with a border community in Tijuana, Mexico, then began visiting women incarcerated at the Vista county jail in San Diego. Says Warner-Robbins: "I spent two years, just listening to and learning from the women about what they needed to change their lives." That careful listening led Warner-Robbins to found Welcome Home Ministries (WHM), a nonprofit that helps formerly incarcerated women rebuild their lives and their spirits after release.

In the eleven years since its founding, WHM has helped more than 3,300 women, some of whom serve as volunteers and advocates for the program. "It is so rewarding to see lives totally changed—women able to recognize their potential for the first time. Our program is becoming a model for the nation." Warner-Robbins is working with Wheaton College and the Department of Justice on national accreditation standards for reentry-after-incarceration programs to ensure that all programs will be of high quality. As she explains, "We have to raise the bar—provide women with the very best tools to succeed, and encourage them, believe in them."

OPPORTUNITIES ACROSS THE SPECTRUM OF HEALTHCARE

There is no shortage of leadership opportunities for women in the health professions. One physician admits that she learned that lesson too late:

I didn't do enough research about health careers. I could have found out what a physician assistant did or what a nurse practitioner did or what a social worker did. I just didn't understand the scope of the medical profession. There were times, especially at the end of my residency, when I was so overwhelmed…. I wouldn't do it again. An MD isn't the only way. (Mills, 2001)

Today the profession of physician assistant is one of the thirty fastest growing professions in the United States, along with medical scientist, physical therapist, and occupational therapist (U.S. Department of Labor, 2005).

One of the most important areas for leadership opportunities is education. Spiraling costs of professional education result in an urgent need to pay off debt from student loans. In many cases, this need pushes new physicians, dentists, and nurses into practice rather than teaching. In the long term, however, a career in medical, dental, or nursing education may compare favorably to practice income.

The debt factor, added to the graying of medical, dental, and nursing school faculties, is creating a critical shortage of health faculty across the country, with women, particularly women of color, in shortest supply. Fewer women in a specialty or in an academic department means fewer role models and mentors for other women, perpetuating a male-dominated practice in many specialties and affecting the future direction of healthcare research. A shortage of women leaders in medicine also fosters the male model of professional education as competition rather than collaboration and care.

Professional nursing would seem an obvious choice for women who seek leadership opportunities, especially since the need for nurses has never been greater. America faces the greatest shortage of nurses in the history of the profession, a crisis likely to intensify as today's nurses (average age, 47) retire or leave the profession for other reasons. Nevertheless, nursing is increasingly a road less traveled as enrollment in basic nursing programs continues to decline.

Even though opinion polls show that nurses are among the most trusted professionals, less than 2% of high school students indicate that they aspire to a career in nursing. Why? Image, based on ignorance about what nurses do, is part of the problem. A college student whose mother is a nurse offers a clue:

I see how patients appreciate my mom, especially if she is helping when they're having babies. But my professors ask me why I want to be a nurse, especially because I am studying biology and taking pre-med classes. The first thing they always say is "Don't you want to be a doctor?" The perception in society is that being a doctor is better, superior.

That attitude is precisely what Catherine Gilliss, former Dean at Yale School of Nursing, addresses:

The image that most people have of nurses is a woman in white, running around with a bedpan, working weekends, evenings, every holiday, with a great deal of self-sacrifice, to the point where one never sees one's family, never reads a book, never sees a play or gets involved in a bridge game or a discussion of anything intelligent. In fact, I have had more conversations stop dead in their tracks in the first-class cabin when someone says to me "And what do you do?" [I carry a briefcase and have a laptop.] "I'm a nurse," I reply. (Mills, 2001)

The world of nursing extends far beyond the hospital bedside into every facet of community health, across generations and across continents:

• Nurses are leaders in hospice care and HIV/AIDS care both here and in sub-Saharan Africa.
• Nurse midwives not only care for pregnant women and their babies but also provide primary care in the hills of Kentucky and other rural communities and other countries.
• Nurses serve in local, state, and federal government.
• Nurses start and run companies and foundations.
• Nurses do research—developing the scientific evidence for nursing practice.

As Gilliss explains, "The common denominator is that nursing leadership is aimed at enhancing the health of others through whatever mechanism is available within moral and ethical bounds. The sky is the limit."

Women health professionals are leaders in the environmental health movement, working to prevent acute and chronic health conditions related to the contamination of our air, food, water, and soil. As advocates for children with asthma, autism, and other neurodevelopmental disabilities, as well as for people with cancer and other chronic and life-threatening diseases, these health professionals and scientists shape public health policies to prevent illness and disease by protecting the environment.

During the past fifty years, Americans have moved beyond conventional Western medicine to embrace complementary and alternative medical (CAM) therapies such as acupuncture, naturopathy, yoga, herbal medicine, biofeedback, and massage. These therapies are based on a holistic approach to healing, also called mind-body medicine, rather than the specialized "body part" pathophysiologic approach of Western medicine.

The new emphasis on mind-body medicine is expanding the options for women in the healing professions. According to author Jean Achterberg (1990), mind-body medicine incorporates the ancient thread of consciousness that sees woman as healer:

Women of a special caliber—the vast majority, well-trained professionals—are appearing in great numbers. They can be found working in hospital emergency rooms, well-baby clinics, and hospices. They staff shelters for battered women and victims of rape…. They see body, mind, and spirit as the inseparable nature of humankind; they believe that any healing ministrations have an impact on each element of this triune nature.

Every professional organization offers fertile ground for growing leadership skills, beginning with local chapters of national organizations. Serving on a committee can be a starting place for women to showcase their talents and abilities.

PATHWAYS TO LEADERSHIP

Male-dominated cultures, over time, can make even the most competent and strong women begin to doubt themselves…. Instead of trying to fix our feminine selves to fit the male standard, perhaps we need to continue to change the world of work to allow, accept, and even seek the different ways we women communicate and lead. Deborah Collins-Stephens This Is NOT the Life I Ordered, 2007

Unless we find a way for men to bear children, women's resumes will continue to differ from men's. Pregnancy, childbirth, and childrearing will continue to intervene. For most women who choose to have children, the path to the top is more of a spiral than a straight line.

Seattle psychiatrist Julia Murray considers her career a work in progress. Graduating with a major in dramatic arts, she had no plans for a career in medicine. A few years and life experiences later, however, she decided to consider that option and completed a pre-med program at the University of Washington:

There was both age and gender discrimination at that time, so I didn't get into medical school the first time I applied. But I kept going, completed a degree in cellular and molecular biology, and got into medical school the next time I applied.

Murray set her sights on becoming a physician because, among other things, it would allow her to support herself without being on a full-time schedule:

That was kind of a heretical notion—that you weren't going to be a slave to your job. The whole culture of medicine expects one to be devoted to the job and to the profession. Any kind of life you have on the side is a bonus, like icing on the cake. I didn't buy into that—ever.

Two pregnancies during medical school and residency sidetracked Murray's plans to be a child psychiatrist. But, at age 50, after a decade of practicing general (adult) psychiatry, she closed her practice and entered a residency in child psychiatry, graduating in June 2000. Says Murray:

As all of the professional development has gone on, I have had family issues to deal with…. I will get to sorting out my long-term career, I think, before retirement. But who knows?

CHALLENGES TO WOMEN'S LEADERSHIP

Each woman on the path to leadership faces challenges familiar to every woman who seeks power and influence in a male-dominated culture. Balancing personal and professional responsibilities; being judged by different standards than those applied to men; working with men who may be easily threatened by bright women; dealing with sexism, sexual harassment, and racism; being paid less than male colleagues for the same job; and making time to take care of yourself are common issues.

Women in the healing professions face all these challenges, and more: surviving expensive, extended professional education; staying abreast of the latest health science research and technology; protecting quality of care despite dwindling resources; shouldering the awesome responsibility of caring for vulnerable human lives; and, finally, surviving and thriving in a male-dominated culture.

Balancing Personal and Professional Life

The challenge of balancing a career with marriage and motherhood is not unique to women in healthcare. Most women today have two jobs, one outside the home and another at home. "No wonder that 80 percent of top executives are men with wives at home full time, and more than half of all female senior executives are women have no children" (Bravo, 2007).

Women physicians cope with the stress of discrimination, lack of role models and support, and overload. Women in academic medicine are paid less, promoted more slowly, and may lack mentors to offer advice and guidance. They face pressures about if and when to have a child plus the "normal" wife-and-mother vs. career conflicts (Robinson, 2003).

In a two-physician marriage, the wife usually assumes primary responsibility for running the home, even when she makes more money than her husband. Although the incidence of depression in women physicians is no higher than that of the general population, the rates of divorce and suicide are much higher. Despite all this, however, most women physicians are generally satisfied with their careers.

The sustained stress and intensity of medical education coupled with marriage and children can exact a high price. Pregnancy, planned or not, can make the balancing act even more difficult. Vanderbilt physician Patricia Temple's life testifies to just how difficult:

About three months into my (pediatric) internship, I found out I was pregnant. We had our baby at the end of my internship. I said "Here I am, a pediatrician. I love children. Why should I continue with every other night rotation and work as a resident? I want to spend time with my child, and I can do this half-time." Boston City Hospital agreed to let me be half-time; then I found out I was pregnant again. I thought…if I keep this up I'll never finish my residency, so I went back full-time and finished my residency in three years.

After a stint at Harvard in the school of public health, Temple and her family moved to San Francisco, where she worked in ambulatory pediatrics at San Francisco General Hospital and ran a quality-assurance program. "That allowed me to be in administrative medicine," Temple explains, "but my marriage fell apart." Two years later she remarried and instantly became the mother of two more children—a total of four children ages 5 through 10, with two 8-year-olds in the middle. "It was overwhelming…there was no question then I had to work half-time."

Women who master the balancing act have an advantage in today's multitasking environment. According to Cora Tellez, CEO of Sterling HSA, Oakland, California: "When you have children, you are more likely to be an effective manager because you have to balance infinite demands against finite resources. Resources for a mom are time and energy—and it's true in executive life as well. I often find that people who have families are far better able to endure, to overcome, those challenges and to meet the incredible competition for time and energy."

Tellez's own story validates that statement. When her younger son was just 4 years old, Tellez became the manager of Kaiser Permanente's Hawaii Plan. Because her family did not want to move, for the next five years she commuted every week between Hawaii and San Francisco. It taught her an incredible lesson in balancing work and family:

When the plane touched down in San Francisco, that was it for work. I told my people "Unless the place is burning, don't call me. If it's burning, do something."

Tellez called it "a stretch opportunity…it stretches everything you do to determine what you're made of, what you want to do that's important to your life" (Mills, 2001).

Double Standard

Women seeking to advance their careers confront a double standard. First, women have more diverse career paths, so their resumes reflect winding pathways, unlike the resumes of "typical" leaders (that straight line to the top!). Search committees often stumble into gender stereotyping and perceptions, often because there are not enough women on the committees.

Second, women are questioned differently during interviews. When questioning women, interviewers stray into "intangible fuzzies" such as family responsibilities. Men aren't asked such questions, even though they may have responsibilities and interests that could conflict with their professional performance.

Making sure that search committees have more women members, particularly women of color, could help eliminate this double standard, since women are usually the only ones who notice the hidden gender discrimination in the selection process. Having only a "token woman" on the search committee makes it possible for the others to ignore the problem.

Salary Gap

Equal pay for equal work has long been the rallying cry of the women's movement. Although equal pay was legislated in 1963, and pay inequity is not as great as it was in the 1960s and 1970s, it still exists—even at the top. For example, Fortune Magazine's "10 Best-Paid Executives for 2006" are all men, and they're making 2 to 3 times as much as the best-paid women executives (Seid, 2006).

Pay inequity extends into the health professions. For example, a study of family physicians found that white women physicians earned 8.6% less than their male counterparts and black women physicians earned 22% less than white male physicians (Weeks & Wallace, 2006a). A study of internists' income yielded similar findings: white female internists' income was 19% lower than their white male counterparts; black female internists' income was 29% lower than white male counterparts (Weeks & Wallace, 2006b). Similar gender disparities were reported in the income of emergency physicians (Weeks & Wallace, 2007).

One reason for the inequity is that women physicians tend to choose specialties that pay less, such as internal medicine, family practice, and pediatrics. Another reason is that women physicians spend more time with each patient and thus see fewer patients in a given amount of time. In addition, black primary-care physicians are more likely to care for the underserved, as well as the medically indigent and those with more chronic health problems, which may reasonably affect their annual incomes.

Sexism, Gender Stereotyping, and Sexual Harassment

Gender-based stereotyping is alive and well in business—men AND women do it. Catalyst.org, 2007 Women "Take Care," Men "Take Charge"

Gender stereotypes permeate healthcare as well as business, despite the growing number of women health professionals. When perceptions are based on stereotypes rather than reality and performance, women's salaries and advancement to leadership positions suffer. A study of mid-career academic women found that a majority acknowledged their workplaces were "unfriendly to women" and some suggested that "nothing much has changed for the last 20 years."

There are many more women at lower levels and very few at higher levels and in leadership positions, and "not for lack of talent." A majority of the women perceived gender inequity (Kalet et al., 2006). Even when men and women with equivalent preparation begin their first faculty appointment, women are less likely to receive office/lab space, protected time for research, or their first grant-supported position (Ash et al., 2004).

The Catalyst 2006 survey of corporate officers and top earners in business found that, at the current rate of change, it will take women 47 years to reach parity with men as corporate officers of the Fortune 500 companies. How long will it take for women in healthcare? Only time will tell.

Sexual harassment is nothing new for women in healthcare, particularly nurses. Until passage of the Civil Rights Act of 1964, women had no legal remedies when they were sexually harassed. But the issue moved into the national spotlight in 1991 with the televised Supreme Court confirmation hearings for Clarence Thomas.

During those hearings, Anita Hill testified under oath that during her clerkship with Thomas he had made sexually suggestive comments and shown pornographic materials to her. Suddenly the issue had a name, and women began to speak out and to file claims. Corporations and public institutions developed policies on sexual harassment and discrimination. Today some progress is evident, but sexual harassment continues in healthcare education and practice.

A survey of fourteen U.S. medical schools found that women experienced sexual harassment and gender discrimination significantly more than men, most commonly in general surgery and obstetrics/gynecology, and these behaviors were most prevalent in academic medical centers and community hospitals (Nora et al., 2002). Another study of graduating seniors in twelve U.S. medical schools found that women reported the following experiences more frequently than men: stereotypical comments; sexual overtures; offensive, embarrassing, or sexually explicit comments; inappropriate touching; sexist remarks (Witte et al., 2006).

Another study suggests that gender-based discrimination and sexual harassment are common in medical practice and may be even more prevalent in academic medicine. Approximately half of the female faculty surveyed had experienced some form of sexual harassment, and the researchers reported that these experiences were "similarly prevalent across the institutions in the sample and in all regions of the United States" (Carr et al., 2000).

Early in her academic career, one young medical-school professor, a single mother, realized that she was seen as fair game for men, whether single or married:

I heard there was a betting pool going on about my gender preference. One day my superior came into the examining room, shut the door, put his arms around me, and stuck his tongue in my mouth. I protested, thinking "This is not happening here!" I found out later he went out and said, "That's it. If she didn't kiss me, she has to be gay." (Mills, 2001)

Racism

Racism coupled with sexism is an onerous double burden. One woman remembered:

Let's just say my experience in medical school and my residency weren't what I thought they were going to be. I always thought, "you do a good job, you get through college, and you're going to do just fine, you're going to be successful and life is going to be great, and you won't have to deal with racism because you've worked so hard." I figured we did that in college and wouldn't find it in medical school. I thought you'd proved yourself and people shouldn't look at the color of your skin first and make a decision about your qualifications, but it was worse in medical school, and really bad in residency. (Mills, 2001)

Today's physicians, nurses, and dentists have too little resemblance to the diverse populations they serve, leaving many Americans feeling excluded by a system that seems distant and uncaring. The Sullivan Commission, 2004

Only when leadership in healthcare mirrors the racial/ethnic and gender diversity of the United States will there be hope of equal access to healthcare for all people. Achieving this goal will require increasing diversity throughout the healthcare workforce from which future leaders will emerge. Increasing diversity means equalizing access to high-quality health professional education for women and minorities.

Failure to diversify the health professions not only limits the opportunities for women (and men) of color to achieve leadership positions but it also undermines the delivery of care to minorities. Under-representation of minority caregivers contributes to disparities in treatment and health outcomes based on race and ethnicity. Minority caregivers also make a difference in how health systems work to reduce cultural and linguistic barriers.

Increasing diversity among researchers influences the medical research agenda, helping ensure that understudied health conditions are appropriately investigated (Terrell & Beaudreau, 2003). For example, decades of research on breast cancer focused primarily on the disease in white women and used the findings to determine treatment for all women. More recent studies have shown, however, that black women have different, more aggressive, types of breast cancer than white women—types that do not respond to therapies typically prescribed for white women with breast cancer (Carey et al., 2006).

As of May 2006, Hispanic Americans, African Americans, Asian Americans, and Native Americans made up more than one-third of the U.S. population (U.S. Census Bureau, 2006). Yet these groups account for only 6 percent of physicians, less than 5 percent of dentists and 7.5 percent of nurses. Similar disparities are evident in the faculties of health professional schools. For example, minorities make up only 4.2 of medical school faculties, 8.6 percent of dental school faculties, and less than 10 percent of baccalaureate nursing faculties (Sullivan Commission on Diversity in the Healthcare Workforce, 2004).

Lack of diversity is also apparent among physician assistants, chiropractors, and medical and clinical laboratory technologists and technicians. However, graduates of radiologic technology programs are more ethnically diverse. Hispanics/Latinos are overrepresented (19% versus 13% of the general population), while blacks/African-Americans are slightly under-represented in these programs (8% versus 11% of the general population) (New York Center for Health Workforce Studies, 2006).

Efforts to increase diversity in the health professions must begin early in the academic pipeline. Programs such as FACES for the Future, mentioned earlier, are needed to help minority students perform better in science and mathematics while in elementary and high school. "Promising students must be encouraged to pursue these fields during undergraduate and professional training, and they must be provided with a variety of tools and support to ensure their success" (Institute of Medicine, 2001).

Becoming a doctor or a dentist demands that you delay earning a real income for at least twelve years beyond high school. This is an extraordinary hardship for many minority students. It also means women are age 30 or older before they enter medical or dental practice. Some are already wives and mothers by then; others find the tick of the biological clock impossible to ignore.

The cost of medical, dental, and nursing education continues to rise even as public monies for scholarships and fellowships are disappearing. Students in medicine and dentistry from all but the most affluent families may graduate with accumulated debt of $50,000 or more. Burdened with such staggering debt, few graduates choose careers in education, public health, or community service. Instead, most choose careers with the greatest immediate income potential. For women, this makes full-time employment a necessity at a time when part-time might offer better quality of life.

Despite a number of reports outlining barriers to increasing diversity among health professionals and programs to overcome those barriers, federal funding to support these efforts has decreased since 2000. For example, in fiscal year (FY) 2006, funding for Title VII and VIII Health Professions programs were cut by one-third and one-half, respectively. These cuts were not restored in 2007, and the FY 2008 budget proposes an additional 94.6 percent cut to Title VII and a 29.7 percent cut to Title VII (which includes nursing schools).

These funding cuts mean that, in the midst of a growing shortage of nurses, nursing schools are forced to turn away between 42,000 and 92,000 qualified applicants primarily due to an insufficient number of faculty as well as insufficient clinical sites, classroom space, clinical preceptors, and budgets (AAMC, 2007).

Making Time for Yourself

The healing professions impose a double caregiving burden on women health professionals: caring for patients and caring for family at home. But who cares for the caregiver? It has to be a do-it-yourself project, a fact that women need to learn early. Making time to take care of yourself is a survival skill.

One woman describes leaving her teaching career to pursue a career in nursing when her children were ages 2 and 4. It proved to be a painful experience, but worth it:

For the better part of 25 or 30 years, I was in and out of school, working, and going back to school, trying to balance my life and keep my marital relationship going and being a full-time student or a part-time student. I didn't have any support coming from my husband. It was, "Well, if you chose to do this, lots of luck."

You feel you're not doing a good job in the workplace and you're not doing a very good job of being a mother at the same time—that's the frustration. Women are forced to put their own needs at the bottom of the priorities list. We really need to put our needs at the top. I was divorced eventually because I had just simply starved myself out of a nurturing relationship.

Taking care of yourself is not just about being able to sustain yourself as a leader. It's also about self-esteem. Author Mary Catherine Bateson (1989) explains:

Today, those who begrudge themselves care, feeling that their role in life is to care for others, can be persuaded to think about issues of health and stress reduction. As a result, a little cherishing of the self is translated into responsible behavior, even a way of caring for others…. But self-care is important for its own sake as well. It is intimately tied to self-esteem, with the implication that the one who is cherished is important and valuable for his or her own sake.

Failing to take care of yourself can lead to burnout, a syndrome that affects 30 to 40 percent of physicians and nearly half of all registered nurses at some time during their careers. The three major signs of burnout include: (1) detachment, especially from patients; (2) exhaustion, both physical and emotional; and (3) loss of satisfaction or sense of accomplishment.

LESSONS FROM WOMEN LEADERS

Believe in Yourself

The first step on the upwardly spiraling pathway of leadership is knowing who you are—your abilities, your values, your priorities. This is knowledge acquired through continued reflection on life experiences. When you have self-knowledge, it shows. Dattel (2003) advises women to take a few minutes and jot down the answers to three questions:

• Who am I?
• What do I want?
• What are my needs?

Then, women can move on to establishing a 1-year, 2-year, 5-year, 10-year and beyond plan.

Bumping up against the barriers of a male-dominated healthcare system makes it tough to keep smiling, but you must, even if you're gritting your teeth. Self-confidence makes it easier to have a positive attitude. Self-confidence also enables you to speak up—to test your ideas. As Harvard professor Rosabeth Moss Kanter (2005) explains:

There sometimes is a difference between the men and women in the willingness to claim air time in class. The men seem to feel that they can start talking and eventually they'll have a point to make. The women are slightly more likely to feel that they ought to have something valuable to say before they say it. Although that's not all bad, there's a kind of self-censorship going on.

Believing in yourself also means promoting yourself—not just celebrating your accomplishments, but documenting them for people important to your continuing success. Self-promotion is not "bragging"—it's a smart business strategy because you want others to believe in you too. Just find the style that works best for you (Shapiro Snyder, 2006).

Set Goals and Priorities

You need to set goals and priorities, and you have to be willing to say "What am I going to give up?" Yvonne Maddox

Knowing yourself, what you want, and what you need makes it easier to chart the course for your career. Unless you set goals, how will you measure your progress? Unless you know where you want to go, how will you know when you've arrived?

Realistic goals need to reflect more than what you want and need. They also need to reflect an honest appraisal of your own strengths and weaknesses and the context of your life now—your partner, your family life, your economic situation, your additional education—as well as your long-term vision for your career. What sacrifices are you willing to make in the short-term? In the long term? And what is your timetable for accomplishing these goals—your 1-year, 2-year 5-year, 10-year and beyond plan?

Women physicians are challenging the traditional culture of medicine as a total commitment and role identity with no room for the rest of life. One physician puts it this way:

You make choices about priorities. A priority is to sleep at night, to stay healthy, to stay happy, and to have other activities in life. When I'm at work I want to give everything I can and really be there for people. For me, working is 40 or 50 hours a week. But being in that compulsive sleep-deprivation cycle that many physicians endure is really not what I want to do.

I think I'm always going to be part-time in some respect. I don't want to give up my practice of medicine. I just love it and it's something I've wanted to do since I was 8 years old. I want to do that until they just kick me out. But I have the responsibility and opportunity, along with my husband, to raise three boys into being responsible, healthy young men. So that's the first priority. (Mills, 2001)

Build a Support System

The pathway of leadership can be cold and lonely without a support system. The fortunate find support at home with an understanding partner. In school, in practice, and in professional organizations, colleagues and mentors can also offer valuable support for each other. One physician recalls her residency experience:

There were ten or twelve of us women, and [we] were and are very unusual people. It was very useful for us to have each other. I can't imagine young women having to go through this without having some support, or at least some sense of virtual support from alumnae, that they could talk to just to realize that residency is a uniquely challenging period of life where some of us go into an emotional deep freeze.

Support can also include hired help—a house cleaner, a babysitter, an errand service. These are investments that buy you time to work on your research grant, write an article, study, relax, enjoy your family, read a book, take a hike, or whatever you need or want to do.

Learn the Rules

"Work hard, play by the rules, be nice, be polite, and you will get ahead." Our mothers were right, up to a point. Taking that advice, you do get ahead—your hard work is rewarded—until you hit the glass ceiling. Or, as one physician called it, the "gauze ceiling."

Being the best at what you do is not enough to break through the gauze ceiling into positions of leadership. It's not enough to have clinical skills; you need political skills as well. Leaders make a difference in their world by influencing others to support the leader's vision or cause. To make a difference, you need political skills. Everything is political—your workplace, your professional organization, your community, your government. You need to gain political skills early in your career.

The word politics is a loaded term, heavy with images of shady characters in smoke-filled rooms, wheeling, dealing, and often stealing. But politics is really a neutral term. According to Policy and Politics for Nurses, "Politics means influencing, specifically, influencing the allocation of scarce resources. Politics is a process by which one influences the decisions of others and exerts control over situations and events. It is a means to an end" (Mason et al., 2002).

Becoming influential is something that can be learned, and it has as much to do with attitude as with behavior. Both aspects are necessary (Sullivan, 2004). Becoming influential includes such skills as understanding power and how to use it, communicating effectively, understanding the political process, and dealing with difficult people and situations.

The workplace also offers an opportunity to hone the political skills essential to successful leadership, especially when the workplace is the hospital. For example, one nurse noticed that certain doctors in the hospital where she worked seemed to enjoy giving nurses a bad time, talking down to them, and publicly reprimanding them for real or supposed "bad" behavior. This nurse called her colleagues together and proposed a new approach to nurse-bashing doctors: whenever any of them saw a nurse being hassled by a doctor, they would call a "Code 13" and the room number. All available nurses would rush to the location and surround the doctor. It didn't take long for the doctors to realize that their behavior was unacceptable (Chenevert, 1997).

Nurses have learned how to be an advocate for the patient, but what they seldom learn in nursing school is how to advocate for themselves and for their profession. Like many women, nurses need political training in advocacy and lobbying and negotiating and all the rest. Otherwise how can they stand up to a hospital administration that says to take the RN off your name tags and replace it with "Care Provider"? Nurses need to say "Excuse me—we don't do that." Patients have the right to know who is an RN and who isn't. Putting "Care Provider" on name tags allows hospitals to disguise unskilled and unlicensed personnel as nurses in an effort to cut costs.

Take Risks

In 2001 nurse Theresa Meyers moved from changing policy to changing the hospital itself from the ground up. Formerly director of emergency, trauma, and critical care services, Meyers is now the director of construction for Memorial Health System in Colorado Springs. She served as liaison between architect and builder during the design and construction of two new buildings, one of which includes a 69-bed emergency department (ED). "The position came open, and although I didn't have a background in construction management, they wanted a nurse with leadership skills," she told the American Journal of Nursing. She recommends "that anyone building a hospital have a nurse on board."

Theresa Meyers' leadership regarding what makes a hospital and an ED work promises to make the new facilities more efficient for caregivers and more comfortable for patients and families. Innovations such as a locked behavioral unit in the ED for intoxicated or suicidal patients create a quieter atmosphere than found in the typical ED. In addition to hospital design, Meyers oversees maintenance, power plants, environmental services, clinical engineering, security, and emergency management (Belcher, 2007).

Forget Perfection and Keep a Sense of Humor

Nurse author and entrepreneur Melodie Chenevert says: "Perfectionism is a close cousin of all-or-nothing. It leads to procrastination, which leads to paralysis." It can also lead to stress, anxiety, and unhappiness. Chenevert cautions that we shouldn't use someone else's success as evidence of our personal failure. It's preferable to just go for your personal best.

A fully functioning funny bone can help us survive the worst of times, especially when we can laugh at ourselves. Kerri Wilks talks about what it meant to be the first woman chief resident in neurology at Albert Einstein College of Medicine, and the first resident ever to get pregnant while chief resident.

Every Wednesday I had to get the bagels at 5 a.m. and make the coffee for fifty people. I was so sick while I was pregnant, and one morning I was driving to work with bagels on the Cross Bronx Expressway and a policeman stopped me because I was in the median, throwing up in a bag. He said "Lady, get out of the car. Are you still out from last night?"
I said "I'm so sick. I'm pregnant." And he said "Lady, you need a doctor." I said, "I am a doctor." (Mills, 2001)

Find a Mentor, Be a Mentor

Mentors change lives, as anyone who has had a mentor will tell you. Anesthesiologist Kristin Sun left a research training program where she was working under the direction of a male pediatric surgeon and went to work with a young female surgeon who had just finished her pediatric surgery fellowship.

She [the female surgeon] was very involved and wanted to be a good researcher, a good clinician, get her own academic career going, [and] be a good mentor. I worked with her for a year and a half and that was really a productive period of laboratory research and writing papers and presenting at professional conferences. (Mills, 2001)

A woman physician whose parents were both alcoholics tells of being mentored by

…the kind of man I was never around as a child. He had been a Navy Seal and was such a community leader. He became president of our medical society and encouraged me to do that. I was the first woman to be the president of our medical society in over 80 years, so I really got to develop a lot of leadership skills.

He said "You know, in the end, the best can be just good." I still think of that in trying to be the best. I think, I'm doing really good. I like to watch the birds, do some artwork, take walks. If I have to be the best, I'm not going to have time for myself for really living. (Mills, 2001)

Learn to Roll with the Punches

Expect the unexpected. In today's world, change is one of the few things you can count on, so it makes sense to learn to manage it. The authors of This is NOT the Life I Ordered! (Collins Stephens, 2007) dissect "the messy, unpredictable nature of change" and suggest that women embrace change instead of fighting it.

First, develop a new attitude toward change. Don't ask yourself "why" questions: Why did the accident happen, the presentation flop, the relationship sour? Instead, ask yourself "how" questions: How can I make what happened work in our lives? How can I help? How can I move forward with this?

Second, ask more questions: What's the good news in this situation? What actions could I take that would benefit all involved? Who (or what) could help me out in this situation? Collins Stephens found that approaching change as "transition" with the beliefs that (1) there is good news, (2) we're in charge, and (3) help exists, "makes all the difference in whether we feel overwhelmed or encouraged."

URGENT POLICY ISSUES

Women's leadership is critical in addressing the most urgent issues: the health of women and children, the shortage of women health professionals in practice and in academia, the lack of racial/ethnic diversity in the health professions, the cost of professional education, the apparent disconnect between medical education and real-world patient needs, and the need for universal access to healthcare.

Women are the majority population in the United States, yet women's health has long been neglected by both researchers and practitioners. Although women live an average of ten years longer than men, those additional years often are marred by poverty and one or more chronic illnesses. Until the 1980s, women were not included as subjects in clinical trials and other federally funded health research. The Office of Research on Women's Health was established at the NIH only in 1990.

Violence against women of all ages remains a critical health issue and the healthcare system is too frequently ineffective in responding. One study (Blumenthal, 2001) reported that 1 in 10 medical residents feel unprepared to counsel patients about domestic violence or to deal with nursing home patients. According to the study, these residents also feel unprepared to handle other conditions more common in women than men, including depression and chronic pain.

The health of young women is of paramount importance because their bodies are the first environment for our children. Research indicates that this environment is contaminated: amniotic fluid (Foster et al.,2000) newborn cord blood (Fukata et al., 2005) and breast milk (Landrigan et al., 2002) have been found to contain pesticides and other chemicals.

A growing number of scientists believe that exposures during fetal life and early childhood may contribute to the "new morbidity" challenging pediatricians: children with depression, eating disorders, substance abuse problems, learning disabilities, autism, and other neurobehavioral disorders. Girls as young as 7 or 8 years of age are developing breasts or pubic hair. Childhood cancer is the second leading killer of children under 18; only accidents take more young lives than cancer. One out of 6 American children lives in poverty, which sets the stage for a host of health problems.

Women health professionals understand what it means to take care of everybody. They do it every day, both at home and at work. Women's leadership in healthcare will infuse health policy with that understanding, a wisdom that comes not only from education but also from lived experience. Women's leadership will also change healthcare practice and the larger culture in many different ways.

As one woman explains: "We have unlimited opportunities for leadership…in the home, in the community, and in the professional community. We are leading our kids, we are leading our Girl Scout troops, taking leadership on boards of directors or in hospitals. Those are all leadership roles and we need to recognize them as such and have a sense that we are doing important work." As women across the healing professions recognize the importance of each other's contributions and the power of their collaboration, they will do what it takes to transform healthcare in America.

Posted September 6, 2007

Expires October 1, 2009

Copyright © 2007 Wild Iris Medical Education. All rights reserved.

Accreditation   Home
Site Map   Contact   Privacy   Disclaimer

CriticalCareCEU.com is a division of Wild Iris Medical Education
© 2008 Wild Iris Medical Education, Inc.