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Feminist leadership throughtotal quality managementMarilyn Lewis Lanza RN, DNS, CS aa Associate Chief, Nursing Service for Researchand Quality Management , Edith Nourse RogersMemorial Veterans Hospital , Bedford, MA,01730, USAPublished online: 14 Aug 2009.

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FEMINIST LEADERSHIPTHROUGH TOTAL QUALITY MANAGEMENT

Marilyn Lewis Lanza, RN, DNS, CSNursing Service for Research and Quality Management, Edith Nourse Rogers

Memorial Veterans Hospital, Bedford, Massachusetts, USA

Feminist leadership in nursing can be achieved through Total Qual-ity Management. Total Quality Management (TQM) is a philosophyand technology that represents the foundation of a continuouslyimproving organization. The feminist leadership ideas practiced bynurses, such as empowering staff and decision by consensus, arealso central to TQM. Feminist leadership utilizing TQM enablesemployees to creatively contribute to the system without fear orintimidation. Employees at all levels in the organization are thenempowered. The role of the feminist leader using TQM is one offacilitator rather than authority figure. Feminist leadership in nurs-ing can spearhead the opportunity for improvement to providehigh-quality, cost-effective health care in a troubled and complexeconomic environment.

Feminist leadership in nursing can be achieved through Total QualityManagement (TQM). In fact, feminist leadership and TQM have muchin their respective processes in common. This article explores feministleadership, TQM, and how both can be integrated in nursing.

FEMINIST LEADERSHIP IN NURSING

Feminist leadership is familiar to nurses if not by name, then by theelements they recognize. Although nurses may or may not be able toarticulate feminist leadership as a theory, many nurses practice at leastportions of it on a daily basis. A review of the literature of feminist lead-ership reveals how it applies to nursing practice.

Received 20 September 1993; accepted 20 January 1994.Address correspondence to Marilyn Lewis Lanza, Associate Chief, Nursing Service for

Research and Quality Management, Edith Nourse Rogers Memorial Veterans Hospital,Bedford, MA 01730, USA.

Health Care for Women International, 18:95-106,1997 95Copyright © 1997 Taylor & Francis

0739-9332/97 $12.00 + .00

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Gender Differences in Use of Power

The U.S. population is 51% female, yet women are vastly underrepre-sented in significant positions of leadership. For example, only 6% ofgovernors, 2% of senators, and none of the heads of standing congres-sional committees are women (Ciabattari, 1996; Logan & Howard,1992). Nurses, of whom a vast majority are women, are employed by andrelate to a traditional patriarchal power system.

Melia and Lyttle (1986) described gender differences in assumptionsand approach to the workplace that are unproductive for women in amale-dominated system. Whereas nursing embodies the value of caring,the system in which most nurses work values economic efficiency andhigh-tech cures.

Miller (1976) noted that men and women often relate differently topower, with the masculine model demonstrating power-grabbing andwielding it over others, while the feminine model is one of power-shar-ing. Power-grabbing involves holding power close to oneself andenhancing one's relative power by taking power from others. It is"power over" someone (Hall, 1992; Rowan, 1984). Power-sharing, onthe other hand, connotes sharing one's influence with others. An exam-ple of power sharing is Barrett's (1988, 1990) theory of power usingRogers' (1980, 1990) Science of Unitary Human Beings. The theory ofpower is characterized by awareness, choice, freedom to act intentionally,and involvement in creating change. These characteristics are congruentwith concepts basic to the feminist ideology, which seeks to amplifywomen's freedom and choice.

Feminist Qualities of Empowerment

Benner (1985) warned that nurses who define power or nursing exclu-sively in traditional masculine or feminine terms are making a gravemistake. To adopt a definition of power that excludes the power of caringdoes not gain the power of self-determination. Adopting coercive, domi-nating notions of power or strictly public-relations approaches abandonsthe values and commitments required for powerful caring and excel-lence; it adopts the pathologies inherent in a unipolar view. Empower-ment is the antithesis of this view.

Benner (1985) identified six different qualities of power in nursing:transformative power, integrative caring, advocacy, healing power, par-ticipative/affirmative power, and problem-solving power.

The feminist ideas of Wheeler and Chin (1989) detailed effectivepower as empowering, rather than threatening and coercive. Feministpower is derived from self-awareness, responsiveness to others, a focus

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on consensus, and a desire for growth. The feminist alternatives arefamiliar to nurses, but nurses are not accustomed to thinking of them aspower because of experiences and learning in the traditions of the patri-archal power model (Wheeler & Chin, 1989).

A feminist model of empowerment for increasing the power and polit-ical involvement of nurses was presented by Mason et al. (1991). Thismodel is consistent with espoused nursing values and hence appropriateto use in altering the traditional, paternalistic health care system whichnegates these values (Allen, 1984; Mauksch & Campbell, 1985; Reverby,1987). This model for political action and empowerment involves thedevelopment of three dimensions: (a) raising the conscious of sociopolit-ical realities; (b) positive self-esteem; and (c) political skills needed tonegotiate and change the health care system.

Supporting this feminine style of leadership is the exploratory studyof Muller and Cocotas (1988). They examined the professional experi-ences of nationally prominent female leaders in Washington, DC, whohave recently been at the forefront of changing national health policy.The leadership style of these women differed from the traditional mas-culine style. The female executives characterized their managementstyle as participative, person oriented, grounded on facts and compe-tence, and politically astute. They combined a personal, collaborativeorientation to managing people with a rational, objective approach tomanaging tasks.

TOTAL QUALITY MANAGEMENT (TQM) IN NURSING

A definition of quality is fitness for use (Juran, 1988, 1989). Qualityconsists of those product features that meet customer needs (Juran,1989). Product is the output of any process and includes goods and ser-vices. A customer is anyone who is affected by the product or process(Juran, 1989). Managing for quality is carried out through a trilogy ofmanagerial processes: quality planning, quality control, and qualityimprovement (Juran, 1988). In health care, the product is the professionalservice (e.g., psychotherapy) that nurses (or other professionals) provideto customers (i.e., patients).

TQM is the buzz word of the moment. Most health care institutionsnow say they are "implementing TQM" or Total Quality Management.According to national expert Donald Berwick (1992), TQM may mistak-enly be seen as a fad. People are learning terms, not methodology. Ittakes 10 to 20 years to accomplish the change to TQM (Berwick, 1992).Added institutional pressure comes from the fact that the Joint Commis-sion on Accreditation of Health Care Organizations (JCAHO) has placedits "agenda for change" squarely within the philosophical context of

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98 M. L. Lanza

TQM (Ente, 1989) and the 1997 JCAHO standards (1997) are based onTQM.

TQM is a philosophy and set of guiding principles that represent thefoundation of a continuously improving organization. It is the applicationof quantitative methods and human resources to improve the material andservices applied to an organization, all the processes within an organiza-tion, and the degree to which the needs of the customer are met, now andin the future. It integrates fundamental management techniques, existingimprovement efforts, and technical tools under a disciplined approachfocused on continuous improvement (Deming, 1982, 1986; Juran, 1989).

Berwick (1989) concluded that problems, and therefore opportunitiesto improve quality, are usually built directly into the complex productionprocesses, and that defects in quality can only rarely be attributed to alack of will or a benign intention among the people involved with theprocesses. Even when people are at the root of the effects, the problem isgenerally not one of motivation or effort, but of poor job design, failureof leadership, or unclear purpose. Berwick (1989) further concluded thatquality can be greatly improved when people are assumed to be tryinghard already and are not accused of sloth. Fear of the kind engendered bythe disciplinary approach poisons improvement in quality, because itinevitably leads to dissatisfaction, distortion of information, and the lossof the chance to learn.

Real improvement in quality depends on understanding and revisingthe production processes on the basis of data about the processes them-selves. The theory of continuous improvement works because of theimmense, irresistible quantitative power derived from shifting the entirecurve of production upward even slightly as compared with a focus oneliminating or reducing the extreme cases (Berwick, 1989). Berwick(1991) outlined the basic principles of TQM applied to health care. Hehighlighted the work of Deming and Juran by emphasizing the impor-tance of giving freedom to the staff to act with creativity and authorityand focusing on the system, not the employee, for problems.

Important Elements of TQM for Nursing Leaders

The continuous improvement process begins with top management.Managers learn to use their own expertise and judgment not to controlbut to coach employees' talent and knowledge. Managers rely on the par-ticipation and teamwork of their employees to prevent errors before theyhappen rather than correcting them after the fact (Deming, 1986).

Removing intimidation as a management style releases people to ques-tion long-standing policies or procedures and bring up new ideas in thesearch for better performance. Interdisciplinary teams strive to improve

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processes by focusing on problem prevention, elimination of waste, andfulfillment of customer needs.

The focus of TQM is (a) the process, not the person, and (b) the cus-tomers whose needs are to be met, which includes patients, their families,as well as health care providers (Andrews, 1991). Commitment to qualitythroughout an entire organization can be accomplished by attacking thesystem, not the employee (Crosby, 1979; Deming, 1982, 1986; Juran,1964, 1979, 1989). Quality issues are most effectively addressed byexamining the operational process, not simply looking for someone toblame. Blaming does not solve the problem, it simply changes the focusof attention.

Empowerment is a central concept in TQM. It is the process of releas-ing the expression of personal power (Burns, 1978). Because personalpower is already present within the individual, empowerment is not a giftone gives to another individual. Power is released by removing the bar-riers that prevent its expression (Bell & Zemke, 1992). The assumptionis that a worker will put forth his or her best effort only if the work has apersonal meaning.

Empowered organizations set high goals and hold members account-able for the results. At the same time, they give employees a high degreeof freedom and devote resources toward meeting organizational goals(Boyadjis, 1990). An empowered organization encourages people to takerisks, enabling them to grow and succeed. An empowered organizationbuilds a culture that attracts and develops people with superior capabil-ities, enabling them to achieve outstanding results (Bell & Zemke,1992). It increases individual responsibility, discretion, and autonomousdecisionmaking. An empowered organization releases an individual'screativity and potential by providing him or her with the freedom to act.It encourages employee commitment, risk taking, and innovation and itinvests substantial responsibility in the people who implement the solu-tions to problems.

Leaders who move their organization from a traditional posture toone that embraces TQM must understand (a) the essential concept ofempowerment as applied to all employees, (b) the change in role of thetop manager from authority in a hierarchy to facilitator of employees'strengths and skills, and (c) the steps involved in change beginning withthe cultural assessment of the institution, resistance, and the process oftransition.

Few organizations would admit not promoting members' abilities ornot setting high goals to which members are held accountable (Boyadjis,1990). Few managers would claim to discourage professional or personalgrowth among subordinates. Similarly worded values appear in mostorganizational mission statements that managers use to set department

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goals. Significant differences exist, however, between empowered groupsand those not empowered. These differences are primarily in what peoplewithin the organizations think about themselves and others (Boyadjis,1990).

Managers in empowered organizations pay more than lip service tothese beliefs (Boyadjis, 1990). Empowered managers devise ways tomake employees' jobs meaningful and productive (Boyadjis, 1990).

The Pygmalion effect, or law of self-fulfilling prophesies, holds thatmanagers' expectations for performance and their treatment of associateslargely determine associates' performance and career progress (Livings-ton, 1969). The key to communicating these expectations lies not somuch in what is said as in how a manager behaves. Empowerment man-agers place high expectations on their own performance as well.

Traditionally, managers and supervisors are problem-solvers and tech-nical experts (Boyadjis, 1990). In empowered organizations, managersbecome facilitators, keepers and distributors of information, and guides.They create communication mechanisms that allow workers to ask ques-tions. Facilitating may involve personal coaching, encouragement, or act-ing as a liaison for a work group with other groups or managers to allowfor the best team performance. According to the 1997 JCAHO standards(1997), effective leadership defines and establishes a clear vision forwhat the organization can and should become, encouraging staff to par-ticipate in the development of this vision. Effective leadership developsleaders at every level of the organization who can help to fulfill the mis-sion and vision of the organization.

Every organization is also a human society. Before launching into anextensive effort of motivation for quality, upper managers are advised tocommission a survey to determine the state of the cultural pattern and itsimpact on quality (Juran, 1989). The cultural pattern is a body of beliefs,habits, and practices that the human population has evolved to deal withperceived problems (Juran, 1989). The cultural pattern is the actual moti-vator of human behavior in the company relative to the attainment ofquality.

Managers must deal with cultural resistance. A clash of cultures ariseswhen the advocates for change present new ideas to the recipient society.The recipient society examines the proposed change from the followingstandpoint: What threats does this change pose to the cultural pattern ofthis society? The cultural pattern of the recipient society includes suchvital matters as status, beliefs, and habits. Often, these take precedenceover organization rules.

The advocates for change focus their attention on the technologicaland managerial benefits of the intended change. Often advocates fail toconsider the impact of the change of the cultural pattern. Some advo-

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cates are unaware of the importance of or even the existence of a culturalpattern.

Four Stages of Transition

Manz et al. (1990) have identified four transition stages that managersand supervisors traverse during implementation of employee empower-ment.

The first stage is suspicion, uncertainty, and resistance. In their study,many supervisors felt threatened and resentful about the change. Theyreported feeling that the change somehow involved punishment for pastpersonal failings and disbelief that the workers would be able to do theirjobs without direct supervision.

The second stage is gradual realization of the positive possibilities.The supervisors gradually realized that line authority over a worker doesnot necessarily equate with behavioral control. The supervisors graduallyassumed the role of resource to their teams and formed teams of theirown.

The third stage is defining the new role. As part of the transition inthe organization, supervisors and managers formed self-directed workteams to define the roles they would play in the new climate. This gener-ated understanding and ownership among the supervisors and managers,and their groups then negotiated the behaviors they would like the man-ager to exhibit within those roles.

And the fourth stage is learning one language. During the managers'training, they participated in role plays to rehearse appropriate newbehaviors. They outlined and practiced their new approaches to theirworkers, from studying the effect of certain words and tones with variousindividuals to how others in the group would react to the situation. Thediscussion dealt with physical arrangements, word choices, sequences ofdialogue, and even audience expectations and reactions. The role playsallowed the managers to establish the boundaries of their new roles, pro-duce plans to act out when faced with difficult situations, and take thetime to consider their work teams' reactions. The involvement of man-agers and supervisors needs to begin as soon as a decision to empowerworkers is made. Forming work groups to develop their roles under thenew system is a powerful tool in gaining management and supervisorysupport.

FEMINIST LEADERSHIP AND TQM IN NURSING

TQM provides an opportunity for feminist leadership that is theessence of current nursing leadership ideology. In a recent study Caroselli

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(1992) found a positive relationship between feminism and power definedas "freedom to act intentionally."

Process of Empowerment

Empowerment of employees is a central process of both feminist lead-ership and TQM. Nursing can look to what it has learned from its ownhistory to be able to lead empowerment. The process of empowermentthat has emerged from the experience of other powerless groups providesa framework of action that nurses can use. Essentially this process hasthree stages (Attridge & Callahan, 1989).

The first stage is consciousness training. Group members learn to rec-ognize and value their own unique characteristics. They applaud theknowledge and expertise of their own members and gain power, not byassociation with those in the dominant group, but by forming liaisonsand increasing their visibility. The role of support is crucial in stage one.All members are the target for empowerment rather than an elite few.Here, knowledge or expert power and referent power (with reference toassociation with each other) are the sources of power. Knowledge takeson special meaning. It refers not only to the knowledge that guides thepractice of nursing but also to the belief that what nursing does is uniqueand irreplaceable.

In the second stage, often labeled coalition building, the cohesive butstill oppressed group can begin to strengthen another source of power,numeric power. Confident that its members speak together, it can reachout and form relationships with other groups and individuals who sup-port its cause.

The third stage is one of transformation and may occur gradually or,as is the case with some political revolutions, abruptly and violently.Here the values and goals of the oppressed group and their allies perme-ate or are thrust upon the dominant culture and become dominant them-selves.

The integration of feminist leadership and TQM can result in manypractical and cost-saving advantages. When employees are empowered tosolve a problem, self-esteem is heightened and there is less resistance.They accept as their own a problem and direction to find a solution,rather than resisting an idea imposed by administration. Resistance canresult in lowered productivity and a lack of commitment to the organiza-tion's goals.

One example that demonstrates the contrast of outcomes between atraditional leadership style and a feminist leadership style using TQM isone frequently faced by hospitals, where costs are reduced by eliminatingnursing staff positions. With the traditional hierarchical approach, specificpositions would be targeted and the staff informed. Reactions might be

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overt resistance through union demonstration or "sick outs," or the moreinsidious apathy. With the feminist leadership approach using TQM, thestaff would be informed of the institution's financial problems whichnecessitated reducing the cost of staff. The staff could be empowered toexplore the problem and possible solutions. They then could study andevaluate the implementation of their solution. In this way, they are partof the process and not simply the victim of it. They can often offer cre-ative solutions and find ways to diminish the use of human and materialresources.

The overt message as institutions approach TQM is to abandon thetraditional model of paternalistic or hierarchical management in favor ofone that empowers the employee and makes decisions by consensus. Topmanagers become leaders and coaches rather than authoritarian heads ofbureaucratic institutions.

Feminist leadership can be achieved through the TQM movement;however, one must be cautious, observant, and somewhat wary. Whilethere is much pressure to implement TQM, it is naive to think that thosein the highest level positions will relinquish their power easily. Top man-agers did not arrive at those positions by chance. It is an easy assumptionthat there is something about the power or prestige of the position that ishighly attractive. It may be that the top managers will embrace TQM atboth the overt and covert level; however, the possibility exists that TQMwill be employed only on the surface while the traditional system remainsin full power. This is the basis of the warning from Don Berwick (1992)that TQM can be seen as a fad, with staff learning terms but not method-ology.

Despite the warnings, nurses can be active in the opportunity forimprovement to implement feminist leadership through TQM. The defi-nition of power offered by Barrett (1990) as the capacity to participate inthe process of change captures the essence of feminist leadership. It isalso the central tenet of the TQM process of empowering the employeeand the process of decision by consensus (Scholtes, 1988).

Recommendations

The following are recommendations for nurses who wish to institutefeminist leadership through TQM:

1. Become familiar with the feminist theory and TQM philosophyand technology.

2. Survey institutions on a formal and informal basis about theirintent to institute TQM. The formal survey includes talking to topmanagers and looking at institution Mission Statements and QualityManagement Plans.

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The informal survey is obviously more difficult. Network with col-leagues and talk with staff. What is their perception about theeffect of TQM involving them?

3. Outline how your ideas of leadership by consensus are central tothe accomplishment of TQM.

4. Present your ideas to top management in your role as current orpotential administrator, educator, consultant, or simply participantin TQM.

5. Evaluate the impact of TQM on the health care institution.

Many approaches are possible. For example, on a global level, affectingthe entire institution, the nurse could evaluate the level of patient satis-faction (external customer) with the care they received and staff satisfac-tion (internal customer) with the care they provided, both before theimplementation of TQM and at various points in the development of theTQM program. The design is a quasi-experimental time series design.

On a more specific level, the impact of a particular process actionteam could be assessed on the outcome of patient care. For example, if aproblem with assaultive behavior was identified, a process action teammight be formed to study the problem and make recommendations for anintervention such as specific staff training on aggressive behavior. Acomparison of the rate of assault by patients on wards where staff didand did not receive the training would then be possible. Measuringassault rates on wards before and after training could also be an indicatorof the effectiveness of the intervention.

It is important to be sure in performing any evaluation, that the indica-tor is derived from the standard of care. The standard must be realistic,understandable, measurable, believable, and achievable (Katz & Green,1992). Indicators, a quantitative measure that can be used as a guide tomonitor and evaluate the quality of important patient care and supportservice activities, must have the attributes of validity, face validity, sensi-tivity, and specificity.

Validity: The degree to which the indicator accomplishes its purpose—the identification of situations in which the quality of care and ser-vices should be improved.

Face validity: The extent to which the indicator is intelligible—do themeasure and hypothesized relationships make sense to the informeduser.

Sensitivity: The degree to which the indicator is capable of identifyingall cases of care in which actual quality-of-care problem(s) exist.

Specificity: The degree to which the indicator is capable of identifyingonly those cases in which actual quality of care problems exist(JCAHO, 1990).

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REFERENCES

Allen, D. (1984). Division of labor by gender, professionalism and the control of nursingpractice. In S. Geiger (Ed.), Sex/gender division of labor: Feminist perspectives (pp.93-103). Minneapolis: University of Minnesota Press.

Andrews, S. L. (1991). QA vs QI: The changing role of quality in health care. Journal ofQuality Assurance, 13(1), 14-15, 38.

Attridge, C., & Callahan, M. (1989). Women in women's work: Nurses, stress, andpower. Recent Advances in Nursing, 25, 41-69.

Barrett, E. A. M. (1988). Using Rogers' science of unitary human beings in nursing prac-tice. Nursing Science Quarterly, 1, 50-51.

Barrett, E. A. M. (1990). Visions of Rogers' science based nursing. New York: NationalLeague for Nursing.

Bell, C , & Zemke, R. (1992). Managing knock your socks off service. New York:American Management Association.

Benner, P. (1985). Novice to expert: Excellence and power for clinical nursing practice.Menlo Park, CA: Addison-Wesley.

Berwick, D. B. (1989). Continuous improvement as an ideal in health care. New EnglandJournal of Medicine, 320(1), 53-56.

Berwick, D. (1991). Curing health care: New strategies for quality improvement. SanFrancisco: Jossey-Bass.

Berwick, D. (1992, April 4). Presentation to Governor's Advisory Commission onQuality Improvement. Boston, MA.

Boyadjis, G. (1990). Empowerment managers promote employee growth. Health CareFinancial Management, 44(3), 58-66.

Burns, J. M. (1978). Leadership. New York: Harper & Row.Caroselli, C. (1992, October 30). The relationship of power and feminism in female

nurse executives in acute care hospital. Paper presented at Sigma Theta Tau HonorSocieties' Alliance Nursing Research Conference, Salem, MA.

Ciabattari, J. (1996, October 20). He said, she said: Women executives and the gendergap. Parade Magazine, 20.

Crosby, P. B. (1979). Quality is free: The art of making quality certain. New York:McGraw-Hill.

Deming, W. E. (1982). Quality, productivity, and competitive position. Cambridge, MA:Massachusetts Institute of Technology, Center for Advanced Engineering Study.

Deming, W. E. (1986). Out of the crisis. Cambridge, MA: Massachusetts Institute ofTechnology, Center for Advanced Engineering Study.

Ente, B. H. (1989). Brief overview of the Joint Commission's agenda for change.Chicago, IL: Joint Commission on Accreditation of Health Care Organizations.

Hall, C. M. (1992). Women and empowerment: Strategies for increasing autonomy.Washington, DC: Hemisphere.

Joint Commission on Accreditation of Health Care Organizations. (1990). Primer onclinical indicator development. Chicago: Author.

Joint Commission on Accreditation of Health Care Organizations. (1995). Accreditationmanual for hospitals. Chicago: Author.

Juran, J. M. (1964). Managerial breakthrough. New York: McGraw-Hill.Juran, J. M. (1979). Quality control handbook. New York: McGraw-Hill.Juran, J. M. (1988). Juran on planning for quality. New York: The Free Press.

Dow

nloa

ded

by [

Tex

as A

& M

Int

erna

tiona

l Uni

vers

ity]

at 0

3:20

04

Oct

ober

201

4

106 M. L. Lanza

Juran, J. M. (1989). Juran on leadership for quality. New York: The Free Press.Katz, J., & Green, E. (1992). Managing quality: A guide to monitoring and evaluating

nursing services. St. Louis, MO: Mosby.Livingston, J. S. (1969, July/August). Pygmalion in management. Harvard Business

Review, pp. 82, 84.Logan, J., & Howard, A. (1992). The world according to he and she. New York: Dell.Manz, C. C., Keating, D. E., & Donnellon, A. (1990, Autumn). Preparing organizational

changes to employed self management. The Managerial Transition: OrganizationalDynamics, 19(2), 15-26.

Mason, D. J., Backer, B. A., & Georges, A. C. (1991, Summer). Toward a feministmodel for political empowerment for nurses. Image, 23(2), 72-77.

Mauksch, H. O., & Campbell, J. D. (1985). Political imperatives for nursing in a stereo-typing world. In Perspectives in nursing/1985-1987. New York: National League forNursing.

Melia, J., & Lyttle, P. C. (1986). Why Jenny can't read: Understanding the male domi-nant system. Saguache, CO: Operational Politics.

Miller, J. B. (1976). Towards a new psychology for women. Boston: Beacon.Muller, H. J., & Cocotas, C. (1988). Women in power: New leadership in the health

industry. Health Care for Women International, 9, 63-82.Reverby, S. (1987). A caring dilemma: Womanhood and nursing in historical perspec-

tive. Nursing Research, 36, 5-11.Rogers, M. (1980). Nursing: A science of unitary man. In J. P. Riehl & C. Roy (Eds.),

Conceptual models for nursing practice (2nd ed., pp. 329-337). New York: Appleton-Century-Crofts.

Rogers, M. (1990). Nursing: A science of unitary, irreducible human beings. In E. A. M.Barrett (Ed.), Visions of Rogers' science based nursing (pp. 5-11). New York: NationalLeague for Nursing.

Rowan, G. R. (1984, Spring). Looking for a new model of power. Women of Power, 1,67-68.

Scholtes, P. R. (1988). The team handbook: How to improve performance teams.Madison, WI: Joiner Associates.

Wheeler, C. E., & Chin, P. L. (1989). Peace and power: A handbook of feminist process(Publication No. 15-2301). New York: National League for Nursing.

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