The body and doing gender: the relations between doctors and nurses in hospital work
Karen Davies, Department of Sociology, Lund University, Box 114, 221 00 Lund, Sweden. e-mail: email@example.com
Abstract This article attempts to show how the concept of the body – as it has been applied in feminist thought – can be utilised in trying to understand the changing and at times problematic working relations between doctors and nurses in Sweden. Three approaches are applied with respect to the body: (1) Doctors and nurses belong to two different collective bodies which embody historical constructions of masculinity and femininity – which in turn have influenced how members of each corps have seen and worked with the other and how they approach each other even in the present day. (2) Gender is inscribed on the body. It is contended that in social encounters we never interact with each other as genderless beings, although we may very well take gender for granted and its importance may possibly be most salient in initial encounters. A nurse, then, never just interacts with a doctor – it is a female doctor or a male doctor and this makes a difference. ‘Doing gender’ is accomplished in these practices. (3) There is the question of situatedness– where (hospital staff) bodies find themselves on the ward and in the hospital in the daily run of things. Space and place are not neutral but are linked to relations of power and gender and class. How doing dominance and doing deference are accomplished – but also changed – in hospital work is addressed.
‘Doing gender’ has become a useful and widespread concept in feminist theory and gender research1. It suggests active performance and subjectivity – bringing our attention to the ways in which gender relations are (constantly) created, maintained and contested in interaction and daily life. It lets us understand that gender and gender relations are not a static pre-given but are moulded in ongoing actions where at least two partners need to be present. As an analytical tool, it lets us examine how others (willingly or unwillingly, consciously or unconsciously) do gender when interacting with us, but equally how we are accomplices (willingly or unwillingly, consciously or unconsciously) in the doing. Yet the active and continuous form implied in the ‘ing’ of the doing equally signals its transformative status, indicating that relations can be changed. The doing can and does change form (for better or for worse).
Closely related to doing gender are the concepts of ‘doing dominance’ and ‘doing deference’2. While power relations are inevitably on the agenda in the term doing gender, doing dominance and doing deference highlight more clearly the nature of unequal and oppressive relationships at work – where gender may be central, but also, of course, other relations such as class and ethnicity. In this paper I shall discuss more closely the ways in which doing dominance and doing deference can be understood in a hospital setting when examining the everyday working relations between doctors and nurses and in particular between women doctors and nurses. Gender, and even class, are placed centre-stage.
My introduction so far might suggest that doing gender, doing dominance and doing deference focus solely on an individual level, that it is only individuals’ actions that are of concern. It is, however, not that simple. Individuals’ actions have to be understood within a wider societal setting where structures, symbols and discourses – all imbued with gender – are taken into account. There is a relentless and reflexive process of these other levels influencing individual action and individual action similarly constructing, maintaining and even altering these structures, symbols and discourses. The various levels are intertwined. In the vein of Dorothy Smith's (1987) work, it is important to explore the social relations individuals bring into being in and through their actual practices. Central in Smith's work is this notion of social relation that cannot be collapsed into people's goals, objectives or intentions. As Smith argues:
It [the notion of social relation] provides a procedure of analyzing local work practices – the locus of the experience of the subject – as articulated to and determined by the generalized and generalizing relations of economy and ruling apparatus (Smith 1997: 167).
In other words, everyday life and the practices we find there should not be our focus of attention in themselves as pure ethnographic description. Rather they are a starting point for unveiling what lies behind – for helping us uncover gender and class relations at work, and to understand the complex interconnections.
In the late nineties I carried out a qualitative study – involving shadowing doctors and nurses in their daily work, as well as a number of in-depth interviews – at the Departments of Surgery and Ophthalmology at a Swedish district general hospital. Participant observation was carried out over a period of five months. Forty-two individuals (25 doctors and 17 nurses) were formally interviewed. In addition a focused interview with a group of nurses was also carried out. Both men and women were shadowed and interviewed. Originally I was interested in trying to establish if women doctors received poorer service from, and/or were less respected by nurses (who are still overwhelmingly female3), than their male counterparts4. Might their shared gender explain the poorer relationship between women doctors and nurses? It seemed an important question to ask, given that women are rapidly increasing their numbers in the medical profession5.
As the research moved along, and I became more familiar with the field, the original research question was both broadened and re-evaluated. It seemed more relevant to enquire how the relationship between women doctors and nurses was possibly of a different nature (perhaps worse but, equally, perhaps better?) than was the case between male doctors and nurses. Other important changes were also apparent at the time, influencing my focus. One was nurses’ strategies at professionalisation (where one's own independent duties are emphasised) which meant that the word service – their role as handmaidens – appeared antiquated. Another was the fact that the medical profession in Sweden has been subject to processes of deprofessionalisation, proletarianisation and disempowerment6. The above developments mean that the boundaries between nursing and medicine are being renegotiated7. At the same time, the two professions are, importantly, historically imbued with particular gender relations and build upon certain notions of femininity and masculinity which, while under fire at the present time, still equally leave their mark in an important fashion. My interest thus became directed at examining the relationship, with its inherent conflicts, between medicine and nursing more generally from a gender perspective, while also keeping my specific interest in the working relations between women doctors and nurses in view.
It is not my intention to present this study's research findings as such in this paper, although some empirical data will be presented. Rather I wish to illustrate how the problematic of doing dominance and doing deference in hospital work can be approached with the help of another concept that has gained importance in feminist and social research in recent years, namely the body (see, for example, Bordo 1995, Davis 1997, Featherstone, Hepworth and Turner 1991, Shilling 1993 and Turner 1996). I use the body analytically in a variety of ways. On the one hand, there are real bodies involved, situated in space and place, evoking interactional patterns linked to gender and class relations. On the other hand, the body is used in a more metaphorical sense and refers to the bodies of medicine and nursing. Just as we can use the phrase a body of knowledge, the bodies of medicine and nursing imply that the professions embrace collective values, views, ways of working, knowledge bases, etc. – which understandably affect how the two (collective and individual) bodies approach and understand each other. The various levels – embracing the body and gender relations – seep into each other, which will become apparent in the following pages.
It can perhaps be pointed out that the body is implicated in a further way in a qualitative study such as this. It is of course my body inscribed with its gender, race, age, immigrant status and schooling in a Western tradition that privileges me as a knower. It is my body – on the ward, in the operating theatre – that is the standpoint from which the study is carried out.
The paper will be structured in the following way: (1) First the bodies of medicine and nursing will be examined from a gender relations perspective. In a sense, this section is an important background to the following two sections. (2) The fact that ‘gender is inscribed on the body’ and thus affects interactions between doctors and nurses will be addressed in the second section. (3) Finally, the question of situatedness – where the bodies (of doctors and nurses, men and women) find themselves in the daily run of things – will be approached.
The bodies of medicine and nursing
While medical training can be seen as a ‘toughening up’ process preparing students for the rigours of a doctor's life, nurse training is an object lesson in submission. In nurse training others get tough. The nurse is taught to follow rules, to be deferential to doctors, and the importance of routine is emphasised (Mackay 1993: 43–44).
This quotation comes from the beginning of the 1990s and it can be argued that this description with regard to nurses is no longer totally correct. Change is underway. Yet traditional relations still hold sway to a large extent – relations that were initially premised upon doing dominance and doing deference.
Nursing today comprises a number of different skills and expertise. Medical technical knowledge and related skills are central to the occupation, although the nurse's working day also involves a large degree of communication and administrative/managerial work. At the same time an important attribute of nursing from its inception to the present day is caring– the ability to nurture, to give comfort, show concern, dedication and warmth, make emotional contact and even sacrifice. By elaborating upon a discussion of caring as below, it should become clear how a certain type of femininity, a particular idealised quality and identity, was woven into the construction of the occupation. Admittedly, being technically competent is arguably an important component of contemporary hegemonic masculinity (Acker 1990) but despite nursing's emphasis on the technical, this has not meant that the profession is constructed in masculinist terms.
Caring is not of course only the prerogative of nursing – it is seen as an important element in many women's jobs (including work within the home) and is indeed often equated with a ‘feminine attribute’. The point of feminist work has been to show that this attribute is not natural in itself but part and parcel of a particular discourse. At the time nursing was being established, at least in Britain, as an independent occupation for middle class women in the mid-19th century, its related sister – caring – was being emphasised as a desirable and necessary quality in all women regardless of class – it was something to be striven for by women, a part of their education. In her book Formations of Class and Gender (1997) Beverley Skeggs links the inculcation of a caring attitude in the 19th century with the concepts of respectability and responsibility. Women were given responsibility for upholding the moral standing of the nation – they were in other words to civilise the nation, to be responsible for social order, and were of course blamed if they did not succeed in their part of the colonial project. Skeggs shows how this attitude was linked to the concerns of hygiene, sexuality, the centrality of the family and women's place in it. But furthermore their education into a caring subject position was interlaced with socialisation into acceptance and enjoyment of this subjectivity. What is important in Skegg's work is that it shows how a caring self– a particular identity – is discursively constructed as a normative feminine ideal. In other words the construction of femininity and caring go hand in hand. The following quotation from 1905 clearly shows this in relation to nursing:
Nursing is distinctly woman's work . . . Women are peculiarly fitted for the onerous task of patiently and skilfully caring for the patient in faithful obedience to the physician's orders. Ability of care for the helpless is woman's distinctive nature. Nursing is mothering. Grownup folks when very sick are all babies (Hospital 8 July 1905: 237) (Quoted in Gamarnikow 1978: 110).
A caring self and related (constructed) feminine attributes were not cast independently but in relation to (a certain type of) masculinity that prevailed at the time. Femininity meant dependency and subordination in relation to masculinity. Nursing was unequivocally created as subordinate to medicine. As a male doctor wrote at the end of the 19th century:
My name and reputation as a man and surgeon depend on my ideas being carried out as I would have them carried out . . . The nurse is not employed as consultant, as critic, as arbiter, she is strictly an executive officer (Hospital 31 July 1897: 164) (Quoted in Gamarnikow 1978: 109).
Writing ‘as a man and surgeon’ clearly indicated the gendered relations involved. Gamarnikow (1978) saw a parallel in these turn-of-the-century relations of the nurse-doctor-patient triad with the family structure. Ideologically, nurses could be seen as ‘mothers’ (doing the nurturing work), doctors as ‘fathers’ (making the decisions in a patriarchal manner) and patients as ‘children’ (where decisions were made over their heads and little or no autonomy was encouraged). This patriarchal style did mean that: ‘In return for being prepared to behave as handmaidens nurses could expect gratitude and protection, the approval and recognition of powerful men’ (Pringle 1998: 190).
Celia Davies (1995, 1996) has persuasively argued that the foundational underpinnings of a profession – where medicine's status is of course firmly assured – are inextricably bound up with a certain masculinist ideal, what could be called, I would argue, ‘hegemonic masculinity’ in Connell's (1995) terms8. The qualities that are associated with this form of masculinity, which Connell shows are historically constructed, can be described in the following terms: rationality, hierarchical authority, objectivity, decisiveness, physical and mental strength, competitiveness and individualism9. Drawing on Rosalyn Bologh's work (1990) and relating back to Weber's ideas about bureaucracy, Davies (1995) shows how the construction of public man (or the ‘manly man’ in Weber's terms) is infused with a discourse of hegemonic masculinity:
He is / . . . / restrained. His belief in a cause disciplines him to self-control, and to a careful weighing of courses of action in pursuit of the cause. He must use his intellect and arrive at an independent judgement / . . . /; he must apply rational criteria to his decision-making. He must not allow his vision to be clouded by sentiment, and in this regard must welcome and foster the distance from others that this entails (Davies 1995: 33).
Indeed compare this to the description of the qualities and inscribed body of the doctor – which the medical student needs to learn:
In medicine, the inscribed body of the physician, both male and female, is marked as decisive, objective, rational, and above all, composed. The performances incised on medical students’ bodies are from head to toe, including a forthright gaze, handshake, and stride, along with countless other nuanced ways of moving throughout the halls of medicine. Doctors control interviews, procedures, practices. Of course the doctor's body may touch or exhibit other caring gestures, facial expressions, or tender tones, but it is a body in control of itself (Wear 1997: 105–106, emphasis in the original).
The construction of (these forms of) masculinity and femininity, of medicine and nursing, exhibit quite differing qualities and of course it is here that we can find one of the reasons why women doctors may find their position problematic – they have to find space in an area that has already been defined by masculinist ideals and where values and behaviour, that women doctors may feel are a part of their own constructed femininity, are questioned. Or as Joan Acker (1990) puts it:
Women's bodies cannot be adapted to hegemonic masculinity; to function at the top of male hierarchies requires that women render irrelevant everything that makes them women (1990: 153).
Hegemonic masculinity in our society is given privileged status. Hegemonic masculinity also involves homosociability – the preference for similarity, to work and play together with other men, to appoint others cast in their own image10. Risberg (1998) argues that homosociability means that men at workplaces, despite internal antagonisms and different positions in the hierarchy, behave unitedly in front of women and in so doing maintain their position of power. In her latest book Lindgren (1999) suggests however, that homosociability – at least within surgery – is in crisis. One reason given is the introduction of new technology. Homosociability implies a hierarchical order where senior men receive respect from younger men who in turn receive tutelage from the older. New forms of surgical operations using computers and digital pictures –‘Nintendo surgery’– are easily and skilfully learned by the younger generation, whereas the older may have difficulties. The senior artisan can no longer train the junior doctor. The traditional hierarchical order is turned around and the previous holy alliance between men is put to the test.
Quotations that I used earlier from Gamarnikow (1978) in relation to nurses and hegemonic masculinity were from the turn of the last century. When looking back in history, we somehow expect a clear clash between hegemonic masculinity and the situation of women to rear its head, but we assume (or at least hope) that hegemonic masculinity may have disappeared – or at least weakened its hold – in the present day. Let me, though, cite the opinion of J.R. Benson, a leading British surgeon, who in 1992 wrote the following in the Lancet (quoted in Pringle 1998: 69). It can be seen as an example of how hegemonic masculinity ensures its position and dominance by rejecting notions of gendered social constructions and by calling upon a discourse of biological difference (and where psychological differences are imputed as naturally given):
We live in a world where a policy of sexual equality, especially at work, prevails. However, in reality the sexes differ not only biologically, but also in less tangible, more subtle ways in respect of psychological make-up . . .
Apart from the long and unpredictable hours of work that inevitably involve sleep deprivation, surgeons also sometimes have to operate (often on long and difficult cases) when very fatigued. In my experience, female house surgeons are not as tolerant of sleep deprivation and more prone to succumb to exhaustion than their male counterparts . . .
Some aspects of surgery – for example, procedures for emergency thoraco-abdominal trauma – demand a certain attitude of mind and level of confidence, with a minimum of diffidence and hesitation and absence of any impression of panic. Such qualities may be to some extent gender dependent in favour of the male psychological constitution (Benson 1992: 1361).
Doing masculinity can be understood as performance or ‘masquerading’. Pringle (1998) points out that masquerading suggests acting and duplicity and implies that something may well be hidden in the masquerade – that if we take the veil away we will discover something else. She suggests that all versions of masculinity – including the surgeon's – are to some extent masquerades, ‘which may stem from a sense of lack or fragmentation, and lay claim to an omnipotence which is impossible for anyone’ (Pringle 1998: 81). If masculinity is performance, if it is socially constructed rather than biologically given, there is of course no reason why women shouldn’t succeed in mastering the performance. On the other hand, it is perhaps the masculinist project with its props, roles and accoutrements – and insistence on hierarchy – that is rejected. And while doing masculinity is perhaps masquerading and therefore ‘play’, it becomes ‘deadly reality’ in its consequences, namely it ensures ‘doing gender’/‘doing dominance’ and therewith disadvantages and hurts women.
Analysing medicine and nursing in terms of projects of masculinity and femininity helps us understand the tensions and problematics involved in present-day relations. Nursing ardently struggles to attain professional recognition, yet caring, with its emphasis on closeness and emotional aspects, is not part of the masculinist definition of a profession. This is then, as Celia Davies (1995) argues, the professional predicament of nursing. Specialisation, mastery and impersonality – the hallmarks of a profession – sit uneasily with what nurses see as central to their occupation that emphasises holistic care. There is furthermore an additional problem. The ideal of a profession rests importantly upon the notion of autonomy. Yet professional autonomy is dependent on the hidden work of others. The work would be impossible without the recording, filing, service duties, preparatory and follow-up work of (primarily female) others. ‘It is only through this activity that the work can take on its active, agentic and distant and controlling character. Autonomy therefore, turns out to require considerable additional work without which it cannot be sustained’ (Davies 1996: 670). Thus Davies argues that a further predicament for nursing in aspiring to professional status is that its own work is part of a gendered division of labour that helps support and preserve the medical profession.
It is not, however, only nursing and the masculinist vision of a profession that jar badly. I would argue that even medicine is in a process of redefining what a profession means and questions its masculinist base. In recent years a debate has arisen around the inhumane aspects of medicine, suggesting that there are shortcomings in everyday relations with patients11. Compassion, respect for the individual's dignity and integrity –seeing the individual patient, caritas and self-knowledge are all important aspects on the agenda. Thus it would seem that even within medicine, the traditional notion of profession is being both questioned and reformulated. Are curing and caring to be once again united12? It is often at this intersection of caring and curing that the possible (and assumed) contribution of women doctors is raised – frequently in relation to a more essentialist gendered understanding. But as Pringle (1998) argues:
More interesting than any absolute truths about the differences between men and women is the discursive production of difference and the subjectivities that get constructed in relation to these meanings. Therefore the issue is not whether women doctors are truly more caring than men but what can now be done with such claims. Can they be used to fracture the associations between medicine and masculine authority, to open the ground for a rethinking of what we want medicine to be? (Pringle 1998: 221).
Pringle sees masculine authority woven into the medical profession as illustrating what she calls ‘medical modernity’. As we shift into late or postmodern times, we could argue that one way of doing things, one way of being a doctor or nurse becomes obsolete and that the narrow constructions of masculinity and femininity that have been a part of medicine and nursing become historical figurations. It is also interesting to note that, as Celia Davies (1996) points out, what can be called the ‘new managerialism’– while assuredly problematic in many ways – has provoked more overt gender talk and starts to question and to some extent unmask the values associated with hegemonic masculinity.
I have tried to show in this section that doing dominance and doing deference have undoubtedly been part and parcel of how medicine and nursing were historically constructed in relation to each other. These relations are at the present time in flux – yet they still importantly influence how the two collective bodies understand the other and work with the other.
Gender is inscribed on the body
I would now like to move our analysis to another level and argue why the inscription of gender on the body is central to understanding the working relations between women doctors and nurses – and between male doctors and nurses.
We may well imagine that sex/gender is not important when interacting with other individuals – that other qualities are more salient – but we are always aware whether the person we are talking to, or interacting with in some other sense, is male or female13. Our senses automatically register this information whether we wish it or not. It is almost impossible to continue an interaction if we cannot work out the sex/gender of the other individual. As Cecilia Ridgeway (1997) has argued:
Thus, although we may be able to imagine an ungendered institutional script whereby ‘the student talks to the teacher’, we cannot interact with any actual student except as a male or female student. The sex categorisation of self and others, even in institutionally scripted settings, is a fundamental process that injects a variety of gender effects onto the activities and institutional contexts that people enact (1997: 220).
In a similar vein it can be argued that a nurse never just interacts with a doctor or vice-versa, it is always a female or male doctor, a female or male nurse14.
Drawing together empirical findings and theory from social psychology/social cognition, Ridgeway (1997: 220–21) delineates how interactional processes, infused with gender, work. Our perception of others is always hierarchical. It begins with an initial classification that works on an automatic basis and is prompted by a very small number of primary social categories, which in time take the form of a more detailed typing depending on the circumstances. In Western society, sex is one of these primary social categories – indeed as I suggested earlier ‘we automatically and unconsciously sex-categorize any specific other to whom we must relate’, to use Ridgeway's words (p. 220). But it is not only in the initial meeting that this sex-categorisation takes place:
Yet sex categorisation continues because the actual process of enacting an institutional script with a concrete other evokes habitual person perception, and with it the culture's superschemas that define the basic attributes necessary to make sense of any person (Ridgeway 1997: 220).
Cultural superschemas evolve hand in hand with gender stereotypes, which describe what behaviours can be expected from a person of a given category. Subsequent detailed typing may fade the original (stereo)typing – whereby other identities take larger command15. However, they may also increase in their tenacity and steering of behaviour. Ridgeway continues:
In work settings institutional identities are likely to reside in the foreground for actors. Evidence indicates, however, that even when other identities are the most powerful determinants of behavior in a situation, cultural gender stereotypes become effectively salient (i.e. sufficiently salient to measurably modify actors’ expectations and behavior) under at least two conditions: when the interactants differ in sex category, and when gender is relevant to the purposes or the social context of the interaction (1997: 221, emphasis in the original).
Gender stereotyping in our society usually works to the advantage of men, suggesting that they are more competent in a field and imbuing them with higher status. In the medical world, default stereotyping can include attitudes, such as ‘male doctors are better clinicians’, ‘better in the operating theatre’, ‘better in positions of authority’, ‘better at dealing with conflicts’, etc.
Reskin (2000) draws attention to the fact that although some employment discrimination (while I am not interested in employment discrimination as such here, the arguments are transferable to an understanding of how we treat people in different ways in work settings) results from people pursuing their group-based interests or prejudices, much discrimination is the result of normal cognitive processes which are divorced from an individual's motives as such. In other words, beliefs or actions may occur automatically regardless of what we may more consciously think. Categorisation is a non-conscious process. Reskin (2000: 3) reports on a study carried out by Bodenhausen et al. (1998) where subjects in an experimental study were asked to avoid sexist statements in a sentence-completion task. Findings showed that subjects were able to succeed in this request if enough time was available to complete the task, but if they felt time pressure their constructed statements were even more sexist than those where the subjects had not been instructed to avoid making sexist statements. This may well have ramifications, I would argue, for how men and women work in a hospital setting when stress and lack of time certainly hold sway at the present time.
When asked in my study whether the gender of the doctor plays a role when working together – nurses answered in the negative, arguing that it was primarily a question of personality. Both male and female doctors can be easy or difficult to work with. Supported by Ridgeway's and Reskin's contentions, I would argue that nurses might like to think that the doctor's gender is of no significance (and indeed in our times of overt equality talk it would be politically incorrect to state otherwise), but that in reality it is hard to escape the fact that gender stereotyping is implicated in social interaction – whether one likes it or not16.
On the one hand, then, we have unconscious gender stereotyping raising its head – influencing attitudes; on the other, the situation is complicated by the gender-class divide – by the realities of doing dominance and doing deference. Traditionally, medicine has meant doing dominance. Whereas traditionally in society at large, being a woman has meant doing deference. Women doctors thus straddle between the two, finding themselves in some kind of no man's land. The following nurse sums up the situation:
If a female doctor shows herself to be the slightest superior, then it's much more difficult for her. One gets slightly confused – I mean she's a woman, like us, but she's a doctor and has higher status than us and still she comes here and doesn’t know anything and I’ve worked here for 20 years . . . it's probably unconscious . . . it's harder for a young female doctor than a young male doctor.
Women doctors’‘doing dominance’ is thus problematic in the nurses’ eyes17. Or as another nurse put it:
The male doctor is usually more authoritarian. He plays his ball game regardless. And if he says to me, ‘Go and take that patient's blood pressure’, then I go and do it. I don’t stop and think about it, whereas with a woman I might have thought that she could go and do it herself. I’ve got less patience with regard to an authoritarian attitude if it's a woman. If I say, ‘Do it yourself’, the men don’t do it. They’ve been pampered for too long. The women give in more easily – a bit embarrassing really – they think, ‘OK, I’ll do it myself’.
My data would suggest that it is not only a question of nurses having problems with the women doctors doing dominance, the female doctors themselves may be uncomfortable with this mode of behaviour. Pingel and Robertson (1998) give further support for this in their study. As one woman doctor said:
I find it difficult to ask for help with things I could do myself – yesterday I hesitated in asking an assistant nurse to clean the floor when an incontinent woman wet herself – I mean it's preposterous to imagine that I should clean the floor and be late for my out-patients – and yet all the same it's hard asking another woman for help with the dirty work (My translation) (1998: 26).
Gender stereotyping can however become less salient with time. My material seemed to indicate that women doctors encountered most problems as newcomers, whether it was as a newcomer to a department18, in the emergency room or in the operating theatre. When they had shown their competence and knowledge, and that they were ‘OK people’, then the nurses were often more enthusiastic about working together with them than with male doctors19. If, however, the women doctors continued to have what were considered authority problems (being too bossy, too hard) then the nurses tended to treat them more harshly than their male counterparts (regardless of the doctor's position in the hierarchy).
One important reason why the nurses could, however, prefer working with a female doctor was the latter's amelioration of doing dominance; the nurses felt that they were given more space in their joint encounters with a patient. They appreciated the type of mutual communication20 that could emerge with a woman doctor. Many of the female doctors supported the contention that they ‘included’ the nurses:
The round is important because that's when we [the doctor and the nurse], together, put the picture together. Some of my male colleagues get at me for this attitude. They say, ‘You’re the one deciding’. OK, maybe it's a female dilemma; it's hard to be totally authoritative. Of course we’re not always in agreement. But I can often learn an awful lot from the nurses who are experienced. It is a dialogue– that we together decide what is best for the patient. But this requires us to really make the decisions together, because if one of us starts thumping our fist on the table and doesn’t bother to listen to the reactions of the other who's going to be carrying out what's been decided, then I’ve noticed it just doesn’t work (Female junior surgeon).
While doing dominance and doing deference was an issue of relevance between women doctors and nurses – in terms of reducing its saliency, it was also an issue within the medical academy itself. The doctors’ narratives made it clear that those lower down in the hierarchy, regardless of gender, were subservient to those higher up. But, in addition, there was evidence in my study, as well as in the general literature in the area, to show that women within medicine encounter particular difficulties and differential treatment21. Typical for some of the women doctors in my study22 were the following opinions:
We have to take our starting-point in men as the norm – we have to adapt ourselves to their rules. We’re only allowed in as guests (Woman orthopaedic surgeon).
They [the male doctors] want tough boys for this job because they were tough boys themselves (Woman surgeon).
My clinic is like a military camp where the top rooster gets unbelievable respect (Woman physician).
Female doctors working in departments where there are few fellow women doctors frequently experience a sense of outsiderness; that male doctors – particularly their seniors – do dominance towards them23. Some of these women related how they would purposefully form alliances with the nurses so as to offset the masculine environment they felt forced to be a part of, and which was destructive to their own identity as women and doctors.
Situatedness: the body in space and place
Social and feminist geographers (see, for example, Rendell et al. 2000 and Duncan 1996) have brought our attention to the ways in which space and place are instrumental in social relations.
The appropriation and use of space are political acts. The kinds of spaces we have, don’t have, or are denied access to, can empower us or render us powerless. Spaces can enhance or restrict, nurture or impoverish (Weisman 2000: 4).
Once again, the body becomes central here since the appropriation and use of space is directly linked to where the bodies (of doctors and nurses, of men and women) locate themselves and/or are located in the daily run of things. Situatedness is also closely linked to doing dominance and doing deference. In this final section, I illustrate how these relations can actually be enacted, first in relation to women doctors within the medical hierarchy, and secondly with regard to the (shifting) boundaries between doctors and nurses.
Within certain specialities in particular, being accepted as a woman doctor is a hard fought battle24. Interestingly, the female body is used at times as a reason for their exclusion, or at least for questioning their suitability in spaces that historically have been constructed as masculine, such as orthopaedic surgery and general surgery. It is the size and strength of the female body that is brought into question. It is not a body, it is argued, that can meet the demands of certain operations. Stamina may be lacking. It is not a body that commands authority and respect from staff assisting operations. Admittedly, these were not opinions openly raised by the majority of the respondents in my study – I would imagine that equality debate in recent years has inhibited what can be seen as openly discriminatory talk. Nevertheless the fact that it was mentioned spontaneously by a number of women doctors is evidence of its persistence.
A female orthopaedic surgeon showed the inconsistencies in the arguments sometimes put forward. Her example, outlined below, clearly highlighted how the female body is socially constructed rather than simply biologically determined; how senior male colleagues do gender and do dominance in the process. Orthopaedics is a speciality where the number of women doctors is especially low – in fact this is where, along with thoracic surgery, we find the least number of women in Sweden; the figure for 2001 was 8 per cent (Physician statistics 2001, Swedish Medical Association). It could be argued that the reason lies in not enough women choosing this speciality. Interestingly, however, many of the women pre-registration house officers told me that they found the speciality exciting and said that they might seriously consider making this their choice of speciality. Orthopaedics involves both younger and older patients, requires concrete skills and is felt to be rewarding since patients frequently improve after operations and treatment. Suffering – which is so much a part of many specialities – is less evident here. For these reasons, it is attractive. But is the speciality interested in keeping women?
The woman orthopaedic surgeon I spoke to described how women seldom stayed long – they disappeared into other specialities. Subtle forms of exclusion appeared to be at work. An example was given to show how the body is used to question women's suitability. Recently a woman house officer had started work and was required to carry out an emergency operation on a hip fracture. The second on call was contacted. The operation does require some strength, it was argued by my interviewee, but this is not what is most important; rather it is a question of technique. The senior doctor called in though, commented afterwards upon the woman doctor's purported frailness. This caused my interviewee to react in the following way:
They start straight away by measuring her physical strength. And yet we’ve had guys here that are much more ‘delicate’. So I said to him, ‘Have you thought about when we competed in the Vasa race25 the other day – here all the male doctors take part in this competition – that she beat them by two hours, that she was much faster than any of the male doctors here – and you go around here and call her weak!’.
Body size was also commented upon by the women surgeons I followed into the changing rooms before operating. Their smaller bodies made it harder for them to assert claims on space in the course of their work. Showing their (extra) worth and competence was necessary if they were to be taken seriously in the operating theatre. And indeed operating equipment did not always seem designed with a slighter body and hands in mind. The women surgeons often had to stand on footstools to reach a patient comfortably.
It was not only in the operating theatre that the women surgeons felt at a disadvantage. Their ‘wrong bodies’ elicited wrong reactions from patients as well.
I don’t know how many times – especially in the first years of course – when I’ve seen patients on the round twice a day, 75 per cent of whom by myself, I’ve admitted them, operated on them, discharged them, written prescriptions for them, signed their taxi receipts and sick leave forms, explained things to them and then asked if there is anything else they’ve wondered about and they say, ‘When is the doctor coming?’ (Female ward surgeon).
While smallness was the theme usually commented upon, one woman doctor at another clinic, who was rather large, mentioned her size as disadvantageous. She took too much space; something she felt contributed to her poorly functioning relations with the nurses.
Regardless of whether comments about body size were openly aired or not by male doctors or nurses, the women doctors were very conscious of their bodies – their fitting or not fitting into expected norms. They had internalised various cultural superschemas (Ridgeway 1996) with regard to space-place-body. They were very much aware that they were seen as being the wrong bodies in the wrong places. ‘Body’ could be made less salient with time if their expert and experiential knowledge came to the fore. Cassell (1996: 43) suggests that there is a double rebuttal that needs to be revoked, as summarised by one woman in her study: ‘Either you’re not a woman, you’re a bear, a dog, or a lesbian; or you’re not a surgeon, you’re no good’. The latter is challenged, as many of my respondents argued, by showing that they are good at their jobs – and not just good, better than average. With regard to being a woman, Cassell's respondents spoke of the importance of wearing lipstick so that it would not be assumed that one was a lesbian. ‘One woman described how, as a medical student on a surgical rotation, when called to the emergency room in the middle of the night to attend to a gunshot wound, the older female resident would remind the two of them, “Oh, we have to put lipstick on!” ’ (Cassell 1996: 44)26.
Let us now leave the situation of female doctors and apply our gaze to the meeting of the two professional bodies once again. A renegotiation of certain spatial boundaries and rituals – perhaps not widespread as yet – would appear to me to be evident of current changes in the organisation of hospital work and in a levelling of status differences, at least in Sweden. The situatedness of bodies is highly relevant here.
The morning round can be taken as an example. Traditionally, space and place have unequivocally spelled out status and position. The long train of individuals trooping into the patient's room is not a haphazard formation. The consultant takes the lead, the lowest person in the hierarchy comes in last. Indeed, one problem I experienced in my fieldwork was to know where in this formation my own presence would be normatively correct so that I did not overstep a boundary. I discuss below another type of morning round to show how the situatedness of bodies in space can provide a certain sense of empowerment for the traditionally subordinate group; that doing deference can be ameliorated. The round, described above, is still in full force, at least on some of the wards I studied. But it should perhaps be pointed out that it is a far cry from an earlier regime where patients ‘stood (sat) to attention’ when the consultant came in, where doctors did not talk directly to the patient but only communicated through the staff nurse and where even the paper baskets were emptied in advance so as not to offend the consultant!
On one of the surgical sections I studied, a different form of morning round had been introduced. Doctors (consultants, the ward surgeon, house officers and pre-registration house officers) congregated in a room on the ward in the morning and seated themselves around a round table. Primary nurses – who were responsible for three or four patients – came in separately but in succession and also seated themselves at the table. Patients – their condition, their problems, their follow-up treatment – were then discussed. The nurse initiated discussion by first presenting a latest summary and appraisal of the patient. After the ‘conference’, doctors, unaccompanied by nurses, visited each patient.
Nurses were overwhelmingly positive about the new routine, doctors were more wary in their comments: ‘It takes too much time, we need to get off to the operating theatre’. ‘You need an old-fashioned round, so that the nurses can learn’. In particular, the house officers felt they had difficulty in grasping the situation of all the patients. Some of the consultants drew out its advantages though: ‘We spend more time on discussing the patient from various angles, including the social and what will happen to the patient when he/she leaves the hospital, in addition to talking about various investigations and lab results. We can sit down and discuss in peace and quiet’.
Interestingly, the nurses felt that they had won time with this form of round, especially as they did not accompany the doctors into the patient (unless it was felt that there was a special reason to do so). Previously, time would be wasted waiting in the corridor for the doctor to get to their patient. Now the doctors might have to wait if the nurse could not drop everything on the spur of the moment when it was time to discuss her/his patients.
As I understood it, it had been the nurses that had pushed for the new order of things. The nurse manager gave the following reasons for its implementation:
It's an attempt to minimise the number of people that are in the patient's room. What's the point of a whole flock? In part it's a question of confidentiality – when you’re standing there in the corridor . . . And then the doctors, they get irritated when the cleaning trolley arrives or when the food trolley is on its way out. They themselves don’t see that they stand there and take up a lot of space [in the corridor] during quite a long period of time. When the new electronic case records system was introduced, it became obvious that the old routine wasn’t feasible any longer. I tried to argue that sooner or later they need to sit down somewhere when all the medication and case records are on the computer. We can’t do a traditional round with a lap-top and everyone trying to peer into it. You have to be able to sit down at a larger screen.
Nurses in my study emphasised their advocacy role as well as their concern for the patient and this type of round, one could say, facilitates this. The following citation from a nurse working on another ward where a traditional round still held sway explains further why an advocacy role is difficult with the traditional routine:
We just rush in and out. No meeting either before or after. I don’t like this system. I’d like to see some sort of briefing before we go into the patient, I’d like to be able to say to the doctor, ‘This is how it's been for Mrs Persson this morning . . .’. Unfortunately the doctors discuss treatment strategies in front of the patient. The patient just sits there like a big question mark . . . And then it becomes extra work for me. I have to ‘clean up’ after the doctors on this type of round.
The nurses on the new round indeed argued that the method allowed them to ‘charge themselves’ beforehand, it allowed them to prepare their arguments. My own observations – and comparing these to ‘presentations’ or information-exchange on the traditional round – noted well-structured and well-argued presentations.
Improving patient care was an argument used by both doctors and nurses in justifying a new form of round. Surprisingly, establishing more egalitarian ways of working between the two professions was not taken up by my respondents. And yet it seemed to me that this was one of the (unintended?) outcomes and an important one at that. Space and situatedness were utilised in the traditional round to ensure medical authority; it was a way of doing dominance. The culturally determined spatial rules, admittedly unwritten but none the less widely understood, saw to it that each person knew their place in the hierarchy (including doctors within the medical hierarchy). Sitting around a table, by contrast, places bodies on an equal footing and provides the opportunity for real discussion27. Sitting down diminishes the importance of size (and dominance/deference) – that may be of relevance in relation to male doctors.
A closing note
Some empirical findings from my study have been presented in this paper but my main aim has been to suggest how the concept of the body can be used when examining doing dominance and doing deference. While hierarchical relations between doctors and nurses have seen important changes in recent years, gendered relations and practices still hold sway – both in traditional and new forms. Bringing in the body, focusing on the embodied ‘other’, provides us, I would argue, with new tools for comprehending why this is the case. The body – which was earlier largely excluded in sociological thought – is, notwithstanding, an important aspect of the notion of social relations. In other words, applying the concept of the body in a variety of ways – as suggested in this paper – gives us analytical access to the very complicated and multi-layered relations at work at the crossroad of gender, profession, hierarchy and bureaucracy. It also helps us see where gender relations can be contested and change introduced. Although I have examined these questions particularly in relation to the two main categories involved in hospital work – doctors and nurses – I assume that the framework is relevant for other workplaces where different professions or occupations interact, and where doing dominance and doing deference is part of the nature of the gendered organisation.
The research on which this paper is based was supported by a research grant from The Vardal Foundation, Sweden. This paper is a re-working of a presentation at the European Research Training Network: Women in European Universities’ mid-term conference in Lund in October 2001.
As far as I know West and Zimmerman (1987, 1991) were among the first to introduce the term into the accepted conceptual vocabulary in their article with the same title – even if it was implicit in earlier feminist work. It is also implied of course in some of Goffman's work.
Cassell (1996), for example, uses these terms in her study of women surgeons.
Despite attempts to interest more men to enter nursing in Sweden, the percentage of men working as nurses was 7.6 per cent in 1999 (http://www.vardforbundet.se/medlem/stat/hel_del.htm)
Internationally and nationally there was some evidence that this was the case. See, for example, Heising 1995, Lindgren 1992, Mackay 1993, Porter 1992, Pringle 1998, Risberg 1998.
Women constitute just over 50 per cent of students in current medical education in Sweden as well as in many other countries (see, for example, Crompton et al. 1999) and are fast increasing their share as practising medical doctors. The top positions – including consultants – are still, however, overwhelmingly held by men. Consultants (Sw: överläkare) consisted of 75 per cent men and 25 per cent women in 1995 (Nordgren 2000: 70). 39 per cent of women doctors were at the junior doctor level in 1998, while the equivalent figure for men was 25 per cent (Nordgren 2000: 70).
See Nordgren (2000) for an interesting analysis of these processes.
A number of other elements also account for the changed relationship: work organisation on the ward and in the hospital (e.g. primary nursing); the significance of ‘welfare illness’ (as opposed to infectious diseases) as the major medical panorama – which in turn requires a different form of care; down-sizing, rationalisations and market economy ideas and their implementation.
I am aware that the concept of masculinity has been criticised (see, for example, Hearn 1996), but I still feel that hegemonic masculinity is of relevance to the discussion here.
Acker (1990: 153) writes ‘Currently, hegemonic masculinity is typified by the image of the strong, technically competent, authoritative leader who is sexually potent and attractive, has a family, and has his emotions under control’.
Hegemonic masculinity also involves homophobia. Connell (1995) shows how homosexuals constitute a different form of masculinity, one which is considered substantially subordinate to hegemonic masculinity.
The establishment of a professor's chair in humanistic medicine at the Karolinska Institute, Stockholm suggests, I would argue, the importance of a differing discourse.
See Fisher (1995) for a much wider discussion around the issue of curing and caring.
Chatting on the Internet is perhaps an interesting exception. Using nicknames, altering identity, makes it possible to be genderless or change gender. In this sense, it is perhaps possible to argue – in postmodern terms – that identity is not fixed. At the same time, communication on the Internet is not face to face – does this make the centrality of gender less important – the body as such is not present? Are embodied face-to-face contacts always characterised by the need to determine the gender of the other?
While male nurses were included in my study, their numbers were far too small to draw out a more detailed gender analysis.
Tilly (1998) discusses the treatment of women in men's jobs, such as concrete truck driver and rapid-transit conductor. Initially, he argues, it is difficult for women to be accepted for the job they do since they are seen as women. But with time recognition for their work can be achieved as well as less harassment. ‘With experience, the relationship shifts from predominantly man/woman to predominantly worker/worker. Accumulated local knowledge actually produces a change of script’ (1998: 98).
In subsequent discussion, the nurses would in fact often provide evidence of responding to a woman doctor differently or of a woman doctor behaving differently towards them.
The question of women doctors and authority is more thoroughly addressed in Davies (2001).
Junior doctors have to frequently move department and ward as a part of their training.
Sexuality could, of course, also affect the relationship – so that (female) nurses are/were more likely to help a male doctor (this of course presupposes heterosexuality). Space does not allow me to develop this more comprehensively in this paper.
I am aware that this could be interpreted in terms of binary oppositions: women are good at communication and men are not. This is not what I am trying to argue – at least not on an essentialist level. If the women took time to communicate, it was primarily because – I would argue – they saw the need to create a viable working relationship with the nurses if they were to be able to do their jobs properly and engage the nurses’ co-operation. See Davies (2001) for a description of the type of work women doctors put into ‘winning the nurses over’.
See, for example, Crompton et al. (1999), Hultcrantz (1998), Lorber (1984), Perhson (1997), Pringle (1998), Riska and Wegar (1993) och von Vultée and Arnetz (1997).
In addition to women doctors working in the two departments studied, I interviewed a number of other women doctors working at other departments and hospitals. Older women were less likely to be critical as were the women at the two departments actually studied. The latter may be linked to the fact that it was harder to be critical of colleagues, knowing that I was regularly at their workplace, and more or less knew everybody. Of course it may also mirror the fact that hierarchical and gender relations were of another nature at the departments studied (due to leadership, type of speciality, etc.).
There was a strong feeling that young male doctors today are very different from the older generation in terms of values and attitudes.
Within ophthalmology, a high percentage of women are to be found (just over 50 per cent) as well as working hours that are similar to office hours. The situation for women doctors seemed somewhat easier here.
The Vasa race (Vasaloppet) is an annual, international, long-distance skiing competition – the distance to be covered is 85.8 km.
In her study of women surgeons, Cassell (1996) reports that she found little evidence in her interviews of direct sexism or misogyny and reflects whether this is due to the fact that it is easier for a woman surgeon to cope with her situation by ‘forgetting’ such events. It was rather in informal talks when they related ‘shocking stories’ that women surgeons would admit that they had experienced similar events. My own material is not overflowing with misogynistic stories either. Yet there is often a sub-text around such issues. Regardless, one such story is one story too many.
I am of course aware that spatial arrangements may not be enough to engender equal talk.