Gender, globalization and ethics in public healthcare system: the challenges of nurses-managers in engaging moral dilemmas

Prof. Helena Desivilya Syna

Department of Sociology and Anthropology

and Masters Program of Organizational Development and Consulting

Max Stern Academic College of Emek Yezreel


Abstract: The study aimed at shedding light on women nurses-mangers’ experiences of ethical dilemmas in the era of dual concerns: free-market based health care policy and an increasing emphasis on professional ethical responsibility. The research focused on nurses-managers’ experiences of daily practice.  It examined the role of gender and of globalization culture in nurses’ construal of these experiences and their actual responses to ethical issues. The study was based on qualitative methodology: focus groups and individual interviews.

The findings revealed a great deal of moral dilemmas faced by nurses-managers, most caused by the free-market culture  – greater emphasis on personal responsibility and individualization of risks related – and conflicting professional and gender culture in their relations with physicians.  Nurses-managers actively engage some of these dilemmas by means of action-focused modes whereas other ethical issues are dealt with through emotion-focused modes

Key words: globalization, gender perspective, ethics, management

1. Introduction

Health care professionals operate nowadays in an environment, saturated with tensions between free-market demands and professional ethical responsibility.  Changes in health care organizations, such as a growing concern with cost-effectiveness and a greater emphasis on ethics have affected the nature of nursing practice. They have led to greater emphasis on professionalism, underscoring ethical conduct. These changes have made moral issues and dilemmas more frequent and vivid in nurses-managers’ practice.

The current article is designed to illuminate the challenges faced by nurses-managers in public health systems in the era of such dual concerns. Specifically, it elucidates nurses-managers’ experiences of ethical dilemmas in their daily practice, illuminating the role of gender and of globalization culture in nurses’ construal of these experiences and their actual responses to ethical issues. It focuses on the tripartite linkage among gender, management and ethics in the context of globalization.  Such a synthesis has not received adequate attention in the organizational and management literature.

2.  Problem Formulation

The current study integrated three bodies of knowledge: gender, ethics and management in examining nurses-managers’ modes of engaging ethical issues in the context of globalization culture of health-care public systems. We commence with delineating the main features of globalization and address its consequences on health care providers, especially experiences of moral issues in nursing management practice.

2.1    Globalization and its implications for nursing management practice

Globalization encompasses the following main features: (a) deterritorialization, i.e., performance of human activities irrespective of the geographical location of participants; (b) social interconnectedness, namely, patterns whereby activities in one locality influence the social world of another locality; (c) velocity that is an accelerated pace of human activity and rate of social change (Gasper &Truong, 2008; Gephart, 2002).   The social and organizational consequences of  these patterns involve increasing  individualization of risks,  mounting concern for  cost-effectiveness and cost-efficiency and greater emphasis on professional social responsibility Gephart, 2002; Nielsen, 2006).  Gasper and Truong (2008) maintain that except of the latter consequence, these outcomes in turn endanger human dignity.

Furthermore, globalization precipitates and underscores the conflicting perspectives of managerialism and professionalism (Dawson, 2009).   The schism is examined drawing on the ethics of virtue/virtue approach (doing good for well-being).  Virtue ethics revives Aristotelian concepts and has been applied by various scholars, such as MacIntyre (1985; 1988; 1999).  The major tenet of this neo-Aristotelian approach is that inherently positive characteristics of people (good habits and virtues) enhance their inclination to act so as to promote good and foster community well-being. To attain such a balanced view, various perspectives on well-being may need to be integrated beyond the economic one: social, environmental, religious and professional.  As expressed by Dawson (2009):

“Excellence is achieved through the mastery of the internal good of practice. The point of a practice is to contribute to good of humans, both the wider community and individuals.” (p.97).

Akin to professionalism that legitimizes organizational decision-making, structure and values, good practice legitimizes people’s activities.  However, managerialism may contradict these values, especially in the domain of health care (emphasis on provision of services on equal and just basis) due to its predominant concern with efficiency based on external standards.

Management by nurses in public health care systems constitutes an important test case of management in women dominated profession, albeit in men-dominated organizational culture, thus featuring all of the globalization attributes mentioned above.  Specifically, women-managers operate in a highly dynamic work context characterized by advanced technology, professionalism, and ‘economism’ (cost-efficiency and cost effectiveness).

How do nurses-managers deal with the challenge of protecting human dignity in the face of the consequences of globalization?

According to Gasper and Truong (2008) responding to this call involves actions devoted to alleviating suffering, injustice and exclusion and attempts at human development within and between societies.  These scholars maintain that women usually perform this function; namely, serve as ‘shock absorbers’ of globalization.  Our study examined nurses- managers’ role as shock-absorbers in reconciling the demands of ‘economism’ and professionalism while dealing with ethical issues.  Since the vast majority of nurses-managers are women the current research focused on the relationships among gender, management and ethical conduct.  The next section addresses the intersection among the three domains.

2.2 Gender, management and ethics

The literature shows a considerable disparity between men and women in senior and junior management posts alike reflected in glass ceiling and walls (European Commission, n.d.b.).  In other words, obstacles are placed on women’s path to management posts.  According to feminist researchers in this field, women’s under-representation in top management is a product of the same gender culture that gives men an advantage by rewarding talents and skills considered male, whereas women attain secondary roles only due to their perceived lack of appropriate management skills (Calas & Smircich, 1992).

Women are perceived as “other”, “different” or “not belonging” in the management context. This, then, is not about real, objective differences in management skills between the sexes, but symbolic disparities shaped by emotions and cognitive processes (Butler, 1990; Erikson-Zetterquist & Styhre, 2007; Liff & Ward, 2001).

Studies show that the way women deal with obstacles in the management sphere is mainly based on adapting to the gender culture prevailing in organizations, i.e., an attempt to demonstrate appropriate qualities and skills in accordance with male criteria. These tendencies expose instances of “gender blindness”, or in other words, a lack of awareness in women holding management posts of the influence of gender on the structuring of relations, and the male-female balance of power in organizations (Lewis, 2006). It goes without saying that adopting a conformist attitude preserves both the symbolic and objective disparities between male and female managers. We assumed that women nurses-managers are experiencing similar symbolic barriers in public health organizations, although their actual representation in senior management posts overrides men-nurses’ representation.  Yet, women nurses-managers interact on everyday basis with senior physicians (by and large men) and senior male administrators.  How do they cope with the prevailing perceptions concerning women as “strangers” in the management sphere?

Drawing on Kolb and McGinn’s (2009) construction of the term negotiation as an ongoing activity in organizations, we assumed that women nurses-managers engage in negotiating authority (legitimacy), value (recognition and reward), support (developing networks through mentors) and commitment (definition of “ideal” worker; namely “successful” manger). In other words, they appear to engage the challenges of management in organizations by attempting to speak in a different voice, which exerts impact and is considered legitimate, rather than continuing doing the invisible, unrecognized work or transforming to male managers. This may be a path leading to construction of ‘new femininity’ in management (Acker, 2008; Frenkel, 2008).

Our study examined the interaction dynamics between women nurses-managers and other male professionals in the domain of ethical issues as reflected in daily practice.  To complete the tripartite interface between management, gender and ethics, the next section sketches the linkages between gender, ethical approaches and practice.

We introduce three moral theories that subsequently serve as a framework for our data analysis: deontological ethics, utilitarian ethics, and ethic of care. Deontological ethics maintains that one’s duty is to do what is morally right simply because it is the right and humane thing to do. Hence, actions are morally right or wrong regardless of their consequences (MacIntyre, 1971). Consequential ethics claims that the moral rightness of an action can be determined by judging its consequences, a theory also known as utilitarianism, which values actions on the basis of the total amount of utility it produces. However, utilitarianism emphasizes the best interests of everyone involved (Lyons, 1997). Ethical egoism constitutes another form of the consequential approach, emphasizing maximization of an individual’s own gains based on a belief that one ought to, first and foremost, render self-benefit (Machan, 1997). Deontology and utalitarian ethics represent the ideas of traditional moral philosophy. However, modern feminist thinkers have observed a moral orientation of caring, assuming responsibility for others, and underscoring the importance of the continuity of interdependent relationships. The latter orientation was found to be more typical for women than for men (Bampton and Maclagann, 2009; Gilligan, 1982). The emphasis on emotions rather than on reason as the central route to ethical existence distinguishes the ethics of care from traditional ethical theories that rely on rational and abstract thought (Derry, 1997). Notwithstanding the importance of the latter novel approach to ethics, existing research failed capturing its features due to the paucity of compatible research instruments.

Indeed, Kujala and Pietilainen (2004) have argued that existing research tools focus predominantly on masculinity in moral decision-making, thus silencing women’s voices in this domain. As a response to this lacuna, they have developed a multidimensional ethics scale allowing different voices to be heard and different dimensions to be seen (a gender-diversity sensitive instrument).  Specifically, it encompasses three new dimensions, absent in prior scales: power dynamics, namely, recognition of power dynamics by being sensitive to voiced and unvoiced interests of others and one’s own; relational understanding that is understanding the meaning of relations at both the private and organizational level and accepting the importance of multiple values and voices; emphasis on experience – valuing feelings and emotions as a source of useful information.

The new framework diverges from the prior one stressing universal principles and logical reasoning, while disregarding the value of intimacy, emotions and human relations.

The ethics of care facilitates learning how to respond to ethical issues in a variety of circumstances and contexts.  Kujala’s and Pietilainen’s (2004) exploratory study based on the new scale yielded evidence supporting the diverse principle of female decision-making on ethical issues.

Are women nurses-managers in public health care engaged in ethical decision-making reflecting the new dimensions: recognize power-dynamics, exhibit relational understanding and put emphasis on experience and at the same time meet the requirements of cost-efficiency and cost-effectiveness?  Our study addressed this query – explored the processes of professionalism meeting managerialism in action.

3. Problem Solution

3.1  Methodology

The study was based on qualitative methodology: focus groups and individual interviews.  Thirty women nurses – head of units or departments, employed in public medical centers, participated in the study. The participants took part in five different focus groups. Two additional participants, the directors of nursing services of two large university hospitals, were interviewed individually.  The focus groups and individual interviews were used to probe in depth the moral issues encountered in everyday nursing and management practice. Specifically, we focused on participants’ construal of moral dilemmas and distress, the nature of moral dilemmas, circumstances leading to moral dilemmas and ways of coping with such ethical issues. The focus groups and individual interviews were tape-recorded and subsequently transcribed verbatim. Data analysis focused on thematic analysis, namely participants’

descriptions of their beliefs, knowledge, reflections and feelings about moral issues in their nursing practice (Lincoln & Guba, 1985; Shkedi, 2003). Two experts in qualitative methodology independently analysed the data and then compared the outcomes; disagreements were discussed and resolved.

3.2 Results

The findings revealed a great deal of moral dilemmas faced by women nurses-managers, most caused by the free-market culture, notably greater emphasis on personal responsibility and individualization of risks and conflicting professional and gender culture in their relations with physicians.

3.1.1 Dilemmas resulting from difficulties to bridge professionalism with Managerialism

The core of nurses’ professional responsibility according to the study participants entails answering patients’ call for care.  By contrast, their managerial responsibility emphasizes concern for cost-efficiency and cost-effectiveness.  The clash between these two domains was reflected primarily in the need to provide high-quality care facing the reality of insufficient resources, such as budget cuts associated with medication costs coverage, inadequate space and understaffing, leading to overload.  Insufficient resources, in turn, impede the quality of care.  The following quotations from the focus groups with department head nurses demonstrate the emerging contradiction between the two domains – professionalism versus managerialism:

“There are medications, which are not included in the insurance, there is nothing… we do not make these decisions, it is not connected to nurses, but we work with patients, we face them…” (D.)

“A breast cancer patient was sent to a satellite department following surgery, which is against my professional convictions, there she cannot get the individualized attention from a personal nurse and a personal physician… I usually oppose that, but sometimes it does happen…it’s not right…” (SH1)

“There is insufficient staff , cannot provide the patients what they deserve…I feel terrible when I do not have enough time to talk with patients and their families, my conscience troubles me…“ (G.)

The above citations seem to indicate that for women nurses-managers mangerialism presents a considerable difficulty in contrast with professionalism which appears to be based on solid foundations and assimilated by the senior nurses.  The findings also seem to suggest that some of the physician-head nurse conflicts originate from economism (macro-level policies of free-market economy) encountering professionalism, in particular,  professional orientation based on ethics of care, as put by one of the study as reported by a head nurse of maternity department:

“The physicians are in favor of bringing in as many women for labor as possible, this creates overcrowding in the maternity department, it’s impossible to provide a quality service as promised to women, but it’s a free market, hospitals compete for each woman in labor,  I feel terrible to breech promises concerning the quality of treatment…”

How do women nurses cope with the challenge of economism and managerialism while attempting to maintain their professional standards? The next section presents the major findings in this domain.

3.1.2 Coping patterns: attempts to reconcile the demands of professionalism and managerialism

Our analysis of modes of coping by women nurses-managers with the parallel demands of managerialisim and professionalism draws on the model developed by Lazarus (Lazarus, 1999) in the domain of  psychological stress.  It comprises two major categories of coping: active, problem focused and emotion-focused.  The findings of the current study show that both patterns are used by nurses-managers, albeit in different circumstances.

Nurses-managers’ reported adopting active modes, engaging ethical dilemmas, emanating from the clash between managerialism and professionalism, at the overt sphere. They raise the issues with their direct supervisor (the head of nursing services) as well as confront the physicians in their respective departments, including undertaking formal action – filing a complaint, as reported by one of the head nurses:

“I came in the morning and said to the nurse on duty that she should have dropped the ceiling over this physician’s (on duty) head and immediately reported the incident to the department head physician and to the head of the hospital’s nursing services because I wanted her to see that the  department does not follow the regulations, there is some problem with the department management… the nurse on duty did not want to confront the physician; I went to the department chair’s office and talked to both – the physician on duty and the chair, I said it’s unheard not to attend 8 hours to a patient after cardiologic surgery.  They tried to crucify me,  the physician on duty said that the nurse did not call him… then I responded that he knew he should have seen the patient and made wrong decision not seeing the patient; he told me to mind my own business, not interfere with others’ tasks, its his responsibility. Eventually he got a note in his personal file, this will teach him a lesson, he won’t respond this way anymore…” (A.)

Interestingly, some of our respondents embraced military vocabulary to emphasize their toughness in sounding their voice while dealing with ethical issues, as evinced in the following quotations:

“We are fighters.”  (N1), “I am very militant, it’s difficult to defeat me in combat.” (N2);  I do not give up easily…” (D).

Other study participants revealed somewhat qualified responses to ethical dilemmas, albeit still reflecting resoluteness, as expressed below:

“…If I am sure that my opinion/decision is right, I argue for it, and then bring it up with my superiors, always trying to solve the problem, then my conscience is clean…” (R.)

The respondents in our study reported that institutional constraints sometimes prevent

active, confrontational coping.  Such circumstances lead to stress of conscience, which is engaged either through emotion-focused coping or actions by nurses-managers, notably volunteering, designed to compensate for the system’s inadequacies, as put by one nurse-manager.

“…We are forced to make difficult choices – to which patient allocate treatment/medication, in which patient invest more time and make sure our decisions are just ; we often solve it by volunteering, putting more time; the system puts very extensive constraints on us; the system takes advantage of our conscientiousness…” (Sh.)

Emotion focused coping with ethical dilemmas caused by the clash between professionalism and managerialism was more evident at the at the hidden sphere than at the public domain.  It usually follows an appraisal of a situation as “insolvable” which, in turn, leads to rationalization of inaction, as demonstrated in the following quotations:

“there is a limit of struggle for change/working on the basis of one’s conscience, I won’t waste my energies after several attempts which were unsuccessful, if I feel that there is 90%, not 100% I would not succeed , I would not go in this direction.  I believe when the opportunity reappears, when there is a sparkle of hope to change, a window of opportunity nurses will act, of course not everybody at the same moment, everyone has her/his own red spot or line ; it depends on  personal strength, philosophy, stubbornness, hutzpa, the way they woke up in the morning, their habits, decisions…” (S3)

“How do I cope with frustration /troubled conscience? Sometimes I do as S3 said, I tell myself this cannot be solved and put it aside…sometimes I fight, but it’s primarily a fight with my conscience, if it wasn’t there, I would not be here today…” (E.)

Women nurses-managers also indicated the importance of developing their own support network, which allows building social capital and sounding different voice while reconciling the demands of professionalism and managerialism. Support system promotes a strong sense of professional efficacy, as reported by our respondents:

“Coping by using support and solidarity of other department head nurses, partnering with department head physicians, head of nursing services…seeking support of those who share goals and specific objective.” (R.)

“Our voice certainly counts, the physicians reckon our opinions; they would not proceed without our approval.” (G.)

In sum, women – nurses-managers –  engage ethical issues using confrontational, problem-focused approaches, build support networks, thereby enhancing their social capital and sense of efficacy, and when confrontational and direct problem-focused strategies seem infeasible resort to emotion-focused modes or hidden – behind the scenes – active problem-solving.  Thus, they seem to engage the rivalry demands of professionalism and managerialism, however observing their professional creed appears to be their primary concern.

4. Conclusion

The current study examined how women, nurses-managers, in public-health system address ethical issues in the era of globalization.  Specifically, the focus was on elucidating their approach ‘in action’ – professionalism meeting managerialism.

The findings point out that women, nurses managers, face the consequences of globalization in their daily practice (Gasper &Truong, 2008; Gephart, 2002; Nielsen, 2006).  In line with Dawson’s contention (2009) nurses, heads of departments, frequently encounter ethical dilemmas as a result of a clash between professionalism (providing high quality response to patients’ call) and economism and managerialism (operating in cost-effective and efficient way).   Their attempts at reconciliation of such conflicting demands appear quite successful.  Women, nurses-managers engage ethical issues embracing both problem-focused as well as emotion-focused strategies (Lazarus, 1991; Lazarus and Folkman, 1986) sounding clearly their voice, reflecting professional creed of protecting human dignity but at the same time providing high-quality care.  Thus, their management practice while engaging ethical dilemmas incorporates feminine perspective: reveals recognition of power dynamics, relational understanding and emphasis on experience (Kujala and Pietilainen, 2004).

Albeit, such resolute and respectful approach is not always feasible, leading head nurses to adopt either emotion-focused coping modes or act as shock absorbers, compensating for the public health system’s inadequacies and the pitfalls of economism (Gasper and Truong, 2008).   Overall, it appears that women, nurses-managers actively negotiate value, support and commitment, yet this process entails a long-lasting journey, gradually solidifying women’s voices and building support network – both elements breeding a sense of  ’light at the end of the tunnel’ (Kolb and McGinn, 2009).

The current study opens a new avenue of research – embracing gender perspective in investigating the challenges of managerial practice in the era of globalization, particularly in the domain of ethical issues.  It represents an initial glimpse at the dynamics of decision-making on ethical issues while pooling together three bodies of knowledge: ethics, management and gender.  Future research needs to explore such an intersection in greater depth, using a mixture of research methods and other types of professional disciplines and organizations.


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