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WORKING WITH GENDER IN THE HEALTH CARE CONTEXT: ORGANIZATIONAL COMMUNICATION AND THE ENACTMENT OF IDENTITY

DISSERTATION

Presented in Partial Fulfillment of the Requirements for

the Degree Doctor of Philosophy in the Graduate

School of The Ohio State University

By

Marie B Garland, M A.

The Ohio State University 20 0 0

Dissertation Committee:

Professor Joseph J. Pilotta, Adviser Adviser Professor Mary M Garrett chool of Journalism and Communication Professor Dale E. Brashers Graduate Program UMI Number 9971552

Copyright 2000 by Gariand, Marie B.

All rights reserved.

UMI*

UMI Microform9971552 Copyright 2000 by Bell & Howell Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code.

Bell & Howell Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 ABSTRACT

Although instances of overall gender-based dominance in the health care field have been easy to document, gender-based discrimination, particularly as an ongoing facet of organizational life in this context, has been difficult to explain. I argue that the perspectives of communication scholars working in organizational contexts can provide such an explanation. This is possible because communication scholars can and do simultaneously examine the cultural and discursive constructions of gender and the everyday activity of organizational actors. In this dissertation, I show how organizational actors, through engaging in the communicative action made possible by organizational sense-making codes and against the backdrop of discourses of sexuality and professionalism, enact formations of gender. This enactment can support or resist the differential and discriminatory treatment of men and women in organizational contexts.

An ethnomethodological approach was take to analyze materials gathered through naturalistic observation, textual samples, audiotaped discussions, and focus group interviews. Specifically, the reflective narratives of nurses and components of a social awareness training program for first-year medical students were examined empirically.

Although the contours of the organizational codes for nurses and for first-year medical students differ in meaningful ways, the analysis shows that the discourses of professionalism and sexuality serve as both main cultural discourses for the research

ii participants and as communicative frameworks for gender enactment in health care settings.

The analysis presented here may be beneficial in substantial ways. First, the results can be useful in guiding discussions in future training and continuing educational experiences for health care providers. Secondly, the relationship between the discourses of gender and the sense-making codes of organizing that is developed theoretically and examined in the analysis opens new horizons for theorizing about the social and cultural impact of organizational action. Finally, the conceptualization of the relationship between organizational action, discursive structures, and the social actor's intentional relationship with 'Others’ has produced an initial formulation of a theory of gender enactment, a process that depends on communicative action.

Ill Dedicated to Kyle

IV ACKNOWLEDGMENTS

There are several people without whom this document may have never appeared, and whose spirits are, in one way or another, reflected in the contents of these pages.

I wish to thank my adviser. Dr. Joseph J. Pilotta, for giving me the puzzles I needed to solve out on my own. After seven years, I think I have unraveled half of them, at best, yet I look forward to the time I will spend wrestling with the remainder.

1 also wish to thank the members of my dissertation committee, Mary Garrett and

Dale Brashers, for their understanding and encouragement and for providing the intellectual energy necessary to complete this project.

I thank Andy Hudson, Judy Neidig, and Michelle Thompson for opening their doors and supporting my work in whatever way they could. Acknowledgment is also due to the College of Social and Behavioral Sciences at The Ohio State University for providing the seed grant that launched this research program.

Kellie Hay provided all manner of space—physical, emotional, and intellectual—to get me working on more than one occasion, and for that I am grateful. My appreciation is also extended to Diane Blair, Pamela Tracy, and Cristina Lopez for providing a sounding board, for helping me think through the ideas presented here, and for encouraging me to move on. Most importantly, these individuals, both as women and as peers, have provided profound inspiration. Susan Glover continually reminded me to live in the process of this all, and I am thankful that she listened. Kathryn Kelley deserves high honors for her emotional support and friendship. Life long friends are not found, but made.

To my parents. Bob and Betty Garland, and my sister, Cindy Sullivan, I extend heartfelt thanks for believing in my abilities, and for understanding the choices I have made.

Finally, to Kyle Kubick, for coming along at just the right time, my deepest love and gratitude.

VI VTTA

May 22, 1970 Bom - Methuen, Massachusetts, USA

1992 B.A., Communication and English University of New Hampshire

1994 ...... M.A., Communication The Ohio State University

1992 - August 1999 ...... Graduate Teaching and Research Associate, The Ohio State University

August 1999 - Present ...... Assistant Professor Department of Organizational Communication, Learning, and Design Ithaca College

FIELDS OF STUDY

Major Field: Communication

Supporting Focus: Cultural Studies and Critical Theory

VII TABLE OF CONTENTS

Page Abstract...... ii

Dedication ...... iv

Acknowledgments ...... v

Vita...... vii

List of Tables ...... x

List of Figures ...... xi

Chapters:

1. Introduction ...... 1

2. Women Working in the Health Care Context ...... 13 2.1 Historical Precedents 2.1.1 Gaining Access and Gaining Ground in Medical Training 17 2.1.2 The Formalization of Nursing Practice ...... 21 2.2 Perspectives on the Current Status of Women in Health Care ...... 26 2.2.1 Sociology-in-Medicine ...... 28 2.2.2 Sociology-of-Medicine ...... 29 2.3 The Socio cultural Role of Communication Scholarship ...... 32

3. Theorizing Gender as Communicative Action ...... 37 3.1 Modernist Conceptualizations and Their Political Limits ...... 40 3.2 Postmodern Feminism and the Basis' of Identity ...... 51 3.2.1 Linguistic Subjectivity ...... 54 3.2.2 Communicative Subjectivity ...... 55

4. Organizational Practice and Social Identity ...... 60 4.1 General Paradigms for the Study of Organizational Practice ...... 63 4.2 Feminist Theory and Organizational Communication ...... 70 4.3 The Sense-Making Modalities of Organizing ...... 82

vm 5. On the Practicality of Ethnomethodology ...... 87 5.1 Re-Positioning ...... 88 5.2 The Methodology of Cultural Studies ...... 90 5.3 An Ethnomethodological Fit ...... 96 5.3.1 Accountability ...... 100 5.3.2 Indexicality ...... 101 5.4 The Social Researcher as Research Instrument ...... 103

6. Sexuality as a Gendering Discourse: The Socialization of Physicians ...... 106 6.1 Overview of Methods 6.1.1 Procedures for Selection and Types of Empirical Materials .. 107 6.1.2 Coding Scheme and Procedures ...... 112 6.2 The Relevance of the Curriculum to Medical Socialization ...... 118 6.3 Enacting Gender Through Decision Making 6.3.1 Discursive Shifts and the Stability of Identity ...... 119 6.3.2 Analysis and Interpretation ...... 135

7. Profession(al)ism as a Gendering Discourse: Quantities of Nursing Practice ...... 148 7.1 Overview of Methods 7.1.1 Selection o f Empirical Materials ...... 151 7 .1.2 Coding Procedures ...... 152 7.2 Professionalism as a Standard for Nursing Practice ...... 153 7.3 Professionism and the Contradictions of Organizational Structure ...... 158 7.4 Analysis and Interpretations ...... 163

8. Comparisons and Conclusions: Working with Gender ...... 166 8.1 Theoretical Background and Project Goals ...... 167 8.2 The Influence of Discourse and Organizational Practice ...... 172 8.3 Methodological Critique ...... 175 8.4 Directions for Future Research ...... 178

References...... 180

Appendix A: Application for Exemption from Human Subjects Institutional Review Board Review; Protocol Title: Medical Students Conceptions of Gender Protocol No. 99E0040 ...... 194

Appendix B: Transcript: Medical Humanities Student Group Discussion Excerpt ...... 208

Appendix C: Application for Exemption from Human Subjects Institutional Review Board Review; Protocol Title: Work Narratives and Social Identity; Protocol Number: 97B0203 ...... 216

ix LIST OF TABLES

Table Page

6.1 Coding Schematics for Medical Humanities Data ...... 116 LIST OF FIGURES

Figure Page

4.1 Theoretical Perspectives for the Study of Organizational Communication ...... 73

4.2 Organizational and Identity Practices: Domains of Analysis ...... 83

XI CHAPTER 1

INTRODUCTION

I began the project that has, temporarily at least, culminated in this document more than three years ago. At that time, I separately encountered two people within a span of about five months who sparked my interest in and concern about the position of women working in health care under the managed care system of the U. S. in the late

1990s. Equally important, my meeting of these two people gave me much needed empirical direction for all the theoretical work I had been doing on the relationships between women and the production of scientific knowledge. In some ways, I may have begun this research much earlier, perhaps when I was a first year graduate student and I experienced my first—and certainly not last—moment of anxiety and confusion over the structure-agency debate in critical theory. Perhaps, the project began earlier still, when at some point during my adolescence, I saw through the position of privilege that I have and realized that not all people had equal opportunities. The project, then, is a culmination of many things: a concern for the social status of women; gendered domains of inquiry and the organizations within them; a commitment to the perspectives of Cultural Studies found in communication; and finally, a desire to create change. The reader may be asking, why have you chosen to begin in such a confessional style? The answer I have to offer is simple, and yet, not so simple. The simple answer is that I want to give the reader some background about me, this project, and how it evolved, so that the reader can Judge for him or herself the nature of my practice. The not-so-simple answer starts with debates within the sociology of knowledge. These debates began, arguably, with Michel Foucault’s 1966 publication of Les Mots et les

Choses (The Order of Things: An Archeology of the Human Sciences, 1970), and since then, it has become apparent that one of the conditions of knowledge production is a positioned viewpoint; a viewpoint influenced by—if not determined by—the epistemological biases of an historical time period and not by some objective measure of the Real. Indeed, to say there is an objective real to be measured is itself an epistemological fiction tied to the differential circulation of power supported by the production of knowledge. Perhaps by revealing my own experiences as a scholar, researcher, and person, then, I may open up the possibilities for examining the prisms through which we/I view the current time period and the implications those views may have for the realities with which I am/we are contending.

In addition to opening up discussion about the somewhat socio-individual and thus, epistemologically relevant reasons for embarking on this project however, I would like to take these pages of introduction to encapsulate, to the best of my ability, the theoretical, methodological, and political background for the project represented in these pages. Confessional moments aside, there seemed to be two very practical—that is, political—reasons for engaging in this research; reasons that I will overview here, but that should become more apparent throughout the text of this document. One reason addresses the concern for praxis that underlies critical scholarship generally. The second

reason stems from a need and desire to contribute to a body of communication theory in

particular ways; ways that, for lack of better terminology, enhance our understanding of

the relationships between the discursive and structured aspects of organizations and the

lived relationships among organizational members that sustain or resist them. In

particular, I will show how a communication theory of identity—a theory of enactment— shows us how these two dimensions of experience relate. While I do not mean to imply that a concern for praxis prohibits the development of a theory of gender enactment, I begin with the praxis component nonetheless.

In her introduction to an anthology of essays written by women about their experiences as medical practitioners, neurosurgeon Francis Conley writes, “the common concern, articulated by [the authors], is that a culture shift must occur; a rigid structure become moldable or broken, or abolished. However, lessons from the history of modem medicine do not indicate the correct choice as to how, and by whom, the structure will be altered” (1996, p. vii). Indeed, many feminists and critical scholars have pointed out both the glaring and subtle ways in which female practitioners have been and remain outsiders within the institution of medicine (cf. Bickel, 1988; Davies, 1992; Hammond, 1981;

Komstein, Norris, & Woodhouse, 1998; Lorber, 1993, 1984; Nechas & Foley, 1994;

Riska& W egar, 1993; Walsh, 1992; Wear, 1996, 1997; Witz, 1992).

Another group of health care providers—nurses—are also currently experiencing the impact of a rigid, albeit new, structure. The restructuring of health care organizations brought on by the managed care system has taken a drastic toll on nursing (Huntington, 6

January 1997), such that a 1996 survey of over seven thousand registered nurses revealed 3 that sixty percent of those surveyed reported a reduction in the number of nurses

providing direct patient care (American Nurses Association, 1996). Nursing’s strained

relationship with the health care structure is anything but new, however. In a 1973 article

which appeared in Nursing Outlook, Dr. Jo Ann Ashley, who is credited with building a

bridge between feminism and nursing in the early 1970s (Wolf, 1997) wrote “one finds

an increasing number of predictions that unless nursing does this or that, it will become

obsolete, replaced by something else, or cease to exist ” (Ashley, 1997, p. 23). Although

written over two decades ago, these words ring true once more.

Thus, I began the research that is presented here partially in response to the

circumstances reported above, and thus, envisioned the project first-and-foremost as a

moment of praxis. While the symptoms of gender discrimination in health care

organizations, bolstered by a medical ideology, have been well documented, however,

there has been little investigation into the socio-cultural processes that make such

positioning possible or probable. I contend that communication practice lies at the heart of both that “rigid structure” and of the “culture shift” that Dr. Conley imagines. I also

believe that there is a communicative dimension to the strained relationship between

nursing and medical practitioners; a dimension that is both more than and contained

within the interaction among hospital or administrative structures, individual medical personnel, and nursing staff.

Still, it is clear to me that no simple conceptualization of communicative practice can provide the direction needed to illuminate both the current moment and its possible alternatives. In order to theorize what communication is and does in the health care setting, therefore, I turn to theorizing communication as a kind of link in social theory; a 4 link that that accounts for the interplay between structures and discourses, on the one hand, and our everyday activity on the other. An exploration of the relationship between female practitioners and the institution of health care fits well within the goal of both classical and contemporary social theory generally; that is, the connection of the micro- and macro- aspects of human experience, social order, and action (Turner, 1996; Holton,

1996).

Various theorists have explored the relationships between base and superstructure, agency and structure, institutions and experience—and in that regard, I am no different here. However, I adopt the well theorized contemporary (sometimes called postmodern) position that these aspects, micro and macro, must be seen in a relationship of dynamic reflexivity where each are dependent on and incorporate the other, rather than be seen as distinct or opposing entities or areas of analysis (see Giddens, 1984/1993, or Foucault,

1973, for different theoretical positions on this matter). Theorizing communication within these parameters show how communication practice sustains the reflexivity. This is because communication is at once the window to the discursive and the substance of structure, as well as the basis for one's orientation to the world.

Also in keeping with some positions within postmodernism, I hold fast to the idea that this dynamic relationship is mediated by the mutually constituting components of meaning (or symbolic activity) and experiential (i.e. embodied) awareness, both of which are also tied to and embedded within the practices of communication. Thus, the second- but equally important—reason for embarking on this research project may be seen as an attempt to theorize the nature of such communicative practice within a postmodern framework. 5 There are two poles that anchor my theorizing of communicative practice, relevant to the context of this research and reflecting the densities of the dynamic relationship between structure and agency at the core of social theory. These two poles are represented in the concepts of identity (which is considered to be both discursive and experiential) and the practices of organizing. These are chosen as core areas of exploration because each, in themselves, reveal the tensions described above explicitly.

The micro-macro tensions both identities and organizations contain are based, I argue, in particular kind of communicative practice that has ties to both discursive and organizing frames, on the one hand, and to the experiential, embodied subjectivity social actors rely on in navigating the everyday world on the other. In this scheme, communicative practice becomes the means by which social life takes on embodied significance as well as the reverse. As lucidly stated by John O’Neill:

on the one hand, we have the bodies we have because they have been

inscribed by our mythologies, religions, philosophies, sciences, and

ideologies. But on the other hand, we can also say we have our

philosophies, mythologies, arts, and sciences because we have the body

we have—namely, a communicative body. (1989, p. 3)

That said, it is my hope that this research will aid in the development of communication theory in the following specific ways. One contribution is in the development of an understanding of how communicative practice enacts identities in general and gender identities in particular. In pursuing this project I share with Michael

Hecht (1993) a vision of the future of communication scholarship which stresses that 6 “identity is inherently a communicative process... [where] messages are symbolic linkages between and among people that, at least in part, are enactments of identity” (p.

78). What is missing in Hecht's formation, and indeed, in a good deal of communication scholarship, is a way of conceiving of the tie between the symbolic and the experiential in ways that circumvent individualist notions of experience. And while gendered identities are produced and enacted along a spectrum of difference, I am interested in the privilege associated with unmarked identities, and by implication, the lack of privilege associated with marked identities, making the project at its core a feminist one.

Thus, m primary purpose is to develop and empirically test the concept of the enactment of gender (identity) and to provide conceptual clarity relative to its contours.

The inequalities that exist between males and females in organizational settings result from a conflation of three simultaneous processes which are implicated in communication practice and that contribute to enactment:

• the everyday reconstruction/circulation of the idea of masculinity and femininity—

a discursive activity made visible through communication practice;

• the differential distribution/attribution of those characteristics associated with the

idea of masculinity and femininity onto bodies through one's orientation to

another—a process made possible through communication and its relationship to

meaning as described in Chapter 2, and;

• the production of a context that privileges one set of characteristics over another—

a context which results from the ongoing organizational sense-making activities

which are facilitated by communication. In order to move toward conceptual clarity, then, the empirical focus of this research is on the ways in which such (re)constructions, distributions, and sense-making activities are accomplished and how they work together. By examining interaction in this way, I hope to open possibilities for change in the gendered hierarchies of health care organizations.

Secondly, however, I hold the hope that this research contributes to a burgeoning body of literature whereby the practices of organizing are seen to be, at their core, communicative ones that have political implications. These communicative/ organizational practices not only aid in the completion of the organization’s task at hand, but also facilitate and shape relations of power within the organization and within society, generally. Recent work on this thematic by Holmer-Nadesan (1997) and Mumby (1988) reveal the potential for this line of inquiry. Their work points to the role organizational discursive practices can play in constructing the social identities of organizational actors, such that these actors are positioned differentially in relation to power. I bring to this discussion in a way of conceptualizing the mutually influencing relationship, again, between the symbolic and the experiential in connection with such socially and politically relevant organizational practices. Therefore, I anticipate that this research will also contribute, implicitly, to a body of communication theory that seeks to begin understanding how organizational communication practices facilitate identity production, and thus, power relations, generally.

With the above goals firmly in mind, I will provide information regarding the socio-historical, theoretical, and methodological contexts and perspectives which shaped the investigation, as well as interpretations formed from examining empirical materials. 8 To begin, I provide an overview of the status of women in healthcare, specifically, in nursing and as physicians and physicians-in-training. Such information illuminates the nature of the socio-historical moment within which this research, in my estimation, is politically necessary. Thus, Chapter Two is devoted to a brief introduction to the historical and current political issues facing women working and training in the health care industry. I conclude Chapter 2 by laying out a perspective on communicaiton that helps us see beyond the socio-historical constraints facing women in health care.

In Chapters Three, Four and Five, I will provide insight into the relevant theoretical and methodological perspectives that I believe can shape critical scholarship within this particular context. These chapters include, as described more specifically below, overviews of feminist theorizing about gender and difference, critical and interpretive organizational communication studies, and work in the general area of cultural studies, ethnomethodology, and critical discourse analysis.

Chapter Three is devoted to feminist theorizing about gender and gender relations, and how such theorizing has been and can be used to illuminate the underlying forces that contribute to inequities between women and men in health care. Several scholars, as mentioned above, have provided critiques of the social factors that contribute to the position of women as practitioners. However, these descriptions reflect modernist understandings of gender, the subject and agency; understandings based on what

Neitzsche has termed a metaphysics of substance'. I come to this project with the belief that the practices which have contributed to the current situation women face as health care practitioners can be unsettled when ‘gender’ is viewed through the lens of postmodern feminist theory. Therefore, I provide an introduction to critiques of modernist conceptualizations of the gendered subject and of agency offered by postmodern feminist theory. These critiques, and the changes in theorizing they bring about, suggest a position from which ‘gender’ may be rethought in terms of subjectivity in order to provide revitalized political possibilities for women in health care. In short, this position holds that gender (identity) is a discursive construction, although tied to an embodied, experiential awareness, and actively performed and resisted in everyday interaction. Thus, the position highlights the necessity of examining the relationship between symbolic activity and experiential elements of embodied interaction. This conception of identity, I argue, is a thoroughly communicative one.

The relationship between symbolic activity, in the form of sensemaking, and experiential awareness also informs my guiding critique and creative re-reading of organizational communication. Theoretical work that leans toward revealing this relationship includes more recent interpretive, critical, and feminist perspectives in organizational communication, although few completely integrate the symbolic and the experiential without reference to individualist notions of experience. Interpretive, critical, and feminist theories of organizational communication do, however, provide a broad way of understanding how the ideological constraints of an organizational life are produced, circulated, and resisted through communication activity. Furthermore, this intersection also suggests ways in which organization' may be rethought as a discursive site for the production and resistance of gendered identity. Finally, this body of literature, in contrast to the more prominent structural-functional approaches to organizational communication, provides a starting point for grounding the investigation

10 in ways that are open to examining the relationship communicative practice and

embodied awareness have with identity production.

To grasp the embodied, lived enactments of practices of organizing and their

relationship to the production of identity, however, requires a methodological approach

that is open, adaptive, and yet focused on the kind of communicative practice supported

in the theoretical conceptualizations developed in Chapters 3 and 4. With that in mind, I

present an overview of research methodology within the broad areas of cultural studies,

ethnomethodology, and critical discourse analysis with an eye toward how such

methodological approaches help illuminate the relationships symbolic activity and

experiential awareness. The advantage of working within these methodological

frameworks is that they provide a way of conceptualizing gender, and identity generally,

as an enactment made possible and resisted by discursive activity, the sensemaking

practices of organizational settings, and the contextual orientation of a social actor to his

or her situation. These frameworks, in turn, suggest specific modes of observation and empirical analysis which serve to guide the analyses presented in subsequent chapters.

Chapter Six and Chapter Seven each provide in-depth analyses of both privileged discourses of identity and organizational practice as well as empirical materials which reveal the actors orientation toward the context. These materials, in the form of transcribed narratives and conversations, reflect actors' everyday judgments about the role discourses and organizational expectations play in their own interaction. In both chapters, the first focusing on physician training and the second regarding nursing practice, I attempt to put discourses, organizational practices (sensemaking codes), and actors' accounts into conversation so that the role each plays in producing or resisting the

II other can be seen. This has been no easy task, and requires some uneasy judgments and unfortunate divisions about what constitutes production and resistance. Nonetheless, the conversations prove to be revealing, particularly in how underlying connections between communicative activity, discursive constraints and opportunities, and experiential awareness/sensemaking activities inform both the nature of organizational practice and of identities.

Finally, in Chapter 8 ,1 attempt to draw some comparative conclusions that can illuminate how organizational discourses and discourses of identity act in concert to produce gender identity in particularly politicized ways. In particular, I argue that the discourses of professionalism serve both as a mechanism for the enactment of identities and for guiding organizational action for both nurses and among entering physicians.

That is not to say that there are seamless comparisons to be made in how the discourses of professionalism work' in these settings. Indeed, there are striking differences between groups in terms of what claiming the status of profession means and does for individuals, the ways in which the discourses hide (and reveal) aspects of gender-based inequality, and the role professional status plays for each in organizational life generally. Still, there is evidence' enough to believe, or to make a strong case for believing, that professionalism is both a gendering and an organizing discourse that bridges the structure/agency divide through a communicative mechanism. In short, the communication code' (to use Luhman's terminology) of professionalism acts as a mechanism of both organizing and the enactment of identities.

12 CHAPTER 2

WOMEN WORKING IN THE HEALTH CARE CONTEXT

An entire history of the relationship between women, the female body, and medical/scientific ideology serves as the contextual background for this project, and it is that history I want to explore now, albeit briefly, for the reader. Although I do not present a comprehensive historical survey in this short chapter, I do want to highlight important moments and movements that help frame the nature of the relationship between women and the institution of medicine.' The focus of this history is on the role women have played as practitioners in American medical organizations throughout the last two centuries.

In one sense, the history presented here is "by the book" — with the exception of work by Morantz-Sanchez (1978) reported here, most of the information I provide illuminates the "official records" of women in nursing and medical education.

Admittedly, this practice takes such information out of its socio-historical context. I draw bits and pieces, selectively at best, from the fabric of some historical past' in order

' When referring to the organizations and institutions through which services aimed toward the prevention of disease and the treatment of illness are delivered, as well as the dominant scientific ideology that circulates in those institutions, I will use the term medicine.

13 to create a more cogent narrative which sheds light on the present lives of women working in health care organizations. Examining the past, even selectively, helps frame a history of the present. Such a history is vital for understanding the shape of the current tensions women face as practitioners in health care settings. In short, this chapter lays out 'what is at stake' for women working in health care and what this project may be able to contribute to illuminating and ultimately changing that relationship. As it is in many organizations, the hierarchies in health care settings are also gender hierarchies, but just why there has been such stability of that structure over time and under intense scrutiny remains to be explained.

A difference in the terminology used to refer to the activities of nurses and physicians alike reflects some of the tensions embedded in the hierarchy that have arrived on the scene in the most recent past. A discussion of this shift is not only illustrative of the relationship between women and medicine, but also illuminates the tenuous relationship a large portion of the female working-force in medical organizations have with the institution as a whole. There is a growing emphasis on the distinction to be made between medicine and health care, even though both discourses have had some impact on positioning women in relationship to the experience of health and/or illness.

'Health care' is concerned with a wide range of knowledges and practices ranging from the prevention to the treatment of sickness, illness, and disease, which includes physiological manifestations, subjective experience, and social adjustments for the individual, his or her family and caregivers, and the community as a whole (Turner,

1995). In that regard, the use of the term health care suggests a political and conceptual alternative to medical practice that feminists, particularly, pushed for as a major 14 component of the second wave women's movement (see Boston Women's Health Book

Collective, 1975). Finally, the realm of practice suggested by the term health care, historically, has been capable of including the domain of nursing practice. Yet, health care' is now increasingly the domain of all health care providers, nurses and physicians alike, under a managed care system that increasingly focuses on disease prevention and health maintenance. Health maintenance organizations have also had a

'deprofessionalizing' impact on the work of physicians who are no longer able to determine their own rate schedules and find their treatment preferences challenged by insurance claim adjusters.

'Medicine', on the other hand, is a body of knowledge and domain of practice centered on a physiological body and its changes; that is, on the disease itself and its biological manifestations. Medicine' is typically the domain of physicians. Moreover, medical discourse proposes to describe the body as it is, not as it is experienced by the patient, nor how society might evaluate the nature of the disease. Such a conception falls squarely within modernist conceptions of the body, nature, and reality. "Disease, " summarizes Turner (1995), "is seen as a neutral and natural entity residing in nature, that is, in the body of the patient" (p. 3).

To say that a medical' definition of disease is neutral, however, hides some of power inherent in the act of defining. The discourses of medicine have, as many authors and critics have shown, consistently defined women, through their bodies and 'diseases,' as subordinate members of society (Martin, 1987; Epstein, 1995; Fausto-Sterling, 1985;

Groneman, 1995). In addition to providing a specific type of patient, the construction of the female' as both Victorian mother and hysterical woman, through the language of 15 medicine, also provided a framework for keeping women from the rigors of medical life.

In short, a medical ideology "of female frailty simultaneously solved two issues, namely the disqualification of women as practioners and their qualification as patients"

(Turner, 1995, p. 109). Medicine, then, is the masculine aspect of health care.

The conflict-ridden relationship between women and medicine may be replicated in the 'turf distinction (if there is indeed one) between health care and medicine.

'Women/female/feminine', parallel to health care,' suggests ongoing attention and awareness. On the other hand, medicine, parallel to masculine,' suggests problem­ solving and the application of technology. This relationship becomes clearer by adopting the distinctions offered by Turner’s (1995) description of studies in medical sociology.

Turner argues for a distinction between studies in sociology-in-medicine' and a

'sociology-of-medicine.'

Studies grouped under sociology-in-medicine, in Turner's terms, are understood as those that use sociological research to assist the training and development of medical practice. Using the perspectives of sociology-of-medicine, in contrast, the broader socio­ cultural relationship between medicine and the general population is highlighted. With this approach, the researcher is aided in focusing on, for instance, the role that the terminology for health-services delivery plays in defining distinctly gendered domains, as illustrated above. In general, research in the sociology-of-medicine represents a wide range of more typically sociologically-oriented research, including: the definition of disease and its relationship to the construction of deviance, the relationship between body and mind (i.e., the treatment of patients as well as disease), and the sociology of the

16 professions- Indeed, the idea of a 'profession' is one that matters in this study, and I will therefore focus my review in that general area.

Historically and sociologically oriented examinations have revealed that the establishment of practices of professionalization such as accredited and degreed training and state licensure laws used to separate midwives, lay healers and ‘wisewomen’ from physician-scientists was itself a patriarchal project (Witz, 1992). Also, although nursing has claimed the title of ‘profession’ since the establishment of training schools for nurses, the use of the term profession’ in connection with nursing has not always been (and in some circles, is not now) widely accepted. Abbott and Wallace (1990) argue that despite trait-like qualities one might list for a profession, the “fragile status ” (p. 2) of nursing as a profession may result from the intersection of discourses of what constitutes a profession and gender ideology. “Relative to the paradigmatic, traditionally male professions of medicine and law,” argues Lagemann (1983), “nursing is only incompletely professionalized or partially professionalized” (p. 5). To understand the relationships between women—as both nurses and physicians—and medicine, then, I turn to an exploration of the conditions under which such a claims makes sense.

2.1 Historical Precedents

2.1.1 Gaining Access and Gaining Ground in Medical Training. Long before the struggle for women’s access to traditional professional’ occupations in the United

States took a public stage during the mid-1800s, women in Europe who engaged in medical practice were prosecuted for practicing witchcraft (Turner, 1995). Women, suspected of being witches, “were accused of having magical powers affecting health—of 17 harming, but also of healing. They were often charged specifically with possessing medical and obstetrical skills” (Ehrenreich & English, 1972, as quoted in Turner, 1995, p.

88). Without legal boundaries for keeping women from practicing even ‘folk’ medicine and thus, having access to clientele for such services, the use of a religious doctrine served a sufficient role.

Challenges to subsequent legal boundaries—or at least legally defensible boundaries—did not pass without some attention, particularly in America. The sentiments surrounding the admittance of women into accredited medical colleges, the first step toward entering the profession, throw the patriarchial nature of professionalizing projects into sharp relief. Dr. Elizabeth Blackwell, who in 1848 was the first woman to receive a medical degree, reports in her journal.

The fear of successful rivalry which at that time often existed in the

medical mind was expressed by the dean of one of the smaller schools

who frankly replied to [my] application, ‘You cannot expect us to furnish

you with a stick to break our heads with’; so revolutionary seemed the

attempt of a woman to leave a subordinate position and seek to obtain a

complete medical education. (Blackwell, 1895/1977, p. 61).

Additionally, Dr. Henry Bowditch, a sympathizer to women’s attempts to gain entrance into medical school, wrote in the Boston Medical and Surgical Journal in 1851 (the pre­ cursor to today’s New England Journal of Medicine) echoing the attitudes of his contemporaries: ‘‘[the female] sex unfits you to be our associates”; and “you unsex yourselves in trying to [become doctors], and we won’t even examine into your qualifications” (p. 289). Indeed, a widespread attitude that “women were crippled 18 because of their biology, certainly more in need of medical aid then able to furnish it”

(Walsh, 1992, p. 53) prevented many women from becoming practicing physicians.

Despite the outright hostility brought to bear on the education of women as

physicians by male doctors during the early and mid-1800s, by the end of that century a

dramatic change had occurred. At the close of the nineteenth century a considerable

number of women were physicians, albeit as ‘friendly outsiders’ (Lorber, 1984; 1993).

Women were trained in medicine through programs at separate women-only colleges and

in over 40 coeducational medical schools that, instead of risk losing substantial financial

support, accepted female students—sometimes up to 10% of the total enrollment (Walsh,

1992). According to estimates, 4 to 6 % of all physicians in the US at the turn of the century were women (Morantz-Sanchez, 1978; American Medical Association 1991;

Duffy, 1993), with clusters of female doctors in metropolitan areas such as Boston, New

York, and Philadelphia reaching nearly 18% (Lorber, 1984).

Widespread gains for female physicians were not enjoyed for long. Two significant events shut the doors of the profession in the face of women just after the turn of the century. The Flexner Report, a comprehensive evaluation of US physician training programs published in 1910, recommended the closure of a large portion of medical colleges, including all but one of the women’s colleges (Flexner, 1910). Even before the

Flexner Report, however, the number of female medical students was on the decline, mostly due to the cold responses women physicians encountered from their male

1 9 counteqjarts upon graduation, as well as the discriminatory treatment of women within coeducational schools."

A growing emphasis on the necessity of post-graduate internships (residency programs), 92% of which were not open to women, resulted in an increasing unwillingness of medical schools to accept female applicants. Between 1920 and 1970, overt sex discrimination in medical school admissions was the norm, and between one- fifth and one-third of all female graduates during that period came from the single remaining women’s college, the Women’s Medical College of Pennsylvania (Walsh,

1992). From 1949 to 1966, the percentage of female applicants to medical school rose only slightly from 5.7% to 9.0% of all applicants; while the percentage of female graduates declined from 10.7% to 6.8% of all graduates (AMA, 1991).

Beginning in the early 1970s, US medical schools experienced a dramatic increase in female applicants. Fueled in part by pressure from the second-wave women’s movement, and acting in compliance with federal regulations regarding equality, “blatant discrimination in recruitment and admissions procedures changed dramatically . .. [and] schools began to openly welcome women ” (Walsh, 1992, p. 60). Slightly more than eleven per cent of freshmen medical students were women in 1970; by 1975, that number had more than doubled to 23.8% (Leserman, 1981 ). The most recent comprehensive

- Women's-only medical colleges were already closing prior to the publication of the Flexner Report, primarily because of a push for more open admissions of women into coeducational schools. Once the women’s colleges failed, however, admissions standards and the treatment of women in training became more sharply discriminatory. For example, in 1900, Cornell University took over the New York Infirmary and absorbed its seventy female students. By 1903, the number of women students at Cornell Medical College had been reduced to ten (Walsh, 1992).

20 report on women in medicine, produced by the American Medical Association in 1991, estimates that 39.2% of applicants to—and 34.5% of graduates from—medical colleges in the US were women.

2.1.2 The Formalization of Nursing Practice. The mid-1800s also saw the eruption of public debate over whether or not women should be or could be trained to provide care to the poor, sick, and injured in secular hospitals. Until that time, women provided care for their family members through their role as wife and mother. Women who did care for non-relatives, mostly the poor, were of a religious (mostly Catholic) order, and then, care was limited to church members. The few women who worked in almshouses or other secular hospitals were suspected of being drunkards, prostitutes, or otherwise susceptible to vice (Chitty, 1997; Griffin & Griffin, 1973).

The military necessity for nurses, however, provided an opportunity for women— particularly middle-class women—to organize and pave the road for nurse training schools (Roberts & Group, 1995). The British involvement in the Crimean War and the

Civil War in the United States brought women out of their homes and into the battlefields, and ‘modem’ nursing was bom. Florence Nightingale is certainly the most famous icon of nursing and nursing education. As a well educated member of the upperclass herself. Nightingale’s parents looked down upon her interest in nursing, given its seamy reputation. Following her organization of women during the Crimean War

( 1854-1856), and her prolific writing about the health care system in England,

Nightingale founded the St. Thomas’s Hospital training program for nurses in London

(Chitty, 1997). 21 The impact of war on nursing and its expansion as a field of training was also obvious in the United States. In addition to the success of individual nurses like Clara

Barton and Dorothea Dix in establishing the Red Cross and the U.S. Army Nursing

Corps, respectively, hospital-based diploma (three-year training) programs were established. Programs like the one at St. John’s Hospital and Bellevue Hospital in New

York produced nursing leaders such as Isabel Hampton Robb, Adelaide Nutting, and

Levina Dock, all of whom would later play important roles in establishing the first professional organization for nurses, the Society of Superintendents of Training Schools for Nurses, founded in 1893, later renamed the National League for Nursing Education

(in 1912) and today known as the National League for Nursing (Deloughery, 1998). Dock was also instrumental in the development of the Nurses’ Associated Alumnae of the

United States and Canada, which became, in 1911, the American Nurses’ Association

(Roberts & Group, 1995).

Throughout the early part of this century, however, it was clear that nurses, despite their attempts at creating a distinct, organized profession, remained subordinate to physicians within and outside of hospital walls and maintained the qualities of femininity associated with Victorian ideals. Nursing texts from the first part of this century suggest nurse qualities to include “self-control, dignity, and courtesy ” (Goodnow, 1912. p. 22).

In 1922, Bertha Harmer advised, in the Text-Book of the Principles and Practice of

Nursing. “[s]ympaihy, kindness, and unselfishness are needed, but also something more— something deeper and more helpful, more loving and more spiritual which may support the patient with a feeling of strength, security, and comfort” (p. 5). Even the night

22 nurse’s walk was prescribed, reflecting qualities of femininity. “A quick, pounding step in felt slippers may be very annoying,” it is noted, “when a light, springy, deliberate tread in ordinar>' shoes may be unheard. The size and weight of the person has little to do with the matter, but her clumsiness or grace has much” (Goodnow, 1912, p. 324). Most importantly, nurses were expected to be obedient and display a general deference to superiors, particularly male doctors. Nurses were told that “it is [the nurse’s] place to do exactly as she is told, without criticism of methods” (Goodnow, 1912, p. 197) because her role is to support the physician in the carrying out of patient care. Emily A. M.

Stoney (1916) likewise advised the nurse to “rise when the physician enters the room, and ... remain standing unless asked to be seated; she should hand him her report, answer all questions, then quietly leave the room” thereby observing rules of proper etiquette and respect (pp. 23-24).

From the 1920s through 1970s, during a time when advancement for women as physicians was virtually non-existent, nursing opportunities in nursing continued to expand. A report sponsored by the Rockefeller Foundation—the Goldmark Report published in 1923—provided the impetus for the development of University-sponsored baccalaureate programs in nursing which would be directed by nurses and not affiliated with hospitals.^ In conjunction with legislation resulting from labor movements in the

’ The Goldmark report is also known as the Winslow-Goldmark Report. Josephine Goldmark, secretary to the committee's chairman. Professor C. E. A. Winslow of Yale University, had very useful social research skills, and thus, earned the namesake (Deloughery, 1998). This is, perhaps, the one time a female secretary to a male academic had ever had a work named for her efforts.

23 1930s, such opportunities provided nurses with the chance to receive an education without being subject to the hospital administration’s exploitation of their work efforts

(Roberts & Group, 1995). Finally, the 1930s brought state legislation acts to distinguish among nurses: only those who passed licensure examinations were permitted to engage in particular nursing practices and thus, use the term registered nurse (RN).

The post-war economic and baby boom starting in 1945 also fueled the building boom in hospital construction, which meant more nurses were needed. The new positions of Licensed Practical Nurse (LPN) and Nursing Aid (NA, now Unlicensed

Assistive Personnel, or UAP) were added, creating the need for boundaries between those nursing duties that must be carried out by registered nurses (RNs) according to state practice acts, and what traditionally ‘nursing’ duties could be delegated to licensed, but technical nurses trained at the hospital, and those that could be delegated to unlicensed personnel (Chitty, 1997). Also during this boom, yet another route to becoming eligible for registration was established, the Associate Degree (AD) program, which is typically a

2-year program. As a result of the increased enrollments in the shorter AD program, many three-year diploma programs began to close (Chitty, 1997).

The public relationship between feminism and nursing grew stronger during the late 1960s and early 1970s. Attention turned to media images of nursing—images which sexualized nurses—and nurses began to advocate more actively for union membership'*

(Roberts & Group, 1995). Wilma Scott Heide, who became a registered nurse in 1945 and worked as a nurse and activist during the Civil Rights Movement in South Carolina

'* Collective bargaining has been supported by the ANA since 1946 (Chitty, 1997).

24 during the late 1950s, later served as President of the National Organization of Women in

the early 1970s (Roberts & Group, 1995).

When the debates over feminism’s relationship with nursing subsided following the failure of the Equal Rights Amendment in the U. S. Senate, educational and accreditation changes dominated debates within nursing in the 1980s. The ANA in particular took the somewhat controversial stand that by 1985, only baccalaureate- educated nurses should be permitted to sit for licensure examination. Specialization in nursing also grew, leading to the development of advanced practice nursing, which includes certified nurse practitioners, certified nurse anesthetists, and nurse midwives.

Advanced practice nurses complete additional training (graduate work) in areas such as pharmacology and in diagnostic processes. Pharmacists and physicians have fought the licensure of advanced practice nurses, particularly as model practice acts at state government levels would permit nurses to engage in activities traditionally reserved for physicians (i.e., writing prescriptions).

With this description of more current legislation and legislative debates, I feel it is safe to say that we have caught up to the present. My hope is that the short history presented here helps position the reader to better appreciate the background of the current more sociologically oriented research on women in health care organizations. The following section, then, is devoted to examining again briefly, how scholars from various disciplines have attempted to capture the nature of women's lives as nurses and as physicians-in-training.

25 2.2 Perspectives on the Current Status of Women in Healthcare

Despite consistent gains, structurally speaking, women remain the Other throughout the health care system. Almost two-thirds of all female physicians are clustered in the ‘patient-centered’ specialties of pediatrics, psychiatry, general/family practice, and general internal medicine. In fact, in its special report on women in medicine, the American Medical Association states that women are “about three times as likely to be a pediatrician” compared to their male counterparts, and “less than half as likely to be in general surgery ora surgical subspecialty” (AMA, 1991, p. 12). Yet, the

AMA contends that “women must be allowed to thrive in any institution and in any specialty in which they can make a contribution” (p. 2). It is important to note, also, that the specialties where women are more likely to practice are also among the lowest-paid.

According to the US Department of Labor, Bureau of Labor Statistics (1998), the average annual income of a pediatrician in 1995 was $129,000 compared to the $225,000 average annual salary surgeons.

Several have expressed the hope, however, that as more women pursue medical training, better chances at equity within medicine as a whole will be realized. As recently as 1995, 36% of all students in medical school were women, ranging from a high of

53.6% female enrollees at The Medical College of Pennsylvania to a low of 17% at the

University of Utah (Feminist Majority Foundation, 1995). The increasing presence of women in medical school, coupled with consistent inequities in practice, have led many to examine the content and practices of medical education in the U.S.

For nurses, the picture is in some ways a bit brighter; in others it is more disheartening. Despite cut backs, registered nurses continue to account for the largest 26 single group of health care providers in the United States. Approximately 82.7% of the

2.55 million licensed registered nurses are employed in nursing, with an average salary of

542.000 (full time). Nursing remains a female-dominated occupation, with only 4.3% of all RNs being men.

Most recently, registered nurses have been hardest hit by the “conversion of not-

for-profit health care facilities and insurers to for-profit tax status” (Marullo, 1997

[online]). The managed care system, which is tied to such privatization, has led hospital administrators to cut expenses and operate more efficiently. Because charges for nursing services are included in the general ‘bed charge’ (Roberts & Group, 1995), cost cutting programs have focused on transferring RN duties, where possible, to other practical nursing and assistive staff. Under these new economic conditions, the Pew Health

Professions Commission Report released in 1995 predicted a surplus of 200,000 to

300.000 registered nurses by 2000, and recommended the closure of 10-20% of all nursing schools (Marullo, 1997; Fagin, 1997).

Since early 1998, however, there has been an increasing awareness of a shortage of nursing. Stewart (1998) reports that

[ejmerging trends appear to indicate that, this time around, the

shortage has complex causes some driven by real limitations and

some by artificially created constraints.. .. The new shortage

raises other questions. Are there not enough nurses, bottom line, or

not enough of certain kinds of nurses where they're needed? Are

there too few slots for available RNs under managed care?

([online]). 27 What is most interesting (and disturbing) about the bull/bear market of nursing is that it is a market, subject to market conditions and not to patient needs (c.f. Cheever, 1999).

In short, the 'Otherness' of women in medical institutions currently shows up as an economic otherness coupled with a gendered categorization of work: women physicians concentrated in the patient-centered (and lowest-paying) specialties; nurses—the direct patient-care specialist, subject to the volatile market of mergers, acquisitions, and closures of a large portion of America's hospitals. In such a context, the focus of the research of scholars in various fields has been on how that otherness is experienced and how, on a micro-level, it may be reproduced. It is to that research I turn.

2.2.1 Sociologv-in-Medicine. The majority of studies focusing on medical students examine the status of female-trainees in an attempt to evaluate the relative gender-equity of the structure and practice of medical education, from admission to the completion of residency. The content of these studies range from longitudinal studies of the number of new female students that are admitted each year (and their attendant and comparative demographic characteristics) (for example, see Bickel, 1988) to summaries of the specialties chosen by female vs. male students and the possible reasons for these choices (see, for example, AMA, 1991; Komstein, Norris, & Woodhouse, 1998), to possibilities—or the lack thereof—of mentors for female trainees (Komstein, Norris, &

Woodhouse, 1998), students’ impressions of sexual discrimination or harassment during their first four years (The Ohio State University, 1988; Kassenbaum & Cutler, 1998), or comparisons between females’ and males’ emotional stress levels (and possible causes) during various stages of their training process (Erhart & Sandler, 1990).

28 In the wake of changes in nursing, research on nursing practices incorporates renewed and consistent reflection on organizational themes. Such themes include perceptions of the usefulness and effectiveness of shared governance over nursing staff

(Daiski, 1996; Laschinger & Shamian, 1994; Blanchfield & Biordi, 1996), the role or qualities of the nurse manager within new nursing environments (Hansen, Woods, Boyle,

Bott, & Taunton 1995; Kirkpatrick & Forchuck, 1992; Katzman & Roberts, 1988), and possibilities for layering work responsibilities and subsequent impacts on patient care

(Blegen, Goode, & Reed, 1998). In addition, comparisons between nurses with different types of training and their interactional styles with patients and patient care administrators have taken on heightened importance (i.e. Redland; 1992).

2.2.2 Sociologv-of-Medicine. In what ways these structural changes—for nurses and physicians—impact cultural (i.e., value or meaning based) changes in the provision of health care remains to be seen. Some studies have examined the ‘gendering’ of the profession of medicine (i.e., physicians) through identifying possible changes in professional standards or expectations regarding patient care that may have resulted from an increased number of women in medicine. One early example tracked differences in value-orientations between first- and fourth-year, and between male and female, medical students as a way of determining if a rising number of women physicians (and physicians-in-training) was influencing the ideals of practice in medicine (Leserman,

1981). Although women and men entered medical school with similar outlooks regarding patient care on such measured values as egalitarianism’, Leserman concluded 29 that “as they leave school, women hold both more humanitarian and egalitarian views”

than their male counterparts (p. 146).

However, critics argue that the medical educational system “often forces those in

training to absorb the values of the dominant group” (Walsh, 1990, as cited in Wear,

1997, p. 41). One such value may be staunch individualism; an ideal that is fully

implicated in practices of medical education such as ‘objective’ grading of examinations

which are coded by number only. That students accept individualism as the status quo

standard of evaluation is illustrated by Delese Wear (1997) through responses to queries

about the meanings of feminism of medical students ranging from the first to fourth years. One student, quotes Wear, stated “it doesn’t matter... my peers can’t affect me . .

[they] have no power in my life” (p. 50).

Attempting to fit into the professional ideals of medicine may also include strategic ‘identity management’, as Robert Broadhead (1983) argues in his symbolic-

interactionist study of the creation of professional identity among medical students. One student, reflecting on her application process to medical school, stated:

The first time (in 1973).. f presented myself as a woman who had always

been interested in science, and who was going to be able to be a good

mother and do a good job in medicine. And I didn’t get one interview, not

even one! ... So the next year .. I didn’t even include any mention of my

son in the next essay. I just presented myself as a scientist who had done

research, but that I felt clinical science was better for me. .. I came on

hardcore as a scientist, and more or less omitted any other aspect of my

life. (Broadhead, 1983, p. 21) 30 While no information is provided regarding the success of this application strategy, the fact remains that students, even applicants, are aware of the values of the institution and attempt to adapt to them whenever necessary. As this example illustrates, complete devotion to medicine is expected, and the necessity of making invisible family responsibilities—something more culturally expected of women then men—is built into the institution.

Additionally, several authors have examined the impact of workforce restructuring on nursing's traditionally feminine' modes of caring. Managed care reshapes and transforms ideas of caring, generally (Lammers & Geist, 1997). More importantly, however, scholars and critics have turned their attention toward the practices of medicine as an institution that continues to position women at the bottom of the medical hierarchy as a whole. Health care organizations are the home of a large population of “pink-collar” labor: professional/semi-professional workers serving support roles, the vast majority of whom are female. Ninety-seven percent of nurses, aides, and other support staff are female (Feminist Majority Foundation, 1995).

The use of technology in the nursing field, too, has drawn critical attention.

Rinard (1995) reports that "the interplay among technology, labor process and gender bias" has led to a consistent deskilling of nursing, resulting in a "transformation of nursing by information systems technology [that] continues to radically alter the daily routines of nurses" ([online]). Indeed, structural and technological changes have had an impact on how nurses are valued (or devalued) socially and culturally.

The economic, organizational, and social domains—indeed the very culture of— health care organizations have not been nor seem to be geared toward the success' of 31 women in this setting. However, although the current research regarding the position of

women in health care organizations has helped us to understand the nature of the

problem, as well as how individuals have responded to constraints of the cultural

situation in which they find themselves, such research is poorly positioned to make many

inroads into changing this fact of life'. I now turn to explicating the reasons for this

inability and propose an alternate mode and object of investigation that overcomes the

limitations of the current research. As clarifying the alternate research program is the

focus of the next three chapters, I will also only briefly introduce it here.

2.3 The Socio-Cultural Role of Communication Scholarship

There are two main limitations of existing research on women working in health care organizations. The first limitation, represented best by the type of research included in the sociology-in-medicine perspective, stems from the disconnection between the structural and cultural aspects of organizations and the practices of individuals, work groups, and cohort groups, as well as any possible outcomes. By focusing on patterns of enrollment or supervisory structures, research has drifted from what these things' mean, and more importantly, how they come to mean something (have significance). Thus, this research program hides the role of power and history in shaping such meaning. In short, there is a focus on the symptoms, but not necessarily the etiology of the problem.

The second limitation, represented in the research of the sociology-of-medicine perspective, represents very nearly the reverse problem. The focus of this research is in the cultural role of medical institutions with scant, if any, concern paid to the interactive, day-to-day activities that create, sustain, or perpetuate those frameworks. Without 32 attention to the micro-practices of health care organizations, such research is ill-equipped to examine possible changes in the relationship between the institution of medicine and the cultural milieu. In order to over come both limitations presented here, we need a mechanism for linking the everyday, the micro-interactional aspects of organizing with the cultural role the medical organizations play in—for this research at least—prescribing and constructing gender identity.

The perspective I believe communication scholars can bring to this problem' area overcomes these limitations by connecting everyday practice to cultural systems through an examination of the negotiation of meaning, including how meaning perpetuates or resists practices of domination. I propose that the organizational communication practices within health care organizations provide a modality for the enactment of gender by implicating masculinity and femininity in even the most mundane of interactions and expressions. Bodies, in other words, come to be gendered through communication, and through communication in organizational contexts in particular. There is no 'gender' without communication. To understand how this can be, one must inquire into the nature of communication, generally.

An understanding of communication practice from a phenomenological and hermeneutic perspective helps to focus this investigation both methodologically and conceptually. Methodologically, communication practice acts as a window, making transparent or allowing a seeing through (Pilotta, 1979), to the social domain that is both a limit condition for, and a result of, interaction. This is because communication evokes the social and constructs it simultaneouslv. Pilotta (1979) argues, "the subject or interpreter makes judgments about the world and, at the same time, is part of the world he 33 or she judges" (p. 288). Examining communication allows the researcher to see the how

(not just the what) of one's judgment making and one's participation in the world being

judged. It allows the researcher to see the mutually constituting nature of self and

society.

Furthermore, following Pilotta (1979), "communication is the actualization of

inter-corporeal movement and interconnected meanings which constitute a passive

preunderstanding" (p. 3(X); emphasis added). Communication practice makes meaning

observable. Yet, the search for meaning is not, from the phenomenological point of view,

a "question of a real nature " but of "how these objects are given to the one who

experiences" (p. 300; emphasis original). Meaning is a defining characteristic of

communication, and thus serves as conceptual touchstone for this project.

Meaning must be understood as both contextual and acontextual. The communicator/actor operates within the constraints and opportunities of the situation as it

presents itself and as it unfolds for the actor. "Meaning is recognition " states Pilotta

(1979) and "[rjecognition is a fundamental communication of the body's involvement in

its milieu " (p. 290). Meaning is constantly recreated as the body moves through time and space; as the positionality of one's involvement changes. However, meaning also has

"stability" and thus, there will be an acontextual nature to communication. This stability comes not from a consistency of representation (i.e., the same signified), but rather a consistency of intention—an orienting-to which creates the object of one's own perception.

The perspective on communication presented here helps develop a new way for understanding gender. Here, gender is not taken to refer to the social constructions- 34 masculine vs. feminine—nor the expression of some biological fact (i.e, sex organs), although these two understandings are part of the common parlance, and thus, will necessarily enter the discussion. Instead, gender is understood as expression' which is both the outcome of and a precondition for the attribution of 'masculinity' and 'femininity' to another body (or object); an attribution which results from one body's intentional relationship with that body (or object). Furthermore, this attribution takes place within the parameters of specific contexts which are themselves communicatively created. To say, then, that gender is through and through' implicated in communication practice, both as a precondition for and as an outcome of, is to say that gender/identity is enacted.

The applicability of this perspective can be easily seen by examining a common health care encounter with an eye toward the relationship between communication and gender. A female physician enters the room of a male patient. Despite clues to the contrary—for example, the white coat'—the patient asks, "are you my nurse?" The physician replies, "no. I'm Dr. So-and-So" and the consultation continues. In the course of their interaction, the patient expresses concern about his family and seeks sympathy from the physician. The physician, however, continues to review notes on the chart, check IV lines, and the like, simply nodding and "hmm-hmming" in response. Later the patient tells his wife that the doctor was cold to him, and the physician tells a nurse that the patient was sexist and rude.

From the sociology-in-medicine perspective, as applied to communication practice, we could look at the interaction of the two for specific words or paralinguistic cues that contributed to the character of the encounter. That tells only a part of the story, however. Another component of the story, taken from the sociology-of-medicine 35 perspective, again as applied to communication practice, would examine the discursive construction of femininity and how it impacts the interaction. The critique offered here, while useful, again provides a limited view.

From the perspective that gender is enacted, we would consider yet an additional component. Yes, it is true that the idea of femininity is a discursive construction that impacts on perceptions of medical professionals. It is also true that the specific interaction that takes place is problematic, but not because each actor communicates in a gendered manner. In order to fully appreciate the situation that occurred, one must see the role communication plays in orienting each to the other and in doing so, gendering each other. In this way, we can see the connections between 'macro' and micro', specific practices and cultural thematics. We also, then, open up possibilities for reimagining that relationship.

36 CHAPTERS

THEORIZING GENDER AS COMMUNICATIVE ACTION

As proposed in the previous chapter, transforming the relationship between women and health care as a field of organized activity will require understanding gender as a communicative accomplishment within interaction and through the communication codes (discourses and contextual sense-making practices) which are prevalent in health care. Furthermore, to understand gender as an accomplishment in a politically useful way, I cannot rely on the same types of conceptualizations of gender that have served as foundations for previous research, or even other alternatives. Although these formulations have been empirically useful (in terms of conducting research), I will show why their political usefulness is limited. Finally, developing a firm understanding of what 'gender' is in terms of communication practice helps me meet one of the second goals of the project: moving toward the development of a communicative theory of gender.

In this chapter, then, I address the following: what conceptualizations of gender have been useful both empirically (in terms of this as a research project) and politically

(in terms of the context of concern)? In what ways are those conceptualizations limited?

37 What are the basic contours of a communicative theory of gender/identity? What is the political advantage, if any, of such a theory; that is, how does it frame cultural critique and provide for intervention into systems of domination?

Although I do not intend to imply that the conceptualization proposed here will drastically change the nature of the health care system or centuries of a patriarchal and paternalistic medical ideology on its own, I do believe that beginning to see gender identity as tied to communicative practice can, through additional research and application, begin to change the practices of health care providers. The empirical analysis developed from this model of gender as communicative practice and presented in later chapters is a first, and necessary, step in a much larger process. From this, I hope that social actors can re-imagine their interaction and become more actively aware of their own intentionality.

To conceptualize gender as communicative action, then, I will begin with an overview of several alternative models that draw from a predominantly modernist framework for understanding the gendered subject. The political action made possible through a modernist framework has provided many advances for women in health fields, as well as aided researchers in developing analyses that are aimed toward the alleviation of discrimination, bias, and lack of advancement or authority women (or men in feminized areas) have in health care settings. So as not to overlook these contributions, then, I will attend to the way previous research on women physicians and the status of nurses/nursing have benefited from the modernist framework.

Although powerful in many ways, the modernist framework none the less limits possibilities for change, primarily because it takes gender (identity) as a given or pre- 38 existing component of cultural practice. That is to say, even when gender is presented as the result of a socialization process even if not some purely hormonal, reproductive, or otherwise biological precursor to action or cognition, the underlying basis for such a conceptualization is that gender is seen as a reason for cultural activity and not as a result of (or coexisting among) the same. It is the latter possibility that I hope to explore as both a conceptual and theoretical alternative as well as a political one. This alternative, furthermore, helps develop a conceptualization of identity as a communicative phenomenon.

Following a critique of more modernist forms of theorizing gender and their limits, then, I will develop for the reader some of the main strains of postmodern theories of identity and poststructuralist critiques of the modernist framework in order to move toward an understanding of gender/identity as a communicative phenomenon.

Specifically, whereas other postmodern developments of identity draw on linguistic theories of subjectivity, I propose that a phenomenological or experiential basis of subjectivity, as introduced in the previous chapter, more fully encapsulates the possibilities of examining the doing' of gender as a communicative activity. Taken in combination with already well developed understandings of communication as discursive practice and communication as sense-making (a theme developed in Chapter 4), the theory of communicative practice that underlies the theory of gender identity proposed here, then, is more conceptually aligned with postmodern revisions of phenomenology rather than structuralism.

The political alternative highlighted in this reconceptualization cannot be underestimated. As postmodern feminist critiques have shown, thinking about gender

39 with the series of oppositions (male/female, Man/Woman, masculine/feminine) made possible by essentialist notions of identity has done little to provide a conceptualization of gender that has the possibility of breaking through structures of political and material inequality, as such conceptualization are tied to the ontological and epistemological biases of modernism (cf. Nicholson, 1990). That is to say, in assuming some objective, measurable, and relatively fixed reality at the base of identity pushes conceptions of identity into a framework of difference that makes political action virtually circular.

To break out of this sometimes vicious cycle, gender--and identity in general—needs to be thought of as existing only in and through material, experiential, and discursive relations, not behind or supporting them. In particular, a postmodern conception of (gender) identity—linguistically or communicatively based—focuses our view on the multiple and various discursive (construed broadly) relations which produce gender, and the ways in which gender is enacted and resisted in everyday interaction.

Developing the concepts associated with this distinction between an identity politics’ and a ‘politics of identity’ serves as the final purpose of this chapter.

3.1 Modernist Conceptualizations and Their Political Limits

As mentioned above, a modernist conceptualization of gender (identity) is founded on an epistemological and ontological assumption of real, measurable differences between members of specific social categories that extend across time and space. The search in modernist theorizing, then, is to uncover the nature or causes of those “essential” differences and subsequently, alter the political system so that those

40 differences either don’t matter, or so that they are seen as advantageous to society as a

whole. This is the basis of liberalist politics.

The legal category of Woman (as the binary opposite of Man), the rights

associated with being a legal subject are claimed for women on the basis of their

sameness and/or difference from men. Within the current political structure of liberal-

humanism, feminists can claim a subject position for women, and once within such a

framework, stake political claims on the rights that go with being recognized as a subject.

Mary Wollstonecraft (1792/1992), for instance, working within late 18th century

humanism, argued that although women were quite different from men in many ways,

when it came to what counted, they were imminently rational beings, though they had

been taught to be ‘unreasonable.' Claiming the ability to reason was a necessary first step

for women to gain access to institutions such as science (c.f. Rose, 1994).

Much of liberalist politics rests on the ability of activists to claim that there is no real difference between women's skills, abilities, or perspectives and the status quo' or that such differences are beyond the control of the actor, requiring that legal protection from reprisal be granted. Other arguments within the main liberalist framework rest upon the activists' ability to claim that differences between men and women are useful and advantageous to the society. A culturalist (or womanist) feminism develops this view by- expounding on the abilities of women to maintain relationships and negotiate conflicts.

'Equal' status, then, is claimed on the basis that others do not always value these abilities, skills, or 'special' perspectives. Both the 'essential differences' and culturalist/womanist arguments have been politically advantageous in supporting a rights discourse.

4 1 As seen in the previous chapter, a rights discourse provided for the entrance of women into coeducational colleges of medicine at the end of the 19th century. In this first instantiation, women were considered ‘different’, but not different enough to preclude success in medical school. While still feminine, women were not incapable of intellectual and practical equality. Elizabeth Blackwell’s brother writes of her graduation ceremony,

[Dr. Lee] pronounced her the leader of her class; stated that she had

passed through a thorough course in every department, slighting none; and

that she had profited by all advantages of the institution, and by her lady­

like and dignified deportment had proved that the strongest intellect and

nerve and the most untiring perseverance were compatible with the softest

attributes of feminine delicacy and grace. (Blackwell, 1895/1977, p. 91)

In a similar attempt to justify women’s place in medicine without sacrifice of Victorian values of femininity. Dean Ann Preston, M.D., of the Women’s Medical College of

Pennsylvania, in her valedictory address to the class of 1858, remarked, “we grant that home is the women’s sphere, adm itted... [but] Ladies, it is for the very purpose of making home enjoyments more complete that you have been delegated today” (Morantz-

Sanchez, 1978, p. 5).

A rights discourse, following in the footsteps of the second-wave women’s movement in the United States, is also accountable for the large and sustained influx of women into medicine beginning in the early 1970s. Indeed, the utility of such a position has been and continues to be politically undeniable. Weed (1989) writes, “The U.S. liberal rights system is a rich and complex one...it is flexible, sometimes unpredictable, 42 and not easily reducible to formulaic critiques of it. It is, moreover, the channel through which most social change is currently realized” (xi). That women now account for nearly

20% of all practicing physicians (U.S. Department of Labor, 1998) compared to the 4% -

6% standard of the middle part of this century (Walsh, 1992) is indicative of the political success of the rights-based women’s movement.

The ties between the Women’s Suffrage movement of the early 1900s and nursing as an organized area of practice also show the advantage of the liberal rights system for working women. Well known suffragists such as Lavina Dock, Adelaide Nutting, and

Margaret Sanger were all trained nurses. Lavina Dock once stated,

[W]e owe the existence of our profession to the woman movement; we

owe it all that we are, all that we have of opportunity and advancement;

we owe it our social and educational and economic status; and, all this

being true, we surely own it our gratitude and out recognition; we owe it

our loyal allegiance and our moral support.

(Dock, 1909, in Roberts & Group, 1995, p. 155).

The tie between the suffrage movement, education, and nursing, in particular, is worthy of note: University sponsored baccalaureate programs, pushed for by nursing associations, in nursing provided one of the few modes of educational advancement for women in the early 1920s.

However, the rights system is not immune from periodic collapse, as women find themselves nonetheless marked by the very system that attempts to free' them. Women attempting to enter medical school experienced a collapse on a small scale when the tide of entrance into medical school turned after the turn of the century. Medical school 43 admissions boards could claim that women weren’t denied admission because they couldn’t do the work (i.e., the board was not discriminating against their abilities), but that women were not admitted because they could never become fully certified (i.e., residency programs were closed to women). A larger-scale collapse may be occurring now, as women find themselves part of the medical establishment only at its lowest levels. As the policies of managed care continue to impact the various contours of the medical profession, primary care specialties (family medicine, general internal medicine, general pediatrics) present the “best opportunities ” for stable financial gain through 2006

(U.S. Department of Labor, 1998, p. 186). Coupled with a current physician

‘oversupply’ (U.S. Department of Labor, 1998), one wonders how long it will take for women to be pushed from even these specialties as male students begin to track into them and as tighter regulation on the sheer numbers of students accepted into medical training increases.

The field of nursing, too, is not immune from the compromise that leads to collapse within the rights system. As indicated earlier, opportunities of nurses have waned with the rise of managed care, as registered nurses are too expensive to provide bedside care. In addition, as specialized training in nursing has expanded, leading to the development of advanced practice nursing, advanced practice nurses find themselves in competition with pharmacists and physicians for the right to practice some of the duties for which they are specially trained. State legislatures have been drawn into the controversy (or created it) as they consider changing practice acts to permit advanced practice nurses to take over some activities traditionally reserved for physicians (i.e., writing prescriptions). Other legislative action has focused on the ability of nurses to 44 refuse mandatory overtime or be compensated for working extra-long shifts. For example, the Colorado Nurses Association recently fought against proposed state legislation that would have made nurses' ineligible for overtime pay after working more than 12 hours in a given day. As long as the total clock hours for a week are less than 40 hours, no overtime pay would have been required according to the proposed bill.

Although the proposal failed in the Colorado legislature, forced overtime (more than 40- hours per week) is not addressed by many practice acts and such practices are currently left to the discretion of the employer (American Nurses Association, May/June 1998).

The reason for the inability of liberalist politics to provide sustained and ‘real’ change is due to the philosophical underpinnings of gender identity that are used to claim rights. The system is premised on the fundamental and essentializing question “what is a woman?” because answering the question is the manner in which political rights can be claimed. Yet, this question accepts and glosses over difference, accepting it, rather than asking how women become Women/Other' or how such differences come to matter in particular settings. In short, liberalist approaches start with the biological (sex) and infer from that, the social distinction (gender), even when the attempt is made to improve the position of women.

Alternative questions may be found within socialist or radical perspectives on gender - both of which hold off automatically accepting essenlialized differences but look instead for the systems that produce differences. Thus, I find it useful to summarize other ways in which these alternative perspectives within feminism have addressed the basis of difference and thus, reveal the type of political action (and research perspective) such perspectives make possible. Toward that end, I will summarize work in socialist and

45 radical feminism where absolute essentiaiism is not, at least as obviously, accepted as a basis of difference.

The central concepts of socialist feminism revolve around the core belief that the structure of labor positions women at the bottom' of the class structure. Domestic labor, unpaid labor, is free' to the capitalist. By maintaining the home, and caring for the

(male) worker, the worker is able to be more efficient and productive. Additionally, women help teach and nurture the next generation of workers (male children) or homemakers (female children), assuring the reproduction of the social system through the family/domestic sphere. The alternative, however, is not for women to enter the working-world, as the proliferation of workers added to the workforce further enables the deskilling (and alienation) tied to the production process (Bryson, 1992). The key structure of critique is capitalism.

Radical feminists, by contrast, propose that women's political freedom depends on women’s ability to provide for themselves financially (as well as psychologically, emotionally, etc.). By doing so, women free themselves from the necessity' of becoming an exchanged commodity among men in "service [to] their domestic and sexual needs "

(Bryson, 1992, p. 197). This aim also includes making the workplace open to women, including attention to and campaigns against sexual harassment. The key structure of critique is patriarchy.

Attempts to conflate (or, ironically, marry) these two perspectives are revealed in a variety of feminist works on dual-systems' theories, which draw together the mutually oppressive forces of patriarchy and capitalism. That is, they are oppressed through both

46 their biological role as reproducers (with implications for their role as laborers under conditions of capital) as well as in their socio cultural role as exchanged commodities.

However, the combination does not overcome the foundational limit of either perspective. Haraway (1991), in one of her many insightful and well-crafted expositions of the history, trends, and political usefulness of feminist philosophy argues that

"Marxist/socialist feminisms and radical feminisms have simultaneously naturalized and denatured the category of woman' and consciousness of the social lives of women ' (p.

199). She proposes that, by beginning with a stable social structure (the structure of class, in the case of socialist feminism, or the structure of gender and sexual appropriation in the case of radical feminism; or both together) such positions reduce down' to sex/labor as a defining (i.e., essential) characteristic of the difference between women and men. What is needed to prevent this essentializing step, then, is a conception of these social structures as emanating from something other than the physical (labor, sex).

Finally, a consistent critique of liberal, culturalist, socialist and radical feminisms is the tendency to reduce women's identities to a particular identity. In short, a general blindness to the multiplicity of women’s identities as also raced, sexual, and marked by physical ability and nationality, among other aspects, has plagued such overtly essentialist notions of gender. The focus of these critiques is on the inability of such a position to equally politicize differences among women; a critique which applies to most of research on women in health care.

With few exceptions (i.e. Wear, 1997; Feminist Majority Foundation, 1995), the differences among women as physicians or physicians in training are all but erased, and 47 no mention of career trajectories, mentoring possibilities, stress levels, family

responsibilities, or harassment experiences are reported except under the assumption that

all women mentioned are white, heterosexual, and from middle- or upper-class

backgrounds. Issues of sexuality, ethnicity, and national origin are also conspicuously

absent in discussions of the social-makeup of the nursing profession as presented in

nursing texts. The National Association of Colored Graduate Nurses formed as its own

separate organization in 1908, and was suspended in 1952 when the American Nurses’

Association finally accepted African-American nurses into its ranks. Suspiciously, the

NACGN was reborn in the 1970s under a different name, although African-American

nurses still count among the ANA’s membership.

To counter the problematic of liberal, culturalist, socialist and radical feminism,

feminist theorists have relocated sites of critique from attention to purely sex-tied (or

labor-tied) conceptions of gender to examinations of socialization and experience as

possible grounds for theorizing gender and as opportunities for political engagement.

This perspective shares with liberalist feminism possibilities for political gain, but in the

process, represents another type of essentializing move that is ultimately politically

suspect as it leads to the same kind of circularity found in the rights system.

Socialization theories, or theories of social-psychological or cultural learning,

move discussions of gender out of the realm of essentialized characteristics or structures,

and attempt to draw attention to the fluidity of social experience as a factor in women's

identity development. The basis of these theories is that children learn through imitation of their identified others (drawing from Freud) (Wood, 1997). The main limitation of

such theories is their inability to allow for the production of gender as a basis for or

48 component of political action, at least in any pragmatic sense. As researchers have used this perspective, they produce a proliferation of individuals, making collective action difficult. More importantly, however, socialization theories tend to focus on experience as a determining factor of one's position as female.

But what experiences are most politically useful to focus on? The experience of oppression has been used to unify feminist political projects under the ideal of a ‘global sisterhood’ (Morgan, 1984, in Mohanty, 1992). One significant problem with this conception is that in this aim toward a universality of experience, “[t]he experience of struggle is .. . defined as both personal and ahistorical. .. Experience is thus written in as simultaneously individual (that is, located within the individual body/psyche of woman) and general (located in Woman as a preconstituted collective)” (Mohanty, 1992, p. 82).

Highlighting the similarly personal and ahistorical underpinnings of experienced- based social science research on women in medicine, Judith Hammond (1981) argues that

social researchers must be wary of speaking about women’s experiences in

medical school in terms of personal problems or women’s problems. ..

Use of the service vocabulary of helping along with the publicizing of

resource-support services without pointing to major system change which

would affect all the membership of the profession is a disservice to

women, (p. 164-165.)

Dr. Lucy Candib, a practicing physician also highlights the downfall of this approach. Dr. Candib, writing of her twenty-plus years of practice, describes clear feminist-centered changes to her clinic, including the incorporation of part-time 49 schedules, flexible work schedules, and maternity leave to accommodate the births of eight children by six women and one man in one clinic over a two year period. Still, she admits,

[T]he icon of the community physician is still a white man, one hundred

percent dedicated to practice, whose life is managed and supported by a

full time wife and mother. Women physicians juggling part-time

schedules, sharing practices with nurse practitioners, pumping milk on

their lunch hours, and racing back from the office to the day care center,

these women are still invisible in the idealized imagery of family

medicine. (Candib, 1996, p. 143).

The various perspectives within modernist feminism that have been used to highlight, or have served as the basis for research about the relationship between women and health care organizations have, while promoting women at important historical junctures, run their political course. An important reason for this is an inability to integrate fluidity and (even temporary) fixity, structural determination and individual action. The postmodern turn' in philosophy, and in feminism, hinges on being able to see the interplay between everyday action and systems of power, between movement and moments of condensation (or fixity). Finally, I believe that a postmodern perspective within feminism, or in theorizing gender/identity generally, not only opens up the possibilities for analyses that reveal new forms of political action, but also opens up space for developing a distinctly communication theory of identity. Thus the remainder of this chapter is devoted to exploring postmodern feminist conceptualizations of gender, the possibilities for a communicative theory of identity, and the usefulness of such a 50 conceptualization of identity for examining the formations of health care as a domain where gender is enacted.

3.2 Postmodern Feminism and the Basis' of Identity

The 'basis', if one can correctly say there is one, for postmodern theories of gender/identity is the rejection of any and all foundational, universalist, or essentialist notions of social experience. Strictly speaking, then, there can be no 'cause' for women's oppression (Nicholson, 1990), but rather, a multiplicity of historically contextual and located practices which, in their condensation, produce what we come to know as masculine and feminine. Gender becomes, then, not a category of experience that transcends the situational, but is rather an ongoing and politically implicated act of accomplishment in social life.

Although "the recognition of [gender] as central in understanding human thought and behavior has been a major feminist accomplishment" (Nicholson, 1990, p. 15), the reliance of this recognition on acontexual and ahistorical understandings of human action is less than political useful in many situations, as I have shown. In proposing an alternative to personalized and ahistorical approaches, Scott (1992) argues, “we need to attend to the historical processes that, through discourse, position subjects and produce their experiences. It is not individuals who have experience, but subjects who are constituted through experience” (p. 25-26). By not taking experience at face value, but by interrogating it, moving beyond the personal and the collective identity (however located, and thus, predominately fixed) becomes possible, along with political

51 engagements that are grounded on identities that are always partial, mobile, and situated

(Haraway, 1991).

Such a conception of identity, furthermore, highlights the process of constructing

differences and the role social structures and discourses play in that construction, rather

than locating difference in the biological or sexual domain or in the experiences of

individuals. Conceptualizing gender as a product of discourse and practice, in other

words, shows how such discourses and practices essentialize the subject rather than how

subjects already are'. As Diana Fuss (1989) has pointed out, “it may be time to ask

whether essences can change and constructions can be normative " (6).

There is also a growing recognition within postmodernist thinking generally that

“social structures do not exist in some abstract sense ‘out there’, but only insofar as they

are instantiated in specific practices ' (Witz & Savage, 1992, p. 7). Thus, social structures

and discourse—sites of identity production—provide guiding principles for actors, while at the same time, are reproduced by actors through their use of those principles in their actions. A key component in postmodern theorizing of the subject (identity) then, is that subject's ability to recognize, adapt, and produce himself or herself within the discourse that positions them. In short, we are guided by a subjectivity that develops from our interaction with discourses and our use of those discourses in specific contexts. Witz &

Savage, in explicating this basic claim, draw the work of Giddens and Foucault into parallel.

According to Giddens (1984) “the basic domain of study of the social sciences, according to the theory of structuration, is neither the experience of the individual actor nor the existence of any form of social totality, but social practices ordered across space 52 and time” (p. 2). For Giddens all social relations are recursive, meaning that actors

cognitively draw on discursive ‘rules’ to produce and guide action, and in doing so,

reinforce the primacy of the regulatory discourse which produced the rule.

There is, however, a noticeable reliance on the cognitive (and psychological) understanding of subjectivity built into Giddens work. In The Constitution of Society,

Giddens (1984) offers the idea of discursive consciousness, practical consciousness, and unconscious motives/cognition "in place of the traditional psychoanalytic triad of ego, super-ego, and id" (p. 7). Despite the attempt to refigure Freud's triumvirate, however,

Giddens replicates the inclusion of some true' experience outside of consciousness, rooted in the acontextual and pre-cultural. Thus, while Giddens attempts to bring the fluidity (and the power of that fluidity to fix) social structures into conversation with everyday action, his reliance on the psychological belies his attempt to eschew a transcendental universalism.

Foucault’s fjerspective on the mutually influencing relationship among micro-and macro-social practices is similar, but Foucault incorporates the embodied nature of subjectivity through the idea of discursive awareness. In the case of the prison, for example (Foucault, 1979), power operates not only through the gaze of the guard (the instantiation of structural power), but also through the internalization of that gaze by the prisoner. Discipline does not occur simply through the focus of the disciplinary gaze, but also through the reproduction of the disciplinary gaze by the subject; that is, the subject knows the rule and acts accordingly, whether or not the guard is actually looking. Within this framework, the subject as a fixed entity (i.e., sexed, possessing rights, having experiences, etc.) is no longer a focus of the application of power. Rather, the recursive 53 practices of social organization take center stage, highlighting the way in which discourse and practice interrelate through the production of subjectivity.

Locating subjectivity as a basis of the connection between micro- and macro­ social practices is a key aspect in the development of a postmodern concept of gender.

Predominantly, this focus shows up in well-formulated poststructuralist position on the relationship between language, society, and subjectivity. Yet, there are elements of one's awareness that are not encapsulated by this conceptualization of subjectivity (and thus, for our purposes, gender). Thus, I will explore the linguistic position on subjectivity, and contrast it with the type of intentional relationship described in brief at the end of Chapter

2. Doing so firms up the conceptualization of gender that, while postmodern, relies on communicative activity (vs. language) as a basis. Finally, I will characterize how such a conceptualization of gender helps to focus the project empirically.

3.2.1 Linguistic Subjectivity. Drawing on the work of Jacques Lacan, several feminist scholars have attempted to ground the concept of subjectivity in the function of language as a cultural practice. That is not to say that feminists, generally, read Lacan's work sympathetically. Indeed, as Grosz (1990) argues, "many feminists use his work on human subjectivity to challenge phallocentric knowledges; others are extremely hostile to it, seeing it as elitist, male-dominated, and itself phallocentric" (p. 147). Such criticism aside, the advantage some see in using Lacan's work, particularly in a postmodern framework, is the replacement of a reliance on a notion of the pre-cultural consciousness with a concept of language as the ground of subjectivity. In other words, rather than positing some pre-cultural, preconscious awareness, Lacan argued that consciousness 54 itself is structured like language, and in doing so, proposes that the structure of

consciousness (subjectivity) is itself cultural.

The self-other relationship that precedes entry into the symbolic order (pre­

meaning) begins with the crises of recognition of separateness (of being an individual)

and entry into the realm of the imaginary (the ability to see oneself) (Grosz, 1994). In order to fulfill the desire for connectedness, the now recognizably independent 'self reaches out to its other', but must use language to do so. Thus, the child enters into the realm of the symbolic, and since there is not expression for the connectedness between

Self and Other, the possibility of fulfilling the desire is forever thwarted.

Obviously, the role of desire in constituting the self is an important one. In fact, the social actor is, in this framework, always in search of unity, always a desiring being.

However, the actor must use language to achieve even an approximation of that unity, and as language is masculinist, as many French feminists have pointed out, the desire for unity is not only thwarted by the fact of its linguistic mechanism, but for women, desire is doubly thwarted through the reliance on a masculine language, (cf. Kristeva, 1980).

Thus, the most important aspect of this theory of subjectivity is the relationship it proposes between the actor and language (regardless of how it is tied to desire).

3.2.2 Communicative Subjectivitv. There is, however, something lacking in a

Lacanian perspective on subjectivity from the point of view of communication scholarship. Few communication scholars would agree that aU expression takes a linguistic form. In fact, even a very simplistic understanding of nonverbal communication reveals that the practice of meaning making, a component of expression, 55 does not rely only on representational forms (such as language). An embodied perception of space and time relations contributes greatly to meaning making without regard to representational language. The ability for one to detect deception, for instance, relies on expression and perception of the situation in terms of its sense' more than the words that are used. Thus, it may be more appropriate to state that the structure of one's awareness

(to avoid the additional baggage that 'consciousness' carries with it) is communicative rather than linguistic, per se.

Judith Butler’s (1990) perspective that gender is performative can serve as a starting point for understanding the communicative basis of subjectivity. Identity, particularly gendered identity, is based in action, neither some notion of an essential subject nor some linguistic structure of desire, in Butler’s work. She argues,

[Gjender is always a doing, though not by a subject who might be said to preexist the deed. The challenge of rethinking gender outside a metaphysics of substance will have to consider the relevance of Neitzsche’s claim in On the Geneology of Morals that ‘there is no being behind doing, effecting, becoming; the doer is merely a fiction added to the deed—the deed is everything.’ In an application that Neitszche himself would not have anticipated or condoned, we might state as a corollary: there is no gender behind the expression of gender; that identity is performatively constituted by the very expressions that are said to be its results, (p. 25).

Expression—in short, communicative practice—is at once the action by which gender is constituted while simultaneously, the reflection of the structures of gender that pre-exist such practices. If this is so, then it makes sense for us to inquire into what such expressions are and into the nature of the conditions for their possibility. More detail, then, is required to explain the nature of such expression.'

56 For all her insights, Butler does not have a fully developed concept of communication practice at the basis of her work. Butler locates the actions and practices of identity enactment only in the realm of the discursive, and thus further belies the possibility of examining specific interactional (i.e. performative) moments. The connection between actors and structures is given up in the interest of cultural critique.

While this is an admirable and necessary goal, a more complete understanding of the nature of expression' will help.

To expand upon Butler's attempts to expand the realm of what constitutes subjectivity, Pilotta (in-press, a) offers a reading of the phenomenological nature of social existence, contending that "every particularity is connected to a generality which grounds the concrete world of human activity " (p. 7). By this, Pilotta infers that the minute particularities of everyday interaction, for instance, are not unique to the interactants, although they are configured within the particular dimension of the interaction. In short, the interaction at once produces and reproduces the social order of the generality through the acts of orienting toward one another within the interaction. Expressions, in other words, reproduce the social structure (that which is not unique) at the same time they are fleeting moments of understanding (the orienting toward between participants).

But what is this mutual tuning in' experience? On what is it based? What is subjectivity' here? Pilotta (in-press a) argues that it is achieved through the corporeal orientation toward the time-space dimensions of the interaction (its material existence) and of each other's Being. The basis of one’s awareness here implies an intentional' relationship (i.e. an awareness of something). This concept of experience/intentionality is further grounded in the idea that it is an "active consciousness" that creates the situation 57 and the thing’ of its observation (Pilotta, in-press a, p. 67). Finally, the tuning in to others, the situation, and acting toward both, is achieved by embodied (i.e. communicative) action. This means that the orientation could be vocal/verbal or nonverbal. Still, the orientation, the intentional relationship between interactants, reflects meaning making.

This basis of awareness in an orienting-toward is the means by which the actor identifies the me, the you, and the we. There are, therefore, some connections to be made between the action -here an interactional or communicative orientation--and the actor's identification of self, other, and the space in between. Further, this orientation is contextual ized within not only the orientation of actors, but also the implicit role that structural and discursive play in determining or influencing the boundaries of that context. The intentional relationship reveals, then, not only how participants/actors are orienting toward one another in this moment, but also the cultural influences that prefigure the context of their interaction. These cultural influences can be discursive (i.e. broad cultural regimes of truth) or specific to an organizational setting (i.e., a sense- making code).

My interest is in how these three components work together. The discourses of masculinity and femininity are indeed influenced by many other discourses, including those related to sexuality, the family (patriarchy), the body in general (i.e., its processes), race, and the like. At the base, however, masculinity is active, strong, powerful, big, solid, virile, and "protector". On the other hand (and it is always a binary), femininity is passive, weak, powerless, small, leaky, frigid, and "protectee". These minimal

58 descriptions of how masculinity and femininity are discursively constructed in the west

(and for whites in particular) comprise the discursive component.

The sense-making codes, which are part of organizational life, are necessary for coordinated action, as well as for decision making. The codes point organizational actors toward appropriate actions, rationales, and definitions for organizational events, ideas, and processes. This perspective on the relationship between organization and communication is presented in more depth in the next chapter. I also show, in that chapter, how this perspective on organizational communication can help address questions of the role organizations play in gendering their members in ways that other perspectives cannot.

It is clear, however, that a reconfigured notion of subjectivity that ties directly to communicative practice is necessary to understand how gender can be the outcome of communication activities as well as a precursor for those activities. There can be no single cause. This is the problem that plagues feminist theorizing. In searching for a reason for oppression, feminist theorists have re-essentialized 'gender' in multiple ways.

This work is a first attempt at exploring alternate ways of considering gender' and in doing so, explicating the ties between communication and identity.

59 CHAPTER 4

ORGANIZATIONAL PRACTICE AND SOCIAL IDENTITY

Several factors have pointed me in the direction of organizational communication studies as a framework for understanding the communication practice that helps shape gender. The obvious reason, of course, is that the context within which I am interested in examining communication practice is a very outcome-oriented, 'work-related' one. In describing the general concerns of organizational communication scholars, Kreps,

Herndon, and Ameson (1993) point to the study of coordinated environments and contexts as well as functional relationships and structures, highlighting the ultimate role that pragmatic and interdependent relationships among individuals play as a defining aspect of the field. Still, specifying the domain of organizational communication studies is not an easy task (Wert-Grey, et al., 1997). McPhee has provided the following parameters: "organizational communication is communication which is shaped by and shapes task processes and formal structure" (McPhee, 1988, in Meyers, et al. 1992, p.

243). In short, I share with other organizational communication scholars an interest in those communication practices that are associated with creating and maintaining the flow of meaning and relational ties among multiple interactants in pursuit of multiple and shared goals.

60 In the context of this research, the interactants have the shared goal of the

provision of health care services and communicate to create shared understanding about

proper (useful, effective, scientifically valid and reliable, etc.) health care practices. I

should also specify that I have chosen to focus on interactants who, in one way or

another, have devoted their creative labor to the provision of health care, rather than

focusing on the communication that exists between health care providers and patients,

their family members and the like. In localizing the research in this manner, I have

already restricted my scope to what may traditionally be called the intra-organizational'

communication that occurs among health care providers. And while I will soon show

how the domains of analysis within organizational communication should not be so

arbitrarily delimited, I remain aligned with the traditional core themes of the field

regarding the role communication plays in construction of meaning and the maintenance

(or alteration) of relational structures among goal-oriented interactants.

None-the-less, the more important reason I began working within organizational

communication as a general framework for the project, I believe, is that organizational

theory and organizational communication studies provide a basis for examining the

interplay between a person and her environment. In organizational terms, the

environment could be the relationships of the workplace, the community, or the

marketplace. In more general terms, one could represent the person-environment

relationship with various labels, depending on the philosophical underpinnings one uses

to frame the relationship. Terms like "individual" and "society" reflect a more

functionalist understanding of the relationship; "structure" and "agency" represent a more critical or humanist one. Perhaps more than my interest in exploring communication as a 61 component of goal-oriented relationships, then, I hope to use organizational theory and organizational communication studies as a model for exploring these fundamental dialectics and the way they shape and are shaped by communication practice.

In order to exploit most fully the possibilities of organizational communication theory so that it may serve as the model for examining the person-environment, subject- agent, individual-society dialectical relationship, however, several transformations to current models of understanding (studying, theorizing) organizational communication are necessary. In this chapter, I argue that to exploit the power of organizational communication theory to explore the nature of the dialectics named above, one must be able to more fully integrate a conception of organizational communication as simultaneously productive and reflective not only of power and understanding—themes well developed already in their own rights—and a conception of organizational communication as a means for the enactment of identity. In short, I add to the conception of communicative subjectivity and the basic premises of the discourses of masculinity and femininity presented in the previous chapter by explaining the third and final component of gender identity: the role of organizational sense-making practices. Implicit in my pursuit of this goal is the adaptation of existing paradigms of organizational communication scholarship to reflect the various conversations that arise between organizational communication and feminist theory.

The chapter proceeds thusly: First, I provide background of the "current state of affairs" of organizational communication. This includes a review and my own and others' critiques of the standing paradigms of organizational analysis. My critique stems from the limits of the paradigms to examine issues of identity, generally, and gender in 62 particular as a core component of organizational life. Like favorite sweatshirts, these paradigms remain unexamined in the scholar's comfort in them. Their faults—worn sleeves and frayed collars—are overlooked in light of the fact that they once required some personal sacrifice in their acquisition. And, also like worn out, favorite weekend clothes, there is still a usefulness, if not a nostalgic value, to them. Thus, while I hope to show the limits of the standing paradigms (models, really), I see the value in keeping them, at least to the degree that they can be adapted to integrate with the conceptualization of gender as developed in the previous chapter.

Following the review and critique, I will present my own version of a scheme for distinguishing forms of organizational analysis, and their methodological and teleological implications. As I explore this new model, I will draw attention to the ways in which it can conceptually, at least, allow and encourage the consideration of identity (gender) in the process of organizational analysis. I will particularly focus on the directives and impact a postmodernist feminist position on identity, as developed previously, brings to organizational analysis. Finally, as this perspective draws our attention to specific modalities of practice that help organizational members make sense of and act in their environment, I will conclude the chapter by explicating those modalities that may be used to operationalize gender enactment in this setting.

4 .1. General Paradigms for the Study of Organizational Practice

Two schemas for understanding existing approaches to organizational communication are prevalent in the field. Both schemas attempt to capture the scope of inquiry in organizational studies prior to and through the 1970s and 1980s. While these

63 schemas seem different in content, they are based on some fundamental similarities. In

particular, both schemas tend to focus attention on the roles and nature of meaning and

power as defining attributes of organizational analysis.

Redding and Thompkins (1988) propose three orientations to organizational

inquiry: the modernist, the naturalistic, and the critical. In their overview of these

perspectives, only the modernist traces its history back to the emergence of industrial'

communication as a field of research, directly tied to and growing out of relationships

between Departments of Speech (Communication) and Management and Business

Administration programs through the 1940s (Redding & Thompkins, 1988). The other

two modes of analysis are relatively recent on the scene, stressing the cultural and

subjective domain of organizational life. The interpretivist form falls squarely within the domain of anthropological inquiry, while the critical form of analysis highlights "a kind of consciousness-raising, if not emancipation for, organizational members themselves"

(Redding & Thompkins, 1988, p. 23).

The second scheme, developed by Gibson Burrell and Gareth Morgan, highlights two main dimensions that differentiate forms of analysis: view of reality and perspective on organizational order. By intersecting these dimensions, Burrell and Morgan propose four main paradigms: Functionalism, Interpretivism, Radical Structuralism and Radical

Humanism. The functionalist approach corresponds with Redding and Thompkins'

"modernist" approach, and the interpretivist forms of analysis are overlapping. However, whereas Redding and Thompkins have one form of analysis representing the "critical" school, Burrell and Morgan have two forms of critical work: Radical Structuralism and

Radical Humanism. While both share the idea that "organizational order is political, 64 [and] commitments to support or change this order are also political" (Daniels & Spiker,

1994, p. 10), Burrell and Morgan argue that the radical structuralist form of analysis presupposes an objective reality, whereas the radical humanist perspective assumes a subjective one. Therefore, the radical structuralist position in Burrell and Morgan's scheme more directly corresponds with Redding and Thompkin s (1988) critical' school wherein, "critical theorists (and those of a similar stripe) still assume that there is a truth' out there to be discovered " (p. 23).

Regardless of how many main approaches are proposed, however, the two schemas share the same effect: both indirectly focus the scholar’s attention to the role institutional power plays (or should/should not play) in organizations, as well as the role meaning and subjectivity play (or do not play) in maintaining organizational order.

Conceptualizations of the role of institutional power differ within the categories provided by each of schema as well as between the schema themselves. In the modernist framework, for instance, power is part-and-parcel of the organization’s structure. Power exists through the chain of command or through the definition of roles, particularly as a main component of effective leadership.' Power, thus, is an entity gained through relationship and is necessary for the accomplishment of organizational goals. In a critical framework, on the other hand, the very structure of the organization and the differential distribution of material and symbolic resources creates relations of domination and subordination.

Conceptualizations of the nature of meaning and symbolic activity within the forms of analysis typified in both the schemas vary significantly. At one extreme, meaning resides in some external, knowable world' and symbols are transparent to that 65 reality. At the other extreme, meaning and symbolic activity is the ‘stuff of

organizations; indeed, meaning-making activity is the very foundation of organizations as

symbols are productive of our understandings of reality. I should note, however, that

while the nature of communication activity is seen quite differently in each form of

analysis, there is a shared assumption about the role of communication activity. In short,

communication is seen as a tool for increasing organizational effectiveness or improving

organizational outcomes. This distinction quite clearly helps distinguish between

studying communication and studying organizations; a thin line that is difficult to tread.

Within the modernist framework, for instance, communication is seen solely as a

tool for the accomplishment of organizational goals. That is not to imply that modernist

approaches, especially, have not held sway in communication studies. Indeed, as Wert-

Gray, Center, Brashers, and Meyers (1991) show in their review of organizational

communication research topics and methodologies present in communication journals,

"the modernistic orientation dominated in organizational communication studies" (p. 149)

from 1979-1989. Likewise, Putnam's (1982) review of the paradigms provided by

Burrell and Morgan and their applicability to studies of organizational communication

points out that functionalism "treats communication as a concrete substance by

accentuating the spatial and physical properties of the message " (p. 195).

In the last two decades, however, organizational communication has undergone a steady shift toward interpretive perspectives. While some have declared this development a “paradigm shift” (Putnam, 1983a), one would be hard pressed to find the

kind of supplanting of the previous paradigm' usually accompanying the implied whole scale change. Wert-Gray et al., (1991) report that in 1983, 55.6 percent—only slightly 66 more than half—of all organizational communication studies research reports and theoretical articles published in communication journals approached analysis through naturalistic and critical forms of inquiry. Rather, interpretive and critical/humanist approaches exist alongside previous functionalist approaches, but are made more and more attractive by communication scholars’ desire to stake out a unique perspective on organizational life; one that does not align so closely with management theories and social-psychological concepts (Mumby & Stohl, 1996).

Interpretive approaches focus the scholars’ view on communication as the activity of organizing, not the ways in which communication practice may produce (correlate with, symptomize, etc.) some other variable: productivity, organizational identification, or climate. Beginning in the early 1980s, this approach began making inroads into organizational communication research and posing a challenge to the traditional forms of organizational communication inquiry (cf. Putnam & Pacanowsky, 1983). While the value of such research on a methodological level has been often questioned (Eisenberg &

Riley, 1988), the use of the perspective for rethinking organizational life is seen as having changed our perceptions of the relationship between organizing and communicating.

This shift in perception is due largely to the influence of a variety of intellectual traditions that focus on the epistemic role of language activities and which are used in interpretive research (O'Donnell-TruJillo & Pacanowsky, 1983). The view of language found in semiotics, ethnomethodology, and hermeneutics make it possible for the organizational communication researcher to make direct connections between communication practice and practices of organizing. “Organizations” Kersten (1986) states, “must be viewed as social collectivities that are created and sustained by the 67 communicative actions of human beings” (p. 141). Mumby concurs, stating, "the process

of communication and the process of organizing are one and the same" (1988, p. 95).

The usefulness of the premises of the interpretive approach cannot be

underestimated, particularly in light of this project. If communication creates the

organization, is it that much of a stretch to believe that communication creates gender' as

well? Further, the interpretive approach enables critical work (although it is not identical

with it) by simultaneously expanding the scope of the researchers inquiry into areas

which are not strictly task' related and redirecting (or at least making redirection

possible) the pragmatics of the research away from managerial interests (Deetz, 1982;

Pacanowsky & O'Donnell-TruJillo, 1982).

However, without consideration of the relationships between communication and

power, the idea of organizational culture' produced through the interpretivist framework

lacks critical purchase. Mumby (1996) states in his critique of the interpretivist

perspective, for instance, that scholars should be concerned “with examining how

communication serves the interests of some organizational interest groups more than

others” (p. 57). Others have pointed out, too, that interpretive approaches need to

question the ways in which organizations may be more equitable or humane for some and

not others (Hawes, Pacanowsky, & Faules, 1988).

Likewise, without appreciation of the interpretive focus on the role of language and organizational symbolism in sustaining the organization, critiques of power focused on structure of the organization neglect one of the very means by which the structure is maintained. Over and above the influence of the organization's official hierarchy,

Mumby (1988) argues, "organizational symbols not only create a shared reality, they can

68 also act to reify and make natural' the extant political conditions in the organization,

serving to promote the social reality that favors dominant interests, and limiting the

conceptions of alternative meaning systems " (p. 104).

As far as the application of this relationship to the specificities of organizational

life is concerned, however, Mumby under-theorizes the tie between meaning-making (or

sense-making) activity and power. An alternative formulation of this relationship is the

offered by Pilotta, Widman, and Jasko (1988). Premised on the idea that the

communicative aspect of sense-making in organizations is not restricted solely to

symbolic (i.e., linguistic) forms, Pilotta, Widman, and Jasko propose that communication codes (ala Luhmann, 1979; 1982; in Pilotta, Widman, & Jasko, 1988) are the basis of action selection and interpretation for organizational actors. They further define organizational culture as "an open-ended context framed by significant symbols and modes of legitimated social action that enables selective responses to changes in the communication environment." (Pilotta, Widman, & Jasko, 1988, p. 317) showing the necessity of incorporating symbolic and non-symbolic aspects of the communication process into the study of organizational life.

Defining organizational sense-making systems to include both ties to symbolic activity and action frameworks, it becomes possible to see how power itself can be a communication medium (code). Because "the function of a communication medium is to transmit reduced complexity " (Pilotta, Widman, and Jasko, 1988, p. 329). In short, the critical and the interpretive frameworks within organizational communication analysis can adequately converse. As I will show, this kind of conversation within the study of

69 organizational communication will be necessary in order to incorporate more realistically

feminist theories into the heart of organizational communication.

4.2 Feminist Theory and Organizational Communication

Several scholars in organizational studies have attempted to bridge the space

between feminist theory and organizational theory (see, for example Bullis, 1993;

Marshall, 1993; Mills & Tancred, 1992; Mumby, 1993; Pilotta, 1983). Until recently,

communication scholars have limited the discussion of women/gender in organizations to

the empirical analyses of women's communication in organizations from a variety of

theoretical perspectives. Overviews and meta-analyses of this work (i.e. Wilkins and

Andersen, 1991; Baker, 1991) reveal that "gender or sex differences comprise one of the

most frequently studied topics in complex human organizations today ' (Krayer, 1985, in

Wilkins & Andersen, 1991, p. 6; emphasis added). Most importantly, gender' has been

part of the organizational communication literature in terms of the problems' women face

in the workforce.

There has been little work drawing conclusions about the impact such empirical

analyses have had or can have on thinking about how one can theorize relationships

between organizational communication practices and gender as a culturally constructed

aspect of identity. Attempts exist, however. Buzzanell (1994; 1995) has attempted to

bring organizational communication studies into conversation with a variety of types of

feminist theory in the analysis of specific organizational and communicative practices, to

show how "messages, structures, and practices offer contexts in which gender is constructed and socially negotiated" (1994, p. 342). Mumby (1996) has also attempted to 70 bring feminism and postmodernism, together, to organizational communication studies

through the development of a concept of gendered rationality. This approach has been

influential in my own work, as the focus is on the role of subjectivity in navigating the

organization. However, there is still a determining (i.e., a-cultural) conception of

subjectivity underlying Mumby's work.

I argue that to fully integrate feminist perspectives into the basic paradigms of

organizational communication analysis, we need to rethink Burrell and Morgan's scheme.

Figure 4.1 represents this revised scheme. I should qualify form the outset that this

scheme is intended purely as a heuristic device, developed to map the assumptions of

various perspectives against each other, but without deep attention to the complexity of

any one position. The sole purpose of the scheme is to propose places where feminist

theorizing will fit into and disrupt the present forms of analysis that are available to

communication scholars.

In creating this scheme, I have maintained a version of Burrell and Morgan's first

dimension: view of reality. However, I have termed it Culture/Society to more fully

reflect the role communication as a sense-making activity plays (or does not play) in constructing the view of reality. This dimension shows a range from the belief in cultural

referents existing outside of experience, to a subjective position that relies on a view of

reality as socially constructed.

Also, rather than perspectives on organizational order, I have substituted a general dimension of power, showing the range of positions from that where power is an entity

(something possessed as a thing or possessed through a position or role) to where power is a process (that is, it is interactive or dialogical). This change has been made to reflect a 71 shift from considering the role the researcher plays in influencing (or not) the organization to a general perspective on the nature of influence in an organization.

Finally, I have added a dimension of identity, which ranges from essential/fixed

(i.e. determined by biology, at the extreme, or fixed through practices of socialization) to constructed, or the result of discursive forces. This conception of identity more completely aligns with the version of identity developed in the previous chapter.

Whereas modernist conceptions of identity assume some essential fixity' to identity, the postmodern version reflected in the work of poststructuralists like Michel Foucault

(1990) and feminists working with postmodernist conceptions of subjectivity (i.e., Grosz,

1990), assumes no fixity.

By adding this dimension, the other two dimensions are somewhat transformed in order to integrate more fully various feminist perspectives. Within this three-dimensional scheme, it becomes possible to conceptualize the relationships among organizational sense-making, power, and identity. I should also note at the outset that work in feminist epistemology has helped me develop many of the perspectives presented here, and while these may not be actively operationalized in current organizational communication analyses, I will try to indicate in which ways they might be. Other perspectives, also without current models, appear in the scheme as well.

The functionalist perspective represents the vast majority of research and theorizing in organizational communication from its inception' as a field of study. As an

"amalgam" of traditional (Aristotelian) rhetorical theory, models of human relations, and early versions of management (proto)theories (Redding & Thompkins, 1988), the

"dominant impulse behind the study of organizational communication has always been 72 POWER

Essential Entity • IDENTITV Functionalism

Liberal Feminist • Constructed CULTURE/ SOCIETY Radical Structuralist Interpretivist # # Radical Feminist Objective Psychoanalytic Feminism Subjective • Otuect R«.^ationsTheory/ # Cultural Feminist Lacfedan sychoanalysis

• Radical Hui nanist Marxist/So< ;ialist Feminist ^ Strong Objectivity Process Neo-Marxisi • Poststructuralist Postmodemis Postmodern Feminist

FIGURE 4.1 Theoretical Perspectives for the Study of Organizational Communication

73 pragmatic—aXXQmpimg to discover how individuals or organizations, or both, can be made

to function more effectively" (p. II, emphasis added). Social structures or culture within

this approach—which includes behaviorism, social exchange theories, structural-

functionalism, general systems theories, and cybernetic systems theories (Putnam, 1982)-

-"is objective, and research is regulatory " (p. 198). Moreover, power is an entity, results

from a position within the organizational hierarchy, as revealed through studies on

superior-subordinate communication and an emphasis on chains of command, levels of centrality, and formalized organizational structure. Finally, identity is assumed to be

fixed. Nowhere is this more evident than in studies designed to examine the differences between male and female managerial communication.

It should be mentioned that there have been inconsistent findings in studies aimed at examining these differences (Wilkins & Andersen, 1991). While reasons for these inconsistencies are hard to come by, Wilkins and Andersen (1991) point out, in their review of this topic, that both the sex of the researcher and the effect of time offer statistically significant explanations of at least a small portion of the variation among the studies they reviewed.

Sharing a view of identities as fixed are the liberal feminist, (Freudian) psychoanalytic feminism, radical structuralist, radical feminist, interpretivist, cultural feminist, (radical) humanist and Marxist feminist, and a standpoint' feminist perspective called strong objectivity.’ In each of these, there is a view of the "subject" or individual as having some essential characteristic, primarily tied to biological characteristics, but sometimes tied to socialization. The differences among these perspectives fall in their views about the nature of power and of culture. 74 Perspectives that share a view of power as an entity with functionalism are the

liberal feminist view, as well as (some) interpretivist and Radical Structuralist or Radical

Feminist views. In both of these views, power (authority or access to legal rights) is

something that is held by a person or group of people in positions that are powerful'.

Liberal feminist and Radical Structuralist/Radical feminist views also presuppose, to

varying degrees, an objective structure to society. As Radical Structuralist views have not generated much of a following in organizational communication studies (Putnam,

1982) except as adopted by radical feminist, I will preview what the radical feminist and liberal feminist views have meant for organizational communication studies.

Rosabeth Moss Kanter’s classic Men and Women of the Corptoration (1977) represents the liberal feminist view par-excellence. While recognizing the subordinate position of women in organizations, Kanter still holds the belief that bureaucracies could be reworked so that women would be able to have' power within existing structures

(Witz and Savage, 1992). The liberal feminist perspective is also best-represented in studies of the glass ceiling' effect (Buzzanell, 1995). Arguments regarding how many women are in different organizational levels, reasons for women's exclusion, and strategies for developing women's potential are all inadequate, however, as "traditional practices . . are still aligned with career rules, discourse, and organizational structures created for and by men" (Buzzanell, 1995, p. 329).

As an alternative to this approach, many have turned attention to changing the structure of organizations. There has been extensive treatment of organizational structure as a mode of masculine domination. These treatments focus on how everyday practices of organizational life are based on hierarchical principals; principals that are ultimately 75 believed to support patriarchy (cf. lannello, 1992). This radical/feminist structuralist

view emphasizes that once the bureaucratic structure changes, women will no longer be

dominated. In fact, changes in an organization's structure are thought to eliminate power'

all together. Therefore, the majority of feminist work in this area focuses on examining

the relationship between the enactment of feminine (or femininist) ideals and

organizational structures.

To overcome those downfalls, critical theorists in the radical humanist, Marxist,

and socialist feminist paradigms have focused on ways in which organizations are sites of

domination through the ideological and symbolic process embedded in organizational

communication. There is no way of eliminating power, by this view. The are only ways

of managing power to alleviate inequities. In different ways, the cultural feminist,

psychoanalytic feminist and strong objectivity' version of feminist standpoint theory

share teleology toward emancipation, as well as a perspective on power as a process. A

critical psychoanalytic/psychoanalytic feminist perspective stresses the relationship of

psychosexual development to access (or lack of access) to power. The influence of

psychoanalytic feminist theory can be found in communication in media/film studies (cf.

van Zoonen, 1994; Pribram, 1988), and focuses on the operationalization of desire

through the patriarchal gaze. Operationalizing this perspective in organizational communication studies directs organizational communication scholars' s attention to the

role desire plays in the conduct of organizational life such that women are positioned as

an object of power/desire (Burrell, 1984).

Cultural feminists, in contrast to psychoanalytic approaches, assume that women's culture exists outside of, although tied to, sexual development (i.e., gynocentrism). 76 Buzzanell (1995), for instance, proposes an alternative to traditional research on the glass ceiling,' pointing out the need for attention to community (vs. competitive individualism)

- the realm of femininity. A corollary to cultural feminist analyses of organizations can also be found in rhetorical studies. Research that proposes women's voices, or ways of speaking, should be valued in and of themselves, rests on the assumption that these voices have been kept out of the public sphere through practices of patriarchy (cf. Foss &

Foss. 1991). The creation of community, or making space for women's voices, is seen as act of empowerment; a way of sharing power-with.' Despite their differences—whether society and culture is subjective or objective—however, the both cultural feminism and psychoanalytic feminism emphasize a need to focus on women's practices (reading or speaking) and experiences.

For Marxist feminists, particularly, analysis of both processes of patriarchy and capitalism, as developed through dual-systems' theory, wherein women are oppressed through two both their biological role as reproducers (with implications for their role as laborers under conditions of capital) as well as their socio cultural role within patriarchy as a commodity to be exchanged (Rubin, 1975). Examples of dual-systems analyses of organizations include work by Acker (1990), Acker and van-Houten (1992), and Heam and Parkin (1992).

Related to socialist feminism is the feminist standpoint' position of critical realism, which serves as the first standpoint theory to be considered in this scheme.

Hartsock's (1983) appropriation of Marx and Hegel led her to theorize that material life sets limits on understanding, or that the social structure of class reveals some relations to nature and history to some positioned within ideology and not to others. Like Hegel's 77 slave, the oppressed/dominated subject has the advantage (if it is one) from knowing not only from his/her position, but also that of his/her other (the master); "As an engaged vision, the understanding of the oppressed, the adoption of a standpoint exposes the real relations among human beings as inhuman, points beyond the present, and carries and historically liberatory role" (Hartsock, 1983, p. 232).

An additional version of feminist standpoint theory, and the final entry in the group of paradigms for the study of organizational communication presented in Figure

4.1 that emphasizes an essentialist notion of identity, is strong objectivity'. Championed by Sandra Harding (1986), this theor>' pushes' domination beyond the systems of capital and patriarchy, which, in her view, have reified the idea' of women. Harding historicizes

oppositional consciousness' as possible through multiple systems of oppression, including those that operate on the basis of race, ethnicity, ability, and sexuality.

However, as consciousness is still tied to some sort of fixed identity through the role identity plays in subjectivity; Harding reveals the nature of identity as still predominately

Fixed.

Buzzanell (1994, 1995) operationalizes a loosely constructed version of standpoint theory in her attempt to incorporate feminist perspectives into organizational communication. This version of standpoint theory, however, as drawn from Harding, still reifies identity. Buzzanell states "we develop [the awareness of a standpoint] by exploring African American, Latina, and other ethnic and minority women's own distinct experiences with and understandings of organizational life " (1995, p. 344). By using this perspective, Helen Longino (1993) would argue, Buzzanell has multiplied the subject'.

78 This act does not undermine the idea that identity is essentialized, it just re-essentializes it through subjectivity (Scott, 1992).

A neo-Marxist and poststructuralist approach destabilizes the view of language posited by structural linguistics. With neo-Marxist and poststructuralist approaches, the operations through which signifiers are fixed to signifieds is revealed as a moment of discursive or hegemonic power. However, both perspectives are still imbued with ideas of identity as constructed through language or other practices of representation and culture/society as subjective. One effect of this 'fixing' of language is a heightened awareness of the construction of subjects in the symbolic order. For example, discourses of deviance fix subjects and construct their identities according to culturally normative notions of sexuality (Foucault. 1990). In a more Marxian vein, processes of interpellation

(Althusser, 1971) position subjects within ideology. And like Marxist perspectives, generally, power is assumed to be a process.

One example of recent work in organizational communication studies that takes this perspective Maija Holmer-Nadesan's 1997 article "Constructing Paper Dolls: The

Discourse of Personality Testing in Organizational Practice In this article, Holmer-

Nadesan argues that personality testing, in a variety of formats, creates an ontology of personhood where individuals are divisible, stable, and manageable. Personality tests are disciplinary practices that "should be regarded as social discourse that consists of a regulated system of statements and practices whose rules produce objects of knowledge which the discourse identifies, explains, and regulates " (Holmer-Nadesan, 1997, p. 199).

A Lacanian psychoanalytic perspective, which has influenced the development of object relations theory (Keller, 1985) also shares the view that identities are constructed 79 through linguistic practice, although with a more specific connection between subjectivity and language as discussed in the previous chapter. Object-relations theory

(Keller, 1985) draws from Lacanian psychoanalysis the idea that the subject and desire are both constructed through language (particularly, a structuralist/semiotic version of language). Kaja Silverman's explanation of Lacan's theories shows "a close affinity— indeed a virtual collaboration—between the structuring agency of the family and that of the signifier . . .[Lacan] attributes the Oedipus complex the same determinative role as that of language in the constitution of the unconscious, subjectivity, and the symbolic order" (1983, p. 180-181). In short, Lacan proposes a theory of sexual difference that posits that a male/female distinction is meaningless at the level of being, but in the move into the symbolic order, imaginably conceived, meaninglessness becomes meaningful.

However, while having the phallus (symbolically) or not is a social process, the phallus is still, more-or-less, an entity of power.

The final perspective on organizational analysis I will discuss has been saved until now because I believe it most directly related to the operationalizing' of gender that is necessary in this project. A postmodernist mode of analysis, as exemplified by Pilotta,

Widman, and Jasko (1988), offers the empirical grounding necessary. Though without reference to gender, per se, Pilotta, Widman, and Jasko highlight communication practices as "important ordering mechanisms that further the organization's domination of complex information environments " (1988, p. 311). Using Luhmann's neofunctionalist systems model as a backdrop, they further argue that "symbolically generalized codes .. reduce complexity by simultaneously transmitting both selected alternatives from among multiple action possibilities and the motivation for the acceptance of that selection 80 (p. 317). Thus, the codes themselves —communicative in nature—help the organizational actors to order their environment in organizational terms. This includes, but is obviously not limited to, the ordering of persons (status, hierarchy, roles, responsibilities, etc.) within the organization's action domain.

With reference to the latter, Pilotta, Widman, and Jasko emphasize that selective responses (the outcome of communicative media) can also be resistant ones. “Speaking from a structural viewpoint," they argue, "the power of subordinates resides in their position as subordinates” (p. 330), as it is in that position that subordinates can engage in activities such as parody or poaching; that is, use the communication modalities to their advantage or to otherwise subordinate the general and preferred use of such media.

Pringle’s (1989) on the talk of secretaries shows how bitching' can be used to join women at the bottom of the organizational hierarchy into solidarity. Drawing from this perspective, I propose that a bridge be made between feminist theorizing of identity and organizational practice.

The nature of this bridge - its backbone - is the reliance of both on some form of communicative subjectivity. As I argued in the previous chapter, one's orientation toward the environment is tied to an experiential awareness. The awareness that predominates in organizations, too, according to Pilotta, Widman, and Jasko (1988), has the same properties. In short, the signification systems that "express complicated combinations of sense and nonsense discriminations, of 'what counts' selections, with respect to the information environment " (p. 330) within organizations are of the same type as those systems of interaction that orient the organizational actor in relation to others and to the environment as a social actor.

81 4.3 The Sense-Making Modalities of Organizational Practice

Accepting the view of organizations, and of identities, as proposed here and in the

previous chapter fixes, to some degree, the domain of analysis for this project. The relationship between the two is illustrated in Figure 4.2. In particular, I propose that there are practices wherein by selecting from the domain of all possible activity (making 'what counts' selections) the organizational actor not only enacts the organization (its culture, its existence, but enacts gender at the same time. Sharing the same underlying action structure and connection to the main' discourses surrounding the possibilities (as none are purely intra organizational) makes this relationship possible.

Two examples illustrate this perspective. Buzzanell (1995) offers a reading' of the

■glass ceiling' as a socially constructed phenomenon. Buzzanell states: "Because our language and discourse practices often recreate stereotypic masculine and feminine divisions of family, work activities, and occupations, our solutions to add more women or to train women do not make any real differences in women's lives " (p. 321). She hopes, through her research, to address glass ceiling processes which are "defined as language and interactional patterns associated with gender ideologies in which women are devalued overtly and subtly" vs. glass ceiling effects, which are the "differential promotion, development, reward, power, and work structures based on gender " (p. 333).

This shift in focus reflects a sincere interest in eschewing traditional or modernist conceptions of gender as if gender preexisted the act of interaction.

Building off Buzzanell's directive, I would add that the language and interactional patterns that devalue women overtly and subtly (or differentially position men and women, to be more precise) are the very patterns of interaction that help sustain the 82 Domain of Activity (Intentional Relations)

Organizing Practices (Sense-making Codes)

FIGURE 4.2

Organizational and Identity Practices: Domains of Analysis

83 organization. For example, the organizational practice of defining an activity may also define gender. Take the instance of defining "appropriate interpersonal conduct in the workplace" - this may be a 'what counts' selection for organizational members ('what counts as appropriate interaction'). However, there is also, as part of that defining practice, a gendered component: what counts as appropriate interpersonal conduct in the workplace/or whom. As long as appropriate interpersonal conduct' is attributed to men, and masculinity is privileged by the sense-making code, then women's behaviors (even if they are the same) will be considered inappropriate.'

Appropriate conduct may be, for instance, the suppression of emotion, as in, if you're upset about something, you can (a) send an angry email, or (b) confront the offender, but you can not (c) cry about it. Since crying is an activity that is already associated with femininity, the appropriate organizational practice is already coded as a male response. Rather, it would be more feasible to assume that the enactment' of gender in this case would be itself situational: in other situations, I could enact this emotion according to my gender; in that case, it would be appropriate to cry. Thus, I do not mean to imply that men don't cry, or that all women do, but the context already codes (and is coded by) gender.

By way of providing another example, let me respond to Putnam's (1983b) explanation of conflict cycles. Viewing the way she addresses the problems women face in relation to my own version of the relationship between gender and organizational communication may help clarify the reversal' I am proposing. Putnam (1983b) proposes that the creation of double bind' messages puts women at a disadvantage in organizational contexts. In fact, she proposes that women are the victims' of such 84 conflict cycles. These cycles are rooted in "[c]ontradictory messages" which "evolve from the way we tie observed behaviors to verbal messages" (Putnam, 1983b, p. 41). In some instances, this could happen when women are simultaneously told that their input is as valued as any others', but then reminded of their token status' as the voice of women.

In other instances, women who admit to feelings of inadequacy to male supervisor who offers managerial training help may be seen by men to be reifying the stereotype of femininity and thus, do not receive assistance (i.e., she can't change, why try?).

Furthermore, since women have more to loose by calling' their superiors on these messages, Putnam argues, women remain trapped. Part of their remaining in the grip of the conflict cycle also arises from differences in how men and women engage in conflict

(Putnam, 1983b). Putnam sees that women are more open to collaboration and compromise, whereas men are more likely to compete for the upper hand' in conflict situations. By not approaching men in this attack-defend' conflict resolution pattern, women effectively reinforce their token' position.

I propose an alternate way of viewing this situation. Rather than seeing sex (and sex differences) as a precursor to specific behaviors (in this case, the propensity toward contradictory messages or preference for compromise), we should view the behavior first and then view how it is coded according to the discourses of masculinity and femininity and thus, how it codes the actor. We can also view the organization's role (its sense- making codes) as a way in which the behavior is coded. The actual act of coding the behavior comes as part of the interactants intentional (acting toward) behavior.

Taking Putnam's (1983b) initial example of the assertive manager who is seen as a 'bitch' is illustrative here. We have a code for managerial behavior and a discourse of 85 masculinity that work together; these are codes that support one another. On the other hand, the code for managerial behavior (what counts as managerial behavior) does not match with femininity. Thus, when someone encounters a female manager who adopts the code of managerial behavior, the contradiction is disruptive. The person simply does not know how to orient toward this manager. In the perception of the subordinate, the woman is expected to be feminine (culturally, woman=feminine), and so, the behavior marks her non-feminine behavior as bitchy or masculine (both opposites here, of feminine). Her gender is questioned. On the other hand, if the behavior was feminine', the person would code her' as feminine without question; no disruption would occur.

In both cases, 'what counts' as appropriate behavior in particular settings (the sense-making practice of organizations which create manager ) is coded by discourses of femininity and masculinity. The combination of these two serves as the context for the interaction or for the actor's intentional relationship to another. I set out to determine the practices (the 'what counts' selections) of the organizations associated with the provision of health care that are associated with masculinity and/or femininity and thus, in their co- determinate relationship with communicative subjectivity, also create and sustain gender.

In the next chapter, I explore more specifically the methodological program that helps to highlight such practices while still focusing attention on how actors orient to each other and the situations they face.

86 CHAPTERS

ON THE PRACTICALITY OF ETHNOMETHODOLOGY

Before outlining the methodological principles and methods of investigation that have served to guide the project, I believe it is important to summarize the foundational conceptual assumptions upon which the investigation rests. By way of this summary, I also hope to open up a more concrete methodological space within which to place the project. While that space, broadly, can be considered that of cultural studies, I hope to show how this particular project fits within the already diverse and fragmented

(anti)discipline of cultural studies, particularly as a form of postmodernist cultural critique.

Positioning the project as a cultural studies' project, however, does not provide the kind of detailed guidance for research methods found in other approaches, even those squarely within the interpretive and/or qualitative frame. I will highlight the methodological weaknesses of cultural studies as a field—particularly the lack of a well developed set of ‘tools’ for the study of interaction—and thus the need, in this project, for incorporating a more foundational perspective on methodology. However, I want to maintain the positive contributions cultural studies makes toward a methodological program. In particular, cultural studies approaches to cultural critique reveal an acceptance of and openness to interpretivism combined with an eye toward the political nature of the research process.

The methodological perspective I arrive at by way of comparing this project with the political background of cultural studies lays the groundwork for the remainder of the

8 7 chapter. The bulk of the chapter is devoted to specifying how ethnomethodology, in particular, contributes to the general directive of cultural critique within cultural studies, but with advantage of also including practical ways of operationalizing human activity. I also hope to clarify the ways in which ethnomethodological approaches open up possibilities for a specifically feminist postmodern methodology capable of accomplishing the socio­ political goals of the project in the specific context outlined in Chapter 2. That is, 1 propose that ethnomethodology, as it highlights both how people orient to a situation or another

(indexicality) and the discursive and contextual factors that influence that orientation

(accountability), gives us the ‘tools’ to engage in the critique necessary in this setting and to keep communication practice firmly at the core of the investigation.

Finally, drawing on the phenomenological (i.e., experiential) underpinnings of both ethnomethodology and naturalistic inquiry generally (Lincoln & Cuba, 1985), I will conclude the chapter with an overview of the research orientation that guides the remaining chapters. The general principles developed from a phenomenological perspective on social research also suggest specific guidelines for the reader’s Judgment of the quality of the research presented here.

5.1 Re-Positioning I began, following the general introduction, with the presentation of the current sociopolitical context surrounding health care and within which gender/identity needs to be problematized. 1 showed, in both historical and current senses, the organizational positions of particular practitioners of health care. In short, an examination of several symptomatic traces reveals that gender is indeed something that matters within this context.

While most of the attempts at examining the foundation of inequalities presented in

Chapter 2 focus on the position of ‘women’ in healthcare, however, I argued in the subsequent chapter’s discussion that a revised concept of gender identity is necessary in

88 order illuminate new political possibilities; possibilities that do not take the category of

‘woman’ for granted. In contrast with modernist conceptions, a postmodern version of the subject shifts the ontological framework of gender’ from that of essential (even socialized) qualities of the individual into the realm of interaction. In keeping with a postmodern feminist conception of identity, I explored how gender/identity can be considered as produced and experienced discursively (linguistically and communicatively), existing in and through the contextual practices surrounding human actors.

This conceptualization of gender focuses the researcher’s attention on the role everyday interaction plays in maintaining identities, particularly those of gender (Butler,

1994). I also argued that herein, too, lie opportunities for examining the role such ritual acts serve to resist institutionalized forms. The moment-to-moment enactments of gender provide the possibilities for understanding and navigating the political landscape. Finally, these enactments and the possibilities of resistance within them are tied directly to contextual horizons of their very existence. In examining gender as a product of interaction, the researcher cannot, and must not, ignore the situational and contextual (i.e. organizational) factors that constrain and help define the impact of such interaction on stabilizing the social domain.

As an important context for the project at hand is the context of organizational interaction, I detailed a perspective within organizational communication studies that lends itself to seeing organizational action as productive of social reality. This context also fits well conceptually with the concept of identity proposed in Chapter 3 since organizations, as a context, are also themselves constructed through communicative activity. I argued, in chapter four, that definitions of the organization’, and the researcher’s analysis of organizational life, should be based on the idea that organizations are produced within and through organizing as communicative activity. This perspective on organizations rests on the assumption that organizations are action frameworks (Pilotta, Widman, & Jasko, 1988)

89 rather than entities with stable material properties (i.e., a physical plant with machinery; see

Collins. 1994). The relationship between discourse/communicative practice and organizing is both a productive and reflective one.

To focus the analysis, I drew on connections between discursive activity and the experiential orientation of actors within organizational sensemaking frames. As Pilotta,

Widman, and Jasko ( 1987) state, organizations are sensemaking systems and the practices of organizing serve to shore-up the boundaries of necessary and appropriate interpretations of actions, ideas, and choices. That is not to imply that individuals make ‘sense’ out of organizational life in any cognitive or psychological sense (although ‘awareness’ might be a useful term here). Rather, organizational actors constantly reinterpret, redefine, and redeploy the symbolic currency of organizations in a communicative and interactional modality. But, as Pilotta, Widman, and Jasko (1987) also argue, via the work of

Luhmann, this sensemaking process is mediated by communication as a modality of power, both subordinating and resistant.

In short, up to this point, I argued that both organizational analysis and the analysis of identity help us see how communication, generally, is the means through which social life takes on interactional significance and political consequence. That is, communication connects organizational actors to social structures, and vice-versa, through communicative subjectivity. The question thus became, which communicative modalities, as they have direct impact on the formation and use of communicative subjectivity, sustain organizations and enact identities in concert?

5.2 The Methodology of Cultural Studies

Based on the above description of the work thus far, it is clear that I have grounded myself in ways that parallel that of the cultural studies tradition in social research, critique, and theory. In particular, I am directed to those theoretical and methodological

90 perspectives that highlight connections between social practice and subjectivity as both the

ontological ground and the epistemological window through which identities and

organizations can be known. This conceptualization fits well within the theoretical and

political imperatives of cultural studies as a field of work.’ The reasons for this

relationship are many, including, but not limited to, an explicit focus on the social

determinants and uses of identity; a focus which has become the central thematic of cultural

studies in recent years. As Nelson, Grossberg, and Treichler (1992) state, “cultural

studies has become increasingly concerned with the complex ways in which identity itself

if articulated, experienced, and deployed” (p. 9).

More specifically, this work fits within the domain of cultural critique and critical

social theory due to three main factors: (a) the development of meso-level theory, that is, an explanation of broad cultural themes in light of their use in everyday interaction; (b) an epistemological stance that highlights the role of meaning (and thus subjectivity) as productive of this relationship; and (c) a concern for critique, that is, for exposing relations of power that position social actors in hierarchical relation. All three of these factors influence methodological choices in particular ways. In terms of method, procedures that highlight the macro-micro relationship are needed. In terms of empirical materials', I focus on symbolic (vs. numeric) relationships. And finally, in terms of my position as a researcher, I am concerned with the position of my own work within the privileged discourses of academic life.

While these three components are the main reasons for the relationship between this work and the general goals of cultural studies, I believe it is also useful to appreciate the trajectory of cultural studies independent of this specifîc project and its relationship to academic work. Many have attempted to define the terrain of cultural studies, each offering different histories and trajectories (see, for example. Hall, 1981, Storey, 1996, Johnson,

1986, Grossberg, Nelson & Treichler, 1992). Nelson, Grossberg, and Treichler (1992)

9 1 offer that cultural studies might be defined, as other ‘disciplines’ are, through its “particular domain of objects,... unique set of methodological practices, and ... founding tradition and lexicon” (p. I ). I hope to show that as a field, cultural studies, while home to a well defined domain of objects and a diverse, yet identifiable lexicon, lacks the methodological sophistication necessary to develop grounded social theory, particularly cultural critique of interactional and communicative moments.

Cultural studies does indeed have a core (if awkwardly defined) set of objects of study. Culture, as a key concept, is “understood both as a way of 1 ife—encompassing ideas, attitudes, languages, practices, institutions, and structures of power—and a whole range of cultural practices: artistic forms, texts, canons, architecture, mass-produced commodities, and so forth” (Nelson, Grossberg, & Treichler, 1992, p. 5). In short, the domain of objects within cultural studies includes both the stmctures of social life, expressed as shared (and contested) structures of meaning, and the everyday practices that help create shared meanings (or contest them). Most importantly, however, we must remember that in examining this relationship, the overall goal is to bring into critique the way in which the relationship between these elements constructs relations of domination.

The ‘culturalist’ mode of conceptualizing culture, arguably, focuses one’s analysis and critique on the processes of the production, circulation, or reception of cultural forms to the expense of slighting the structural influences on that process or the products it produces. While this may be thg paradigm of cultural studies, it is by no means homogenous. The culturalist form of critique, furthermore, highlights the ‘micro’ aspects of society in terms of agency. As Bennett, Martin, Mercer, and Wollacott (1981) propose,

“the transition between conditions of cultural practice and its outcome is never automatic, never guaranteed in advance; how one is translated into the other depends on how the gap between them is filled” (p. 10). Thus, culture becomes changeable and open. In such a

92 position of obvious enthusiasm for the politically committed critic, however, one tends to overestimate the ability of cultural actors to change such forms.

The structuralist paradigm in cultural studies (Hall, 1981 ) on the other hand, tends to emphasize the categories, classifications, and frameworks of culture that precede the experience of cultural actors. In this light, the structuralist paradigm offers the insight needed to clarify the limiting conditions on cultural activity, and in doing so, offers an important perspective on the workings of power, particularly ideological power. Reflected in the work of Althusser ( 1971) and the semiotics of Saussure (1959/1983) and Barthes

( 1957/1972, 1977), both material and symbolic ideological power are analyzed explicitly In stressing the structural aspects, one severely limits the possibilities of human agency.

One of the constant struggles within cultural studies, then, is with its lack of an integrated theoretical program that puts both interaction and social structure into conversation. Focusing solely on interaction (culturalist) or systems (structuralist) has limited the ability of cultural studies scholars to draw out the relationships between the two.

The ultimate effect of such a problematic is the inability of cultural studies scholars to bridge what Williams, following Vico, defined as ‘culture’ to begin with: “a mode of development which was at once, and interactively, the shaping of societies and the shaping of human minds” (1977, p. 17) encompassing the elements of a “whole way of life.”

Similarly, as Hall defined culture: “both the meanings and values which arise amongst distinctive social groups and classes, on the basis of their historical conditions and relationships, through which they handle’ and respond to the conditions of existence; and as the lived traditions and practices through which those understandings are expressed and in which they are embodied” (Hall, 1981, p. 26).

One of the reasons that cultural studies scholars have difficulty integrating both shared meaning and value and lived traditions results from an incompatible use of methods

93 for analysis and critique. In fact, to say cultural studies has an identifiable set of methods at all would be misleading. Nelson, Grossberg, and Treichler (1992) state that cultural studies’ “methodology, ambiguous from the beginning, could best be seen as a bricolage” as “no methodology can be privileged or even temporarily employed with total security and confidence, yet none can be eliminated out of hand” (p. 2). Thus, scholars use ethnographic methods to examine the practices everyday life, and semiotics to examine the structure of meaning among a group (however defined), but cannot put these two methods in conversation. What is needed is a way to examine how meanings are made in the contexts of their making. This is one fault' in cultural studies I hope to avoid.

There are, however, several commitments of the project' of cultural studies that are politically and practically necessary for the conduct of social research; commitments that I agree with and adopt as my own. Johnson (1986) raises the point that cultural studies cannot be simply another academic discipline due to the power involved in ‘disciplining’ a field of study, generally. One reason cultural studies resists disciplinarity is precisely because of its founding’ lexicon; a lexicon that draws from philosophy and aesthetics, psychology (psychoanalysis), sociology, anthropology, media studies and communication, history, languages and linguistics, sociology, and economics, to name a few. In this sense, cultural studies is transdisciplinary. Furthermore, or most importantly, the use of multiple discourses keeps the project form being constrained in any single disciplinary home. This is imperative to the political project of cultural critique embedded in cultural studies as containment within any discipline will lessen the possibilities for translation between one field of study and another, or between a field of study and the application of that field to everyday life.

Cultural studies resists disciplinarity—indeed, is anti-disciplinary—because of the politics of critique that is its central mode of operation. Cultural studies must remain committed to it the “sense of intellectual-political connection that has been important for

94 cultural studies” (Johnson, 1986, p. 42) since its inception. “Above all,” states Johnson,

“we have to fight against the disconnection that occurs when cultural studies is inhabited

for merely academic purposes or when enthusiasm for (say) popular cultural forms is

divorced from the analysis of power and of social possibilities" (Johnson, 1986, p. 42).

This component of critique has had direct impact on the chosen objects of study and

the f>erspectives through which those objects are examined, if not the specific methods of

analysis. Most importantly, this commitment specifies that research be conducted with the

goal of change and change that occurs in the interest of exposing relations of power. In

organizational settings, this can be a very difficult goal to reach, as access to organizations

is granted by those already positioned as privileged by such relations. No manager, in

short, would want a researcher to come in and instigate civil unrest' by helping employees

realize the systems of their oppression. Evidence of this struggle is seen in Chapter 6.

Lastly, as cultural studies is at its base committed to examining the “cultural

practices—within both academic and everyday life—that create, sustain, or suppress

contestations over inclusion and exclusion” (Nelson, Grossberg, & Treichler, 1992, p.

12). This final point highlights the self-reflexive nature of work in cultural studies: what

is at stake in doing the project? In researching and ‘writing it up’? In addition, for me, taking the cultural studies directive on self-reflexivity, I must be at all times aware of my own position as a ‘wanna be’ researcher, attempting to investigate and to ‘write up’ what I find in the context I have chosen to investigate; completing the project as a dissertation that grants me membership into a certain elite ‘club’ upon which my own livelihood and career depend. I should note that this presents methodological challenges’ not encountered in many forms of research, not merely limited strictly to those of a positivist ilk.

In summary, while cultural studies, as a field to turn to and within which to place this project does not offer the kind of methodological rigor that helps the researcher focus

95 his or her analysis on the relations between social structures and everyday practices, the

goal of cultural critique, as well an attention to the political nature of the research process

and the use of knowledge within the academy, are important guidelines for my own

research. Finally, a concern for meaning and identity, and the relations between them

(Johnson, 1990/1996) aligns this project with the core problematics of cultural studies.

With that in mind, I will focus my attention on developing the bridge between theory and conceptualization developed in previous chapters with the methods of observation, selection, and analysis of interaction that is presented in the chapters to follow.

5.3 An Ethnomethodological Fit

The emphasis on interaction within organizational structures that is part of this project requires a specific methodological program not well developed by cultural studies.

However, the ideal of keeping both interaction and social structure in the air as components of culture (and institutions) is present in ethnomethodology. The purposes of the present section are to (a) overview the trends in ethnomethodology and critical discourse analysis that directly relate to the connections between talk and social structure, on the one hand, and talk and the activity of ‘doing gender’ (West & Zimmerman, 1987) on the other, and

(b) to focus on the ideas of accountability and indexicality as methodologically useful.

A tradition of examining the relationship between talk' and social structure in a broad sense can be found in ethnomethodology. Though some argue that one cannot infer broader social-structural issues from analyses of talk in-situ, others within a sociological tradition have pointed to the necessity of such an approach. I first turn to examining this research tradition for its methodological directives. A comparison between the general program of ethnomethodology and its adaptation in the area of conversation analysis serves to highlight the core use of the broader perspective.

96 Ethnomethodology, broadly, undergoes significant transformation when used as a backdrop for conversation analysis. Early conversation analyses are concerned with the patterns of mundane conversation and the way sin which actors or participants in these interactions imply rule-based conversational orderliness. As Psathas (1995) observes, “the interest is in discovering structures of interaction, the orderliness of phenomena, that are independent of cohort particulars, that is, the orderliness does not depend on particular persons in particular settings” (p. 46). This research tradition is geared toward understanding the features of mundane conversation that apply to the construction of order within conversation between any combination of participants.

The general ethnomethodological base provided by Harold Garfinkel (1967) and developed in further detail by Heritage (1984) and Drew and Heritage (1992) however, does attempt to address connections between the social/structural context and particular interactional moments. Drawing on the social phenomenology of Alfred Schütz, ethnomethodology (as Garfinkel imagined it) works off the basic premise that "social facts" are indeed accomplished, over and over again, by members. In accomplishing these facts,' members use typifications, ideas, values, and prior experiences, as well as the in- situ awareness of the context. In short, members' act in their surroundings in ways that resonate with their understanding of that situation, and in doing so, create the facticity of that situation. The researcher's job, then, is to "[suspend] all commitments to an a priori or privileged version of social structure, focusing instead on how members accomplish, manage, and reproduces a sense of the social structure. Analysis centers on the properties of practical reasoning and constitutive work that produces the unchallenged appearance of a stable reality" (Holstein & Gubrium, 1994, p. 264).

Moreover, Denzin and Lincoln (1994) argue that the, "interpretive procedures and practices that give structure and meaning to everyday life ... are both the topic and the resources for qualitative inquiry" (p. 204). Finally, versions of standpoint epistemology

97 have been used to connect ethnomethodological projects to more critical and feminist work

(Denzin & Lincoln, 1994, p. 204). Thus, as a way of examining the relationship between structure and action, as well as the nature of gender within that relationship, ethnomethodology already holds significant promise for the project.

It is of particular importance, too, that this research tradition draws directly on institutional settings as the backdrop for formulating the contours of the general methodological program. Beginning with Garfinkel's (1967) initial investigations in clinical and legal settings, and his followers' accounts of the institutionalized interactions within educational, journalistic, and social organizations, and the occult (Drew & Heritage,

1992; Garfinkel, 1986), the interplay between social collectivities as a context for creating' the facts of social order. Recent scholarship on organizational discourse (i.e. Lemke,

1999, and ledema & Wodak, 1999) points to the rich tradition of clinical settings and bureaucratic organizations that have been primary sites of investigation.

While researchers have used ethnomethodology in its broadest sense in the study of organizational life, many researchers (particularly within communication studies) have focuses exclusively on conversation analytic approaches within the general program of ethnomethodology to explore the relationship between gender' and interaction. Before I continue with an examination of the specific methodological tools' provided by ethnomethodology, then, I would like to examine the differences between the ways in which conversation analytic approaches and general ethnomethodological approaches illuminate the nature of gender as further example of the difference between the two perspectives. This comparison, I hope, will illustrate how ethnomethodology can be used to study the interplay between structures of gender and the structures of sensemaking activities within organizations, without essentializing either the facticity' of gender or assuming some elusive stability to organizational life.

9 8 The impact of different traditions arising from Garfinkel’s (1967) initial formulation of ethnomethodology has also impacted the formulation of ideas about how gender relates to talk-in-interaction. A brief review of the scholarship in conversation analysis indicates that women are conceptualized as communicators with their own styles distinct from that of men and that, in some cases, there are political consequences to this behavior. For instance, research on story telling (McLaughlin, Cody, Kane & Robey, 1981) indirectness

(Rundqhist, 1992), interruption (Zimmerman & West, 1978, Makri-Tsilipakou, 1994), the use of minimal responses (Reid, 1995), and the management of conversational shifts (West

& Garcia, 1988) all examine the differences and similarities between men’s and women’s speech patterns (both in same-sexed dyads and in mixed-sexed dyads) and point to the implications such differences or similarities have for understanding both conversational and broader social control. However, each of these studies takes the ‘identity’ of woman (or man) as already given.

Ethnomethodologists working with the concept of gender (i.e., Kessler &

McKenna, 1978), however, show how gender is “done” through everyday interaction; that is, how it is performed. Garfinkel’s own revolutionary and "profound analysis of gender considered as a produced institutional fact " (Heritage, 1984), focussed on Agnes, a person with male genitalia and female sex-category identification who had to ""learn"" how to be female. Garfinkel s analysis “makes visible what culture has made invisible—the accomplishment of gender” (West & Zimmerman, 1984, p. 131). West and Zimmerman

(1984) point out, that “gender [is] an accomplishment, an achieved property of situated conduct” and that the scholars attention to gender in this formulation “shifts from matters internal to the individual and focuses on interactional, and ultimately, institutional arenas ”

(p. 126). In short, the ‘matter’ of gender is not found in the biological features of interactants, although biology does play a role in interaction as it assists the actors in orienting toward each other. When contradictory evidence surfaces (i.e., when one’s

99 perception of the sex of the other is altered by the addition of new interactional information)

interactants must re-orient to each other.

This orienting process can be seen in the “pronoun game” that homosexual couples

often play with their ‘straight’ counterparts. By not using a gendered pronoun to refer to

one’s sexual partner, a gay male or lesbian can ward off one's judgment of his or her

sexuality. When the sex of the partner is revealed to the observer, however, the once

ambiguous sexuality of the observed is sedimented and all further interactions are

conducted accordingly. What is important, then, especially from a methodological

standpoint is how one’s understanding of the other’s sexuality is accomplished, not

whether one’s understanding is true or false (i.e., is real’). The ability of ethnomethodologists to see' how such an accomplishment happens depends on the use of two key methodological tools': accountability (reflexivity) and indexicality.

5.3.1 Accountabilitv. A reflexive accountability of action is a key component in the analysis of social action. Actors "act " as it were, in relation to their understandings of the contours of specific circumstances and contextual components unfolding through their very action. This does not imply a "think-then-act" sequence, however. Indeed, both action often precedes reflection, and it is only when pressed for explanation that actors can call on the specific rule that they, ironically, enacted as a way of defining the situation of their action but which, to them, seems to precede their activity. Heritage states, "the common norms [of a social context], rather than regulating conduct in predefined scenes of action, are instead reflexively constitutive of the activities and unfolding circumstances to which they are applied " (1984, p. 109). In general, “social actions are” in this research tradition, “actions conducting-the-affairs-of-a-social-order” (Sharrock & Button, 1991, p.

171 in Psathas, 1995, p. 65).

100 This perspective guides the researcher’s analysis of social life by focusing their attention on the activity and interpreting it as it relates to the defining of the situation. In the case of the current project, for instance, this means that those actions that seem to "conduct" traditional gender ideology (define, enact, resist, etc.) are attended to, rather than focusing on the actions of specific persons. Rather than taking social structure as given, and therefore, as a determining force of any specific instance of social interaction, many scholars in this ethnomethodological tradition look to the actions involved in reproducing the social and institutional structure. Accountability shows the influence that both the discursive constructions of gender have on interaction as well as the influence of organizational sensemaking processes. Zimmerman and Boden (1991) summarize,

'"members produce and reproduce the features of social structure, in particular, its cohort independence, facticity, and constraining character” (p. 7).

5.3.2 Indexicalitv. Although accountability connects talk to gender and social structure in a very general sense, one can also examine the contextual forces present in the specific constructs of interaction that produce gender for insight into the performative aspect of gender. Sociolinguist Elinor Ochs, working from a tradition of critical discourse analysis, addresses usefulness of ‘indexicality’ for understanding gender in recursive relations to, vs. as a precursor to, communication. Ochs (1992) describes the relationship of language to gender as (a) non-exclusive, (b) constitutive, and (c) temporally transcendent. By non exclusive, Ochs means, simply, that linguistic formations are not the

‘property’ of a person with a specific set of gender (social) or sexual characteristics. As an example, she discusses the use of tag questions’ which, in English, are not only associated with female speakers, but are also associated with ‘‘stances such as hesitancy, and social acts such as confirmation checks ” (p. 340). Thus, a particular linguistic expression/pattern cannot be read off the sex of the speaker. Rather, (b) language

1 0 1 constitutes gender. Since linguistic features mark social acts or activities, and such acts or activities may be indexed through gender, gender is constituted through linguistic practice.

As Ochs (1992) states,

knowledge of how language relates to gender is not a catalogue of

correlations between particular linguistic forms and sex of speakers,

referents, addresses and the like. Rather, such knowledge entails tacit

understanding of (1) how particular linguistic forms can be used to perform

particular pragmatic work (such as conveying stance and social action) and

(2) norms, preferences, and expectations regarding the distribution of this

work vis-a-vis particular social identities of speakers, referents and

addressees, (p. 342).

Finally, (c) although language has the power to constitute the current context through indexical expressions, it (language) also constitutes past and future contexts.

Thus, the power of language transcends the given moment of its utterance. Ochs (1992) states, “the relevance of temporal transcendence to this discussion of language and gender is that societies establish norms, preferences, and expectations vis-a-vis the extent to which and the manner in which men and women can verbally recontextualize the past and precontextualise the future” (p. 346).

In summary, the practices by which social actors make sense of and make the contexts of their interaction are both reflexive (making the accountable) and indexical

(position oneself and others within the context). While these practices apply to both gender and organizational practices independently (among other things), there is an area of overlap between the two; an overlap I have argued for in previous chapters. Therefore, the focus of my attention is on those actions that are simultaneously gender practices and organizational practices.

102 Restricting my vision, as I have done here, is one of the many ways in which I, as

a researcher and as a person play a role in the research process. Thus, I will now turn my

attention to the final methodological consideration to be overviewed in this chapter; the role

of the researcher as a research instrument, and the impact this has on the process, generally

speaking, of research.

5.4 The Social Researcher as Research Instrument

One of the inescapable facts of conducting ethnomethodological research, as

alluded to earlier, is that the very structure of the research process is the same structure that

members or social actors use in making sense of their own activity. Thus, there is a doubly reflexive' nature to such research. This necessitates, for good' or bad' that the researcher herself is becomes part of the research process. While this may be directly observable (i.e. participant-observation), it may also be less directly obvious. This form of social research, to put it broadly, "demand[s] that behavior norms be recognized and embedded in a social context which provides them with substance and meaning.

Therefore, behavior cannot be understood merely [by] outlining its observable features, but, more importantly, has significance only when its social meaning is appreciated"

(Pilotta, 1999, p. 12). To appreciate social meaning, the researcher relies on her own awareness and understanding of the situation, as well as those provided by the members

(either directly or indirectly).

Lincoln and Cuba ( 1985) also observe that the researcher cannot escape the fact that her presence in the research environment shapes the activity in that setting. They state "the

mutual shaping' that both investigator and respondent(s) undergo is not unlike .. .'mutual causality' " (p. 100). However, they caution that including the researcher's subjectivity into the research process cannot be taken lightly. The propose that "we find ways of going down into [our primary subjective experience] and rescuing material from it, which is then

103 raised to conscious awareness" (p. 103). Indeed, at all phases of research—not just during

data collection and analysis' the researcher would benefit from encouraging such

awareness. The inescapable fact of the researcher's direct connection to the research process —

from design to write up' - then cannot be ignored, and it also should not be taken as a sign

of invalid or unreliable research results. Indeed, when choosing to conduct interpretive,

particularly ethnomethodological research, the measures of the quality of the research take

on very different forms than one finds in scientistic research. As Pilotta states, "given the

life-world premise, phenomenological social scientific inquiry must not only speak from

the social process as a condition of conducted experientially grounded inquiry, it must also

return to that very social process as the only available resource for establishing its

authentically intersubjective verticality [sic] or, if you will, its claim to social truth"

(1999, p. 2). For example, the term validity, usually reserved to indicate an assessment of the

researchers ability to operationalize a construct so that it does indeed capture the construct

empirically (Neumann, 2000), is transformed. Rather than making that assessment on the

basis of the researcher's operationalization, validity is measured' by the researcher's

ability to show how the concept, as articulated in the research design or analysis, fits with

the members' existing and socially normative uses of the term/concept—the concept has experiential validity (not unlike face validity, by the way).

Additionally, the concept of dialogic 'interobjectivity' (Pilotta, 1999) is taken as a primary means by which the research act should be judged. Rather than partnering' with research participants (and perhaps, create a false sense of the totality of the participant's involvement with the research), Pilotta proposes that the idea of interobjectivity is in fact a way of preventing against otherwise "idiosyncratic interpretations" prevalent in interpretive

104 research. Interobjective understandings would impact the overall design and conduct of the

research, not Just the interpretation of data', making the research reliable' in its own right.

These two directives support each other, but mean different things in terms of the

process of the research. Although maintaining some degree of experiential validity is

necessary, interobjectivity is also a requirement. In some instances, particularly when a

researcher is interested conducting cultural critique, participants may not recognize their

own experience in the concepts provided by the researcher. Asking a participant, in other

words, to comment on their interpretation of their experience only produces another

interpretation. Also, given that the general goal of this work is to provide some conceptual

grounding, the perspective may not yet be ready for the test of experiential validity.' The

responsibility, then, is on the researcher to present detailed descriptions of the events as

they unfolded by his or her involvement (orientation) in the situation so that the reader can judge the interpretations the researcher offers of those events.

Despite the preceding discussion of general methodological frameworks, the role of

the researcher, and the standards by which the quality of the research can be assessed, I

realize that the reader has yet to be informed of the specific processes of collection and

assessment of empirical materials. I leave this discussion to each of the analysis chapters

to follow, as multiple methods have been used to gather and code the materials - each

dependent on the situations of their availability. What does hold the research presented in

the remaining chapters together, however, is the methodological premise that guiding both

my practice as a researcher and how I can understand the practices of social actors is based

in the life world situatedness of accounting for and referring to.

1 0 5 CHAPTER 6

SEXUALITY AS A GENDERING DISCOURSE:

INTERACTION IN THE SOCIALIZATION OF PHYSICIANS

In this chapter, I present an analysis of how gender is enacted within the the

socialization of medical students. Toward answering the research question, “how are

gender identities enacted through the practices of organizing?” this chapter provides the

results of an analysis of my own observations and of transcribed interactions among

medical students. In short, I show which discourses are drawn upon as ways of making

activities (interpretations) accountable by social actors in the process of doing

organizational work. Finally, through a focus on the structures of the use of these

discourses, it becomes possible for me to offer some tentative conclusions about how

social actors orient toward others in interaction and the impact of all three components on

the enactment of identity.

The chapter proceeds thusly: first I will describe the research procedures I used to

gather empirical materials. These procedures actually represent a wide range of

possibilities within a phenomenological and ethnomethodological orientation to research,

for reasons I will explain below. Secondly, I will present the details of my coding

procedures. These procedures, which reveal attention to multiple layers of analysis, are

then illustrated through the analysis of a specific episode. This analysis, augmented by observational data, will make possible some tentative conclusions about the organizational

practices that frame how gender is enacted in this setting. In particular, I will show how

106 the discourses of sexuality and professionalism are used as a way of reinforcing traditional conceptions of gender.

6.1 Overview of Methods

6.1.1 Procedures for Selection and Tvpes of Empirical Materials. Given the particular contextual constraints of this project, the methods for collecting empirical materials are best grouped under the heading of case study fieldwork’, as a variety of specific methods were, where possible, incorporated into the process of gathering the information that could provide Insight into the cultural milieu surrounding physician socialization. The primary contributing factor to this approach is that my participation in this setting, defined by the stated purpose of training medical students, was limited by not only legal and ethical constraints (such as review of the project by the Institutional Review

Board for the Protection of Human Subjects) but also by pragmatic and administrative ones. Therefore, I believe the reader will best appreciate the variety of materials, and the possibilities for subsequent use of these materials in the analysis, by understanding the nature of those constraints.

As I began negotiating the parameters of the project with a representative of the medical education student support staff (my main ‘field’ contact), I stated that I was interested in how medical students understood gender. This proved to be my first mistake, as I was then directed into settings and situations where gender was an explicit topic of focus in the educational process. Rather than opening up opportunities for observing the everyday interaction that medical students engage in as part of their general training, thus providing materials that could be analyzed in terms of possible implicit assumptions about and enactments of gender, my description of the project sent me down the road to observing how medical students explicitly negotiate gender issues as a formalized activity.

107 That is not to say that what I learned about the socialization of physicians from these

discussions was irrelevant to my stated conceptual framework; rather that my being given

access to these particular settings made for somewhat messy and complicated analysis.

A second contextual factor that became a mode of directing the project in ways I had not imagined came from concern by the appropriate ‘field’ authorities regarding access and confidentiality; in short, a concern for the protection of human subjects. Although I recognize the responsibility I have as a researcher to complete the appropriate protocols for review, I also found myself negotiating not only with the IRB, but also with the field authorities who were in a position to grant or to deny my access to the field.’. As it turned out, their concern for process, supported by the principle of the IRB, made for a very specific protocol detailing what I could record and what kinds of permissions would be required to observe specific interactions. I should state at the outset that I followed that protocol (Protocol No. 99E0040; see Appendix A) in accessing time-bound discussions, but also include as data’ here information I gathered as an observer in public lectures and in other public settings.

The most important impact of these two situation-based boundaries to my research practice is the impact they had on the subsequent bifurcation of types of empirical materials and how each type are used in the analysis. One group of research materials was gathered as a result of my own observational practices. I include in this group both my observations of the negotiating phase of this project and observations gathered in public settings. In the negotiating phase, I became poignantly aware that my research practice—the questions I was asking, the requests I was making, my position in this context—were indeed met with cautious and guarded responses by those who provided access. Thus, I treat the negotiating stage as data’ in its own right, turning in an almost auto-ethnographic manner to the methodologically oriented portion of my research journal for illuminating information about what gender (and discussions about gender) are in this setting.

108 Additional observational ‘data’ came from, as stated above, my participation in and observation of public lectures and the interaction of students in public settings. I did indeed set out to observe the content and manner of interaction of a lecture-discussion module offered in the Medical Humanities curriculum and part of an instructional series on the

Doctor-Patient Relationship. I acted as an observer-participant in this setting, as my identity as a researcher was known, yet I did not take part personally in the discussions or activities of the students and their facilitators (Atkinson & Hammersley, 1994). My observation of this setting resulted in a set of field notes that were compiled as part of my general note-taking in this setting, since note-taking in a classroom setting is not obtrusive or unusual (see Bogdewic, 1992).

The use of observational data, while not directly within typical’ ethnomethodological research practice, nonetheless supports the methodological goals of the project. Specifically, an awareness of the context from a more general standpoint is helpful in guiding my interpretations of how participants may be making activities accountable through their interaction. Moreover, the use of observational ‘data’ fits well within the realm of naturalistic and phenomenological forms of inquiry (Lincoln & Cuba,

1985) as it provides possibilities for orientation to the setting to the researcher. In short, using observational data enriches my ability to interpret, from the social actor’s point of view, what particular interactional activities may mean. I have included observational data here, however, as a secondary type, used to support where appropriate a more specific ethnomethodological analysis.

The other group of research materials included in this analysis, as the primary data gathered in this project, consists of transcripts produced from the audio-recordings of two specific events. The first transcript was generated from a discussion among a subgroup of medical students in response to prompts provided as discussion-starters. The prompts describe situations of potential bias or harassment among hospital personnel; between

109 medical students, residents or interns, and their superiors; and between doctors and patients

or their families. The prompts were geared to elicit discussion not only about gender bias

or discrimination, but also the bias directed toward persons on the basis of their race,

ethnicity, or religious background. Permission to audiotape this discussion was gained

from the participants in accordance with the parameters of Protocol No. 99E0040.

The second transcript was generated from the contents of a panel presentation that

was provided for the medical school class as part of the module on cultural diversity

mentioned above. Although my primary role on this particular day was that of ‘public

observer’, I asked for, and received, permission from the panel participants to audiotape

the presentation. Each participant was made aware of my reason for being present, as well

as the general parameters of the research project I was conducting. I assured the panel

participants that I would keep their identities confidential in my reporting, and they agreed

to allow me to tape the discussion.

The two transcripts described above were used to focus on the way in which gender

is implicated in communication practice. One piossibility for describing that “way” is to

focus on the contents of the talk. These contents are interesting in their own right as they

illuminate the types of things people say, or their symbolic representations of what gender

is/does/means. As Heritage (1984) however, this approach views language primarily as representational, ignoring the more constructionist view of language as action in its own

right. To overcome this tendancy, I used the transcripts to help me to reconstruct how

gender is talked about; or the conversational and presentational conventions that enable the

discussion to take place in context. In other words, the transcripts aided my recall of how

participants oriented toward each other in the process of accomplishing organizational goals. Given the topic of the discussion/presentation, I found it difficult to separate these two activities, but painstaking efforts (and months of reading, interpreting, reading,

interpreting....) helped to reach that goal.

110 The separation between what is what is communicated and how it is communicated is important one, both theoretically and methodologically. As Edley and Wetherell (1997) state, an emphasis on ‘top-down’ approaches to the study of discourse reveals how social actors are “spoken through or by discourses” by reference to “analytical concepts of discursive regimes, interpretive repertoires, cultural narratives, and subject positions” (p.

205). This type of approach is most concerned with the meaning (structurally speaking) of the contents of talk. Nonetheless, reflecting upon only the symbolic representations of gender included in talk would reveal information about the discursive universe that actors draw upon, perhaps given their position within that universe (or at the edges of it).

An emphasis on “bottom-up” approaches to the study of discourse, however, permits that “attention is focused on the action orientation of people’s discourse; that is, upon the kinds of things accomplished through talk” (Edley & Wetherell, 1997, p. 205).

This approach highlights how social actors make interaction meaningful. Meaningful social action occurs when actors orient themselves to each other and to the contextual aspects of the interaction. In this analysis, an important context is the organizational one; that is how actors infer from and contribute toward the construction of organizational activities in the process of their interaction.

That said, however, there is an advantage gained by putting these two approaches into conversation. From the researcher’s perspective (particularly mine), the possibility lies in whether or not there is a relationship to be seen between the ‘how’ of talk and the ‘what’ of talk, opening up possibilities for viewing in a more general sense, reflexive nature of macro- and micro- social practices. In order to reveal how those two perspectives can be kept in conversation, I now turn to the methods of coding’ or interpretation that guided my reconstruction of these transcripts.

I l l 6.1.2 Coding Scheme and Procedures. In keeping with the general perspective on the relationship between organizing and communicative activity described in Chapter 4, field notes (observational notes) and both transcripts were selectively read for evidence of how participants accomplished organizational goals. Three types of organizational practices, in the form of sense-making codes, were identified: Defining, Selecting, and

Contextualizing.' These three codes are reflective of (although not identical to) the types of knowledge required of organizational members as proposed by Sackmann (1985).

Sackmann (1985) proposes that organizational culture can be seen as a kind of cognitive map that enables organizational actors to reduce the complexity of organizational life. While the structure of the map may apply to multiple ‘organizations’, its contents are specific to a single organizational group. The structure of the map includes four types of organizational knowledge that is required to help reduce the complexity that organizational members encounter in the process of their day-to-day interaction. The types of knowledge include dictionary, directory, recipe and axiomatic knowledge. Dictionary knowledge includes how organizational members define concepts or objects within the organization and the qualities they attribute to the same. For instance, dictionary knowledge helps organizational members define quality’. Directory knowledge helps organizational members in the process of attributing causes to actual occurrences. Directory knowledge provides the reasons, so to speak, for why an organization is doing well (or poorly) in the marketplace. Recipe knowledge guides actors in the conduct of organizational affairs by providing prescriptive guidelines about what should/should not be done. Finally,

' In actuality, four codes were initially developed. The fourth code—Relating—however, did, upon further reflection, reveal specific instances of indexicality. That is, these conversational activities showed how the speaker positioned him or herself in relation to others. Since all accountings are indexically related to the context (see below), I decided that the activity code’ was not solely an organizational activity. 112 axiomatic knowledge, generally generated from the most powerful members of an

organization, provides governing principles, in the form of ‘why’ answers, to the reasons

for the existence of the organization.

To the extent that organizational members fill’ in each category of organizational knowledge with the same details (define things similarly, attribute the same causes to events, share prescriptive guidelines for action, etc.), there is said to be an organization.

Sackmann (1985) argues, however, that organizational members share the contents of directory, recipe, and axiomatic knowledge, while dictionary knowledge depends, in part, on the member’s position within the organizational hierarchy or the member’s identification with an organizational sub-group that is aligned with a specific organizational function.

For instance, while members of a production-oriented group and a sales-oriented group may not have the same definition of an innovation (which relies on dictionary knowledge) they nonetheless share similar causal-analytical, prescriptive, and axiomatic knowledge.

Sackmann’s (1985) research, however, relied on an interview procedure that asked organizational members to identify what they needed to know in order to succeed in their work. In relying on such a procedure, Sackmann was unable to see how organizational actors may create the knowledge sustained in each category or domain of knowledge.

Since my own focus was on how the organization was accomplished (not the character of the resulting organization), I relied on my observation of the activity, not (as in

Sackmann’s case) the perceived result of activity. In coding my transcripts and field notes,

I nonetheless found Sackmann’s categories of knowledge to be heuristic, as they aided me in identifying what interactants were doing’ in an organizational sense.

As the reader can see, I adopted Sackmann’s idea of dictionary knowledge without much modification. The use of the concept of dictionary knowledge helped be see that the interactants were indeed defining the actions, behaviors, and ideas under discussion. In this setting, interactants propose qualities or characteristics that help to define an activity or

113 behavior. For example, to define ‘sexual harassment’ interactants may invoke concepts such as hierarchical power, a feeling of uneasiness, touching, making sexual comments, etc. Activities which somehow ‘attach’ one concept to another in order to clarify the former were considered defining’ activities.

Given the particular context of my observations, however, I collapsed what would be the production of Sackmann’s directory knowledge and recipe knowledge into a single category of activity: Selecting. Whether the interactant was referring to past events that, in fact, occurred (did happen) or could have occurred (may have happened), or if the interactant was creating prescriptive statements (should happen), the underlying similarity is the selection of a cause or reason for action; real, hypothetical, or potential. Activities wherein interactants are stating why they would do, should do, or did, in fact do something were considered selecting activities. For example, when interactants state that one should report harassing activities, would have reported such activities if a particular action had occurred, or did report an activity because a specific action had occurred, I took those statements as providing selection criteria for action.

The similarities between both defining activities and selecting activities, on the one hand, and descriptive utterances in a general sense, on the other, deserves some attention here. According to Heritage’s (1984) interpretations of Garfinkel’s work on accounts and accountings, “during a substantial portion of their daily lives, ordinary members of society are engaged in descriptive accountings of states of affairs to one another” (p. 136). The majority of talk, in other words, serves the purposes of making statements about the ‘way the world is’ either explicitly or implicitly (i.e. in context). Defining activities and selecting activities, as presented above, serve just that purpose, with various degrees of explicitness.

Whereas defining activities or practices are explicitly descriptive (X is Y; X has the qualities of Y), selecting activities or practices may be implicitly descriptive (Actor A would do B because X has the qualities of Y).

1 1 4 Finally, I do not believe I spent enough time observing in this setting to illuminate any kind of deep-seeded axiomatic knowledge, at least not that I could rightfully say was empirically available to me. However, the third type of activity I have proposed comes from the difference in my methodological approach vs. Sackmann s. As I was specifically focused on interaction, there seemed to be an additional type of talk, meta-talk, that complements and extends the defining and selecting activities. This meta-communication serves to orient interactants to the situation at hand, or helps them to categorize the situation. This activity I termed contextualizing. Statements such as “what I’m providing here is just one example” help to contextualize, for other interactants, that there are other equally valid examples of the same kind. In this way, contextualizing activities are also explicitly indexical; that is, they explicitly refer to how one is oriented to the context and to the other interactants. More importantly, however, they serve here as organizational activities.

Following the initial coding used to identify the organizational practices accomplished through the interaction, I then made a second coding of the transcripts and of my notes to identify the discourses that underlie or enable organizational practice. This process rested on the simple question of what makes what was said, sayable, or what was

“done”, doable? So, for instance, the statement that “how you respond to [potentially sexual advances] is what matters,” reflects the speaker’s reliance on discourses of individualism in (in this case) defining a specific activity (sexual harassment). In keeping with the second example provided above, the interactant who laughs as another states

“depends” in response to the question, “How may guys would be flattered [by a potentially sexual advance]?” reveals a reliance on the discourse of heterosexuality in (in this case) selecting the ‘appropriate’ response. A summary of the discourses that were thematic throughout the transcripts and my observations are reported in Table 6.1. The reader should note, however, that the discourses listed in Table 6.1 could be used by interactants

115 in the process of defining, selecting, or contextualizing, although I will provide insight into the more thematic or repeated ‘pairings’ that I observed in the interpretations.

Upon completion of the second coding activity, I selected a particularly ‘rich’ episode for further, more detailed analysis. This episode was chosen for its instantiation of multiple discourses and the accomplishment (or attempted accomplishment) of multiple organizational activities by the actors involved. This episode also comes directly from a transcript (although supplemented by my notes), and thus, provides the best empirical traces’ of the actors’ accountings. The episode was used to generate an analysis of the sequence of the interaction and the relative weight given to particular discourses.

Organizational A c tiv itie s Defining Selecting Contextualizing D isco u rses Professionalism Legality Bureaucracy / Individualism Education Hierarchy Sexuality Emotion/Body

Table 6.1 : Coding Schematics for Medical Humanities Data

Most importantly, this coding stage began a shift toward more specific attention to the production of discourse (a bottom-up’ approach) rather than a focus on, on one hand, the accountability interactants reveal in their talk (the discursive universe that guides them) or, on the other hand, the results of the talk (the activity). Continuing with the examples above, the speaker uses a transitive statement (the evocation of “is”) in support of defining as an activity. In the second example, the nonverbal, paralinguistic laughter reveals agreement with the selected action (i.e., “I hate to say it, but I agree with you that it would depend on what the woman was like”). In short, participants are actively engaged in the production of gender by drawing from discursive resources, organizational codes, and their

116 own sense of their relation to the contexct and to each other. Through the use of these practices, the interactants also reconfigure past ‘talk’ about the issue at hand and prefigure future interaction.

As organizational actors accomplish the organizational practices of defining, selecting, and contextualizing, drawing on particular discourses and using communication modalities to accomplish such ends, the interaction enacts gender. That is to say, interactants engage in indexical practices through their talk and reflexivelv reconstitute the discourses that enable it. Utterances are ‘triply’ indexical: “[the utterance’s] referent could not be determined without a physical (or verbal) context. The sense of particular expressions ... could not be made without the use of context. Finally, the sense of the utterance—now unavoidably construed as action—could not be made without evoking a social context which was co-ordinated with the sense of the particular descriptive terms’’

(Heritage, 1984, p. 152). This facet of language—its indexicality—enables social actors to play off the discourses and sense-making codes at hand and enact them by providing future interpretive contexts.

In short, the three-stage coding procedure produced interpretations that carry the following structure: Interactant A engages in organizational practice X by drawing on discourse Y. In doing so. Interactant A may also position his or her utterances in relation to relevant identity categories, thereby assigning an identity to the other that either supports or resists a traditional construction of that identity.

To organize the presentation of the data’, I will show how interactants draw on discourses and employ particular communication modalities to accomplish organizational activities. Following the presentation of the chosen sample episode, I will summarize how, thematically, the episode relates to other observational data. Finally, I will present some tentative conclusions about how, in the process of constructing organizing activities, these social actors draw on discourses that construct gender.

117 6.2 The Relevance of the Curriculum to Medical Socialization

A brief description of the culture of student involvement in the medical humanities curriculum is helpful, however, before I present the episode below. The episode differs from all other observed interactions in the following way: attendance at the discussion that produced the episode was mandatory. In fact, all lecture-style meetings for the class, which is the second-semester installment of the Doctor-Patient relationship series, were not mandatory. I was warned ahead of time by my main field contact that students ‘just don’t take it seriously.’' The impression I had from this, and that was supported later on, was that the cultural issues module (if not the entire second session of the class) was not a core component of the curriculum, even though all first year students were required to enroll.

On the first day of my three days of observation of this class, attendance was perceived as unusually high, at least in the morning session. This was attributable, I believe, to the fact that a newly appointed, high-ranking University official was guest lecturing. That morning, there were 105 students in attendance (just under half the medical school class) and both the speaker and the course personnel remarked that attendance was unusually good. The speaker, noticeably, further stated that ‘it was good to take time out, to take advantage of the opportunity to learn about other cultures, to be exposed to other cultures, to think about values in the larger society.’ Another speaker that day, in explaining his nickname ‘Dr. Culture,’ commented that his interest and position of authority on cultural issues grew from his ‘hobby’ in diversity issues. Both speakers reinforce the idea that this part of the curriculum is not part of the normal medical school experience; that it is, indeed, an add-on.

' Statements included in single quotation marks (‘) are paraphrased from my notes. Exact statements, gathered from transcription, are included in double quotation marks (“). 118 When the afternoon session began on the first day, 86 students returned. Two students sitting near me commented Tf it’s a repeat of this morning. I’m not staying’ and

‘This is so pathetic.’ Attendance steadily declined from one observation day to the next, and several students came and went from lecture sessions at all times during each presentation. On the final day, the afternoon session drew a group of 64. Unfortunately, the other 150+ students didn't hear one of the participants of a gender-based discrimination panel say that afternoon:

“/ skipped so many medical humanities classes. I skipped so many lectures

because, oh my gosh, / have to study for biochemistry, I have to study for

anatomy, I don't want to sit in this lecture,... you've heard that before. I'm sure.

Well, if I had only known. If I had gone to just a few, I probably would've had a

clue what to do when I got in certain situations. "

On each day of my observation, I sat in the back of the stadium-style lecture hall. I observed on each day a variety of activities, most of which were not related to the class content. Some students nearby were reading what looked to me like general anatomy notes, another was completing a cross-word puzzle, and a limited few took brief notes, particularly in response to the prominent guest-speaker. In short, the module I observed was obviously not considered integral to the curriculum by students, and to some degree, by the administrative personnel and guests.

6.3 Enacting Gender Through Decision Making

6.3.1 Discursive Shifts and the Stability of Identity. The episode is taken from the student discussion group (see Appendix B for a full, uninterrupted transcript of this episode). The discussion proceeds by having a student read a prompt, or sample situation, and then students are invited to indicate how each might respond to the situation. This

119 exercise is particularly relevant to ethnotnethodological analysis since the process of sensemaking—or making activities accountable—is readily apparent to the researcher.

There are two moderators in this discussion, one African-American male and one white female. The moderators, although chosen perhaps to represent the cultural experiences of white women or African-American men, do have the work experience necessary to provide insight into everyday life in hospital settings, something the students have yet to encounter. They also are committed to the Doctor-Patient interaction ‘team’ and serve as educators in this program in multiple ways. Many have personal connections to members of the ‘med ed’ personnel. In short, they have strong working relationships with the program and experience in working with students as they explore social issues in medicine. In this first episode, the prompt is as follows:

A male senior resident is on service with a female attending who is known for

flirting with male residents and male medical students. She often comments on

their dress—for example—we 're going to have a contest on the best ties, and

frequently comments to male students on how cute they look. She is very touchy to

this particular resident, to the point of him feeling uncomfortable. She comments

one day on what nice eyes he had and what a nice ass he had.

There are several areas of social knowledge that students in the discussion must draw on in responding to the prompt, including but not limited to, their knowledge of the organizational and bureaucratic hierarchy (bureaucratic discourse), the accepted legal definition of sexual harassment or sexual discrimination (legal discourse), impressions of appropriate social/public behavior in institutional settings (discourse of professionalism) and their knowledge of heterosexuality (discourse of sexuality). These discourses come into play in the discussion about this prompt as students define, select reasons for action, and situate a context for their talk.

120 The perceived relevance of discourses of (hetero)sexuality is immediately apparent, and its impact on the construction of gender (female submissive/subordinate) is obvious.

The student who read the passage laughed immediately upon finishing. This would indicate that this student, at least, either believes that the situation is untrue or that the situation is otherwise somehow unbelievable. In other words, drawing on what the student knows about male-female interaction and the nature of social prescriptions regarding the expression of desire, he is astounded (thus laughter) that the situation would even occur.

In this situation, the laughter reveals a structure of understanding that positions the hypothetical pair such that the woman's actions, in particular, as seen as unusual.

One of the moderators for the discussion continues the laughter; laughter that is supportive of the reader’s interpretation that the situation is unbelievable (i.e., that it would not occur) within a framework of heterosexuality. This interpretation is supported by her subsequent clarification. She comments at the outset “Wasn’t mine” indicating that she had no control over the choice to include it as a starter for discussion (she had, it should be noted, chosen the prompt for a previous discussion), and thus denies responsibility for its possible lack of fidelity to the real world."

Following her attempt to contextualize the possibility of the prompt’s fidelity, the moderator then asks, indicating that the learning exercise should continue, “so, as a male resident, or as a medical student, as a Med three or Med four and this comes up, how do you guys feel? Would you report this to the med ed people? ( 1.0) or .. . (2.0), is it something that you’d blow off?” ^

At first, it would appear that she wants to check how angered the ‘guys’ (“as a male resident”) would “feel”, if at all. Her assumption may be that there could be some interpretations of the situation that are dissimilar to her own, or to the reader’s, at least on an emotional level, and she leaves open that possibility. The moderator draws upon

^ Numbers appearing in parentheses are approximated pauses; i.e., 1-count, 2-count, etc. 121 bureaucratie discourse and uses organizational argot (med three, med four) to highlight the

institutional hierarchy that may already define the situation as harassment. She also

invokes a legal discourse to define the situation as harassment by offering that the activity

could be reported in a formal sense. Assuming that there is a shared agreement about the

idea that the activities of the attending are defined as harassment, the moderator directs the

discussion initially as a selecting activity by asking what someone would (should) do.

This attempt to jump into selecting action was rejected by a second student. The

student asks, “so, she’s writing your recommendation?” The moderator responds, “she’s

just a fraud ” then laughs. The group laughs along with her. She continues, “no, yeah,

she’s your senior, she’s your attending. She’ll be grading you.”

From the student’s standpoint, the question for clariOcation may not be, in this

instance, illustrative of a lack of knowledge of the ‘definition’ of sexual harassment, but an

attempt to focus future discussion on the power dynamic of the situation as the basis for

selecting appropriate action. Before appropriate action can be selected, in other words, a

specific definition must be taken as preferred. Using a question, the student attempts to

define the situation not in terms of sexual proclivity or desire (perhaps an obvious reason

why the original laughter occurred), but rather in terms of the superior/subordinate

relationship that exists between the two people. The attempt to define the situation this

way, as a way to prefigure an appropriate selection, distinguishes between the role

discourses of sexuality play and discourses of the bureaucratic hierarchy on which legal definitions depend.

The moderator accomplishes two things with her response. First, she provides context for the discussion (no, she’s a fraud) in order to again emphasize that the situation

as presented could be real. However, she also provides very specific defining characteristics of a situation where harassment could occur (she’s your senior, she’ll be grading you). In doing so, she makes an obvious turn toward defining as the primary

122 organizational activity of the group at this moment. She also draws on bureaucratic discourses (the hierarchy) in order to reinforce a particular definition.

Another student adds, “I think the fact that she’s grading you is exactly the point,’ thereby confirming the offered description of the situation and furthering the defining activity. The student continues, “’cause when I was at this AMA meeting or CMA meeting, I forget which, a few months ago, and there was someone there talking about harassment in medicine basically...um.” The student continues with the narrative, and is supported in his story telling by the female moderator:

Student: I mean the general comment that harassment occurs... Moderator: ...hmmhm... Student: ...when someone in power... Moderator ...hmmhm.. Student ... is using that pow er... Moderator ...hmmhm... Student ...to influence... Moderator ...hmmhm... Student . . .or get something from someone... Moderator ...hmmhm... Student . . .who is under their control. And that’s exactly what this situation provides... Moderator ...hmmhm, hmmhm, good...

The student also invokes a legal discourse as well as a professional one (AMA meeting or

CMA meeting). The use of transitive statements such as “harassment occurs when ” and definitives such as “and that’s exactly what this situation provides” emphasize the focus of activity on defining. The moderator, at the same time, provides contextualizing information by using paralanguage to support the student’s efforts. She is in effect offering the student (and others) feedback that this is the ‘correct’ way to view the situation.

123 The student, however, continues: “now how you handle it is a different story,

‘cause you kind of have to fish your way out of it and still get a good grade, so ah....(several second pause)” In this statement, the student shifts from defining the situation to selecting the appropriate action. Here, the bureaucratic/educational discourses are still contributing: how does one confront a superior and still be protected? And the student’s incomplete statement indicates that there is no easy answer.

Faced with a rather long pause, the same moderator asks “Just out of curiosity, guys, how would you handle something like this?” The question supports the previous speaker’s the shift from defining to selecting as the main activity. The moderator also contextualizes in the situation by asking, specifically, for response from the males (guys).

This contextualizing activity, though not specifically meta-talk, does direct the flow of the conversation.

A fourth student offers, without much hesitation, “I’d laugh it off.” The reasons for this selection are unclear at first, and the moderator (still the female moderator) asks,

“because of the grade situation? ” In doing so, the moderator connects a defining activity to the selecting one, and brings the bureaucratic discourse back into play.

The student, however, rejects the cause offered by the moderator as a reason for action. He states “no, no. I mean, I guess it’s (1.0) it’s a very different situation for guys, men and women, and ah, (1.0) I can’t imagine feeling so uncomfortable that I’d really really worry. I mean, I know it’s a huge gender issue, but ah...(long pause). ” The student’s response begins with a repeated “no”, and some hesitancy (I mean, I guess), showing that the cause offered by the moderator is not the same cause he had in mind, while at the same time, showing that he is unsure of how to state his own reason for

‘laughing it off.’ The student also offers that the how one defines the situation (whether it is sexual harassment or not) may depend on the sex of the target of the behavior. He does this by first indicating that the situation should not be defined as harassment (it’s a very

124 different situation for guys) and corrects himself to clarify that the situation has specific qualities depending on the target’s sex (men and women).

The discourse of heterosexuality again supports this student’s contribution; a discourse that equates masculinity with sexual aggression. Since the male, in this case, is not the aggressor, this situation should not be interpreted as sexually aggressive. The discourse of sexuality also helps him define appropriate male (masculine) interpretation and action in this situation by emphasizing the level of comfort (protectedness) males might have in this situation (really really worry). Finally, the student defines this activity

(potentially sexual harassment) as a “gender issue ” and, given his previous statements

(can’t imagine...I’d worry), it’s clear that by “gender” he means “women’s” issue.

The student has also opened up the possibility that one’s level of comfort in the situation might be taken as the defining quality of whether or not the activity is sexual harassment. A fifth student takes this cue and states “I think it comes from, just, exactly, I mean, how comfortable you feel with it. I mean, if you’re not that real comfortable at all, then, I mean, you should confront her about it. But if it doesn’t seem to bother you, or you’re used to it, or your social background...it’s not that odd for you, I mean, if it’s not a big issue, then you should probably just go with it. Rather than cause a lot more problem than you need.”

This student, using the definition offered by the previous speaker (comfort determines the quality of the act) offers multiple reasons for selecting to avoid confrontation. The student relies most explicitly on a discourse of individualism invoked through a repetition of the direct, singular ‘you,’ to make this selection.

The second moderator summarizes the student’s statement and offers the opportunity for others to respond. In doing so, he provides the contextualizing meta-talk:

“Is there consensus that ah, it’s different since the victim is male?” He also invokes the discourse of legality (victim) in helping to define the situation; in effect redefining the

125 situation as a result of previous selection activities. To paraphrase by what is understood by the participants, not what is said by the moderator; Is there consensus that a woman superior commenting on a body part of a male subordinate would not represent an instance of sexual harassment because the victim is, indeed, male? The moderator also offers the student an opportunity to reject his interpretation of the statement (contextualizing meta­ talk) in stating “I think I heard you say that.” The statement, however, also puts the student on the spot, and forces the speaker to admit to making what could be construed as a sexist statement.

The student replies, “yeah, I said that” and the group laughs. The speaker continues, “I could agree with that. Although culturally, I think it’s” and the speaker is cut off by another student. What is most interesting in this exchange, I believe, is the group laughter. There seems to be support in that laughter for the interpretation that the student is

Tessing up’ to having made a sexist statement. This, of course, relies upon the group’s understanding of both what is publicly sayable about sexual harassment as well as that the speaker has made the assumption that a woman would be more likely to be a victim in this situation (i.e. play the victim, perceive themselves as a victim). The laughter, here, is in fact resistant.

Additionally, the speaker began to say that “culturally, I think it’s...” and although interrupted, was clearly indicating that the masculine response (laughing it off) may be the incorrect response in a social sense (culturally...). In other words, the speaker indicates that the ‘correct’ thing to say in this situation would be state that the events should be construed as sexual harassment. The impact of selection activities on defining the action is also apparent. The ‘correct’ definition is not the males/masculine definition because the selected action would correspond.

Continuing a focus on the normal’ or social definition of sexual harassment, the next speaker offers, “I think he’s right. I don’t think you could reverse the situation and

126 come out with the same result.” It is initially unclear whether or not a discourse of legality

(accepted social definition) or of heterosexuality works to support this statement.

Subsequent speakers work to provide clarity.

Before they are able, the first (female) moderator inteijects, “yeah, I was going to ask the women how they would respond.” In asking for the women to respond, the moderator alters the dynamic of the hypothetical situation. This shift could mean that she’s asking the women to take the perspective of the attending, that she’s asking the women to take the perspective of the resident (and implicitly thereby changing the sex of the attending to male), or if she’s asking the women to respond as if they were the male resident in this situation. The possibility that the moderator intended to reverse the positions of the actors so that the attending is male and the resident is female is selected by the speaker/student as she continues.

“Absolutely, I mean, I think it’s a power issue, a lot of it, and um, sex is power.”

The speaker here, drawing on the reversed dynamic, conflates the discourses of sexuality and bureaucratic (hierarchical) power in order to illustrate that sex (sexual advances) are a way of enacting the authority of one’s position. In doing so, the speaker defines the act, as it has been reconstructed through selecting a response, as an instance of sexual harassment.

The speaker also offers, “And I think that for a lot of ways, females have been in the passive, uh, um, I guess...” As the speaker searches for an appropriate word, the moderator offers, “role ” and the speaker continues, “role, in that relationship. So, ah, I don’t know ” Interestingly, though the speaker began with a statement of surety

(“absolutely”), she ends with a statement that reveals she is unsure: “So, ah, I don’t know.” This could reveal that the speaker is unhappy with her previous conflation of sexuality and bureaucratic power, as she reflects on the fact that the woman is not, in this

real’ instance, in the subordinate position. In other words, if the female is in the position of authority, then perhaps sex is not power.

127 I think it is also of note that the speaker uses terms like “passive”, and when

prompted, “role.” This ‘choice’ of terminology, too, could be leading to the indecision the

speaker reflects. A “passive role” is something a person accepts because of their

personality (by nature, someone is passive, and they therefore accept such a role). An

alternate way of phrasing the dynamic here is that the woman is in a “subordinate position”

which shifts the responsibility of being a victim’ away from the person/woman and to the

structure of the organization.

The speaker is, however, relatively sure about how men would respond if targeted

by a female in a position of authority: “ I’d guess that about 90% of all men would do the

same thing, just laugh it off.” Here, she disconnects the discourses of sexuality and

bureaucratic power and emphasizes the former to show that on the basis of the heterosexual

advance, men would be less threatened. This emphasis also downplays the defining activity

offered at the beginning of her statement and highlights the act of selecting.

The second moderator clarifies, “Playing devil’s advocate here for just a second,

though, in this particular dyadic relationship, the woman is the one in power, um, so” In

this contexutalizing statement, the moderator focuses the discussion back to the original

prompt, indicating that the group is not talking about typical’ sexual harassment, but this

‘atypical’ case. In “playing devil’s advocate” the speaker is asking the participants not to

accept the most common perception of sexual harassment, as well as invoking a sense of

one that is willing to reveal weaknesses in the majority opinion. Most importantly, though,

this statement directs attention to the reasons for selecting action to the sex of the attending.

The same student continues, “I think that, absolutely, but I think that still, I mean,

it’s not a very threatening thing. ” The student indicates that she recognizes the dynamic of the ‘real’ situation, and also uses the discourses of sexuality to define the situation as more closely related to everyday interaction (vs. sexual harassment). She also indicates, in effect, that a male superior engaged in the same activity directed toward a female

128 subordinate would be a “threatening thing.” She continues, “I mean, she’s not saying, you

know, have sex with me or I’m going to give you a bad eval. You know that’s not what

she’s saying, and I don’t think the men feel threatened in anyway that she’s you know,

going to try to force herself on them or something like that.” The speaker evokes other

voices, here—the voice of the hypothetical attending—to support her defining activity.

Finally, she states, “I think that’s the issue” indicating that the role sexuality plays in this

situation is what makes it possible to define the situation as “non-harassment” and to justify

previous speaker’s choice of action (their selecting activities) to ‘laugh it off.

The second moderator clarifies, “whereas if the situation was reversed that would

be a legitimate fear” to which the student speaker replies, “u hum.” The moderator

confirms the student’s distinction, both definitional and in terms of the selection of action.

In short, the moderator states, since men are not sexually passive, and women are not

sexually aggressive, then the situation would not be one of sexual harassment, and

therefore, the appropriate response is to ignore the advance.

Everyone in the group does not accept this resolution. Another student offers the

following. “I don’t think that’s entirely the issue. I think there can be times when a man can be flirting with you and be in a position of power, and ah, the point is you can’t react to

it the way you’d like to react to it, because he is the person in power. ” The speaker uses the more typical’ definition of sexual harassment to show that what is important in defining the act is the difference in levels of authority between the attending and the resident. However, the speaker also resorts to a very individualized type of response by using the you’ pronoun once more: “you can’t react to it...” The speaker adds, “It doesn’t mean that he’s necessarily going to force himself on you, he’s taking advantage of the situation” highlighting that the important feature in the definition is the authority, not the potential for sexual aggression. In this way, the speaker reinforces the bureaucratic/legal definition of sexual harassment, but in this case, on individual grounds.

129 The same speaker also states, “And I think we need to distinguish here between, um, whether we consider it terms of how we would judge the attending. Are we judging the attending and saying that it’s okay because she’s a woman? I don’t think we’re saying that. ’ The speaker further rejects the discourse of sexuality as the reason for making assessments—defining the activity— from the point of view of the attending, but still reinforces the discourse of sexuality as the reason for selecting action on the resident’s behalf. “It’s the wrong thing to do, no matter what” the speaker offers, revealing a reliance on the bureaucratic/legal discourse in defining the action, “but it just seems that if you were a man, or ( 1.0) you might react differently in this situation” emphasizing the role of the individual (“you might”) and sexuality (“a man”) in determining selection.

Another student contributes to the discussion, reinforcing the role a discourse of sexuality plays important in selecting a response. This time, however, sexuality is explicitly referenced in bodily terms (emotional vs. cognitive ones). The student states: “I agree that I think men tend to feel less physically threatened even if it’s on a visceral level”

The student also invokes the bureaucratic structure in selecting the appropriate activity: “but

I do think and I think this goes back to what Brad was saying, the power she has in this situation is very real, and the threat that, um, if you do confront her, she may give you a bad review, is a very real threat.. .”

The student also reveals the distinction a discourse of sexuality makes between a masculine possibility for response and a feminine one, as well as the defining role a discourse of bureaucratic power plays. The confusion apparent to the student and to the rest of the group reveals this clearly. The student concludes: “ ... whether she’s a woman or a man, and in that sense, 1 think that most of us would be, men or women, I mean, what if it was a lesbian? You know, 1 mean, either way, it doesn’t exactly matter. There’s a perceived power discrepancy there. I lost my train of though in there somewhere.” The student begins by stating that the sex of the ‘offender’ is inconsequential for defining the

130 activity or selecting action on bureaucratic grounds, and attempts to justify the statement by

reference to the idea that either men or women would be threatened by either a male or a female who acts in such a way while holding a position of power, at least professionally.

In following through with his thought, however, the student states “what if it was a

lesbian?” Here, the interpretive scheme he sets up falls apart, as does the student’s own

thought process. The student also reveals the assumption that has served this discussion

from the beginning—that the hypothetical participants in the prompt are heterosexual.

In making the statement “I mean, what if it was a lesbian?” the student is attempting

to elicit a reaction from the women in the room on the grounds that they (women) could be

the target of harassment by the woman in authority in the situation as presented. However,

there is the realization that the situation is still tinged with sexual aggression. This is

evidenced by his statement “either way, it doesn’t exactly matter.” He rejects his own

interpretation of the situation he created in favor of a reliance on bureaucratic means for

defining the situation. The role discourses of sexuality play (in this case, discourses of

lesbianism) is nonetheless evident.

Another student offers support for the bureaucratic definition of the situation,

although again, still revealing the impact discourses of sexuality in selecting potential

responses. The student states. “I think it makes a difference in the extent that most men

would react differently, which is pretty much what Rob and Laura said. ” In this statement the “difference” the student is referring to harkens back to the moderator’s inquiry

regarding the consensus that “it’s different since the victim is male.” The student continues, “most people would react differently, but there are men out there for who it would really bother and it does,” setting up “most people ” as male and singling out those males who are ‘different’ from the majority of men. He concludes, downplaying the sexuality distinction in favor of one based on, again, a bureaucratic/legal perspective.

However, before coming to this conclusion, the student again considers the possibility that

131 the defining attribute of the situation is the individuals emotional response. He states, “I don’t think it’s any different than if it’s a man or a woman, ‘cause if it bothers you, and the cor... " The student seems to abandon the emotional criterion in favor of a bureaucratic or legal definition. The student concludes: "it meets the criteria that it’s the person in power is the one, like initiating the situation, then I don’t think it’s any different at all. ” The “it’s” here, of course, refers to the situation, casting the basis forjudging the activities of the

‘harasser’ first on the basis of the individual’s response, but more importantly, on the basis of the legal “criteria.”

At this moment in the interaction, both defining the situation and selecting the proper response (and guidelines for that selection) seem to be well exhausted topics.

However, the moderator highlights the role sexuality plays in the interpretations that have been made by the participants, particularly the male ones. The first moderator asks, “How many guys would be flattered? ” Here, the moderator is asking for students to, again, "fess up" to their perhaps personal reflections on the situation that was presented, and allows them the opportunity to construct their (hetero)sexuality as within a framework of masculinity.

A student answers, “Depends” and laughter ensues (such roarous laughter, in fact, that I cannot make out several seconds of the recording). The laughter is a good indication of agreement, as well as indicating that the student, taking the position of the "victim" here, would consider the actions of the attending as harassment if he wasn t attracted to her. If he were attracted to the attending, or found her to be sexually desirable, the laughter indicates, he would not consider himself to be a victim of harassment. In order to clarify, the moderator questions, “Depends?” attempting, perhaps, to nudge the student into saying exactly what is left implicit in the laughter.

The second moderator offers his viewpoint, and saves the student from immediate embarrassment. He begins, “from an historic standpoint...” but is unable to take the floor.

132 Multiple conversations are occurring at once, and the (second) moderator's comments are

overlooked as students assess the implications of the laughter. The students hint toward

the reasons for the laughter, although with an ironic posture (i.e., they state, but don't endorse, the legal guidelines here). The first moderator interrupts, “Come on you guys, you would be..." indicating perhaps that the students are denying what she knows to their most common response (i.e., to be flattered). Throughout this moment of the interaction, there is the recognition of the difference between what is stated, based on the bureaucratic and legal discourses that frame the discussion and the unstated, or implied discourses of sexuality that frame the discussion toward importantly different ends.

The second moderator regains the floor: “From an historic standpoint, I suspect that had you asked the question twenty years ago, when I was in medical school, all of us, myself included, would be” and the first moderator finishes his thought, “you’d be flattered.” The second moderator concurs with her interpretation: “I’d be flattered.”

The moderators, in this instance, reveal the possibilities that students (particularly male students) may not actually assess the situation in the manner that they have proposed they would. The second moderator's comment, which positions this historical moment as a determining factor in stating one's true' response, reveals that even though one may not say he is flattered by the attention of the female attending, the possibility that he is flattered remains, even if he would not state so ‘today’. The historical condition changes what one would say, not necessarily how one would respond ‘viscerally’. The basis of this response, however, is still based in a commitment to (hetero)sexuality as the determining factor in assessing the situation.

The student who initially responded with "depends" attempts to clarify his meaning.

“Yeah, I don’t think, I mean, it’s one thing, I dunno, this is going to sound bad. . . “ The student begins by contextualizing (prefiguring) his statements, admitting that they do indeed reflect stereotypical assumptions about gender. He continues, “but thinking you’re

133 flattered by an older woman telling you you have a nice butt is kind of odd,” indicating that for the target of the behavior to find flattery in the comment already assumes that that person/target is somehow ‘sexually suspicious’. Nonetheless, if he (the speaker) is to accept the possibility that he is indeed flattered by the statement, his response is as follows:

“but the thing is, if a woman tells me I look nice, I don’t take it as any kind of threat at all.

You know, I take it that she, you know, has something wrong with her. ” The group laughs. The statement regarding the character of the attending deserves some attention, as it configures the sexually suspicious person now as the attending, not the resident (the adopted position of the speaker) if flattery occurs. More importantly, though, it serves as self-deprecating humor, and allows the speaker to save face while admitting, even hypothetically, that he would be flattered.

The student then completes his thoughts by comparing his hypothetical response as a target of the behavior to what his own response would be if he were to observe the same behavior, but under the conditions where the attending is male and the resident is female. In doing so, the student recognizes the different role the bureaucratic or legal discourse surrounding his interpretations would play in each situation. “I don’t get mad. I know maybe it’s wrong for her to do that, but when I hear a guy say that to a girl, I think, that’s definitely wrong. Especially if he has, if he’s in a position of power. ”

The student also clarifies that the role a bureaucratic or legal discourse plays when the target of the behavior is male differs from when the target of the behavior is female on the basis of individualized responses grounded in a framework of (hetero)sexuality that defines male sexuality as aggressive and the opposite of female sexuality. “It goes back to, for some reason, if a woman says it to a guy, I don’t read it as, I want to have sex with you,” but if a guy says it to a girl, that’s the normal connotation, I think, is now I’ve said you look nice, now you owe it to me to get a nice evaluation or something like that.”

134 The conversation continues to address the situation as presented, but in the

remainder of the students' discussion about this particular prompt, the focus shifts toward

the role that the "med ed" people could play in this situation. This reflects the students'

attempts to assess the institutional practice and structure, rather than the contours of sexual

harassment and how, as organizational actors, the students would/should respond. In

short, the focus shifts toward the reporting structure of the organization, and away from the details or character of the situation at hand. Before I move on to recast this episode in terms of the organizational and ‘gender’ work that is occurring in more specific terms, I do want to highlight specific instances where actors use their talk to position themselves along gender-lines.

6.3.2 Analysis and Interpretation. Gender is enacted, in this situation, through the discourses speakers draw upon, the organizational sense-making activities they engage in, and the structure of the discussion itself (their orientation to the topic, if not to others).

Given the analysis presented here, the latter seems to carry the most weight. Through the organizing activities of defining the situation and selecting potential responses to the situation, social actors have used the discourses that serve as social knowledge, as well as selectively reinforced those discourses. To understand exactly how these components work together, I present the following summary and interpretation.

In the episode presented above, there are clear distinctions made between how one defines a situation and how one might respond to it. The latter influences the former, certainly, but the latter also influences directly the construction of gender. These distinctions are made through the invocation of distinct discourses at particular times and for particular purposes in the discussion. In terms of defining the situation, the discourses of bureaucracy and legal responsibility dominate; both initially and in the final decision making of the student group. However, discourses of sexuality and individualism are

135 predominant in the actors’ attempts to select appropriate action. That is not to say that

attempts at selecting appropriate action in this situation do not impact definitions of what

sexual harassment is. Indeed, as the interactants muddle through what actions may be

appropriate, the decision as to whether or not the situation reflects an instance of sexual

harassment shifts. This instability shows that perceptions of appropriate social activity are

influenced by the discourses of (hetero)sexuality and individualism, on the one hand, and

by a discourse of bureaucracy/legality on the other. Even though there is an obvious

attempt to invoke different discourses in defining the activity than those used in selecting

appropriate social responses, the impact their combination has is important.

The combination, in fact, is what helps to reinforce more traditional views of

gender through the evocation of discourses of sexuality (male=aggressive,

female=submissive). The overall outcome of this distinction is to reinforce traditional

views of masculinity and femininity. This outcome is easiest to see by considering how the

conversational thematics shift in three distinct phases. Each phase also points to the

function particular discourses play in constructing gender through the role of bureaucratic

or legal intervention, the questioning of visceral experience, and assumptions about the

fixity of identity. As I examine each phase, I will also show how these subsidiary

assumptions play out. In what follows, I will re-read the episode according to this condensed framework. I will also add, where appropriate, supporting data from other observations to support my interpretations of how gender is constructed, and to what ends, by the use of these discourses within the practices of organizing.

The first phase, a short introductory one, is primarily a defining phase supported by the discourses of bureaucracy, legality, and to some degree, professionalism. The second phase focuses on selecting a response both for the resident as presented (male) and for an alternate situation (with a female resident and a male attending). In this second phase, the overlap between selecting and defining is important in distinguishing the contribution of

136 different discourses. In short, if the resident is male, both sexuality and individualism play

a role in defining the activity and selecting the appropriate response(s). If the resident

would have been female, both sexuality and bureaucratic/legal discourses play a role in

selecting activities and thus redefining the situation. In the third and final phase, there is a

distinction made between defining and selecting activities that reinforces traditional views

of gender on the basis of discourses of sexuality. That is to say, whereas the definition of

the situation may be stabilized by the invocation of discourses of bureaucracy, the

possibilities for selecting action remain destabilized through the role the discourses of

sexuality play.

The discussion presented above begins with attempts to define the nature of the

interaction on the basis of its resemblance to bureaucratic/legal definitions. The discourse

of professionalism is also evoked in these opening moments (“AMA meeting or CMA

meeting”). In fact, the importance of bureaucratic, legal, and professional discourses in

shaping discussions about gender is undeniable.

The use of these discourses is also available to social actors within this module

generally, and are reinforced by the situational framing that such actors provide. Two other

instances show the importance of these discourses in constructing identity. In the first

example, the prominent University leader mentioned earlier speaks about addressing

cultural diversity to the medical school class. In the second example, a physician addresses

the class about the way the medical profession has attended to women’s concerns. To

varying degrees, both of these examples also reveal the limitations of the use of potentially

equalizing’ discourses. I will take each one of these situations in turn.

As mentioned at the beginning of this chapter, a prominent University official spoke to the members of the medical class on the first day of the module. The speaker outlined a four-phase initiative to promote excellence throughout the university, one of which is attention to diversity. In discussing the importance of ‘diversity’ as an institutional issue,

137 the speaker reported on historical traces of inequity in the professions, the changing

demographic make-up of the United States, and the contribution a diverse population plays

in promoting the quality of education. The speaker proposed that Universities, generally,

needed to be committed to the principles of Affirmative Action.

In framing possibilities for managing diversity in terms of Affirmative Action, the

speaker does use legal and bureaucratic discourses. In explaining the principles of

Affirmative Action, the speaker is careful to discuss the use of ‘quotas’ in an attempt to alleviate the misconception that Affirmative Action involves hiring according to specific

identity categories. In doing so, however, the speaker focuses solely on challenges to

Affirmative Action programs that were “illegal” in their design through holding positions aside for minority students. Rather than using the legal definitions of appropriate

Affirmative Action activities, as sp*ecified in 29 USC 1608, the speaker focuses on those cases where Affirmative Action programs have become legally questioned.

In the second example, a physician spoke to the medical school class in attendance about the relationship between women, gender, and medicine. Only a portion of this presentation was dedicated to examining concerns over women’s access to medical education; by far, the majority of his presentation was on women’s health issues. This speaker began with a litany of rhetorical questions: What are gender issues? Is it Just about the differences between men and women? Is it about sexism or feminism?

It is worth note that the term feminism here was used as a ‘dirty word’ as the speaker equated sexism with feminism. The speaker also commented that sexism and feminism were “not really the case anymore” when it came to examining different ways of educating physicians or different ways of practicing. The speaker spoke briefly about the national average of women in medical schools, the number of deans of colleges of medicine that are women, and the percent of academic faculties that are women. This way of framing gender’ issues to speak about the representation of particular groups in medical

138 practice reinforces the representational foundation of bureaucratic and legal discourses.

The speaker then quickly shifted the focus of the presentation to ‘gender-differences’ in disease.

In both of these examples, the ‘public’ purpose is to frame gender as a legal or bureaucratic issue. However, both examples also point to the near impossibility of maintaining definitions of gender and gender issues as well as diversity’ and diversity issues’ solely on legal or bureaucratic grounds in attempts to promote equality. In the first instance, while Affirmative Action programs are touted as systemic forces at play in promoting equity, significant attention is paid to the failure of these programs from a legal front. In the second instance, while women’s health is given particular attention, the attempts to discuss gender issues, particularly in relationship to the role women play as medical practitioners, are undermined by attention to the ‘waning’ of feminism socially. In both cases, there is a reluctance to rely on the one discourse that does, at least on the surface, promote opportunities for women.

That is not to say that alternative uses of the legal/bureaucratic discourses can not be made, although here, too there are specific implications that result in a similar emphasis on the difference, and this, subordinate nature of the subject that is marked by those discourses. The categories that make the discourse viable are also the limit conditions of one’s identity.

As seen in the student’s discussion, gender is a women’s issue. Women are defined by gender as identity in this setting is fixed according to categories. In attempting to explore how gender identity, in particular, gets done' in this setting, I ran into the importance of this type of understanding of identity more than once. When I first began to negotiate the details of the project in the entrée phase, I was offered the assistance of a research fellow assigned to help with curriculum evaluation in the program as a whole. As

I attempted to describe what I wanted to do it was obvious to me that the research fellow

139 and my field contact had difficulty thinking of gender as a constructed phenomenon. They

did, however, offer the idea that I could use preexisting scales to measure the participant's levels of masculinity or femininity and thus, rank people on a gender-continuum. Once one's gender identity was established thusly, I could then look for possible correlations between their ranked-gender score and their interaction patterns.

Indeed, all ‘diversity’ issues are issues brought to consideration because of the presence of non-white, non-male actors. Interestingly, the moderators for the group discussions are chosen to specifically represent particular populations (female, hispanic, etc.) On the draft schedule I received for the entire module, alongside each day’s events it is clearly indicated who the speakers will be. For the discussion session, the document includes the names of four physicians and “+ five Ethnic Population Physicians”. The idea of having members of particular cultural groups speak (or in this case, moderate) a discussion about cultural diversity seems to have been a strategic educational choice; a woman who claims Appalachian heritage spoke on Appalachian Culture and Medicine; a

Chinese-American male spoke on Asian Culture and Medicine; and a white male who claimed ‘‘my wife is Hispanic, though” spoke on Hispanic Culture and Medicine. The underlying perspective on identity offered through these examples is that a person’s identity is a fixed, and categorical, quality of their being.

As a member of a category, marked participants (‘the parade of Indians’) do display their group identity. The patients who visited to speak to the class wore the costume one would associate with their heritage to portray their identity. It is interesting to note, too, the women who participated as panel participants were the only medical personnel who visited the class wearing a medical uniform (white coat or scrubs, stethoscope, pagers). While the obvious reading of this attempt is to show their identification with their professional group, the subtlety of their choice is that it marks them as different.

140 The problems posed by focusing on the fixity of identity or membership in a cultural group and its relationship to ‘diversity’ were evidenced by the comment of a visitor to the class who attended to hear the presentation of the prominent University official. He asked me directly, ‘what’s this talk about? what does diversity mean? You have representatives of the eastern block countries here, Scandinavian countries ... but they always lump white men together because that’s the target. And they become underrepresented’ He continued in a lowered voice, and then what do you do about the women? Do they consider them as white? We have a lot of Semite women here.’

The other primary discourse at work in the student discussion, the discourse of sexuality, and its interaction with discussions of visceral experience serve as the second defining factor of how gender is done’ in this setting. During the second phase of the discussion, the primary organizational activity focuses on selecting appropriate action, although the definition of the situation as either sexual harassment or not does become ambiguous (and thus, the focus of organizational effort) as the selections are made.

Two situations, in fact, arise. The first, given a male resident and a female attending, promotes the use of discourses of individualism and sexuality as a reason for action, and influences the definition of the situation as not sexual harassment. The second possible situation, involving a female resident and a male attending, relies on discourses of legality and bureaucracy, as well as sexuality, to define the interaction as sexual harassment and to select responses accordingly. In comparing these two situations, it becomes clearer how conceptions of gender along traditional lines are reinforced by the use of discourses of sexuality and its influence on interpreting individual experience.

Within the situation as presented—male resident and female attending—there is agreement among the participants that basis for selecting action is the victim’s level of visceral comfort. Not until the situation dynamics are reversed do the participants accept the possibility that this comfort level is not a determining factor in defining the situation.

141 This decision reflects the primacy of the discourses of sexuality over those related to the hierarchy of the bureaucracy (structure) of the organization in guiding the participants.

This reliance, in conjunction with the topic of the decision, constructs the male resident as

‘not sexually nonaggressive’ and thus, masculine. This construction takes on more meaning by comparing the situation as presented to the proposed alternative dynamic.

In the proposed reverse situation (female resident, male attending), selecting activities are based on bureaucracy, sexuality, and (to a lesser extent) individualism for women. Participants agree that the woman may feel uncomfortable, and the main factor in defining the situation as harassment and in selecting responses is based on assumption of sexual submissiveness. This conception of female sexuality is also supported by the initial laughter. The activities construct femininity along traditional lines.

Additional evidence of the construction of male and female sexuality along such lines comes from the second transcript. In one particular instance, an audience member asked the panel participants if they ever encountered gender-bias that was initiated by hospital personnel other than physicians or surgeons. One of the panel participants replies:

.. . um with male-female, and this is how it’s been traditionally for a long time,

male physicians and female nurses, there was a lot of things going on. You know,

traditionally there’s a lot of intermarriage there, you know, there’s a lot of flirtation,

um, and in general, I think it still holds to some extent, where if I’m a male

resident, I can flirt with a female nurse, and man, I can get all sorts of stuff done.

When it’s female-female, it’s really different. And to some extent, you know,

you 're trying to foster some relationship or friendship, but, you know, you don't

want it to feel forced, or anything like that. Whereas everyone should feel

confident, competent, to get sort of. . . so, and sometimes you almost feel that it’s a

power thing, that I can’t give an order necessarily to a nurse in a certain tone of

voice, I have to make her agree that it’s right. Or I have to make it up later, and it’s

142 very hard for me to make it up later. And it's, it’s a very subtle thing, and I ’m sure

nobody thinks of it, the nurses don’t necessarily think about it, but it’s harder, I

think, being female and trying to get things done with female nurses.

The moderator of the panel adds.

Well, what’s interesting is you bump up against an old pattern of communication. I

mean, male-female, all this sort of back and forth. And it’s historical. And nurse,

a lot of times can get things done, quite frankly, by flirting a little bit, and you

know, they can get things done. They can’t do that with women. You know, they

have to communicate differently.

In this exchange/presentation the assumption is made that females, as nurses, can gain the

compliance of male physicians by acting submissively (flirting) and in doing so, exercise at

least some power. The female resident in this excerpt bemoans the fact that traditional

feminine behaviors are not available to her in this situation.

One student in the sexual harassment discussion, however, does attempt to remove

the discourse of sexuality from the deliberations, and focuses solely on the discrepancies of

authority reflecting the importance of the bureaucratic and legal discourses. This separation

ushers in the third and final phase. This separation between the definition of sexual

harassment (based in the bureaucratic) and the basis for responding (based in sexuality)

highlights the construction of difference between the masculine and the feminine. This is

possible - this separation - because of different assumptions about male and female

sexuality; differences that mark gender. In short, regardless of the definition of the

activity, there are differences between men and women and these differences are apparent

in the possible responses actors would engage in.

It is also interesting to note, in this final phase, that the relationship between the emotional/individual response and sexuality is discounted for females as a basis of responding, but not for males; that women have to stick to the bureaucratic definition of the

143 situation to justify their response, whereas men can deploy the individual/emotional

response as a way of defining the situation. This difference in standard reveals the bias

inherent in the organizational sensemaking procedure such that it reflects male priviledge.

This dynamic follows through when presenting possible organizational actions for all

already marked individuals.

This distrust of the subjective in situations of assessing potential bias or

discrimination is obvious in other settings as well. Students in the discussion, and in

general, are concerned with what really' happens in medicine; are the situations provided

from real experiences or are they made-up teaching cases? Upon learning that a case is

hypothetical (a teaching case), they cease to engage it with vigor (i.e., answer questions

briefly or even sarcastically). This is evidenced by the moderators insisting on using the

prompt as provided despite the initial questioning of its fidelity.

In another instance students were asked to state ‘the first thing that comes to mind’

while viewing a photograph of a young, African-American male. Several students yelled

back at the facilitator in this auditorium-style lecture, “athlete” indicating that they were

aware that athlete was the intended stereotype to identify. To bolster the idea that students

recognized the difference between using a stereotype in real life’ and being prompted to

use a stereotype as a teaching tool, another student offered “Sprite drinker,” referring to the

Sprite commercial campaign Image is Nothing, Thirst is Everything, which features

everyday athletes most of whom are African-American. My interpretation of this behavior

is that students are interested in generalizable facts' and unwilling to seriously consider

events that are likely to be or could be untrue or subjective; an interpretation not

inconsistent with the idea that these are scientifically-oriented students.

This favoring of real’ situations also tends to impact the credibility students are willing to attribute to the personal testimonies of individual speakers. As subjective experience, personal testimonies are suspect. With relation to the issue of gender, this bias

144 toward objective criteria was evident in a conversation between two medical students I observed immediately after the panel discussion. The three members of the panel spoke extensively about practices of discrimination that they, personally, had encountered. The two students I observed following the discussion (one male and one female), were sharing their impressions of the event. One remarked T get what she’s saying, but I wonder how much that just depends on her. I mean, she just talked about ‘knowing’ that it’s happening. It needs to be more specific. You’ve got to be able to see it.’ The other student replied, yeah, how do you know it’s not just what she sees.’ There is, in this discussion, a clear distinction between objective fact and subjective impression. In both instances, too the questioning of subjective impression is emphasized in discussions about the marked individual.

Even those who find themselves outside the dominant discourses of the institution find themselves questioning their subjective experience. One of the panel participants related several instances of what would be, categorically speaking, instances of discrimination. In relating her narrative, she mentions several points of dawning awareness, expressing all the while that she did not trust her own experience. She states that she “didn’t think anything of it’’ until a male physician “whispered some little things under his breath to another male doctor, ‘why do we have to have this girl around?” It was only then that she thought “wow. Wow. I couldn’t believe it. To me, that was the shocker.”

The moderator and another panel participant point to the necessity of attending to the intuitive experience, rather than discounting it. The panel moderator states “well, you’re not sure of yourself... and you’re always questioning yourself. That always questioning yourself means that there is something wrong.” The resident on the panel also adds later, “[instances of discrimination are] really subtle, and you’re not going to know necessarily that it’s gender and necessarily discriminatory. And I’m not saying that you

145 need to be hypersensitive or, you know, to the point where people will be upset at you or

whatever, but it’s definitely something to keep in the back of your mind.” Later, the same

resident also states, “If at anytime you’re in a situation where, you kind of, the hairs on the

back of your neck stand up? Get out of the situation ” Through this discussion, the panel

participants recognize that the visceral experience of the target (women) is suspect, and

emphasize the need for women to pay attention to that experience. In doing so, the panel

participants also support the idea that such experiences are usually discounted.

In summary, difference is created through the distinctions made between male and

female sexuality (aggressive vs. submissive) and differences in the importance of (and

viability of) basing organizational responses on visceral experience. Individual response

isn’t treated as useful if coming from a person of the marked category, or if it’s used to discuss the possibilities of discrimination or prejudice. This is a double standard, whereby the masculine visceral response is taken as a possible guideline for action, but the female’s response is not.

The discourses used to support the student group discussion about sexual harassment are also evident in the instructional choices of the medical humanities program generally. Just as the students interacted to define a particular event and to select appropriate responses, so to do other members of the medical humanities program—the presenters, the facilitators, and other students—use these discourses to define gender, generally, and to facilitate an understanding of what actions may be appropriate or not in a given situation.

The use of bureaucratic/legal and professional discourses, as shown above, do have their benefits in perhaps providing a level-playing field, but the resultant impact is that they also serve, as many scholars have argued, to mark the subject of the ‘protected’ group.

Additionally, where emotional or visceral responses are taken as evidence of the quality of a situation for members of the majority group, a suspicion of subjective experience is

146 activated when called upon by members of the marked group. Both of these situational outcomes are supported by the defining and selecting practices of the organizational members.

147 CHAPTER?

PROFESSION(AL)ISM AS A GENDERING DISCOURSE:

QUALITIES OF NURSING PRACTICE

Nursing has had a strained relationship with other occupations that ‘embody’

authority in a variety of practice settings. As the history of nursing has revealed (Chapter

2), the development of schools of nursing in the US did not necessarily provide women

with a means to a secure financial future. Rather, nursing schools often functioned to

exploit nursing students through low or no-pay jobs with demanding hours in return for

training and experience. Further, until there was much demand for hospital care due to

the rise of medical technologies after WWn, even trained nurses did not have stable employment in places other than battlefields. As schools of nursing separated from hospitals, however, and became supported in college environments (presently, BSN,

MSN, and PhD programs), and as nursing developed its own associations and specialties, nurses began to claim a ‘professional’ status of their own. If only the relationship between the idea of a profession and nursing as an occupational category was so simple

(Witz, 1992).

As Turner (1995) argues, “the critical issue in the absence of professional status in the history of nursing has centered on the question of gender” (p. 146). While nursing

148 does indeed carry the markings of ‘a’ profession, such as licensure, altruistic service, and

specialized training, nursing fails to exhibit other qualities associated with a profession,

especially in the present economic structure of health care financing. Nursing and patient

care generally operates through an extensive division of labor; nurses earn a wage that is

determined by market conditions; the conditions of the nurse’s workplace are under the

control of a higher authority; and finally, nursing unions, most notably the American

Nurses’ Association, have developed to protect nurses against workplace practices.

These four features help to identify nursing as a bureaucratic occupation rather than a professional one (Turner, 1995).

It would be easy, to say the least, to argue that because nursing is female- dominated or is centered on feminine activities, a capitalist and patriarchal society has denied full professional status to nursing. However, one might also argue, as I attempt to here, that the discourses of professionalism genders nursing feminine and thus, makes access to professional status virtually impossible. In other words, gender is an outcome of professionalization, not a reason for it.

It should also be noted at the outset that nurses are caught in a rather difficult position, here. Whereas feminists have argued that professionalization is itself a patriarchal project, as seen in critiques of medicine, nurses’ access to professional status has been one of the main components of their ability to further the status of women in society. In short, if nurses do claim professional status, they are contributing to the closure that has been decried by Marxists and feminists alike as the basis for inequality.

On the other hand, if nurses do not claim the professional status that is at least partially

149 available to them, they suffer further inequities in the workplace and nursing is devalued

socially.

What is the manner through which the discourses of professionalism contribute to

the enactment of gender in the lives of nurses? As medical students do, nurses enact

gender against the background of a discourse of professionalism. The organizational

practices—the sense-making codes—that bring this discourse into importance include

both idealized descriptions of nursing practice and a system of symbolic complaints. In

the distinction between what it means to act professionally (idealizations) and to be

identified as a member of a profession (the focus of complaints), the role

‘professionalism’ plays in constructing gender is clear. Acting ‘professionally’ and being

a member of a professional’ group are not the same, particularly for nurses. This

distinction, and the ways in which it is interpreted and applied, helps to highlight how

identity is implicated in these discourses.

In order to highlight how the idea of professionalism’ is associated with acting in a particular way on the one hand, and belonging to a social group on the other, I will distinguish between a discourse of professionalism as a providing a set of behavioral norms, and professionism, as the discursive framework for identifying occupational groups. Indeed, it is this distinction that plagues nursing generally. In short, while nurses perceive themselves acting professionally (and do, by all accounts), the economic and structural factors of hospitals as organizations deny the status of a profession to nurses as an occupational group.

To show the tenuous relationship between these discourses, and how these discourses interact to define nursing, I will present some of the major thematics 150 developed from examining the interaction of several nurses in group interview situations.

These interactions show how actors draw on ideas of professional behavior and the

discourse of professionism in order to construct the contradictory position of nursing. As

before, the chapter proceeds thusly: I will overview the procedures used in gathering

empirical materials and the general coding processes used in interpreting those materials.

I will then present excerpts from those materials to show how the discourses described

above work in the process of nurses’ talk about their jobs. Finally, I will draw out the

implications of the interpretations I provide for assessing the ways in which the

statements the nurses offer, as organizational practices cast against the discourse of

professionalism, are modes for enacting gender.

7.1 Overview of Methods

7.1.1 Selection of Empirical Materials. The materials used in this analysis was drawn from transcripts generated as part of a previous, pilot study (Garland &

Neidig, 1997). In that study, focus group interviews were conducted. Although recognizing the possibility of group conformity in answers, the advantages of the focus group setting were determined to outweigh potential drawbacks. First and foremost, the group setting encourages participation by creating a comfortable, peer-centered environment. Secondly, this setting encourages the formation of group interaction and decentralizes the role of the investigator in its generation. This is particularly important since interview narratives may tend to be more formal, and therefore less natural to everyday experience (Cortazzi, 1993). Finally, since focus group participants were at

151 least acquainted with one another, the group setting itself simulated a working environment.

The research protocol was approved by the applicable Institutional Review Board prior to participant recruitment (See Protocol Number 97B0203, Appendix C). For the purpose of this analysis, transcripts from only two of the three groups interviewed are used. The second and third groups (five and four participants, respectively) consisted of veteran RNs (average length of time in nursing was 22.34 years, with a range of 12 to 34 years). Of those two groups, one group consisted of nurses who currently work in an inpatient setting; the other group included only nurses working in outpatient settings. I have chosen to focus solely on these transcripts as the nurses who contributed to them have long term experiential knowledge of the organization of the hospital and would be, therefore, more able to recreate the organizational dynamics.

Participants were solicited through purposive and snowball methods, and recruitment flyers were posted in local hospitals and in the college of nursing at a large,

Midwestern university. During the interviews, the group moderators asked questions from a predetermined schedule, each with potential follow-up inquiries. Interviews were audio-taped and transcribed verbatim. For this analysis, the transcripts were used in their original form, although interpretations generated from coding the transcripts during the pilot study further influenced subsequent analysis.

7.1.2 Coding Procedures. Using the categories categories developed from the pilot research, transcripts were reread with an eye toward the impact each thematic previously identified had on the understanding and appreciation of the others. Three 152 main themes were developed from the pilot study. Two themes were chosen for further

analysis here. These two themes were chosen because they represented the participants’

attempts at describing and accounting for their everyday work activities.

The first major theme concerned assessments of what nursing is in the ideal.

Participants identified general qualities required by nurses and illustrated how nursing

‘should happen’ through comparisons between themselves and other nurses or by

describing interaction between themselves and patients, doctors, or other hospital

personnel. A second major theme concerned issues related to particular moments of struggle in current nursing practice. Here, participants identified systemic changes and the impact of these changes on their perceived credibility and/or authority. Here again, descriptions of interaction with others (particularly doctors and unlicensed assistive personnel) provided insight into nurses’ perceptions of their own place in the organizational hierarchy. The reexamination of those portions of the transcripts that relate to each of the themes described above included an analysis of the processes the participants engage in order to make sense of their own position within health care.

7.2 Professionalism as a Standard for Nursing Practice

The first major thematic identified from previous transcripts reveals attempts by the participants to describe their idealized versions of nursing practice. These idealizations reflect both the positive qualities identified with nursing and contrasting negative behaviors that signify poor nursing. These idealizations reveal the character of nursing in only somewhat gendered terms. More importantly, however, these idealizations focus on particular roles, activities and places of action (at the bedside)

153 which serve to construct the identity of the actors. Taken as a whole, these idealizations

both reinforce and resist traditional conceptions of gender.

Activities range from the traditional ‘caring,’ to perceptions of holistic assessment

(not necessarily gendered), to an appreciation for commitment to work. When asked

what nursing meant to them, one respondent stated, “holism - generally knowing a lot

about the patient; being able to understand the medical and emotional, etc...” and another,

“I kind of like the philosophy of nursing... Looking at someone as a whole person.

Kind of putting together pieces of a puzzle instead of just kind of this focal visit.”

Specific connections between a holistic and a caring approach were also made: “a

component of nursing that I see.. .what nursing means to me, is the caring aspect. There

might be a medical piece you might work with, but then there's a psychological social

piece that's really kind of comprehensive and holistic.”

M aggie', a veteran nurse with over thirty years of experience, made a specific

connection between a holistic and caring approach, and the personal quality of empathy

that is required to perform in the nursing role. She stated, “I think there’s a lot of

empathy that you have to have. I mean you have to have it to be a good nurse, regardless

of where you’re working ... I think it’s also critical that we know who we’re taking care

of, who they love and who loves them. That’s part of taking care of the patient. ” The capacity for empathy, and the nursing practice it enables, is compared to the technical skills a nurse must possess, revealing the breadth of abilities required. Cindy, a nurse

with over 25 years experience stated, “Well, I’m sure [someone] working in an ICU

' The names of the participants have been changed to assure the confidentiality of their responses. 154 would feel differently than I, but I don’t think it’s necessary to know every lab value, I think that the heart of nursing for me is compassion for what the patient is going through and what the family is going through.”

In addition to compassion and empathy, there is a commitment to both the patient and the job itself that is essential quality nursing practice. Katherine, an experienced nurse (20+ years) echoes the importance of commitment: “But just like you were mentioning ... I can remember working until one or two [in the morning], I remember doing that, too. But every single chart was perfect, every single person’s IV was perfect.

You just didn’t want to leave until everything was perfect”

Maggie concurred, clarifying how staffing levels under managed care have impacted the nurse’s ability to engage in the committed, direct patient care that characterizes quality nursing practice. Even though an overwhelming RN-to-patient ratio from past times of understaffing is being re-experienced in the current managed care context, the nurses' desire to compensate for the lack of support is impacted by a loss of respect. “Well, my very first job was a 32-bed gyn unit with 32 cry-baby women”

Maggie relates, “No offense to all people here, as we are all women, but I mean having their hysterectomies and everything. We had 2 RNs and an aide and we ran our butts off.

We didn’t start charting until midnight and we didn’t leave until 2 a.m. And you know, you’re a new grad and you think this is the way everything is and (health care administrators) treated us as professionals for a while. And then they respected what knowledge we had and the knowledge we could bring to the patient and we got to do direct care.”

155 In addition to the holistic, caring, and committed, albeit realistic approach that is

exemplified in the best nurses, many of the participants identified the nurse’s role as

patient advocate as an important part of nursing practice. Sheila, a nurse with over 20

years experience stated, “I think that the patient advocate [role] is kind of what I feel is

[an important aspect of care]. You can kind of take their side when you understand what

it is that they want and need. I can go to bat for them.” This role is especially important

in a managed care environment, because, as Julie emphasizes, patients “sort of depend on

you and they confide in you. And you know the doctor won’t spend a lot of time with

them . . . So, they develop a relationship with me too. And sort of count on you as the

person to make sure everything they need, they get from the doctor.”

Quality nursing also comes from the ability to provide patient education, and the

role of educator is identified as an important aspect of nursing. Who might become a

nurse? “Someone who is a good teacher because . .. as a nurse you do a lot of teaching.”

Again, Maggie concurred: “I think one of the most important hats that nurses wear is

educator. And you wouldn't believe how often no one has taught (patients what to do

immediately after surgery)...that they have to ambulate. I don't know if it's because I just

talk people to death or if it's just a core value with me. New grads just say ‘here, get up

and walk.’ (But, talking to them as a person) makes all the difference. It makes them a

party in their own health.” This, of course, requires communicative skill and an

important aspect of nursing education is “learning how to present and approach in a

timely fashion that (patients) can understand, not giving them too much at one time. ”

Being a compassionate caregiver, as well as educator and patient advocate, all provide nurses with the opportunity to affect change in the lives of those they serve. That 156 nursing can be “powerful” was identified most directly, although somewhat hesitantly, by Bill. Bill states,

. . . a characteristic of nursing that I really like, keeps me going is how . .

[and this] sounds egotistical, how powerful nursing is. Because its really

doesn't always happen, but I'm sure there are nurses in cancer, you know,

people that are dealing with extreme situations. There are those success

stories. You do see people who we know are able to kick their drug habit,

get their lives in order and it's due in large part, they do a lot o f the work

obviously, but its due in large part to nursing. You know, to having good,

supportive nursing. And the intervention that nurses do it's not anything

that the doctors did. You know, just by prescribing clonodine. / And so

really, that's what keeps me going is the belief in nursing as a real

powerful force . . .can be in people's lives

Although one might argue that constructing what it means to be professional in one’s nursing duties is constructed along somewhat gendered lines, it is also possible to see in these statements how the nurses construct professional behavior along the parameters of general altruism. The nurses also reflect the ability to understand the situations that surround the patient and the patient’s needs not solely in feminine terms, but also in terms that align with education and the ability to advocate for the patient and independent from the physician. The idea of acting professionally in this instance need not be exclusively feminine, revealing possibilities that the idea of professional behavior as presented by these nurses can resist traditional conceptions of gender.

157 However, nursing is feminized through the discursive practices of professionism,

as is reflected in the symbolic complaints that nurses offer. Through the content and

structure of the complaints presented below, it is possible to glimpse the gendering nature

of the discourses of professionism by examining how nurses resist the positions offered

by such a discourse.

7.3 Professionism and the Contradictions of Organizational Structure

While these nurses recognize the qualities of professionalism, they also articulated

very explicitly the problems of the managed care system that make their services

‘unprofessional.’ Within this system (although the difference from other financing

systems may be one of degree rather than type) nurses do not have the workplace

autonomy associated with being a member of a profession (see Dalton, Speakman,

Duffey, & Carlson, 1994). They also indicate that pressures on their everyday activities

come from both management and those organizational members that serve as assistants in

patient care activities (UAPs). The gendering impact the discourses of professionism

have on nursing is revealed through the resistance inherent in a system of symbolic

complaints.

Complaints serve as important release valves for frustration, but more importantly,

they provide opportunities for resistance to the structure of the organization. Studies on

secretaries (Pringle, 1989) and clients of a human service organization (Tretheway, 1997) reveal the resistant impulse bitching represents. Although bitching marks the bitch' according to class as well as gender (middle-class women presumably do not bitch), the activity serves as a way for subordinated women in general to manage their 158 marginalization (Pringle, 1989). This is because bitching often parodies the dominant

discourses of the organization. By engaging in this parody, bitching reveals both the

nature of the discourse that dominates, as well as in some way, actively resists that

discourse (Tretheway, 1997).

Turner (1995) argues that complaints among nurses, in particular, function to

“[unite] nurses together as an occupational group with a common experience and

language. The complaints de-legitimize the authority structure of the hospital” (p. 151).

In this instance, however, the complaints also help to highlight how professionism

constructs nursing as feminine.

However, the vocabulary of these complaints does not focus most explicitly on the

doctor-nurse relationship; a relationship that Turner proposes is central to the vocabulary

of complaints. The focus of the complaints presented here is on the economic impact of a

revised healthcare financing system and the impact this system has had on nursing. For

example, the increase in use of unlicensed personnel to assist in patient care is seen by

the nurses as an outcome of the managed care system, and a reason for decreased quality

in nursing practice. Finally, complaints about dress and identification also contribute to

the complaint vocabulary.

Darlene, a nurse with over 20 years experience, illustrated the personal toll that accompanies increased pressure on fewer nurses; “It's much more difficult, now... you have more responsibilities and not any more time. You have less time . .. but you're still taking care of people and you're still going through all the good things and all the bad things that happen when you take care of people. But it's still harder, but I don't think it's

159 any less rewarding. It's amazing how you do manage to get that stuff done, all the emotional stuff that you need to do.”

Maggie described the work load changes and resulting time-crunch as slave labor:

“But you know you don't urinate for 12 hours and you don't eat and you grab all your charts just so you can get a chance to sit down. And they may tell you (with no notice that it is mandatory that you stay and work the next shift) — all that equates to slave labor. I mean you get a paycheck but it's not the way, not the way members of a profession should be treated.”

The impact of multiple types of caregivers is also identified as a reason for decreased status of nursing. Cindy described the UAPs as less reliable: “[There are] so many non-professional people at the bedside. (Nursing) jobs were eliminated. They needed to put in an alternative position, so they put them at the bedside. And the patients should be what this is all about and [UAPs] don’t want to be there, but they want a job.”

Cindy also described other responsibilities and lack of effective management that detract from patient care and the bedside nurse’s status: “[Y]ou've got a lawsuit-happy population, so that a good 10% of your time is in documentation of things that you're not even doing or that you shouldn't have to deal with. Like charting that this person is not a fall risk who is 22 years old and coming in for a minor surgery... There's a lot of constraints and not support from nursing management. There's a definite pecking order....and the people giving direct care are definitely at the bottom and it seems that they should be closer to the top. Y'know we are why this place continues to function and why there aren't more lawsuits and we re just told what to do. ”

160 Cindy attributed these changes directly to the managed care environment forces

which now: “Generally,. .. diluted the professional staff and that diluted the quality of

care. I really hate to say this but the whole dollar and cents is killing us and I think

about how much revenue is being generated and I know it’s not as much as what it used

to be because a lot of the fat has been trimmed but it's still a lot of revenue and [still]

we re understaffed, we don't even have enough auxiliary staff. I know there's revenue

somewhere and we re about giving care to patients. We're not about how many people are

sitting on a board somewhere attending meetings. We're about giving care at the

bedside. It's just so frustrating and really it's a crime because you know that there's funds

somewhere. It's going to marketing to make good commercials.”

The nurses we spoke with also articulated a loss of organizational status that

comes from being directly involved with patient care. Julie stated, “If we look at the

structural hierarchy .. the power structure in the hospital.. . nursing used to sit at the

top. . . nursing is now down. We re like a little subcategory ... so that just goes to show

you how they value nursing. It has gradually gone down further and further and further.”

Others agreed: “we re at the bottom of the food chain ... and middle management (has)

gotten pulled so far away from the bedside and .. . how can you manage people if you

don't have an idea of what these people are doing. You don't have an idea of what this

assignment is .. . and you just randomly say, well, there's a body and we'll just put this

body in this staffing hole.”

The loss of support from management is emphasized by other nurses, as well,

both in the inpatient and outpatient settings. Lee Ann, who currently works in an outpatient setting, stated “you look at the clinical environment (outpatient clinic)... if 161 we want to try to get a nurse, I mean we have to try to put all kinds of money together to

get one to come on board. Our supervisor is an administrator ... has no degree, doesn't

value continuing education . .. it's complicated because all we are are our names on these

fractional pots of money. (Non-clinicians) evaluate you, but never see you in action.”

Lee Ann also stated how these changes impact inpatient nursing; “Nurse managers used to know every patient on the floor. Now nurse managers hardly know who work for them. I mean, it's impossible.”

Outward signs of a changing role and institutional identity are seen in subtle and not-so-subtle changes in uniform and identification. Sheila stated, for instance, “I graduated ... quite some time ago. You still wore your cap, and you know the white starched uniform. I feel like nurses were treated better in the hospitals.” Bill also saw a change in dress as a significant alteration of a nurse’s identity; an alteration that takes away from the perception of maturity and status: “(when I was a young nurse).. the nurses that were staff nurses were older women. They were mature and . .. recently when

I went to visit my (hospitalized) friend ... not only were everyone in pajamas, but it was like being on (a college) campus. You know, there didn't seem to be any kind of maturity in the staff.”

Another sign of the changing nurse identity is seen on the identification badges nurses are required to wear. While this means something different to BSN graduates than it does to other RNs (who may have other credentials), the loss of this identifier is significant. The inclusion of credentials on the name badge is important, not just as a status marker, but in order to build justified credibility with the patient. Sheila stated,

“They took away our credentials (certified diabetes educator) from our name tags . .. and

162 I think that's very important when you are teaching diabetic patients. Lee Ann compared

the nurses’ name badge to other name badges in the system: “For the physicians, MD is

right up there (displayed in the highly visible top area of the ID badge). But for RN's it's

down on the bottom. When I look at that.. . that's LEE ANN. But the average Joe off the

street doesn't have somebody to tell you what to watch for. I think they're trying to make

everybody look alike so that nobody knows who everybody is.”

These complaints remind us of the ‘non-profession’ status of nursing. A focus on

technical knowledge (vs. interpretation), increased fragmentation of the workforce, limits

on autonomy, and pressures from para-professionals are key elements to the construction

of the antithesis of a profession within the discourses of professionism. As these nurses

draw on this discourse to frame their frustrations with the work environment, they also

resist the very discursive system that genders their work through casting that work as

deskilled and atheoretical. In short, the discourse of ‘being a professional’ feminizes

nurses’ work.

7.4 Analysis and Interpretations

The tenuous relationship between nursing and profession(al)ism that others have articulated at a theoretical level are evident in nurses’ own descriptions of their work roles. Whereas others have looked at the structural, historical, and economic ways that professionalization constructs gender (so that, for instance, nursing has a unique relationship with the professions because the work group is female-dominated), I examined how nurses construct their work roles through the discourses of profession(al)ism and the implications those constructions have for maintaining the 163 gendered (i.e., feminine) nature of nursing. That nurses do, in fact, resist the discourses

offered to them by aligning themselves as patient advocates and educators, and as

committed providers of health care services in addition to the more traditional ‘caring’

and ‘compassionate’ descriptions reveals somewhat resistant possibilities. In addition,

through their articulations of their frustrations—their vocabulary of complaints—they

cast the gendering nature of discourses of professionism into sharp relief.

The organizational practices that facilitate these constructions are descriptions of

idealized practice and symbolic complaints about the structural constraints on such

practice. At the individual level, a discourse of professionalism seems at least capable of

producing opportunities for surpassing gender-based discrimination thereby effectively

neutralizing the role identity plays in organizational settings. That is to say, it makes

sense culturally to state and is experientially viable to imagine, that a woman or a man

can simultaneously act professionally (or not), but that the actions, regardless of their

quality, are a reflection of the actors abilities and skills. Idealizations of nursing practice,

not limited to gender-themes, do draw from and contribute to the discourses of professionalism.

On the other hand, when nursing is considered at the macro level (i.e. at the level of culture and meaning), the discourses of the professions’ prevent nursing from being considered ‘a’ profession. In other words, it makes sense culturally at the present historical moment, due to the nature of a ‘profession,’ as described above, to state that nursing is not a profession. The implication here is that regardless of what happens in everyday practice, the group or the entirety of nurses (male or female) are not

164 ‘professional’ in the collective, cultural sense. The symbolic complaints of the nurses in this investigation reflect the implications of these cultural influences.

165 CHAPTERS

COMPARISONS AND CONCLUSIONS: WORKING WITH GENDER

In this final chapter, I would like to present the reader with a sense of what I hope has been provided by the project as a whole as well as point toward the types of research

I hope this project will encourage in the future. As I stated in the introduction, my aim has been to examine how organizational practices and cultural discourses work together to help sustain and (re)create gender in health care settings. Additionally, I hoped to provide insight into the relationship between communication and gender, generally, by articulating and empirically testing a concept of enactment. The contribution of this project, then, is to both organizational communication theorizing in the phenomenological and critical traditions, as well as to offering possibilities for real change for women in health care. I will summarize here the reasons for developing those specific objectives as well as the degree to which I believe I was able to reach them.

The project, in my estimation, successfully integrated the manner in which discourses and organizational practices work together to frame the concepts of gender.

However, there was minimal integration of the third component: the orientation social actors take toward each other, or the intentional relationships that enable the assignment and distribution of those gender characteristics to particular bodies. Part of the reason for this, I believe, lies in my application of the ethnomethodological framework to the

166 specific situation at hand. However, I still believe the framework I have developed to

articulate the concept of gender enactment (and identity enactment in general) can

produce new fruitful research; research that can extend these temporary conclusions and

help lead toward more grounded opportunities for change. In the remainder of this

chapter, I will expand upon these themes.

8.1 Theoretical Background and Project Goals

As stated in the introduction and developed in later chapters, an analysis of

communication practice helps us see the relationships between socio-structural practice

and everyday interaction, as communication practice is the means by which we

instantiate and challenge the cultural discourses that surround us. Theorizing

communication thusly is theorizing communication as social theory generally. I

approached this project with the primary aim to articulate a conception of gender

(identity) that reflects this understanding about the relationship between communication,

social reality, and everyday interaction.

I argued that a communication theory of identity would contribute to this

overarching goal. The structures of identity exist out there’ as much as they exist in the

way social actors recreate those structures in their everyday lives. The ubiquitous nature

of social power, made central in postmodern theories of society, makes the appreciation of this way of theorizing identity unavoidable. Social practices serve as nodes of the

instantiation of power and its countervailing force, resistance, in all facets of our lives.

The forces of identity-work, and the resistances to such forces, are a, if not the, prime

167 example of how social structures and the minutia of everyday life work together in relationship.

Feminists concerned with these relationships looked first to experience as a place to investigate at least part of that equation. However, poststructuralist theorizing of identity brought the idea of experience into question, particularly as a means of forming resistances to powerful discourses (Scott, 1992). Attempts at theorizing experience outside of language leads ultimately toward a biological essentializing (Keller, 1985) when what is needed is a way to theorize experience (a positive contribution in the abstract) with the embodied particularities of our lives without reducing one to the other.

These feminists recognized the already constructed nature of such experience, and proposed a theory of subjectivity that was influenced, although not fixed, by discursive regimes which relate, at least partially, to the sexual (i.e., biological) development of males and females (Grosz, 1990). I proposed that such a theory of linguistic subjectivity, while functionally useful in attempting to understand the relationships between cultural or discursive forces and the lived social actor, was limited by its reliance on a theory of langue rather than a full conceptualization of parole. In doing this, all social action became indeterminate; a position that many have argued is incompatible with the political project of feminism (cf., Nicholson, 1990).

Given that limitation of theories of linguistic subjectivity, I proposed a conception of identity that was tied to communicative subjectivity. All awareness is awareness of something; all action is meaningful action in that way. The fact that we ‘tune in' to our surroundings and the contexts of our interaction is reflected in and enabled by our communicative practice. The context of our interaction guides this intentional

168 relationship and can be reinforced or changed (or both) by our communication practice,

which is always tied to our embodied expenence (O'Neill, 1989). Our embodied

communication, too, becomes part of the context to which we respond and from which

we draw clues as to the meaningful relationships we are enacting (cf., Pilotta, 1979; in-

press b). In short, our communicative practice mediates our context-dependant sense-

making activity and the discursive, symbolic representations that surround us, by

enabling our capacity to orient toward and act in relation to others and to the contexts of

our action. This communicative practice is what I have called enactment.

I then turned by attention to a specific context of action—organizing

activities—as a possibility for developing a clearer picture of the contextual aspects of

enactment. In Chapter 4 ,1 attempted to situate existing feminist critiques of culture and

organizational practice within an already developed framework for types of research and

theorizing about organizing activity. Rather than maintain the original parameters of that

model, however, I proposed several changes to the basic framework. For instance, I

proposed that society can be seen as existing along a continuum of the subjective-

objective distinctions of epistemology and that the nature of power be seen as either an

entity or a process (or somewhere in between).

1 also added a third dimension, rather difficult to represent in two-dimensional

form, to reflect the various contributions of feminist theory generally, and feminist work

in organizational studies in particular. By adding that dimension, I argued, the role

organizational practices play in constructing identities could become visible. Simply

speaking, in accepting the position that the organization is the result of the shared constructions of its members, and that the exercise of and resistance to power is part of 169 those constructions, I also hoped to open up a space to consider identity as part of that

process. To fully explore these considerations, however, one has to allow that identities

are as much a product of construction as the organization itself. In this way, the practices

of making ‘what counts’ selections in the discursive environment are also practices of

encoding and enacting gender. In short, organizational activities make possible and

reflect awareness of gender identity. In creating these connections, I believe I am

continuing (and extending, challenging) the work of other organizational communication

scholars who have turned their focus toward identity, generally, and gender in particular

(cf., Buzzanell, 1994, 1995; Holmer-Nadesan, 1997; Mumby, 1993, 1996; Tretheway,

1997).

In order to investigate the enactment gender, I argued for the use of the directives

of ethnomethodology. Ethnomethodology was considered to be an appropriate

methodological framework for a cultural studies project’ as it shares with the general

aim of cultural studies a concern for “both the meanings and values which arise amongst

distinctive social groups and classes, on the basis of their historical conditions and

relationships, through which they ‘handle’ and respond to the conditions of existence;

and the .. . lived traditions and practices through which those understandings are expressed and in which they are embodied” (Hall, 1981, p. 26). The specific concern

with both meaning and meaningfulness that is part of the ethnomethodological framework allows for the consideration of, and focuses attention on, the ways in which the activities of social actors (with no accounting for the cognitive or otherwise psychological character of those activities) are tied to the broader social meaning- structures. 170 Two key assumptions guided the analysis of collected empirical materials; both of

which arise from the ethnomethodological framework. The first assumption is that social

actors act in ways that are ‘accountable’ and that such accountings’ are implicated in

their descriptive activities and in the structure of interaction as a whole (Heritage, 1984).

These accountings can reveal the influence of discourses of femininity and masculinity as

well as the role organizational practices play in making action reasonable.'

Secondly, the specific intentional (i.e. oriented) activity of the social actor is seen

in the indexical relationships that are implicit in interaction (Heritage, 1984). This

indexicality is tied to accountability by extending the parameters of the discursive and

organizational context into specific interaction. In other words, the activities of

interaction rely on and refer to (although not directly) contextual frameworks to give

character to the activity. The "referent, the quality of the statement, and the reason for

the statement (its purpose or function) are all contained within the utterance and as such,

configure the context of the interaction and prefigure future interactions" (Heritage,

1984, p. 152).

After articulating a conceptual and methodological framework for the enactment

of gender, I proposed that a test of these concepts would help clarify their usefulness.

Thus, my second goal was to employ these assumptions in the analysis of the interaction

of members of healthcare organizations. The setting for this research was chosen not

because of esoteric interest in health care practitioners, but because of the importance of

gender as a mechanism for structuring health care organizations. My review of the history

of both nursing and medicine made the case that the difficulties present-day women have as physicians and nurses have as professionals are by no means new. Thus, I anticipated

1 7 1 that gender is indeed something that "matters" in this context. The analyses presented in

Chapters 6 and 7 point toward the relative usefulness and completeness of my conceptualization of the enactment of gender. It is to an assessment of that completeness that I now turn.

8.2 The Influence of Discourse and Organizational Practice

As I stated above, I believe I reached the goals summarized here to the extent that the project provided some insight into the organizational practices or modalities that enable the deployment of discourses of masculinity and femininity in organizational settings. Several practices were identified: defining and selecting practices operated in the medical humanities program and idealizations and complaints helped nurses to position themselves in relation the context of their interaction. Most importantly, each of these practices enabled participants to articulate their orientation to each other through and in some cases, despite, the discourses of bureaucratic control, legality, sexuality, and professionalism in order to enact gender in these settings. In what follows, I summarize how each of these practice-discourse relationships do gender work by providing a backdrop for intentional relationships.

Through an analysis of the interaction of medical students—both their discussion and the general context of the medical humanities program—I was able to see how the interactional features of defining events and activities and selecting appropriate responses to situational occurrences are influenced by and help to reify traditional conceptions of gender. In particular, in the context of the discussions, defining activities were deployed to neutralize gender through a reliance on a discourse of bureaucratic control and legality. 172 However, the limitations of this approach, as many feminists have suggested, is that the

“marked’ subject for whom the definitions are intended to protect remain strikingly

visible in their absence. Other uses of these discourses in ‘defining’ activities (based in

observation) showed those limits. Furthermore, selecting activities—as seen in selecting

appropriate responses or in assessing viable (truthful) subjective impressions—are

premised on discourses of sexuality and heighten the distinctions between masculine and

feminine.

Briefly stated, conceptions of gender (and identity generally) as a fixed property of individuals was supported by discourses of bureaucracy and legality that are used to define such things as sexual harassment and affirmative action: to assess the appropriate mode of dress; and to make educational choices. Most importantly, however, traditional conceptions of gender are supported by the creation of difference between ‘masculine’ and ‘feminine’ on the basis of a discourse of (hetero)sexuality. The ties between the discourses of sexuality and a discourse of visceral response’ further the creation of difference in these practical interactions by maintaining distinct criteria for the reliability of subjective interpretations of, and corresponding reaction to, organizational events.

Through an analysis of nurses' descriptions of nursing practice, I argued that both idealizations of nursing practice and a system of complaints revealed the gendering effect of discourses of professionalism. A comparison between how nurses constructed their idea of acting professionally (doing the best job one can) within the qualities of nursing practice and the complaints nurses made with regard to the system of health care

(reflecting a resistance to the discourses of professionism) provided insight into the gendering function of the discourses of profession(al)ism generally. 173 More importantly, however, nurses used these idealizations and complaints to

construct their own position within the health care system. In doing so, they reinforced

and to a greater degree, resisted the gendering impact of these discourses. Although

‘speaking through’ the discourses, the use of them as supportive of both idealizations and

complaints helped to show the ‘replicated’ function of the discourse; that is to say, the

particular uses, here, reveal the tensions such discourses embody.

Although both nurses and medical students occupy the same’ organizational

sphere, I nonetheless find it difficult to many comparisons between the two groups. To

some extent, the role ideas of professional behavior play in both situations serves as a

common thread, although the articulation of ‘professional’ behavior in the medical setting

is much less of a focus. However, beyond the circulation of (and importance of) this

discourse, nurses and physicians still work in different organizational contexts. This difference is directly the result of the sex-stratification of the health care organization in particular or medical institutions in general.

Another contributing factor to this inability to make concrete comparisons across the specific contexts of analysis lies in methodological choices. 1 also hold myself accountable to my methodological choices for my own inability to specify actor's orientations toward each other and their situations (in addition to organizational codes and the discursive terrain) in clarifying the concept of gender enactment. 1 now turn to a brief critique of my own use of ethnomethodology and the associated opportunities for future research.

174 8.3 Methodological Critique

One weakness of the current investigation can be attributed I believe, to my own

use of an ethnomethodological framework, not the premises of ethnomethodology in

general. I encountered an inability to examine specific orientations that actors had

toward their surroundings although I was able to articulate the relationships between

organizational codes and discursive constructions that could guide that orientation. This two-point, vs. three-point dynamic may be because the contexts of the interaction I observed and participated in. These contexts are influenced by the following.

There was, for instance, a distinct difference in the context of the empirical materials used in the analysis between the groups, making comparisons difficult and more general conclusions nearly impossible. While ‘data’ gathered from medical students was most appropriate for ethnomethodological analysis (although it too had its drawbacks, as I describe below), the transcribed narratives gained from interviewing nurses were contrived in their presentation. That is to say, the transcripts of the medical student discussion group, as well as my observations of the medical humanities program provided evidence of the everyday’ interaction of medical personnel-in-training, at least to the degree that accounting practices are visible. ‘Data’ gathered from nurses, on the other hand provided reflections on organizational practice, not the interaction itself.

An additional complication here—and one that affected both situations of observation—is that the type of empirical materials used focus attention toward accountability, and not indexicality (reflection, decision making), making it more likely that organizational codes and discursive practice would be highlighted while actor's

175 intentional relations would be downplayed. Without careful attention by the researcher, observation of actors' orientations would be easily overlooked (as they were here).

Others have argued that reflective narratives and other reflective descriptions serve important organizational functions in their own right (see especially, Ashcraft and

Pacanowsky, 1996). Nonetheless, as reflective representations of organizational life, I am not surprised that the types of practices I observed were of the ‘idealization’ and

‘complaint’ variety. These types of organizational practices, and the impact they have on the enactment of gender, may have as much to do with the context of data collection as they are indicative of organizational practices on their own. Thus, it is understandable that I was unable to synthesize the types of organizational practices of interest across situations.

Likewise, the discussions of the medical students, while illuminating, were so obviously moments of reflection on the role of gender, that I find it difficult to accept that the behavior they describe is the type of behavior that would occur live’. In other words, to protect their own reputation, students may present themselves to be more cautious (in both directions) than they might be in the course of their regular interaction.

That said, while I do believe I addressed the question of how organizational practices and discourses contextualize one's intentional relationship to another body, and thereby enabling the distribution of gender' to those bodies, I realize that I was unable to specify the nature of that orientation. I can state how and which specific organizational practices can be aligned with certain discourses related to the construction of gender (i.e., how, in the course of accomplishing the organization, they draw on and deploy

176 discourses that construct gender), I did not focus on, and thus cannot specify, how social actors may enact gender in terms of their relationships with each other.

Another methodological problem occurred not only in the situations selected, but the overall design (and time frame) for the research project. I spent so little time in the field’ that while I was able to get a glimpse at the broad contours of the medical humanities program, I was still more or less becoming accustomed to the setting myself to be able to focus on how interactants oriented to each other. Limited interaction with nurses, too, left me with very little information about how they orient to each other in the workplace.

The transcripts generated from the medical humanities group discussion provided much more detail in terms of how interactants were orienting to each other and the situation, but by not observing basic intentional relationships, I was unable to specify the indexical relationships that distribute gender in interaction. While there are numerous examples of interactants explicitly addressing themselves as masculine or feminine (and always heterosexual), there are equally enough instances that where there is ‘insufficient evidence.’ The reader will benefit from knowing that I removed all indications of speaker sex from the transcripts before I analyzed them in order to reduce the influence of assumptions 1 might have had due to that awareness. Overtime, I honestly forgot the sex of most of the speakers (as indicated by vocal qualities, for instance). Perhaps my inability to categorize the speaker(s) solely on the basis of what was said and how

(contextually speaking) is indicative of a very loose relationship between gender and the acts of orienting. Still, the fact that I was able to find a few instances where speakers constructed their identities and the identities of even hypothetical others along gendered

177 lines leads me to believe that rather than finding a lack of a relationship between

communicative practice and the enactment of gender, I may have been focusing on the

wrong interactional details.

In analyzing transcripts from nursing interviews, I again found myself struggling

to avoid assumptions about gender. I attempted to look for conversational features that,

again, position the speaker in relation to the context of the discussion or in relation to

other participants. I chose specifically not to look for traditional conversation analytic

associations of gender (hesitancies, etc.) as I felt such concepts come ‘weighted’ with the

flaws I addressed in Chapter 5. However, by following a discourse analytic approach, I

was. as with the analysis of the medical humanities transcripts, able to assess how

interactants speak through discourses, or in this case speak in contradiction to them.

8.4 Directions for Future Research

In general, however, both the strengths and weaknesses of this investigation point the way toward possibilities for future research. I believe there is enough here to warrant future investigations into the relationships between organizational practices, discursive constructions and the social actors' orientation toward each other as a three fold process by which communication is tied to—enacts—gender identity. Using the primary practices of defining, selecting, idealizing, and complaining as I have identified here, I would continue to investigate the usefulness of these practices and others like them within the same general ethnomethodological framework, but with more attention to indexicality. I believe that our understanding of social and cultural implications of organizational

178 practices have been and can continue to be greatly expanded by continued investigation in this way.

Simultaneously, I believe that if these practices are to be fully appreciated for their implications for identity, the discourses and orientations under observation need to be expanded to include race, class, and sexuality, as a start. I do believe that this basic framework can be useful toward these ends. As an example, when white students talk about the need for more diversity in their colleges and universities, they identify programs that will help "attract them" and "support them" as minority constituencies on campus. Without explicit reference, the description of effective diversity management techniques' and the discourse of diversity generally always marks the other' as a person of color and the speaker as white and privileged (i.e., I can do something about this for

Them). The concept I have articulated here can help specify how diversity' has come to be the white euphemism for race', and more specifically, for black.'

While the sustained analysis of organizational practices from a critical and interpretive viewpoint has developed its own distinct body of literature over the last two decades, I hope that the project I have designed and executed, and reported upon here, pushes that development into a new direction. This direction is one that takes the enactment of identity as a core feature of organizational practice, and in doing so, further aligns organizational communication with the goals of critical social theory in its broadest sense. Given the opportunities for ‘real life’ application of research in organizational communication studies, the possibilities this development holds for creating moments of praxis run wide and deep.

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195 ABSTRACT For Protocol Tide M ^ > » l ri.lw.ralConcennmM of Hender The purpose of this study is to examine medical students’ conoeptkxis of gender and bow these conceptions are negotiaied as pan of their professional socialization process. In addition to learning technical and scientific aspects of medicine, medical students undergo training in the standards of professional conduct which reflea the values of the instinitioa arid the idols of ibe practice of medicine. Thi< iwcludt»» «râlÎMnnm iwm aiwynr in, conceptions of gender, as outlined below. The proposed research contributes to an understanding of the foundations of gender based inequities in medicine. Recent research on medical education has begun to report on the genenl role of women in the training anl socializadon process. The majority of studies examine the status of women in educational programs in an attempt to evaluate the relative gender-equity of the structure and practice of medical educatkxi. ftoim admission to the oonqdetion of residatcy. Other studies have examined the gendering of the profession through identifying possible changes in professional standards or expectations that may have resulted fiom an incnmsed number of women in Critics argue, however, that the medical cducatiofuil system “often forces those in iraiiung to absorb the values of the dominant group” (Walsh. 1990. as cited in Wear. 1997. p. 41). As an historically patriarchal institution, the values and standards with the maimmug»» of male privilege may beocxne the values aixl standards that all students—male or fanmle-oonsider professional'. Such a statement deserves explication on two fironts: how ought we describe the dominant group? And. through what process are the values of that group circulated and susutined? Strucnurally qiealdng. women temain the minority throughout medidne. Female physicians are disproportionately repemenied in the k>west*paid specialities such as pediatrics, psychiatry. ^neraJ/family practice, and general internal medicine (AMA. 1991). Women also su£Rsr fiom inequities in acadrrrur medicine. According to Wear, “the number of full profmsors is very low. only 16 on average per medical school conipaied to 155 men per school” (19^7. p. 9). Support for Wear's (and Walsh's) position. above, comes fiom organizational communication theorists' ootKlusions that cultural values—organizational members' of a shared social reality—are mediated through camnanucative and symbolic activities that are highly influenced by the organizatioo's elite (Mumby. 1988). For medical soidents, learning the notmative triodes of comttainication. as well as the meaning of such symbolic acts, is a «gntfMmf part of their medical training as well as a way in which they are socialized into the institutioo's ideological frameworfc. The values and standards of professiooal' practice, symbolically perpentated by the dominant group and accepted as part of a studeno cnri«iiMrin«i imo the institution, would not appear to be particularly reflective of nor sympathetic to women s sectxid-dass status in medicine and in society. This study seeks to answer the questions: 1) do medical stuilenis’ oonoeptioiu of gender reflea values anl standaids of professiaoal practice tto correspond with a patritaehal institution? And. if not, how ate such divergences responded to by fellow medical students? Data fiom discussion gnxips comprised of first year medical students enrolled in a medical humanities course will be used to clarify conceptions trf gender. The discussions follow no predetermined format, but ate focused on explicating issues presented through which ate provided to the students by the Piogiam Director (see attached for sample). Transcripts of the audio-taped discussion, as well as analysis of the nonverbal interactive componena of the participants' converstation will analyzà for interaction patterns and general HvMwmc trends. Particpants will be recruited with the assistance of the Medical Humanities Aogram Coordinator at the CoUege of Medicine. Each discussion group will meet during their regularly scheduled class period Participants will receive a verW explanation of the purpose of the s u ^ prior to participuion. and no deception regarding the goals of the research will occur at any «««w Participants wUl be asked to sign a consent form (attached) and will be aware that they are fiee to withdraw consent and cease participation at any time without prejudice. No follow-i^ or additional time is required

196 Altbougb the diiniwinB poop sessions will be audio-taped, all panicipamts wiU be assured of confidentialiiy. Panicipana will be allowed to cfaooee a pseudonym car sprêlgr idcmificanoo only, and/or pseudonyms will be assigned «> each partcipaot prior ptnnscnpiioB of the tapes. All nanscript tapes and asaodared documents will be securely stored in a locfcad file denver in the Offices of the Scliool of Jdinnalism and Conununirarinn(Dgtay Hall) and will be accessible only to the principal and co-invcstigator of the study. All subsequent records and repora of the focus group sessions will include the use of pseudonyms for eacfa participant and the location of the research will not be lewealed at any time.

197 G«nd«r Issu* Cass Studiss - Studwit Vsrsion R*vi*%s#d 1/98

1 You are a female intern on service vntfi otner female and male residents. The team gets along well. The male resident is a warm, friendly individual who will often touch an arm. or put his arm briefly around staff, even faculty, m a fnendly gesture. One day on service he put his arm around the female intern and told her what a good job she had done on service.

2. Ms. Smith and Ms. Jones are Ixfth 23 year old female medical students. Both are currently involved in a research project together with a male faculty member. Ms. Smith IS short and small build, often wars casual skirts as well as slacks to work m the lab Ms Jones IS tall and thin, and dresses similarly. All get along weU. and the research project is progressing well. Both students would like to receive a positive recommendation from the faculty member for when they apply to residencies. One afternoon Ms Jones had to leave early. As Ms Smith was working on her project and talking with her advisor, he reaches over and puts his hand on her knee and leaves it there. In other words he didn't just tap her knee'

3. A female intern is holding ttie retractors fOr the male surgeon while on her surgery rotabon. He asks her if she is mamed. she answers "no", 'engaged* The surgeon then asks what her fiancee does, and she answered he is a pediatrician, to which he made a jokingly, rather negative comment which the intem ignored. As the surgery continued, and the patient's diseased organ was exposed, it was noted by the imam that it was dramatically enlarged. The preceding comments from the surgeon to the female intam were "what would you know about big', you're marrying a pediatrician? * And don't get too exerted holding on to something that big'. The surgery staff laughed at the jokes, as they were routine to them.

4 . A male senior resident IS on servies with a female attending who «known for flirting with male residents and male medical students. She often comments on their dress (e g. we re going to have a contest on the "besf ties) and flaquentfy comments to the male students on how 'cute' they look. She « vary touchy' to this particular resident to the point of him feeling uncomfortable. She commented one day on what nice eyes he had. and what a nice ass he had.

S. A 26 year old married female patient who « well known to her physician, has an appointment one day for a sore throat. In the middle of her visit she expresses to him. "I'm sure you know how I feel about you?* He indicated that he did not know what she was talking about she went on to tell him how much she 'loved him', etc This physician is mamed with children and IS known not to be flirtatious.

2/2/98 sn«fv

198 Gcndar Imim Camm StudiM • Studant Vwaien Raviawad 1/M

6. The patient is a ttuny

2/2/M tftsraoocvnnSTMWuturav

199 FEB-ae-99 13.SB FBOM.OSU KKSSABCH FOUNDATION ID.•14♦a93«SSX3 F A C E 2 / 3

19«0KcnnvKa^ OHIO Coiunbus. OH 432X0-KX3

FebiutryS. 1999 Joseph J. PiloOa Associue Professor School of Journalism and Communication 3016 Derby HaU 154 N. Oval Mall CAMPUS

RE: Protocol #99E0040 entitled. *Medical Students’ Conceptions of Gender’ Dear Professor Pilotta: Thank you for your recent submission of the above referenced protocol to be considered for exemption horn human subject leview. In order to complete the review process, please provide the following additional information:

I) A copy of the verbal solicitadoa script to be used. 2} Clatiflcatioa on what students who do not wish to participate will do or go dining the discussion.

Once the above information is received, review of the proposal can be completed. Please feel free to fax the documentatit» to me at 292-5913. or e-mail to ^ ^ #aau.edu.

Thank you in advance for your assistance.

Administrative Assodaie Office of Research Risks Protection

200 School of 211 fourruJism BIdg.. 242 VV«i Iglft Avenue lounuiism and Communication Cuiumbus. OH 432J0-I !>l4-292-n29I (Fa»292-3B0>»I OHIO 30Ib Derbv Hall. 154 N'orth Oval .Mall Columbm. OH 43210-1339 014-292 3400 (Fa« 292-2055) UNIVERSITY

February 12, 1999

Tammy Russell, Administrative Associate Office o f Research Risks Protection Ohio State University Research Foundation 1960 Kenney Road Columbus. Ohio 43210

RE; Protocol 499E0G4O entitled, "Medical Students' Conceptions of Gender"

Dear Ms. Russell.

Please find attached the items you requested in your letter of February 8,1999 1 am forwarding these items on behalf of Dr. Joseph Pilotta, Principal Investigator for the above mentioned research protocol review exemption request.

If you require any additional items, please do not hesitate to contact me directly at 292- 5988. or by e-mail at garland. 1 [email protected]

Sincerely.

Mane Garland Co-Investigator

201 Dear Medical Student.

You are being asked to participate in a research study. The principal investigator and co­ investigators for this study. Dr. Joseph J. Pilotta and Marie Garland, M ^., respectively, are researching the ways in which gender is symbolically part of organizations and piofessioaal learning. Their particular interest is in how new members in health care organizatioos communicate about gender and the relationship they see between gender and their professioiial responsibilities. In ^ t t , they are interested in the judgments medical students make about when, why, and how gender will or will not be important as part of their work and how those judgments are communicated with others. The investigatois hope that the results of this research will contribute grounded examples for future discussions about the role gender plays in interactions between health care professior^s and within the doctor-patient relatiorr&p. Future students and health care professionals in general will benefit from knowing how others may think about the role gender plays in medical encounters. TWs understanding may. in trrrn, help practitioners be more aware of that role in various circumstances. The research process consists of audio-taping the group discussions already scheduled to take place on February 24. 1999 (next Wednesday). Transcripts of the audio-taped interaction will be used to identify conversational patterns and general thematic trends which are part of your discussion. The confidentiality of your conunenis outside of the discussions is assured, should you decide to participate. You will be allowed to choose pseudonyms to identify yourself during discussions, or one will automatically be provided for you when the audio-tapes are transcribed. Research reports arising from this data collection process will identify speakers only by their pseudonyms, and the location of the research will not be reported at any time. No group will be audio-taped unless all members sign the consent form (see aOached). Groups wherein consensus to participate is not achieved will not be audio-taped Further, you are allowed to cease participation at any time without prejudice, and the group will not be audio-taped from that moment onward. [f you have any questions about the research prtrcess, please feel free to contact Marie Garland, Co-Investigator, at 292-5988. or by e-mail at garland. 119osa.cda. If you feel all your questions have been answered, and you decide to participate, print your name and then sign both copies of the consent form (attached). Return one copv to the drop box and retain one copy for your records.

Thank you for your consideration.

Sincerriy. ,

Marie Garland. Ph.D. Candidate. Communication School of Journalism and Communication

202 Response lo requested claiificanon* for

Research Protocol #9950040 entitled, "Medical Students' Conceptions of Gender"

Data from discussion groups comprised of first year medical students enrolled in a medical humanities course will be used to clarify conceptions o f gender. The discussions follow no predetermined format, but are focused on explicating issues presented through scenarios which are provided to the students by the Program director (see attached for sample). These discussions are a scheduled activity and are part of regular course content- Transcripts of the audiotaped discussion, as well as analysis of the nonverbal interactive components o f the participants' conversation will be analyzed for interaction patterns and general thematic trends. Participants will be recruited with the assistance of the Medical Humanities Program Coordinator at the College of Medicine. Each discussion group will meet during their regularly scheduled class penod for the discussion activity. Onlv groups whose entire membership agree to participate will be observed and audiotaned. Groups wherein a consensus of consent to panicipate is not achieved will not be audiotaoed. but will still complete the activity as out forth in their course agenda. Participants will receive a verbal explanation of the purpose of the study pnor to participation, and no deception regarding the goals of the research will occur at any time. Participants will be asked to sign a consent form (attached) onor to consultation with other group members (to prevent coercioni and will be aware that they are free to withdraw consent and cease participation at any time without prejudice. No follow>up or additional time IS required.

* Text ts excerpted from the submitted abstract. Underlined portions represent clarification.

203 School of 211 lounuhsm Bldi;., 242 West ISth Avenue Jounulism 4nd Comfnunication Columbus. OH 43210-1107 OHO 014-292-6291 (Fa% 292-3809) 3016 Derby Hall. 154 North Oval Malt Columbus. OH 43210-1339 614-292-3400 (Fa* 292-2055) LNIVERSITY

Februarv 22. 1999

Dear Discussion Group Facilitator.

As a participant in discussion groups during the ICM I: .Medical Humanities .Module on Cultural Diversity, you are also being asked to participate in a research study. The principal investigator and co-investigators for this study. Dr. Joseph J. Pilotta and myself, are researching the ways in which gender is symbolically part of organizations and professional learning.

Our particular interest is in how new members in health care organizations communicate about gender and the relationship they see between gender and their professional responsibilities. In short, we are interested in the judgments medical students make about when. why. and how gender will or will not be important as part of their work and how those judgments are communicated with others.

We hope that the results of this researcn will contribute grounded examples for future discussions about the role gender plays in interactions between health care professionals and within the doctor-pauent relationship. Future students and health care professionals in general will benefit from knowing how others may think about the role gender plays in medical encounters. This understanding may, in turn, help practitioners be more aware of that role in various circumstances.

The research process consists of audio-taping the group discussions already scheduled to take place on February 24. 1999 (Wednesday;. Transcripts of the audio-taped interaction will be used to identify conversational patterns and the general thematic trends which are part of your discussion.

The confidentiality of your comments outside of the discussions is assured, should you decide to participate. You will be allowed to choose a pseudonym to identify yourself during discussions, or one will automatically be provided for you when the audio-tapes are transcribed. Research reports arising from this data collection process will identify speakers only by their pseudonyms, and the location of the research will not be reported at any time.

Xo group will be audio-taped unless all members sign the consent form (attached). Groups wherein consensus to participate is not achieved will not be audio-taped. Further, you are allowed to cease participation at any time without prejudice, and the group will not be audio- taoed from that moment onward.

204 If you have any questions about the research process, please feel free to contact me at 292 5988. or by e-mail at garland.ll@ M U.edu. If you feel ail your questions have been answered, and you decide to participate, print your name and then sign the consent form.

Signed consent forms can be returned by fax. Fax a c o p y of the signed consent form to: f6l4^ 292-2055. prior to the discussion meetings on Wedtiesday.

Thaitk YOU for vour consideration.

Sincerely,

Marie Garland. Co-Investigator Ph.D. Candidate, Communication School of Journalism and Communication

205 School of -I I fourruiitsm 9ld^, .42 West ISch Avenue Joufnoliiin and CoaimuniciHon Cuiumbus. OH 4J2I0-I lOT 014-292^291 (F j « 292 3909) OHIO 30Io Derbv HaU. 154 Sortft Oval Mall Columbus. OH 43210-1339 O14-292-5400 iFa« 292-2055) SMEuxrv'ERSi'n' PRNOcoi Number 99E0040

Coiucat for Partidpatioa in Social aad Behavioral Research

I consent to panicipatinf in leseareh entitled: Mcdicai Snidcn o ' ConMSiiniii nf fkm k c

Dr. Joseph J. Pilooa (principal invesriguar) or his authorized tepxesemtmrive, Marie Garland, has explained the purpose of the study, the procedures to be foUoeied, and the especied disadoo of my parocipatioiL Possible benefits of the study have been described. I acknowledge that I have had the opponunity to obtain additional infiamatioo tegaiding the study and that questions that I may have raised have been answered to Adi satisActioeL Further. I understand that I am fiee to withdraw consent at any dam and » disoontiiiue participation in ite study without prejudice to me. I understand that this form will be kept coifideaiial aiai will not be assodamd with inftatnaiion I provide in the course of my paiticÿatian in the reseaich. Finally. I acknowledge that I have read and fully understand the consent form; that I sign it finely and voluntatily; and that a copy has been given tome.

Date:______Signed:. (participant)

206 Interested?

Would you mind if your discussion group this afternoon is audio-taped?

Haven’t already returned a consent form?

Extra copies are in the back of the room.

Thanks !

207 APPENDIX B

TRANSCRIPT:

MEDICAL HUMANITIES STUDENT GROUP DISCUSSION EXCERPT

Student #1 : A male senior resident is on service with a female attending who is

known for flirting with male residents and male medical students. She

often comments on their dress - for example- we’re going to have a

contest on the best ties, and frequently comments to the male students on

how cute they look. She’s very touchy to this particular resident to the

point of him feeling uncomfortable. She commented one day on what nice

eyes he had and what a nice ass he had [laughter].

Female Moderator: [laughter] Wasn’t mine - I can say that one. So as a male resident,

or as a medical student as a med HI or med IV and this comes up - how do

you guys feel? Would you report this to the med ed people? or... is it

something that you’d blow off?

Student #2 So she’s writing your recommendation ?

208 Female Moderator: She’s just a fraud (laughter) No - yeah, she’s your senior, she’s

your attending. She’ll be grading you.

Student #2: I think the fact that she is grading you is exactly the point. ‘Cause I was at

this AMA meeting or CMA meeting, I forget which, a few months ago

and there was someone there talking about harrassment in medicine

basically, um. I mean the general comment that harassment occurs...

Female Moderator: .. .hmmhm...

Student: ... when someone in power...

Female Moderator: ... hmmhm..

Student: ... is using that power...

Female Moderator: ...hmmhm...

Student ...to influence...

Female Moderator: ...hmmhm...

Student .. .or get something from someone...

Female Moderator: ... hmmhm...

Student . ..who is under their control. And that’s exactly what this situation

provides...

Female Moderator: .. .hmmhm, hmmhm, good...

Student #2: Now how you handle it is a different story, cause you kind of have to fish

your way out of it and still get a good recommendation, so ah... 209 Female Moderator; Just out out of curiousity - guys, how would you handle something

like this?

Student #1 I’d laugh it off.

Female Moderator: Because of the grade situation?

Student #1 : No, no. I mean, I guess it’s, it’s a very different situation for guys, men

and women, and ah, I can’t imagine feeling so uncomfortable that I’d

really really worry. I know its a huge gender issue, but ah...

Student #3: I think it comes from, just, exactly, I mean how comfortable you feel with

it. I mean, if you’re not that really that comfortable at all, then I mean, you

should confront her about it. But if it doesn’t seem bother you, or you’re

used to it, or your social background it’s not that odd for you, I mean if it’s

not a big issue, then you should probably just go with it. Rather than cause

a lot more problem then you need.

Male Moderator: Is there consensus that, ah, that it’s different since the victim is

male? I think I heard you say that.

210 Student #3: Yeah, I said that (laughter) I could agree with that. It shouldn’t be.

Although culturally, I think it’s...

Student #4; I think he’s right. I don’t think you could reverse the situation and come

out with the same result.

Female Moderator: Yeah I was going to ask the women how they would respond.

Student #4: Absolutely - I mean, I think it’s a power issue, a lot of it, and um, sex is

power. And I think that for a lot of ways, females have always been in the

passive, uh, um, I guess

Female Moderator: role

Student #4: ...role, in that relationship. So ah, I don’t know. I’d guess about 90% of

all men would do the same thing, just laugh it off...

Male Moderator: Playing devil’s advocate here for a just a second here, though - in

this particular dyadic relationship, the woman is the one in power. Um, so

Student #4: I think that - absolutely, but I think that still, I mean, it’s not a very

* threatening* thing. I mean, she’s not saying, you know, have sex with me

211 or I’m going to give you a bad eval. You know that’s not what she’s

saying, and I don’t think the men feel threatened in anyway that she’s you

know, going to try to force herself on them or something like that. I think

that’s the issue.

Male Moderator: whereas if the situation was reversed that would be a legitimate

fear.

Student #4: uh hmmm

Student #5: I don’t think that’s entirely the issue. I think there can be times when a

man can be flirting with you and be in a position of power, and ah, the

point is you can’t react to it the way you’d like to react to it, because he is

the person in power. It doesn’t mean that he’s necessarily going to force

himself on you, he’s taking advantage of the situation. And I think we

need to distinguish between uhm, whether we consider it different in terms

of how we would judge the attending. Are we judging the attending and

saying it’s okay because she’s a woman? I don’t think we’re saying that.

I think we’re saying that, it’s the wrong thing to do no matter what, but it

just seems that if you were a man, or... you might react differently in this

situation.

212 Student #6: I agree that I think men tend to feel less physically threatened even if it's

on a visceral level, but I do think, and I think this goes back to what Brad

was saying, the power she has in this relationship is very real, and the

threat, that um, if you do confront her, she may give you a bad review, is a

very real threat, whether she’s a woman or a man. And in that sense, I

think that most of us would be, men or women, I mean, what if it was a

lesbian? You know, I mean, either way, it doesn’t exactly matter. There’s

a perceived power discrepancy there. I lost my train of thought in there

somewhere. .. (laughter)

Student #7; I think it makes a difference in the extent that most men would react

differently, which is pretty much what Rob and Laura said. Most people

would react differently, but there are some men out there for who, who it

would really bother. And it it does, I don’t think it’s any different than if

it’s a man or a woman, ‘cause if it bothers you, and the cor..., it meets the

the criteria that it’s the person in power is the one, like, initiating the

situation, then I don’t think it’s any different at all.

Female Moderator; How many guys would be flattered?

Student #8: Depends

Female Moderator: It depends?

213 Male Moderator: From an historic standpoint... (laughter)

Female Moderator: Come on, you guys would...(laughter)

Male Moderator: From an historic standpoint, I suspect that had you asked that

question twenty years ago when I was in medical school, all of us, myself

included, would be

Female Moderator: You’d be flattered

Male Moderator: I’d be flattered, [roarous laughter].

Student #8: Yeah, I don’t think - I mean it’s one thing, I dunno this is going to sound

bad, but, thinking you’re flattered by an older woman telling you you have

a nice butt is kind of odd. But, it might be true nonetheless. But the thing

is, if a woman tells me I look nice, I don’t take it as any kind of a threat at

all. You know, I take it that she, you know, has something wrong with her

(strong laughter). I don’t get mad. I mean, I know maybe it’s wrong for

her to do that, but when I hear a guy say that to a girl, I think, that’s

definitely wrong. Especially if he has, if he's in a position of power. I

think it goes back to, for some reason, if a woman says it to a guy, I don’t

think it’s read as “I want to have sex with you”, but if a guy says it to a 214 girl, that’s the normal connotation, I think is, now. I’ve said you look nice, now you owe it to me to get a nice evaluation, or something like that.

215 APPENDIX C:

APPLICATION FOR EXEMPTION FROM HUMAN SUBJECTS

INSTITUTIONAL REVIEW BOARD REVIEW:

PROTOCOL TITLE: WORK NARRATIVES AND SOCIAL IDENTITY

PROTOCOL NUMBER: 97B0203

216 Protocol No. 9 ? ^ < ^ 2 .0 ^ (Office Use Oefy) Ote*. 6/93)

APPLICATION FOR EXEMPTION FROM HUMAN SUBJECTS DVSTITUTIONAL REVIEW BOARD REVIEW *

AD rtifo rrh activitia Ikat wfll iavoivc h aaaa benyi ai raacareh sabjcctt a a st be reviewed a n d approved by tbe appropriate bomam mbjecta laadtmtiomal Review Board, or receive ezcmptioa statua, prior to iaspkoaeatatioa of the reaeareb.

PrWciaal Immellaemr. P-ilnrfj- Tnagph J. ______M m teCSOHaen (Tjpil mil Ub fnm Item ? Acadcak TW»: Associate Professor P baee 292-3400 W . 292-2055

O fM m —c rCev r.rh.'.ol fC ai.iiiii-nigatio-;^ ______Dwwowet We. 0744 r._r_. AOarai; 3016 Derby Kali______154 X. Oval Mall______********

Cfrtavaedfawrtit: Garland. Marie 3. (TmeS WM laa rm IM ■ Tiirf-frti I... . I7)ekmarne Le» P m

► PROTOCOL TTTLE: Work Narratives and Social Identity

• THE ONLY INVOLVEMEMT GY HUMAW SUBJECTS IN THE PROPOSED RESEARCH ACnVTTV W IL L BE W OWE OR MORE OF THE EXEMPHOW CATEGORIES USTED ON THE RACK OF THIS APPUCATTON. k CATEGORY: «W m «an» el , «X . «3___ , S4 , SS , a t ___

k SOURCE OF FUNDING FOR PROPOSED RESEARCH: lOrntAmm

A. OSURF: SpeoMT ______RF Praoawl/Prafcci N o. ______B. Oder (U em lfn College (SBS) and Office of Research. Small Grants

Office Uic: EXEMFnON STATUS: i/ APPROVED DISAPPROVED**

MAY Î 9 1957

Otic Ouvpctsoe

** PnncipaJ [nvesntHor muit nibna m pmocol lo dtc ipprephae Horaan Sebjaas IRB.

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217 ABSTRACT For Frococol Title Work Narratives and Social Identitv The purpose of the investigation is to develop a model of social identity that takes into account both the changing economic and institutional forces and the individual adjustments of women cnyloyed in tbe health professions. According to Vance (1985), female nurses and technicians began to examine their roles in the health care prohKsions as issues about gender in health care came to the fore in the late 1960s and early 1970s. More recently, cost presstues have fueled a rapid ongoing reorganization of the U.S. health care system and the emergence of managed care. Dramatic cost reduction programs have been enacted by hospitals, resulting in significant workforce reductions for nurses and the transfer of nursing responsibilities to unlicensed assistive personnel. The project seeks to accomplish the following aims: 1 ) to determine how women have adjusted to changing expectations reganling the balance between their administrative and caregiver roles, and 2) to understand how these changes in a traditionally female dominated profession have impacted the women’s assessment of their own gender roles. We believe that the narratives women use to describe their work will indicate how they see themselves in this moment of change. Thus, this qualitative study uses focus group interviews to generate personal narrative explanations of how structural and economic changes within the health care system have impacted nurses' perceptions of their female caregiver and gendered work roles. The focus group setting will allow for a relaxed atmosphere within which to explore these ideas, in part due to the peer-centered groupings. Narrative data from focus groups comprised of veteran nurses (employed in nursing for >10 years) and senior nursung students (beginning tiieir careers) will be used to identify thematic concerns. Nurses will be tecniited from among the staff at the Ohio State University Hospitals and other area hospitals tiirough interpersonal contact from one of the Co-Investigators. Judy Neidig. R.N.. M.S. Nursing students will be recruited through flyers posted in the College of Nursing. Each focus group will meet for no more than two hours in a location convenient to medical persoruiel and nursing students (i.e. the College of Nursing). Participants will receive a verbal explanation of the purpose of the study prior to participation, and no deception regarding the goals of the research will occur at any time. Participants will be asked to sign a consent form (see attached) and will be aware that they are free to withdraw consent and cease participation in the study at any time without prejudice. For their participation, subjects will be con^nsated 540.00 for the two hour focus group session. No follow-up or additional time is required. Although the focus groi^ sessions will be audio-taped, all participants will be assured of confidentiality. Participants will be allowed to choose a pseudonym for speaker identification oriiy. and/or pseudonyms will be assigned to each participant prior to transcription of the tapes. All transcript tapes and associated computer disk files will be securely stored in a locked file drawer in the Offices of the former Department of Conununication (Derby Hall) and will be accessible only to the principal and co­ investigators of the study. All subsequent records and reports of the focus group sessions will include the use of pseudonyms for each participant and the location of the research will not be revealed at anv time.

218 Department of Communication 3016 Derby Hall 154 North Oval Mall Columbus. O H 43210-1339 Dept. Office Phone 614-292-3400 FAX 614-292-2055 UNlVERSrTY

Protocol Number

Consent for Participation in Social and Behavioral Research

[ consent to participating in research entitled: Work Narratives and Social Identitv

Joseph J. PUotta (principal investigator) or his authorized representatives, Judith Neidig and/or Marie Garland, has explained the purpose of the study, the procedures to be followed, and the expected duration of my participation. Possible benefits of the study have been described. I acknowledge that I have had the opportunity to obtain additional information regarding the study and that questions that I may have raised have been answered to my full satisfaction. Further. I understand that I am free to withdraw consent at any time and to discontinue participation in the study without prejudice to me. I understand that this form will be kept confidential and will not be associated with information I provide in the course of my participation in the research. Finally. I acknowledge that I have read and fully understand the consent form: that I sign it freely and voluntarily: and that a copy has been given to me.

Date:______Signed:. (par^pant) ^

Signed: Ptùicipal lyestigaimr or H&Autfaorized Representative

219 Demographic Information (all items an optional)

AGE

GENDER:

YEARS IN NURSING;

HIGHEST DEGREE EARNED:

TYPE OH NURSING POSITIONS HELD (Please indicate current ptisiuon with a *):

FAMILY MAKE-UP: CHILDREN? Y N IF YES. HOW MANY? CURRENT AGE(S) OF CHILDREN:______DO YOU CONSIDER YOURSELF THE PRIMARY CARE GIVER? DO YOU UVE WITH A SPOUSE/PARTNER/HOUSEMATE?

220 QUESTION SCHEDULE Protocol Title: Work Narratives and Social Identitv

[ I. Please tell us how long you have been a nurse and briefly describe the kinds of nursing activities you have engaged in since you became a nurse] (applicable only to senior staff nurses) or [ 1. Please tell us about your plans for after graduation] (applicable to senior nursing students). a. Why did you become a nurse? Did anyone influence your choice of careers? 2. What does nursing mean to you? a. What would be some characteristics of a model nurse? b. What kinds of experiences have you had that exetnplify what nursing means to you? 3. How do you see yourself in relation to the kind of ideal that has been described? 4. There have been some very significant changes in health care over the last five to ten years; changes that may have affecte the ways in which nurses do their jobs. What is your assessment of those changes? a. Do you see any constraints on your ability to do your job as you would like? b. Can you describe an instance when these constraints were (or might be) most obvious? c. What kinds of positive changes do you see happening in the nursing profession? 5. What kinds of skills do you thing are helpful or necessary for you to perform your work as you wold like to in the context of a managed care environment? a. What assistance have you had in developing those skills? Can you describe what that training experience was like? b. What about your clinical experience? How would you describe your experience with your preceptor in various settings (outpatient, public health, hospital?) 6. We re wondering about your outlook in various areas of your life, as well as how you view your work as a nurse. For instance, is the attitude or outlook you have about nursing similar or different from the attitude you have about other things, such as family life, hobbies, or community activities? a. Can you give an example of when there is a similarity? b. Can you give an example of when your attitudes might be different? 7. If you had the opportunity to advise someone just now considering nursing school, what would you tell them?

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