Graduate nursing education, in the preparation of nurses for advanced practice in areas of women and their health, has concentrated on specialties in childbearing. Although innovative programs in women's health exist, the majority of programs are titled Maternal -Child, Maternal-Newborn or Parent-Child. These specialities address one small (albeit important) area of women's lives, and are not inherently holistic. In fact, these titles appear to define women in terms of their reproductive capabilities and deny the complex health issues affecting women. Additionally, they negate the holistic nature of nursing.
Recently, the nursing literature has given attention to women's health as a distinct area of nursing practice (Chinn & Wheeler, 1985; Choi, 1985; Dunbar et al., 1981; McBride & McBride, 1981; Mulligan, 1983; Woods, 1982; Woods, 1985). The authors support the aims of feminist activists in reorganizing health care for women that is holistic, rather than disease or provider focused. They identify many aspects of feminist philosophy and feminist theory that provide the underpinnings for new models of womencentered health care. Graduate programs in nursing have the responsibility to address women's health from a holistic perspective, to prepare students for women-centered practice, and to conduct and share research that speaks to women's lived experience.
Women's health is committed to health promotion, maintenance, and restoration of the whole person through women-centered practice. Women-centered implies both identification with and concern for women, taking into account the patriarchal society that has influenced women's development. Additionally, women-centered practice implies that women are in control of their health and health care, and that there is joint responsibility between client and provider. The graduate curriculum provides students with the philosophy and tools for advanced nursing practice. Therefore graduate curricula in women's health must have several purposes: first, to focus the curriculum on the whole person-woman, not solely on issues of reproduction; and second, to socialize students towards feminist practice, in the profession, in clinical practice, and in research.
A feminist framework encompasses feminist consciousness and theory as the foundation for women's health. Consciousness is developed and defined by reflection on women's experience and on the subjugation of women throughout history. Feminist theory suggests that the construction of women's experience has never been adequate because men, rather than women, have described and explained women's experience (Keohane, Rosaldo, & Gelpi, 1982). Radical feminist theory, in its explication of patriarchy and male domination as the level of analysis in the oppression of women, provides a framework for critically analyzing women's condition and for creating change.
The "personal is political" was a slogan of radical feminists of the 1960s that summed up the recognition that women are oppressed in every aspect of life. Personal issues such as rape, wife abuse, or even unnecessary surgery, medicalization of rights of passage, and injudicious use of psychotropic drugs were exposed as areas where women were being exploited. Feminists charged that these issues, when privatized, appear trivial and conceal the ways in which women are controlled. Further, by calling them personal, women's struggles for change become illegitimate. The slogan takes these issues into the private as well as the public domain and suggests that "all relationships between men and women are institutionalized relationships of power and so constitute appropriate subjects for political analysis" (Jaggar, 1983). Millet (1970) states that politics refers to power-structured relationships whereby one group of persons is controlled by another. She suggests that sex is a status category with political implications, thus she coins the term sexual politics.
The ultimate goal of radical feminists is the liberation of women. While some feminists would argue this goal is impossible without radically restructuring society, others suggest that feminist theory gives us the tools to reconstruct women's experience and to move towards feminist praxis - women actively participating in society, no longer acted upon, but acting out of self-determination. Selfdetermination arises out of consciousness of oppression and heightened political awareness, together leading to political confrontation (Barry, 1983).
This is the juncture at which nursing can ally with feminist activists: first to recognize sexual politics in the medical care system as "institutionalized relationships of power" and to analyze those relationships; and second, to reconstruct women's experience through research and clinical practice, to move towards feminist praxis, to empower women towards self-determination in health and health care.
Feminist activists concerned with health and body issues began a social movement in the late 1960s that, for the first time in this century, questioned the authority of the maledominated medical care system (Ruzek, 1978). They had many criticisms of the medical system, all reflecting the underlying patriarchy of society. However, four major issues are critical to the development of consciousness in nurses: the paternalism of the system, the perpetuation of women as sexual objects, the medicalization of rites of passage, and the control of women.
The first issue, paternalism of the system, demonstrates the insidious manner in which healing and health care were co-opted by men and by medicine, and how patients relegated complete authority to their physicians. Prior to the mid 19th century and the ascendancy of the medical profession, a women's culture of mutual help and healing existed. Women guided each other through normal life events (menstruation, childbirth, and menopause) and despite lack of "scientific" research, women were empowered with strength and pride in supporting each other ( Smith- Rosenbeng, 1984). However, as the medical body of knowledge grew, as medicine became legitimized and shrouded in mystery and science, women were made to feel ignorant and disempowered, eventually becoming compliant and passive (Ehrenreich & English, 1973).
The second area of concern is the organization of the medical system. Obstetrics-gynecology, as the entree into the system for most women, is considered central to perpetuating women as sexual objects, with emphasis on their reproductive organs. A good example of science being used to keep women down is the notion of "withering uteri" which needed surgical intervention. In addition, obstetrician-gynecologists, often the primary provider for women from adolescence through menopause, is a surgical specialty presenting a tenuous front as primary health care.
The third area considers normal life events or rites of passage that have been medicalized such as menstruation, childbirth, and menopause. They are not understood as part of the normal life cycle, but rather as "syndromes" or "diseases" needing treatment. To that end, women are at the mercy of the male-dominated medical system.
Finally, feminists argue that the medical profession treats women in ways that uphold the values, beliefs, and needs of a male-dominated system and patriarchal society (Ruzek, 1978).
Lack of explanations regarding alternative treatments, unnecessary surgery, and use of hazardous drugs not only support the stereotype of women as inferior, compliant, and passive, but requires it. In addition, care is frequently based on physician need without regard for the client (for example routine episiotomy, and the use of psychotropic drugs).
Early women's health advocates opposed any involvement with health care professionals. Experience in the system only affirmed stereotypical suspicions that nursing was too invested in the system to be objective about revolutionizing women's health care; that nursing was dominated by medicine and supported the sexist ideology and paternalism. To the extent that nurses, like most women, were in preawakening consciousness of feminism, they were unaware of their oppression.
In a system where physicians traditionally have been in control, nursing had perhaps internalized the values of medicine, consequently identifying with medicine. This explains male identification as "the path of least resistance for women in patriarchy" (Barry, 1984). Perhaps nursing was even more disadvantaged because of the dual subjugation, being women and being nurses.
As nurses become more aware of their own oppression, and as they come to understand oppression of women as patients, a common bond begins to develop. That bond can empower members of the profession, as allies of feminist activists, towards reform of the health care provided to women as well as empower women towards self-determination in health and health care.
A feminist framework for Women's Health in the graduate program predicates the philosophy and conceptual framework for the curriculum. The following philosophy is a beginning point for the development of a conceptual framework and addresses the metaparadigm phenomena of the interaction between person, society/environment, health, and nursing.
PHILOSOPHY OF WOMEN'S HEALTH: Women are integrated beings, and as such are considered in the context of their wholeness. Their active participation in society arises out of empowerment and self-determination. Women are constantly interacting with their environment, rather than reacting to it. Through this interaction, they are enabled to be and become, rather than be controlled or control others.
Health incorporates interrelational phenomena of the entire being. The biological processes are viewed in concert with psychosocial processes and life-cycle variables. Health and illness are viewed as extremes on a continuum, with health viewed as the dominant state. Health, or the integrity of spirit, mind, and body, can be compromised through dysfunction of the bio-psycho-social processes as well as the impingement of environmental influences.
As a helping profession, nursing's goal is the nurturance and nourishment of the whole person. Nursing can therapeutically empower women through diminishing hierarchies of control and power. The expertise of the nurse is a resource to women and is nonauthoritarian. Nursing uses this expertise in a joint effort towards health maintenance and promotion and illness prevention. Caring, as the core of nursing practice, is exemplified by the therapeutic nurseclient relationship, a mutual relationship centered on the woman.
A women-centered approach implies acknowledgement of the patriarchal world in which women have been socialized and in which women are viewed. Women-centered nursing recognizes the fragmentation and medicalization of women's health. Through this recognition, nursing begins to empower women towards self-determination by nursing the whole person.
Nursing looks at a woman's lived experience in determining how best to assist the client in her health efforts. Together they assess her individual needs and plan sound interventions. Nurses recognize that women are self-care agents, and despite the mystique of medicine, can be assertive consumers of health care.
CURRICULUM: The philosophy provides the framework for the curriculum design in the areas of professional responsibility, clinical practice, and research. Each of these areas is discussed in relation to student preparation for advanced clinical practice in women's health.
The profession's sequence of the curriculum is not only important in the socialization of students towards feminist practice, but also in raising their consciousness of professional issues in nursing. Course content in this area begins with a critical analysis of the history of nursing, utilizing a feminist perspective. The purpose in this approach is to assist students in understanding the historical oppression of nursing, and to enable them to begin to reclaim the culture of the profession, ultimately politicizing them towards activism and change. The history of the ascendancy of the medical profession, and specifically the emphasis on medical specialties, enables students to understand issues around control and power in medicine. New models of health care that are holistic and women centered can be developed with consideration given to implementing these models in practice. Content regarding organizational behavior and analysis, change theory, concepts of management, health policy analysis, political and legal strategies, collaborative practice, and role specialization are areas that should be included in the profession's sequence.
Organization of the clinical practice courses moves from the wellness to illness continuum, beginning with assessment of well-women's health status. A comprehensive nursing assessment addresses health states, health concerns, health problems, and health seeking and damaging behaviors (Woods, 1985). Through joint collaboration, the nurse and client can formulate a personal health plan. Students educate clients towards health by assisting them to incorporate sound health practices into their daily lives in areas of nutrition, relaxation, stress reduction, and exercise. Client education assists women to determine their health seeking and damaging behaviors, and to take charge of their health. Further, education begins to demystify medicine, offers choices in the kind of care and alternative treatments available, and empowers women to advocate for themselves.
In conjunction with assessment and health education, students examine the societal trends and needs that affect women's health relative to the social context in which women live, and the multiplicity of factors that impact their health.
Increasing numbers of women living in poverty, the unprecedented increase in labor-force participation of women, and the continuing increase in longevity of women are major societal trends affecting women's health (U.S. Department of Health and Human Services, 1985).
As students begin to look at women and their health from a feminist perspective, they observe how women have been medicalized. Issues surrounding weight and body image, normal life events, and mental health are examples of areas that are examined by reviewing research and critiquing traditional assumptions about women. Students begin to have a sense of how women's experiences, in their own voices, have been neglected.
Other practice courses examine a range of health problems that women experience. While childbearing and reproductive health problems must be addressed from a feminist perspective, this should not be the only substantive content. Given the increase in morbidity and mortality in heart disease and lung cancer, students should examine these areas; health problems of aging women, and physically challenged women are also important areas.
The advantage of examining health problems from a feminist perspective is that the nurse assesses the impact of illness on the client and what that means to her as a woman, given how women have been socialized in present American society. For example, men are counseled regarding sexual functioning postcoronary. How many women clients receive the same attention?
Clinical experiences include students following a caseload of clients with specific health problems to develop expertise in the area. As a nurse specialist, the student initiates contact with clients while working in ambulatory care, following the client as a primary nurse. If clients need hospitalization, the student consults with nursing staff, provides client and staff education, coordinates interdisciplinary care, and follows the client after discharge.
As content in practice courses moves from common health problems to acute and chronic illness, advocacy for clients should be addressed. Options in care, ethical issues, and issues of control become more complex. Collaboration with other health professionals and alternative approaches to health cannot be ignored. As a primary advocate for clients, the nurse must be attentive to their perspectives and needs. Understanding what illness means to the client and how it affects her life are essential variables. Consequently, students should gain experience in attaining expertise of "getting into the other's experience" through listening and counseling laboratories.
A course in alternative healing is a nice adjunct to the practice courses. The interrelation of mind-body in health and illness is an important concept for all health professionals. Incorporating techniques of meditation, progressive relaxation, guided imagery, and therapeutic touch are useful for students.
A women's issues cognate is particularly important in the curriculum, in order for students to understand how women's experience, in all aspects of society, has been neglected. Feminist theory, as a critique modality, is introduced early in the program, in order for students to become politicized towards feminist practice. Faculty should engage students in a systematic critique of society from historical, sociological, psychological, and political perspectives. Emphasis on the historical roies of women and the influences of these roles on women's health as well as health care can be viewed across the life cycle. This approach lends to the identification of health concerns of women from birth through old age, and modalities for change. For example, as students critique social roles and read gender role research articles, they are able to identify weaknesses in classic research that negate women's experience. The message to students is loud and clear: we are only beginning to consider women's lived experience and research must be conducted anew to explain it.
The research sequence is essential to the curriculum since the graduates will be generating the new research of women and their health. As a preliminary step, students master skills in research critique in order to examine traditional studies. Through consideration of the social context in which research has occurred, students appreciate how the social and physical sciences have been the validation of male experience. The imperative then is to explicate the new paradigm of women through research that incorporates a new perspective based on women's experiences, not the constructs of male science.
Students gain expertise in both quantitative and qualitative methods; however qualitative research can be the method of choice in explaining the lived experience of women. It is argued that the methods of modern science have distorted matters, because in the quest for objectivity, researchers have distanced themselves from the persons being studied, denying access to the person's experiences. This approach in the quest for objectivity can (and has) led to inaccurate findings (Reinharz, 1984). Qualitative methods can access the researcher to the person's experience through the use of participant observation, small sampling and in-depth interviewing, as well as other designs. Exploratory studies and pilot surveys to collect basic data will begin to build the data base for theory development in women's health.
Feminist research methods, while qualitative in nature, focus on women-related research questions. Feminist approaches analyze conditions of women's lives, delineate the causes and consequences of women's oppression, and paramount, gather data to formulate theory that wili improve women's state (MacPherson, 1983). Feminist research, however, cannot be confined to academia. Students and faculty alike must take the responsibility towards praxis - women being actively involved in their health care. Without sharing research in professional journals, as well as lay magazines, the very people that we are trying to reach will be ignored.
Women's health is increasingly recognized as a distinct area of nursing practice. The response of nursing to feminist activists in the women's health movement has been to recognize the subjugation of women in the medical care system, and to begin to address new models for addressing women's health. These new worn en -centered models recognize the lack of holistic care traditionally available to women, encourage women's participation in health care, and empower women towards self-determination.
Graduate programs in women's health will produce nurse feminists capable of engaging in clinical practice, research, and theory development that will be on the cutting edge of improving the health of women. These nurse specialists will bridge the gap between feminist activists and traditional medicine and can begin to create changes in the delivery of health care to women.
- Barry K. (1983). Feminist theory: The meaning of women's liberation. In B. Haber (Ed.), Women's Annual (pp. 55-78). Boston: G.K. Hall.
- Barry, K. (1984). Female sexual slavery. New York: NYU Press.
- Chinn, P.L., & Wheeler, C.L. (1985). Can nursing afford to remain aloof from the women's movement? Nursing Outlook, 33(2), 74-77.
- Choi, M.W. (1985). Preamble to a new paradigm for women's health. Image, XVII(1), 14-16.
- Dunbar, S.B., Patterson, E., Burton C., & Stukart, G. (1981). Women's health and nursing research. ANS, 3(2), 1-16.
- Ehrenreich, B., & English, D. (1973). Complaints and disorders: The sexual politics of sickness. Old Westbury, NY: The Free Press.
- Jaggar, A.M. (1983). Feminist Politics and Human Nature. Sussex, England: Rowman & Allenheld.
- Keohane, N.O., Rosaldo, M.Z., & Gelpi, B.C. (1982). Feminist theory: A critque of ideology. Chicago: University of Chicago Press.
- MacPherson, K.I. (1983). Feminist methods: A new paradigm for nursing research. ANS, 5(2), 17-24.
- McBride, A.B., & McBride, WL. (1981 ). Theoretical underpinnings for women's health. Women and Health, 6(1/2), 113-119.
- Millet, K. (1970). Sexual politics. Garden City, New York: Doubleday.
- Mulligan, J.E. (1983). Some effects of the women's health movement, Topics in Clinical Nursing, 4(4), 1-9.
- Reinharz, S. (1984). On becoming a social scientist. New Brunswick, NJ: Transaction.
- Ruzek, S.B. (1978). The women's health movement: Feminist alternatives to medical control. New York: Praeger.
- Smith-Rosenberg C. (1984). The female world of love and ritual: Relations between women in 19th century America, In J.W. Leavitt (Ed.), Women and Health in America (pp. 70-89). Madison, WI: University of Wisconsin Press.
- U.S. Department of Health and Human Services. (1985). Report of the Public Health Service Task Force on Women's Health Issues, Vol. I. Public Health Reports, KKKl), 73-86.
- Woods, N.F. (1982). Women's health: Perspectives for nursing research. Nursing Clinics of North America, 77(1), 113-119.
- Woods, N.F. (1985). New models for women's health care. Health Care for Women International, 6 193-208.