beyond dualism: leading out of oppression

50 Nursing Forum Volume 41, No. 2, April-June, 2006

Blackwell Publishing IncMalden, USANUFNursing Forum0029-6473© Blackwell Publishing, 2006April/June 2006412

ORIGINAL ATTICLE

Beyond Dualism: Leading Out of Oppression


Karen Fletcher, RN, MN, CON(C)

PURPOSE:

To reexamine our beliefs about our

gender identity in order to identify new

possibilities for leading in nursing.

SOURCES OF INFORMATION:

Leadership is

complex. This article is the result of a lengthy

iterative process of exploring the empowerment,

image, leadership, feminist, and oppression

literature. All of this was distilled in the context

of the author’s experience as a nurse and nurse

leader.

CONCLUSIONS:

Moving beyond dualism creates

new possibilities for leading nurses out of

oppression.

Search terms:

Nurse

,

nursing

,

empowerment

,

image

,

leadership

,

feminism

,

gender

,

Strasen’s model

,

queer theory

,

conscientizacao

,

groundlessness

,

residing at

the border

,

human relationship

Karen Fletcher, RN, MN, CON(C), is Director, WinnipegRegional Health Authority Breast Health Center, Winnipeg,Manitoba, Canada R2H 3C3.

Introduction

Many people are aware that our current systemsno longer work. The unhealthy environment ofthe current healthcare system, with its continualrestructuring, with its shortage of nurses, and withits focus on disease, is not conducive for the fullpractice of nursing, with its focus on health, thehuman response to illness, and healing of people. In arapidly changing healthcare system, it is critical fornurses to feel they have the authority to deliverneeded care on their own initiatives. The practice ofnursing today has been strongly influenced by thehistorical development of the practice within hierar-chical, autocratic, oppressive institutions. This hasled to a struggle to maintain authority of nurses innurses’ hands and to fully claim our power as womenand nurses to influence the health and well-being ofthose individuals we care for. Nurses need powerand to be empowered in order to maintain thisauthority.

Yet, despite what we know, nursing is still

challenged by negative stereotypes and

nurses are not empowered—what we are

doing as nurses and nurse leaders does not

seem to be working.

There is a substantial body of knowledge aboutempowerment. Yet, despite what we know, nursing

Nursing Forum Volume 41, No. 2, April-June, 2006 51

is still challenged by negative stereotypes and nurses arenot empowered—what we are doing as nurses and nurseleaders does not seem to be working. I have come tobelieve that the way to lead nursing out of this oppres-sion requires reexamining our beliefs about ourgender identity as our notions of feminine and masculinecreate dualisms that limit our potential to change.Inherent in duality are concepts of good/bad, right/wrong. These dualisms have a significant impact onhow we view ourselves and the solutions we identifyto deal with our issues. The purpose of this articleis to examine how we might change how we thinkabout ourselves and identify new possibilities forleading in nursing.

Our thoughts and beliefs in turn influence

our self-image, our self-image influences

our actions, and our actions determine our

performance.

Changing How We Think About Ourselves

Environmental conditions and identity developmentare intertwined and react to each other. I think Strasen(1992) is correct when she suggests we are incapable ofacting differently from our self-image. She presents amodel that enhances our understanding of who we areand why we have the image we do (see Figure 1). Thisunderstanding, this self-awareness is crucial if we areto change how we think about ourselves, and how weact and perform.

There are a number of factors that shape ourthoughts and beliefs. Our thoughts and beliefs in turninfluence our self-image, our self-image influences our

actions, and our actions determine our performance.The factors that influence our thoughts and beliefs areexperiences, heredity, environment, gender socialization,and reference groups.

. . . nurses’ ready acceptance of medical tasks

and the increasing value placed on the

technical rather than on caring are examples

of adopting oppressive behavior patterns.

Influencing Thoughts and Beliefs: Experiences

Our experiences as nurses are intimately connectedto and inseparable from our experiences as womenand the traditional role and image of the nurse areexpressions of oppressed groups. “Oppressive ideologyis an integrated pattern of ideas, a system of beliefsthat characterizes unequal relations in a social systemby the use of power” (Kendall, 1992, p. 4). Roberts (1983)suggests that groups are oppressed when forcesoutside themselves control them. These controllinggroups have greater prestige, power, and status thanthe oppressed group. The characteristics of theoppressor become more valuable and the tendency is

Figure 1. Strasen’s Self-Image Model (1992).



for the oppressed group to absorb these values. Thismarginalizes the oppressed group and leads to self-hatred and low self-esteem (Freire, 1970). Hedin (1986)suggests that nurses’ ready acceptance of medicaltasks and the increasing value placed on the technicalrather than on caring are examples of adoptingoppressive behavior patterns. Also, the values ofnursing care are rarely recognizable in patient carebecause the values of the medical model are predomi-nant, typical in oppressed environments (Roberts, 2000).

The attributes of oppression, self-hatred, and lowself-esteem lead to horizontal violence as the oppresseddirect their frustration to each other rather than to theoppressor (Duffy, 1995; Freire, 1970; Roberts, 1983).Nurses engage in horizontal violence (Hedin, 1986; McCall,1996; Roberts, 1983) that includes overt and covertnonphysical hostility such as criticism, sabotage, under-mining, infighting, scapegoating, and bickering (Duffy).The experience of oppression creates an environmentwhere nurses are unable to support one another, whichcreates conflict and is reflected in the commonly heardphrase “nurses eat their young.” All of the nurses in astudy by McCall identified that they had experiencedoppression in their work, identified nursing middlemanagement as the prime perpetrators of horizontalviolence, and viewed medical dominance as the mostsignificant reason for continuing oppression.

Influencing Thoughts and Beliefs: Environment

Generally, nurses work in patriarchal medical insti-tutions controlled by men. Our environment is chal-lenging. Kanter (1977) argues that employee behavioris determined by the organizational structure ratherthan intrinsic character that determines work behaviorand that changing the structure of the work environ-ment will increase job empowerment. Kanter’s work isinteresting for nursing in that, if it is the organizationalstructure that determines organizational behavior,then the fabric of the job relationships can be changed,negative cycles can be interrupted, and healthcareorganizations can be changed. Laschinger and her

colleagues have developed a considerable body ofknowledge testing Kanter’s theory and exploring empow-erment from the perspective that empowerment fornurses can be facilitated by changing the environment.Laschinger and her colleagues have consistentlyfound that perceived access to the sources of power—information, support, opportunity, and resources—isrelated to position in the organization (Goddard &Laschinger, 1997; Wilson & Laschinger, 1994) and impactson many factors such as job strain and work satisfaction(Kluska, Laschinger, & Kerr, 2004; Laschinger, Finegan,& Shamian, 2001a), commitment to the organization(Wilson & Laschinger), emotional exhaustion/burnout(Laschinger, Finegan, Shamian, & Wilk, 2003), and trustin management (Laschinger, Shamian, & Finegan,2001b). The research also consistently identifies thatstaff nurses’ perceptions of their own empowermentare consistently low and nurse manager empower-ment scores are only moderate (Laschinger, Finegan,Shamian, & Wilk, 2001).

. . . employee behavior is determined by the

organizational structure rather than intrinsic

character that determines work behavior

and that changing the structure of the work

environment will increase job empowerment.

Influencing Thoughts and Beliefs: Reference Groups

Each individual has many other individuals whohave helped shape their thoughts and beliefs. Asnurses, one of the reference groups that we share incommon is our connection to each other through our


professional issues. One of our issues that impacts onour power is entry to practice, which is one of ourmost unrelenting internal challenges and sources ofconflict. Physicians, schoolteachers, clinical psycholo-gists, and physical therapists all increased their educa-tion requirements when the need for higher standardswas identified (Christman, 1998). Nurses have notdone this, yet the complexity of nursing today requiresincreased standards and requires nurses to be moreconcerned with why than how. Christman asks us toimagine how poor the quality of medical care, dentalcare, and other professional care would be if therewere as many layers of personnel and as much diversetraining as exists in nursing. The debate over entry topractice needs to end; a minimum of baccalaureatepreparation is required.

Influencing Thoughts and Beliefs: Gender Socialization

“The status of nursing in all countries at all timesdepends on the status of women” (Dock in Lynaugh,1980, p. 270). Gender has significant implications forthe roles, responsibilities, and capabilities of the indi-vidual. Nursing is intrinsically linked to the dynamicsof power that affect women in our culture (Clifford,1992). Our healthcare facilities are not gender-neutral;they are strongly patriarchal (Acker, 1990; Acker &Van Houten, 1974; Davies, 1995; Reverby, 1987).Because gender is a key part of the way we interact inorganizations, it renders gender divisions normal,natural, and unremarkable. Acker and Van Houtenidentify the sex structuring in organizations consistingof differentiation of female and male jobs, which arehierarchically ordered with males higher than females.Contrary to what Kanter (1977) suggests, Acker andVan Houten found that sex power differentials mayhave a more profound effect than other organizationalvariables. They found differential recruitment ofcompliant women into jobs requiring dependence andpassivity and control mechanisms in organizations forwomen, which reinforce control mechanisms in society.

Our healthcare facilities are not gender-

neutral; they are strongly patriarchal.

Davies (1995) asks us to look critically at the con-cepts of masculine and feminine and the world createdby men that we live and work in. She suggests thatthere is a level at which we understand the power ofmasculinity but we trivialize it and fail to understandthe full implications of gender. This gendered groundis a reflection of broader societal devaluation ofwomen and the work they do. Austin, Champion, andTzeng (1985) investigated attitudes toward nursesacross 30 language cultures and found the concept“nurse” was consistent with the 1,200 ratings of theconcept “feminine”—both rated as good and activebut weak and not powerful.

The Feminist Perspective

Ashley (1980) suggests that nursing, because of itsgender issues, cannot be effective or self-directingwithout embracing feminism. The feminist perspectiveplaces women’s issues as central and is a processaimed at changing the nature and distribution ofpower in a particular cultural setting (Rodwell, 1996).However, because nursing is bound in an ideologybased on women’s duty and not on women’s rights(Reverby, 1987), feminist thinking has not been part ofthe culture of nursing (Kane & Thomas, 2000). Nurs-ing accepted patriarchy in the form of the medicalmodel. Nursing is an activity that enables medicalmen to gain power. For example, nurses are oftendescribed as the physician’s “eyes and ears.” Nurses“follow orders” and work in a system that often con-ceals nurses’ contributions. The unequal power ofnurses and physicians is a political act manifest ina simple act such as making the physician tea. The



ideals and values that construct nursing practice areinseparable from the identification of nursing as women’swork and the societal value placed on women and car-ing. Political and societal issues confine and constructthe realm of nursing practice and the identity of theindividual nurse (Hallam, 1998). Chandler (1992, p. 71)suggests that nursing leaders have gone from themedical model to the male business model “with narya blink of the eye.” She suggests nurses do not fiteither model and are closer to the relationally oriented,feminist model of empowerment.

The challenge with feminist views is that they stilluse male as the standard (Bowring, 2004). Our leader-ship knowledge is also based on values of masculinity(Calas & Smircich, 1991). Leadership is locked intogender and leadership behavior is anchored to genderidentity. Liberal feminism has had a large influenceon the study of gender and leadership by attemptingto discover whether there are differences betweenwomen and men leaders. Many studies encouragewomen to behave more like men and tie successfulleadership to societal ideas about appropriate beha-vior (Bowring). Helgeson (1995) studied how womenmanagers lead differently than men managers anddescribes what leadership can become when guidedby feminine principles. I think it is helpful, and per-haps necessary, to identify, and even rejoice in, ourstrengths as women living and working in a patriarchalsociety. This approach, however, continues to speak ofwomen and men as either side of an unbreakabledualism and still leaves us with three problems: (a) Itdoes not take into account individual differencesbetween women and men. (b) It measures womenagainst a male standard. (c) Stereotypes of feminineand masculine behavior become the basis of under-standing differences between women and men (Bow-ring). Feminist approaches tie female identity only tothe physical body. Bowring suggests that while weneed to hold on to the notion that identity is tied to thephysical body, at the same time, gender is not tied toour physicality in specific, unalterable ways. If allwomen are not the same and all men are not the same,

and gender is an important determinant of who weare, then there are infinite numbers of gender identi-ties that may be taken on. When we tie gender just tothe physical body, we are still in a dualism and con-strue the body as the foundation of gender. Butler(1993) questions this causality that a particular sex nat-urally leads to a particular gender, which naturallyleads to a particular sexuality. She suggests thatgender is neither natural nor foundational, but is aperformance. Butler suggests that gender/identity isalways changing and that we perform the gender wethink we ought to perform. Shifting our thinking inthis way can take us out of us/them thinking, out ofthe dualisms that leave us stuck in stereotyped beha-vior and limited by causalities that we take for granted.

Dualism is defined as the state of being

twofold and arises from the theory that the

universe has been ruled from its origins by

two conflicting powers, one good and one evil,

but both existing as ultimate first causes.

Beyond Dualism

Dualism is defined as the state of being twofold andarises from the theory that the universe has been ruledfrom its origins by two conflicting powers, one goodand one evil, but both existing as ultimate first causes(Hanks, 1979). A challenge with living in this place ofright and wrong is that it closes us down and createsfor each of us a variety of habitual tactics to approachour lives. We cling to a fixed idea of who we are, andit cripples us because nothing and no one is fixed


(Chodron, 2001). Crow (2003) suggests we are reluc-tant to abandon old ways of behaving because theyserve a purpose. We get security from defining our-selves on either side of the dualisms: good or bad,superior or inferior, worthy or worthless, etc.

Generally, we do not like to have our basic assump-tions questioned so even thinking about residing in aplace where we are not defined, not “in control”(Gunden & Crissman, 1992), that is not either/or, canbe scary (Chodron, 2001). This place has been describedin a number of ways that can be helpful to our under-standing. The Buddhists call this place of “nothingto hold on to,” a place and state of groundlessness.This groundlessness is characterized by flexibility andopenness and it is suggested that holding on to any-thing, scrambling for any ground, blocks wisdom.Crow (2003) calls this place residing at the border anddescribes it as a space between the past and the futurethat is uncomfortable but that is an essential character-istic of innovative leaders. He suggests that nursingleaders need to move away from binary thinking becausethe answers to meaningful situations are rarely blackor white, good or bad. Butler (1993) introduces queer-ing theory to move away from the dualism in femi-nism that measures women against men, and thatties women to their biology. Bowring (2004) suggestsqueer theory can bring a new way of thinking andbecoming to management. Queering creates a certain“nervousness” about words, about practices, and aboutthe relationship between them. A nervousness aboutcategories makes something incomprehensible anduncontrollable, and can be useful for making fluidwhat was seen as foundational. Dualisms have con-strained leadership research and practice. Becomingnervous, groundless, residing at the border moves usout of dualisms and creates new possibilities so wecan stop comparing women to men, study peoplewho also happen to be leaders, and break away fromthe stereotypes that have imprisoned both womenand men (Bowring). Operating beyond dualism with-out the stereotypes, it would also be difficult to ascribedifferential values to feminine and masculine behavior

(Bowring). The problem is not with the beliefs them-selves but with how we use them to feel right andmake someone else wrong, how we use them to avoidfeeling the uneasiness of not knowing what is goingon (Chodron, 2001). Bowring suggests that only whenwe stop thinking of women and men as tied to dual-isms will they be truly free to express themselves andto become whoever they wish, and will eventuallybecome.

Change

The challenge to residing at the border, in that ner-vous, groundless place, is that it is difficult for us to bein the moment (Chodron, 1997; Crow, 2003) and undoour habitual patterns of mind (Chodron, 1997). Funda-mental to learning how to move beyond dualismrequires understanding that change is all there is(Chodron, 1997; Ward, 1998). Health care is in a con-tinual process of change, which is really only a reflec-tion that impermanence is the essence of everything.So much of our suffering is based on our fear ofchange, so we deny that things are always changing(Chodron, 1997). We experience impermanence at theeveryday level as frustration, we expect that what isalways changing should be graspable and predictable(Chodron, 2001). We want permanence, yet we, andthe organizations we work in, are always in transition,nothing is static or fixed. To lead, in fact, to be fullyalive, we need to explore our own discomfort withchange to live, as we can, beyond dualism.

Leading Out of Oppression

The style of leadership in nursing has evolvedbecause as an oppressed group, societal forces haveshaped its leadership behavior. I believe movingbeyond dualism, residing at the border is fundamentaland changes how we think about leading. But how dowe do this? Two common threads that help us learn toreside at the border run through the leadership andthe oppression literature: dialogue and self-awareness.



Although both are intimately connected to each other,I will present each in turn first to see how they contrib-ute to our understanding of leadership.

Dialogue

Freire (1970) suggests that dialogue is the essence ofrevolutionary action and that the correct method ofleadership lies in dialogue. Communication is a keyissue in every organization (Ward, 1998). The purpose ofthis communication is not to impose our view but to dia-logue with others about their view, which reflects theirsituation in the world (Freire). Therefore, dialoguebegins with listening (Ward, 1998). In my experience,to truly listen is not easy; we are often formulating ourresponse before the other person has finished speaking.How often have we ever felt someone has given us theirundivided attention and really heard us?

It is an enormous challenge to speak and actwithout aggression and to not engage in criticism(Stanfield, 1997). Many people spend considerable timeblaming others for their mistakes or for justifying theirbehavior (Kowalski & Yoder-Wise, 2004). Chodron(1997) suggests that the place to start is to notice ouropinions, without labeling them right or wrong. Bypaying attention to our opinions, we can see how solidwe try to make things and how easy it is to get into awar in which we want our opinions to win and some-one else’s to lose. “Opinions are opinions, nothingmore or less” (Chodron, 1997, p. 110), and if we caneven for a moment let them go, we can come back tobeing present in our dialogue, we can reside at theborder with the potential to see and hear in a newway. I think it is important, when working in oppres-sion, to not perpetuate aggression by solidifyingthe sense of enemy. We can then move from an adver-sarial to a dialogue stance, which, in Theobald’s(2000) words, moves us from co-stupidity to co-intelligence. We abandon the dualism of good and badpeople, of friend and enemy, we seek collaboration,partnership and cooperation at every point (Stanfield,1999).

Freire (1970) suggests the revolutionary’s role is toliberate and to be liberated with the people, not to winthem over. The leader, then, moderates the dialogue tofacilitate the development of changed relationshipsthat are necessary to create new understandings in theworkplace (Porter-O’Grady 1992).

Self-Awareness

The Freirean concept of

conscientizacao

underpinsmuch of the healthcare discourse on empowerment.

Conscientizacao

refers to the learning to perceive social,political, and economic contradictions and to take actionagainst the oppressive elements of reality (Freire, 1970).It is a critical consciousness that is a search for self-affirmation and freedom. Freire maintains thatwithout a critical understanding of one’s reality, onecannot truly know that reality. For nurses it is impor-tant, then, to critically examine and understand ourcollective reality: our history, our oppression, and ourgender issues.

It is also suggested that the heart of today’sleadership is finding one’s self (Amendolair, 2003); self-awareness is identified by many as the key to empow-erment and leadership (Bennis, 1989; Goleman, 2000;Gunden & Crissman, 1992; Helgeson, 1995; Mahoney,2001; McBeth, 2003; Roberts, 2000; Sherwood, 2003;Ward, 2002; Swanson, 2000). This critical conscious-ness, therefore, needs to be examined and developed atthe individual as well as the collective level. There aremany ways that we can increase our self-awarenessand we each need to find a path or method that is appro-priate for each of us. Whatever the path or method, todevelop this awareness, we must do our personalwork, which is, actually, our spiritual work.

Dialogue and Self-Awareness: Human Relationship

In nursing, we expect nurses to use themselves asan instrument of care, to develop their ontological car-ing capacity, in their interactions with patients andfamilies. It is this relationship and connection that has


been identified by both nurses and patients as mostsatisfying and contributing to healing. Koerner (2000)suggests that in leadership, the person is the instru-ment. Leadership builds relationship (Ferguson-Pare,Mitchell, Perkin, & Stevenson, 2002) and leadinginvolves using oneself completely (Bennis, 1989), giv-ing of one’s spirit in a way that propels a reciprocalprocess as others give of themselves in return (Sher-wood, 2003). In this way, we use our collective praxis,our reflection and action upon the world, to transformit (Freire, 1970). However, only in this encounter ofindividuals with the revolutionary leader, in theircommunion and in their praxis, can the oppressedempower themselves to construct their liberatingaction (Freire). We use our humanness to beckon oth-ers to move together with us to greater heights andmore intense experiences of being human (Stanfield,1999) through our dialogue and our individual andcollective reflection. Freire reminds us that all criticalwitness, and engaging in meaningful dialogue, involvesthe daring to run risks. This includes the possibilitythat the leader will “not always win the immediateadherence of the people” (Freire, p. 177). Can ourminds and hearts be big enough just to hang out inthat space where we are not entirely certain about whois right and who is wrong (Chodron, 1997) and notneed to blame others for not seeing our vision orthinking differently than we do?

What Does This Mean?

I think it is easy, and understandable, when we seethe challenges we face as nurses and nurse leaders tofeel victimized and have a cynical outlook, and believethat no amount of effort will make our world more liv-able. Yet, we have seen that there is some possibilityfor change. We have seen that social structural factorsin the workplace are important conditions for empow-ering nurses to accomplish their work (Laschinger,Finegan, & Shamian, 2001a). Environmental condi-tions and identity development are intertwined andreact to each other (Roberts, 2000; Strasen, 1992). We

are incapable of acting differently from our self-image,which is determined by our thoughts and beliefs.Examining the influences that determine our thoughtsand beliefs has enhanced our understanding of whowe are and why we think about ourselves the way wedo. And, as we have seen, this self-understanding, thisself-awareness, is crucial if we are to change how weact and how we perform. Yet, if I frame this imagedevelopment, as I have been in terms of a positive self-image, I am back in the dualism of positive/negative,good/bad, of defining an ideal nurse image, thatan individual, if they do not meet this reality, is notgood enough. Queering the approach, residing at theborder, opens new possibilities. Our rejection of the oldstereotyped images then makes way for not one singlenew identity, but many images of what nurses are andwhat work they do. So rather than creating and lead-ing nursing in one right way, we honor our diversityand create a multidimensional profession (Koerner,2000). When we stop thinking of women and men astied to dualisms, they are able to put on the “drag”that suits and are truly free to express themselves(Bowring, 2004). Nursing leaders are then able to facil-itate the creation of environments and systems thatincorporate the greatest number of orienting frame-works and use this richness of diversity as a vehicletoward wholeness (Koerner).

The development of self-awareness through

reflection, in itself, can begin to break

the cycle of oppression and lead to changes

in the structures that oppress nurses.

The development of self-awareness through reflection,in itself, can begin to break the cycle of oppression and



lead to changes in the structures that oppress nurses.However, it is only through dialogue and engaging ina healing relationship that empowerment can occurand the movement out of oppression can be realized.Although the structure and context may change, theneed for shared vision and ongoing dialogue are vitalto the empowering organization (Schmeiding, 1993). Inthis way there is enough physical and emotional safetyto risk challenging the status quo (Kendall, 1992).

Nursing leadership, then, is one human

being connecting to another human being,

whether we are interacting with the

oppressed or the oppressor. It is that simple.

And it is that hard.

There is a danger in a discourse such as this, in anattempt to summarize, to try to minimize the chal-lenges in an attempt to provide closure and to moti-vate and encourage the reader. There is also a dangerof appearing to minimize the vast literature that offersmuch to our understanding of image, empowerment,and leadership by becoming too narrow or simplistic.Leadership is difficult. The tyranny of the urgent inhealth care is ever present and it can be difficult to cre-ate the space we need to reflect and dialogue. Chodron(1997) points out the perplexing tension between ouraspirations to engage in self-awareness and the realityof feeling tired and stressed out—the reality of beinghuman. So, I proceed with caution when I suggestthere is not one way or best way to lead. We need toknow who we are, engage in meaningful dialogue,lead from the heart to the best of our ability, andreside at the border. Residing at the border requires

that we bring our body, mind, emotions, and spirit,our full humanness, to our leadership. Residing at theborder takes us away from dualisms, from us versusthem, and away from “female skills” and “male skills”that create stereotypes that lock us into what isexpected. Residing at the border allows the leader to“hold the space for others to discover it themselves”(Koerner, 2000, p. 15). That space, as all space, issacred space.

Nursing leadership, then, is one human being con-necting to another human being, whether we are inter-acting with the oppressed or the oppressor. It is thatsimple. And it is that hard.

Author contact: [email protected], [email protected]; with a copy to the Editor: [email protected]

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