Le présent article examine la situation des infirmières en tant que groupe de pression selon deux perspectives : celle du conformisme des femmes aux stéréotypes sexistes traditionnels et celle de leur situation désavantageuse dans la hiérarchie de la structure d'organisation. Afin d'accroître le pouvoir de négociation des infirmières en matière politique, l'auteure puise dans les écrits pertinents et propose des modifications dans la structure des services infirmiers. Ces changements se fondent surtout sur une décentralisation hiérarchique ainsi que sur la création au sein des organismes, de groupes conjoints formés de membres du personnel ainsi que de l'administration. Ces groupes seraient chargés d'élaborer les politiques et les normes de la pratique infirmière dans les organismes de santé. Le sexisme que pratiquent les hommes qui obtiennent le pouvoir politique au Canada représente encore de nos jours une force importante qui influence les résultats de l'action politique des infirmières.

The 1970s witnessed a reawakening of the political consciousness of nurses. Not since the struggle for registration at the turn of the century has political action assumed so high a priority on the agenda of organized nursing groups. Fuelled by social and political forces such as the women's movement and the shift from entrepreneurial to political power in Canadian health services, organized nursing associations in Canada have begun to define themselves as political pressure or interest groups having a direct, continuous, and active role in influencing health policy.

The problem for most organized nursing groups in Canada is that their views on policy matters have rarely been heard and found plausible, much less accepted. The women's movement has helped to bring into sharp focus some of the fundamental causes. Most nurses are women, and the cultural conditioning and opportunities of women have been such to effectively exclude them from the corridors of power in our society.

If nursing is to keep up the pressure to have its interests better represented, it is important for nurses, individually and collectively, to be aware of some of the ways in which sexism contributed to their political inexperience and lack of political influence.

Politics and the Male-Female Sexual Dynamic
Politics in health care, as elsewhere, consists in exercising power, consolidating power, or effecting a change in power relationships - or put more crudely, working the system to advance one's interests.

In Canadian society, men, to a large extent, have appropriated the positions of power and authority in public life. Men have also controlled the production of ideas, images, and symbols by which social relations are expressed and ordered (Smith, 1975). It is men's perspectives which have determined which issues or problems are considered salient and whose views to credit or discredit. Further, the policies and procedures of most major social institutions have been built on male values and have been designed to protect and promote male interests (Wood, 1978-79).

Consequently, women who have sought access to traditionally male preserves have not been able to count on society for much encouragement or on the male power-holders for fair treatment. Indeed, until the mid-1960's, the social climate in Canada was basically hostile to the notion of women taking their fair share of political power. The accepted social norm was that politics and the holding of power were incompatible with "femininity" and the "nature" of women. The control of power was seen as requiring a high degree of rationality, objectivity, and stability, properties thought to be lacking or undesirable in females. Women who breached the boundaries of acceptable female behaviour by seeking or obtaining power were considered deviant, unnatural, disturbed, or utterly unhappy.

The strength of these social dictates has rendered problematic women's participation in even the most basic political act, the casting of a vote. Although the situation is changing, the finding that women vote less often than men is one of the most thoroughly documented in social science (Safilios-Rothschild, 1974).

Perhaps the most visible effect of the ideology that "politics is not for women" is the small number of females who have sought or won elective office. Based on the number of women elected to Canada's House of Commons to date, it has been estimated that it would take 842 years for women to achieve equal representation with men ("Emergence," 1980).

Negative images and beliefs about women and power are beginning to lose their deterrent effect as more women seek political office and individuals such as Flora MacDonald in Canada and Margaret Thatcher in Britain emerge as political superstars holding "blue chip" political posts. But there is still a long way to go. Available evidence suggests that in vital ways women in political life remain second-class citizens. The reasons may be found in the reciprocal effects of women's political socialization and the structure of political institutions.

Women's Political Socialization
In the nursing literature and in much of the research and writing on women in North America, the socialization paradigm is the most common way of explaining the difficulties women face on entering public life. This perspective also provides the foundation for popular repair programs for women such as assertiveness training and corporate political exercises described in best sellers like Games Mother Never Taught You.

The socialization paradigm takes as its starting point that male and female children are encouraged from birth to behave and think differently. For females, the object of socialization has traditionally been preparation for the private world of wife, mother, and housewife, and the characteristics assigned to females have included warmth and emotional expressiveness, dependence, submissiveness, and passivity. For men, socialization practices have been aimed at preparing them for public life where the achievement of success requires traits such as agressiveness, intellectual agility, and independence (Tavris & Offir, 1977).

Thus, according to the socialization paradigm, the traditional division of masculine and feminine roles has deprived women of an adequate political education, undermined their motivation to become politically active, and encouraged them to devalue both themselves and other women. That is, to the extent that women have adopted as a guide to life "the ideal female" stereotype, they have grown up psychologically and experientially handicapped for participation in mainstream political roles (McCormack, 1975).

The results of many studies of sex differences in political behaviour may be viewed as consistent with a socialization analysis. For example, in line with the sex stereotype that politics and femininity are incompatible, studies have generally shown that women are less interested, less informed, and less involved with voting than men (McCormack, 1975; Safilios-Rothschild, 1974). Another common finding in political studies is that women tend to vote more conservatively than men and are less inclined towards radical social changes and protests (Safilios-Rothschild). There is also considerable evidence that women vote as their husbands do, presumably using their vote to reassure their husbands of their "femininity" and superior knowledge and judgement in such "masculine" spheres (Safilios-Rothschild).

The tendency among women to undervalue themselves and to hold other women in low regard is apparently on the wane in North America (Tavris & Offir, 1977). However, the lingering effects of traditional socialization practices may be seen in the results of a recent Common Market poll in which about half of the men and over 80% of the women surveyed expressed a preference for male political representatives ("Fewer Women," 1980). In a similar vein, in a 1972 American study close to two thirds of the men and women sampled ascribed to the belief that "most men are better suited emotionally to politics than are most women" (Safilios-Rothschild, 1974). Canadian data from the 1960s cited in the Report of the Royal Commission on the Status of Women in Canada (1970) may be slightly more encouraging. Polls conducted by the Canadian Institute of Public Opinion in 1964 and 1969 have shown that a majority of respondents favoured women playing an important role in politics, including assumption of federal leadership positions. A greater obstacle to fuller participation of women in Canadian political life is the lack of confidence women have in their ability to influence politics. According to a 1968 study by Meisel, women have a very low sense of political efficacy in comparison to men (Report, 1970).

Research on women who have "made it to the top" in political life provides further evidence of women's conformity to traditional sex stereotypes. For example, studies have shown that women often take to the political floor less than men and use a different style in presenting their opinions. Their presentations and speeches tend to be restricted to feminine subjects such as family, health, housing, and children. On subjects considered areas of "masculine" competence - economics, national defence, foreign affairs, and so on - the voice of women has rarely been heard (Safilios-Rothschild, 1974).

Undoubtedly, the degree to which women have been socialized to live in a different world from men has played a part in producing the behaviours just described. However, as sociologist Jessie Barnard has noted, "emphasis on socialization merely offers an easy way out, it does not open doors" (Tavris & Offir, 1977).

It leads women to believe that the problem lies almost wholly within their own psychology and education; that women must somehow change if they are to be admitted to the decision-making and policy strata of society. As nurses frequently express it, "nurses are their own worst enemies." Mounting evidence suggests that a more adequate explanation of the obstacles to women in political life may be found in the disadvantaged organizational circumstances in which most women find themselves.

Structural Determinants of Women's Political Behaviour
The case for a structural explanation of the performance of women in public life has been most fully elaborated by Kanter (1977a). According to Kanter, the difficulties faced by women around issues of power and leadership are built into the dramatically different division of labour between men and women in most organizations. Typically, women are clustered at the bottom of organizational hierarchies; they occupy most of the lower-echelon positions having few prospects for mobility or the exercise of system-wide power. Kanter argues that it is these disadvantaged organizational circumstances, rather than sex differences or sex-role socialization, that define and shape the behaviour of and towards women in public life. From her analyses of large-scale organizations, Kanter (1977a) has identified three factors as critical in limiting the influence of women in decision-making and policy spheres: blocked opportunities for advancement; limited power to mobilize resources; and the problem of tokenism whereby women are kept "in their place" in situations where men vastly outnumber them.

Blocked Opportunity
Kanter (1977b) has found that in positions of blocked opportunity or little mobility, people - be they men or women - respond with various forms of disengagement such as depressed aspirations and self-image, lower commitment to work, and reduced feelings of competence. In contrast, in high-opportunity positions, people have high aspirations and self-esteem, value their competence, and engage in various forms of active change-oriented behaviour. In other words, blocked oppportunities create a vicious cycle: women tend to hold organizational positions offering limited opportunities for advancement and growth; being disadvantageously placed in the opportunity structure they lower their aspirations and orientations to accord with reality and so are less likely to be perceived as promotable.

Powerlessness
Kanter (1976, 1977a) contends that a similar interaction exists between the current distribution of men and women in the power structure of organizations and their leadership behaviour and political influence. As she notes, women have been handicapped by both their low-visibility, low-status positions in organizations and their limited access to the informal social networks, sponsors, and peer alliances which pervade organizational life (Kanter, 1976).

Thus, they tend to be caught in a self-perpetuating downward cycle of disadvantage. They are isolated from other power-holders and so, even if occupying a leadership position, may have little influence. Further, and probably more incapacitating, powerlessness has been shown to produce the rigid, controlling, authoritarian leadership behaviour caricatured in the "mean and bossy woman" stereotype (Kanter, 1976). Blocked from exercising power, powerless leaders substitute the satisfaction of lording it over others. Unable to move ahead, they hold back talented subordinates and restrict opportunities for their growth and autonomy. In turn, these behaviours provoke resistance and so contribute to a further restriction of power (Kanter, 1977a). Kanter (1977a) concludes: "Power issues occupy center stage, not because individuals are greedy for more, but because some people are incapacitated without it" (p. 205).

Tokenism
The third factor that Kanter (1977b) believes is critical in limiting the influence of women in decision-making and policy spheres is tokenism, a problem occurring in situations where women typically find themselves alone or nearly alone in a peer group of men. Such "skewed" groups not only perceive the token woman in a stereotyped way, but they also pressure her to behave in conformity with that stereotype.

In short, the dynamics of tokenism trap women in limited roles that give them the security of "a place" but with little choice about accepting the perspectives of the dominants. They find it hard to gain credibility; they face misperceptions about their role and competencies; they are more likely to be excluded from the networks by which informal socialization occurs and politics behind the formal system are exposed; and they have fewer opportunities to be sponsored. In a process analagous to the biological response to a foreign body, women become isolated both physically and symbolically. Thus, the dominant men are able to preserve their positions of eminence and power.

Structural Constraints and Political Influence
From the structural perspective just elaborated, it may be inferred that the political influence of women is restrained not so much by their own lack of political consciousness and skills, but because of the greater power that has operated against them. What scant research has been done on women's efforts to gain a stronger foothold in political arenas supports this contention. For example, in a rare study of the activities of women's organizations, Dubeck (1977) found that the influence of two elite groups in Cincinnati from 1920 to 1945 varied with the type of issue and the extent to which a shift in power was a part of that issue. As one might expect, efforts to solve social problems, especially in fields congruent with "feminine" interests, were most successful (although by no means all of such efforts were successful). Those concerned with power-related issues, such as government reorganization or the appointment of women to senior decision-making bodies, were least effective. A study by Vickers ("Emergence," 1980), a political scientist at Carleton University, also offers useful insights into ways by which women are kept "in their place" in political life by being nominated in low-opportunity constituencies. Her survey of 1,200 women who ran for elective office in municipal, provincial, and federal levels of government in Canada between 1945 and 1975 shows that 63% of the candidates contested ridings in which their party had not won in the previous five elections. It is also interesting to note the extent to which the opportunities afforded by familial encouragement and immersion in political communication networks have been virtually essential for the election of women to the Canadian House of Commons. Of the 18 women elected between 1921 and 1970, six were widows of former Members of Parliament and one was the wife of a former Member. Two of the widows were also daughters of former Members (Report, 1970).

Studies of interest-group activities in Canada provide further glimpses of the structural barriers to women in political life. As Hartle observes, "It is in the best interest of key actors in the legislative process to exclude some, perhaps most, interests from the process. The key question is, therefore, which interests do have access and why?" (Thompson & Stanbury, 1979, p. 38).

According to Thompson and Stanbury (1979), the policy system in Canada tends to give the edge to recognized interests, that is, groups possessing generous shares of political legitimacy among ministers, bureaucrats, and legislators and having prestige, wealth, organizational strength, and cohesion. They also note:

…the resistance of recognized groups and their bureaucratic sponsors to the recognition of new interests. Outsiders, interests that are not initially included in the policy-making or legislative process, must overcome the entrenched positions of those that are "close to the throne" if they are to win recognition for themselves. Furthermore, the barriers to group organization that can be erected by those having influence (recognized groups and their bureaucratic sponsors) are substantial, if subtle. (p. 38)

For nursing, a chastening demonstration of the exclusiveness of interest-group representation in Canada and the dynamics of maintaining it is provided, of course, by the medical profession. Indeed, Taylor (1960, 1978) has suggested that no other interest or pressure group has been so deeply involved in the initiation and execution of public policy and the use of pressure-group tactics to resist encroachment by other interest groups. This exclusiveness, especially in health care, is beginning to break down, however. With the advent of national health insurance and more recently the fiscal crisis in health care, medicine's degree of control over the delivery of services and the economic aspects of the system have come under direct challenge. More generally, concern over the narrowness of existing interest-group representation in Canada has led recent federal governments to open the legislative process to wider group representation (Thompson & Stanbury, 1979).

What does all this add up to in terms of nursing undertaking an enlarged political role in health care policy-making? What are the implications for nurses who might want to participate in the political process? How do they do it?

Mastering the Political Realities of Health Care
Nursing in Canada appears to be making significant strides in at least one important aspect of interest-group politics, namely communicating and building relations with public decision-makers. In other words, nursing has been successful in gaining a measure of recognition as a key interest group in health care (Mussallem, 1977).

But recognition does not necessarily mean effective influence. Even though government now consults nursing more regularly on policy issues, policy decisions with far-reaching implications for nursing services and nursing education are still being made without the input of nurses. Where input is sought and even where nursing's views on particular issues are accepted, there is a tendency to ignore nursing's policy solutions. This is illustrated by the long-term-care program introduced by the British Columbia government in 1977. It was largely through the pressure of organized nursing in that province that action was taken, but it is interesting to observe that while government accepted nursing's analysis of the need for such a program, they turned to more powerful interest groups to help decide on the program components (G. Parker, personal communication, March 2, 1978).

Noteworthy in this context is the degree to which sex-role stereotyping seriously constrains nursing's policy-influencing ability. Studies by Vance (1977) and Le Roux (1976) of the American nursing leadership suggest that stereotyped notions of nurses and what they do is a problem of significant proportions in the political domain. Although many nurses are now taking on independent and innovative roles in health care and a sizeable body of nursing research is accumulating, nurses are still widely viewed as merely executing physicians' orders. Their knowledge is downgraded in comparison to medical authority, even in areas where medicine has no demonstrable expertise.

This response does not differ greatly, of course, from the stereotyped reactions to women and women's knowledge wherein the sex of the person modifies the authority of their message (Goldberg, 1968). As sociologist D.E. Smith (1975) observes: "There seems to be something like a plus factor which adds force and persuasiveness to what men say and a minus factor which depreciates and weakens what is said by women" (p. 362).

Kanter's work (1976, 1977a, 1977b) suggests that it would be naive and politically hazardous to tackle the problem of sex-role stereotyping simply by attempting to bolster the persuasive powers of nurses or by cultivating a new public image of nursing. These strategies fiddle with effects rather than coming to grip with causes and so rationalize and maintain the existing power structure.

Though we have much to learn about the practical application of Kanter's model, her analyses underscore the importance of structural approaches to helping nurses gain greater political influence. Specifically, there is a need for strategies which take account of the structural forces that support stereotyping - blocked opportunity, powerlessness, and tokenism.

A first point of attack may therefore appropriately be the design of nursing services. Kanter (1977a) stresses decentralization or flattening of the hierarchy as among the more general and important strategies to adopt. As she points out, flattening the hierarchy has the virtue of increasing the number of leadership positions and adding to the visibility and power component of jobs. It also provides more persons with access to the power structure of an organization. Additionally, Kanter stresses the need for opening channels of communication and making system knowledge such as budget, salaries, and the minutes of certain meetings more routinely available for everyone.

Cleland (1978) advocates the use of collective bargaining as an effective process for bringing about some of these changes. Her strategy is built on the principle of shared governance, that is, the creation of joint staff administrative groups who have responsibility for determining the policies and standards of nursing practice within an agency. To Cleland, shared governance represents an important means of democratizing the workplace and providing a more attractive work setting for professionally motivated nurses. It is also an important training mechanism for the development of decision-making and political-influence skills. Further, shared governance brings nurses from various agency units into regular communication with each other and so provides the opportunity for the development of social-support networks in nursing. Given the numerical advantage nurses enjoy in most agencies, shared governance also has immense potential for giving nurses greater political leverage at the system level.

Nurses, especially in leadership positions, also need to be educated about the problem of tokenism and some of the strategies for overcoming it. Particularly important in seeking representation for nurses in policy and decision-making bodies is the support network that might be put in place to help the nurse representative in a skewed group. Certainly, in some circumstances a more effective means of providing nursing input may be through the numerical advantage of the delegation.

No doubt there are many other strategies that should be explored. The crucial point remains. If the nursing profession is to gain effective influence in policy-making, the coupling of structural or organizational approaches with individual initiatives is the first requirement of success.

References
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Dubeck, P.J. ( 1977). Influential alliances? Cincinnati women in the political arena, 1920-1945. In D.V. Hiller & R.A. Sheets (Eds.), Women and men: The consequences of power. Cincinnati: Office of Women's Studies, University of Cincinnati.

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* Reprinted from Nursing Papers, 1980, Vol. 12, No. 4, 6-16.