relationship without an awareness of relationships between men
and women in society through time, as the nurse-doctor relation-
ship is essentially patriarchal’’. Indeed, examining the historical
demarcation strategies of the health professions (e.g. nursing and
medicine)
reveals
the
influence
of
gender,
and
its
use
as
justification for and naturalization of a medical hierarchy.
The public/private domain
In the early nineteenth century there was a clear sexual division of
labor: women were expected to be caretakers of their children and
servants to their husbands, while men did the labor and work
outside of the home. Given such a public/private divide, women’s
entry into the workforce during the Industrial Revolution was met
with hesitation (Sweet & Norman, 1995). Nursing, however,
proved to be a good compromise occupation due to its replication
of ‘‘feminine’’ characteristics. It was said that women could
‘‘embrace
the
virtues
of
true
womanhood’’
in
the
nursing
profession (Hall, 2005, p. 189). In fact, much of the structure of
the medical hierarchy was built upon a patriarchal model. The
chief of medicine was typically deemed the ‘‘father figure’’ while
the superintendent of the nursing school was referred to as
‘‘mother’’ (Reeves et al., 2010).
Such a construction not only served to justify women’s entry
into the workforce, but it also justified (and naturalized) nursing’s
subordination to medicine. For instance, nurses depended on
doctors for approval. As Keddy et al. (1986, p. 746) describe,
‘‘Worthiness was equated with helpfulness to the doctors, much
as the wife was considered to be the appendage of the husband
since she was his helpmate’’. Nurses’ role of caring for the more
emotional aspects of patient care was characterized
as less
important than the work of the physician. However, as Mackintosh
& Sandall (2010) point out, one could argue that this actually puts
nurses in a more powerful position than physicians since nurses
are more aware of the patient’s condition. In other words, the
subordination of nurses within the health care profession was
based in already ingrained gender ideologies and embedded
relations
of
power
–
carework
was
feminized
and
thus
subordinated in both the private
and
the public domains.
The role of education
Nursing was further subordinated through the mechanism of
education.
The
paternalistic
model
of
health
education
and
practice justified and legitimated doctors’ control over nursing
education (Keddy et al., 1986). Physicians typically determined
the nursing curriculum which diminished nurses’ power in a few
key ways. First, it explicitly gave doctors control over what nurses
learned. Second, it implicitly allowed doctors to construct nursing
education so that it was inferior to medical education. The less
valued
carework
was
relegated
to
nurses
while
the
more
prestigious
scientific,
technological
projects
were
housed
in
medical education.
In addition to using education to enhance their power and
authority, physicians also used education as a way to keep women
out of medicine (Witz, 1990). As a part of its professionalization
process, medicine required physicians to be formally trained and
credentialed. Such requirements, however, implicitly excluded
women
from
the
ranks
of
medicine
since
medical
schools
prohibited women from attending. In effect, the gender privilege
men had in society, which gave them access to education, was the
key to their domination over health care (Hall, 2005).
It was not until 1849 that the USA had its first female medical
school graduate, Elizabeth Blackwell. By the end of the 1800s,
19 women’s medical colleges were established, and women
constituted 5% of American doctors. Such progress, however, was
quickly halted in the early twentieth century. Medical education
was
reformed
with
a
greater
focus
on
science
and
a
less
humanistic stance (Flexner, 1910; More, 1999). In turn, not
only was a divide constructed between medicine and the other
health professions, but the divide was also constructed along
gender
lines.
The
health
roles
outside
of
medicine,
which
medicine supervised, were feminized and viewed as inferior to
the specialized, scientific realm of medicine (Reeves et al., 2010).
All but one of the women’s medical colleges closed, and by 1949,
100
years
after
Elizabeth
Blackwell’s
graduation,
women
still comprised only 5% of American physicians (More, 1999).
As
Davies
(1996)
argues,
much
of
the
professional
gender
inequality
is
not
so
much
due
to women’s
exclusion
from
professions, but rather their inclusion in less-defined support
roles.
Expansion and specialization
Indeed, the professional hierarchy in health care remains today,
and although in different form, gender inequalities are also
present.
It
is
important
to
note,
however,
that
while
still
subordinate to physicians, nurses’ roles have expanded in recent
years. For instance, since its development in the mid-1960s, the
profession of nurse practitioner has expanded. According to the
American Nurses Association, nurse practitioners are able to
perform 60–80% of primary and preventive care. By taking over
work traditionally done by physicians, nurse practitioners con-
tribute
to
the
weakening
of
traditional
medical
dominance.
Moreover, researchers have found that nurses have developed
strategies to cope with and diminish power differences with
medicine (Porter, 1991).
Despite these gains, gender and professional inequalities are
still present in health care. Such disparities are especially evident
when examining medicine itself, particularly in its areas of
leadership and specialization (Williams, Muller, & Kilanski,
2012). For example, in the US academic medicine, twice as many
men are full professors compared with women and only 11% of
medical school deans are women. Moreover, women in health
care earn 11% less than men even at positions of the same rank
(Conrad et al., 2010).
Examining areas of specialization within medicine further
reveals inequalities. On the surface, men and women are currently
entering
the
field
of
medicine
at
nearly
comparable
rates,
however,
when
medicine
is
broken
down
into
its
areas
of
specialization, disparities come to the fore (Ridgeway, 2011).
Specialties
such
as
surgery,
anesthesiology
and
emergency
medicine are heavily dominated by men, whereas areas such as
primary care, pediatrics and obstetrics are predominately filled by
women.
Such
divisions
not
only
reinforce
gender
roles
by
relegating
women
to
the
more
‘‘caring’’
(patient-centered)
specializations,
but
they
also
reinforce
inequalities
and
the
health care hierarchy. Specializations largely filled by men have
a higher average salary than the feminized specializations. They
also carry more prestige and power (Williams et al., 2012).
In sum, the hierarchy of health care, both currently and
historically, was built upon mainstream understandings of gender.
How
might
such
gendered
ways
influence
the
success
or
stagnation of IPC? Using EST, we begin to explore the answer.
Gender and IPC
Expectation states theory
EST is an ideal mechanism through which to study the stalled
uptake of IPC, particularly in relation to gender. The theory
examines how key social categories (e.g. gender) are linked
to status beliefs (e.g. men are more competent) and looks at
how those status beliefs organize social interaction in a way
DOI: 10.3109/13561820.2013.851073
The role of gender
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