Health Care for Women International
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Time for a change: Women's health education in Canadian university schools of nursing Elizabeth I. Hagell M.Ed., B.N., R.N. To cite this article: Elizabeth I. Hagell M.Ed., B.N., R.N. (1990) Time for a change: Women's health education in Canadian university schools of nursing, Health Care for Women International, 11:2, 121-131, DOI: 10.1080/07399339009515883 To link to this article: http://dx.doi.org/10.1080/07399339009515883
Published online: 14 Aug 2009.
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Date: 13 November 2015, At: 14:11
TIME FOR A CHANGE: WOMEN'S HEALTH EDUCATION IN CANADIAN UNIVERSITY SCHOOLS OF NURSING Elizabeth I. Hagell, M.Ed., B.N., R.N.
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Red Deer College, Red Deer, Alberta, Canada
As a group, women are the major users of the health care system, both directly, in terms of their own health, and indirectly, as the custodians of their family's health. In the past 10 years, there has been a growing awareness of the particular health concerns of women. One of the results of this increased awareness has been the development of courses that address these concerns. Most have been offered through Women's Studies programs. Recently, a growing awareness of these issues has developed among nurses and nurse educators. However, as Saunders and Taylor (1985) point out, "Nurse educators have been slow to develop courses that address women's health issues" (p. 25). My purpose in conducting this study was to survey university schools of nursing in Canada to discover if topics relating to women's health are incorporated into the nursing education curricula. I found that nursing education curricula tend to present women's health issues in a traditional, medically defined manner, focusing on childbearing and reproductive issues. The important problems of women and poverty, the social construction of diseases, and the social context of women's health were addressed much less frequently.
Fogel and Woods (1981), writing about nursing at the beginning of the 1980s, exemplify the optimism and enthusiasm of the time: Because the nursing profession is able to alter its approach to practice to reflect the health needs of designated populations, because it is concerned with the well being of the total person, because it is committed to fosterHealth Care for Women International, 11:121-131, 1990 Copyright © 1990 by Hemisphere Publishing Corporation
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ing the active participation of clients in health promotion and maintenance and because the profession is comprised almost entirely of women, it is likely that nursing will emerge as the profession most responsive to women's health needs (p. 59). Nursing as an occupation was becoming more and more confident in its practice and research. Nurses were demanding to be part of health care policy decisions. At the same time the women's movement wanted to provide input into social policy formation. These two groups seemed natural allies. Both were composed of women asking to be heard and making creative suggestions for alternative ways of organizing social institutions. Although there has been some integration of these two groups, nursing has not been as responsive to women's health concerns as might have been hoped in 1981. Certainly there has been some progress. For example, there has been a movement within nursing, especially in the United States and the United Kingdom, similar to that within the women's movement, to examine and critique the existing system of medical care and to discuss social factors associated with women's health (Ashley, 1980; GriffithKenny, 1986; Webb, 1987; Orr, 1986). Also, more nursing research is focusing on women and their particular health needs and more articles on women's health issues are being published in nursing journals. Nurses have also become more active in terms of practice, especially in self-help and mutual aid groups. Despite these activities, however, there continues to be evidence that many nurses, practitioners, and educators are unaware of the health care needs of women (Kirkham, 1986; Orr, 1986). Webb (1987), commenting on a research project she conducted in 1983 involving women undergoing a hysterectomy, found that "women in our study did not get the kind of help they needed from nurses while in hospital" (p. 53). In a related study by the same researcher (Webb, 1985) it was found that "negative attitudes toward women as patients were expressed by the majority of nurses" (p. 50). Orr (1987), discussing nursing practice in the community, concluded that Nurses still place insufficient emphasis on the community specifically as it affects women. Many health visitors are involved in organizing mother and toddler groups but it could be argued that the function of these groups is little more than a reflection of middle class values and views of women, (pp. 181-182) In my own research, I received responses such as, "Issues listed here [in the questionnaire] are discussed in regard to all persons—not only in
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relation to females," and "We do not discuss by sex but relate to the individual and family." It seems, then, that although some nurses are aware of the importance and uniqueness of women's health care issues and of the potential for nursing to create positive changes in women's health care, many are not. The question that must be asked is "Why have nurses been slow to become aware of and involved in women's health care issues?" As a nurse educator, it seemed to me that one answer for this lack of awareness might be that nursing education programs do little to expose student nurses to the issues and concerns relating to women's health. There is, in fact, a dearth of information on nursing education and women's health altogether. A study of student health care workers' perceptions of women, conducted in the United Kingdom, indicated little questioning of sex-role stereotyping. "There was little awareness of the social divisions within society, let alone any awareness of the degree of sexual inequality . . . there was little evidence of any other perspective being presented" during the education program (Orr, 1986, p. 75). Andrist's (1988) statement about graduate nursing education could be applied to undergraduate education as well: Graduate nursing education, in the preparation of nurses for advanced practice in areas of women and their health, has concentrated on specialities in childbearing. Although innovative programs in women's health exist, the majority of programs are titled Maternal-Child or Parent-Child, (p. 66) In other words, when such programs do exist, they focus on a narrow definition of women's health. Orr (1987) stated that there is very little emphasis given to any critical examination of women's health in professional education. In terms of nursing education specifically, she noted, "At present, little is taught which is particularly relevant to women and much of the social sciences are, in fact, grounded in and derived from the experiences, perceptions and beliefs of men" (p. 185). Given that there is a lack of information relating to nursing education and women's health, I felt that an initial step would be to explore which aspects of women's health are incorporated into nursing education programs. Specifically, in this study I attempted to examine which issues are being incorporated and which are excluded. The data collected from this study provide preliminary information about the quality and quantity of nursing course content relating to women's health. Before discussing the methodology, data, and data analysis, I will explore the meaning of women's health and why it deserves special attention in nursing education.
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WOMEN'S HEALTH McBride and McBride (1981) stated that women's health is related not just to the diseases of women or their childbearing function, but to the overall experience of women as women. It is about the interdependence of physical and psychological well-being. It is about the social, economic, political, and environmental context in which women live and which have an impact on women's health. Poor housing, sexism, violence against women, and the medical care system itself, for example, all have an impact on women's health. Women's health should be given special consideration for a number of reasons. First, because women share common health experiences in their lives, regardless of race or class (although these, too, have their own particular impact on health), women as a group have particular health needs. Unfortunately, these needs have frequently been overlooked, ignored, or distorted. Another argument to be made in support of giving special consideration to women's health relates to women's role as health guardian in the home: Nurses are one group of workers who should be most concerned about women's health issues, both as providers and recipients of the service. Women take most responsibility for the maintenance of family health in terms of nutrition, safety, and nursing of family members. (Orr, 1987, p. 2) By improving women's health, it is possible to improve family and community health. The World Health Organization's Chronicle (1984) stated, "Since women are the principle providers of health care it is they who most need health education programmes so they can improve their own health and that of their families and communities" (p. 19). This is of interest to nurses, as health promotion has received increasing attention and is now seen as an important area of nursing practice. A final, and very powerful, argument for giving women's health special attention is the fact that women are now demanding health care that is much more responsive to their needs than that provided by the existing medical care system. In the past few years, many individuals and groups have become increasingly aware of the problems created by the medical care system and the particular interests it serves. The system has come under increasing scrutiny, and it is women who have made the most cogent criticisms and who have offered the most creative alternatives. I want to examine in detail some of these criticisms because they have important implications for nursing.
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WOMEN AND THE MEDICAL CARE SYSTEM As a group, women are the major consumers of medical care, both directly, in terms of their own needs, and indirectly, as the custodians of family health. Women use medical services approximately 25% more than men do (Clement, 1987, p. 6). This does not mean that women are ill more often than men are. There are other factors that must be examined to understand the significance of this statistic. The first is that many normal female functions have been defined as inherently pathological—menstruation, pregnancy, childbirth, and menopause, for example—and, therefore, subject to medical intervention. These interventions have ranged from imposed rest to clitorectomies and hysterectomies, and although these procedures are less common today, there is ample evidence that a distorted view of women continues to exist in medical practice. The high rate of prescriptions for estrogen/progesterone supplements and mood-altering drugs (especially for elderly women) and the ever increasing use of technology in childbirth are present day manifestations of this attitude. These interventions have many associated risks, often doing more to create ill health than to cure the "problem." Nor do these interventions acknowledge the social aspects of many women's health concerns. As Clement (1987) noted, "The major health concerns, especially for women, are social problems" (p. 6). Prescribing mood-altering drugs to an elderly woman living alone in poverty is an example of how the medical model cannot deal with many women's health issues. Indeed, this removal of women's problems from their larger context works to silence women. By labeling a problem as a disease, it becomes isolated in that individual, it becomes their problem, and they have to change or adapt. If a problem is identified as a social concern, the onus shifts to society, others with the same problem are identified, and they may come together to create change outside the medical system, threatening the control of physicians. One other aspect of the medical system that is important to examine, in terms of women's health, is the social construction of disease. MacPherson (1985), using a feminist framework, examined the role of science, medicine, and drug companies in the construction of the disease labeled osteoporosis and the promotion of hormone replacement therapy despite the associated risks and the availability of alternative therapies. This is only one example of how diseases are constructed. It is important to recognize that much of what has been labeled as scientific truth is actually a reflection of the beliefs of society. Fee (1983, p. 11) stated that science is socially contingent, and scientific information is constituted in the context of class and gender. Medical
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knowledge cannot be separated from the group that produces it, legitimates it, and profits from it. Historically and today, that group is predominated by white middle class men. Feminists have been among the first to point out the excessive disease orientation and curative focus of modern medicine. Emphasis has been placed by feminists on educating women about themselves and their bodies as well as about the historical, social, and political roots of women's health concerns. This new focus leads to the empowerment of women and the possibility of creating change within the existing system as well as creating alternative services. In recent years, there has been a steady growth in health care groups created and controlled by women. Some provide educational materials only, others provide support and counseling services, and still others act as advocacy groups. The movement for the legalization of midwifery in Canada, and the theoretical critiques of the medical care system and its treatment of women are additional examples of the potential for women to understand and control their own health. It is evident that women are becoming less and less satisfied with the present system and that they will create alternatives with or without the help of health care workers such as nurses. It is imperative, therefore, that nurses become cognizant of women's concerns about their health. The question I address here is whether these issues constitute a part of the nursing education curriculum. METHOD Since there is very little information on women's health content in nursing education curricula, I decided to conduct a survey of all university schools of nursing in Canada, focusing on the basic degree program. Four questionnaires were sent to the dean or chairperson of each school of nursing where English is the language used. The dean or chairperson was asked to distribute the questionnaires to someone teaching in each of the four years of the basic degree program who would know the general course content or someone with an interest in women's health, who would be aware of the issues being addressed. The selected person would then complete the questionnaire. A total of 68 questionnaires were sent out. The questionnaire design was similar to one used by Russell and Gregory (T. Gregory, personal communication, November 1987) in a study of curriculum content relating to transcultural nursing. Descriptive data were collected pertaining to location (Atlantic, Central, Western, and Pacific). Respondents were also asked to identify the
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number of students enrolled in the program as well as the year of the program in which they taught. In terms of curriculum content, the questionnaire identified eight major topics relating to women's health. The topics were selected from a review of the women's health literature and were deemed to be the most frequently discussed. Each major topic had four subcategories. For each of the eight major topics, respondents were asked to identify (a) which of the subcategories were included in the curriculum, (b) the course title and level of the discussed subcategories, (c) the resources used in teaching, and (d) whether nonnursing courses dealing with these subjects were offered. The questionnaire was reviewed by three people with experience in nursing research. Minor changes were suggested and incorporated. DATA ANALYSIS Before examining the data in detail, it is important to note that because of the integrated nature of baccalaureate program curricula, obtaining information relating to specific content is extremely difficult. Therefore, it should be kept in mind that where an item is noted as discussed it may mean it was mentioned briefly or examined in a student seminar. To discern the amount of time allocated to particular topics would require a detailed examination of course materials. To do so was beyond the scope of this project. The purpose of this research was, instead, to obtain general information about which topics relating to women's health are included in degree programs in nursing education. Of the 68 questionnaires sent out, 38 were returned (55%), representing 44 respondents (63%). Unfortunately, because of inaccurate reporting, it was not possible to categorize data according to location, enrollment, or year of teaching responsibility. It was possible to identify the extent to which the identified topics were addressed in the nursing program curriculum. The data collected (see Figure 1) reveal that nursing education programs continue to emphasize the reproductive role of women and to address other issues to a lesser extent. The combination of issues that came under the heading of reproductive health were discussed to the greatest extent (total = 101). The major topic heading that came closest to this was female sexuality (total = 83). It is interesting to compare these two with the topics that were discussed the least. They are mental health issues (total = 58) and diet and nutrition (total = 59). The topic social aspects of health was among the bottom three categories (total = 67).
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It is also useful to examine individual issues in terms of how frequently they are discussed in the nursing education curriculum. The women's health movement, for example, was discussed by only 7 respondents (15.9%). All of the issues under the heading of mental health issues were discussed by 25 to 36%, with an examination of prescription drug use by women as the least discussed category. Fashion trends and the cosmetic industry were discussed by few (9%), whereas body image was the topic discussed by the largest number of respondents (63.3%). Eating disorders was a topic that was examined by more than half of the respondents (54.5%). As noted earlier, reproductive health issues was the category most frequently discussed, and this held true for all of the subcategories under this heading. Other individual topics included elderly women and poverty, which was discussed by less than one half of the respondents (40.9%). Under the heading of social aspects of health, more than half discussed violence against women (52.2%), whereas poverty and health, and women, work, and health were examined by slightly more than a third of the respondents (38.6% and 36.3%, respectively). Environmental issues were discussed by 25% of the respondents. In analyzing the data, it is important to note that in addition to the difficulties presented by an integrated curriculum, there were also problems with reporting that may have related to the questionnaire design and length. Although this study does not present any major conclusions regarding women's health content in nursing education programs, it does raise many important questions. For example, why were body image and eating disorder cited by such a large number of respondents, while examination of the cosmetic and fashion industries was essentially ignored? One answer might be that these two categories can be discussed as diseases existing in an individual rather than as problems developing out of a social context. As individual, medically defined problems, they require individual treatment; as social problems they require social change. And why were mental health issues relating to women cited by so few of the respondents? Given the fact that women are prescribed mood-altering drugs twice as frequently as are men, it would seem an area worthy of examination in the nursing education curriculum. And what about the problem of women and poverty? This is a major concern for women today, and it has an enormous impact on the health of women. In addition to questions about how women's health concerns are being addressed within nursing education programs, an even larger issue is raised by this data. That is the question of whether a holistic approach is being incorporated in nursing education. From the data collected, it appears that, despite the rhetoric of holism, it is in effect the medical
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model that predominates, as social and mental health issues take a back seat to topics that focus on illness.
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CONCLUSIONS AND RECOMMENDATIONS To conclude, the one noteworthy finding from this research is that nursing education curricula seem to present women's health issues in a traditional, medically defined manner focusing on childbearing and reproductive issues. The important problems of women and poverty, the social construction of diseases, and the social context of women's health were addressed much less frequently. Although this emphasis on medically defined concerns is not new, it does suggest that nursing education has not challenged a narrow definition of women's health (or indeed a narrow definition of health in general). There does not seem to be an overall awareness of the variety of women's health issues for nurses as women and as health care providers. One possible reason for the continuance of the traditional view is the lack of a feminist perspective in nursing education. The women's movement has been examining these issues for the past 15 years. Orr (1987) stated, "the growing body of feminist literature identifies women's issues in relation to health care and provides insights about women's role which are crucial to those providing health care" (p. 2). It is time for nursing education to utilize and build on this work more effectively. This requires "a critical examination of what happens in education and a recognition of the value and beliefs which underpin much of existing practice" (Orr, 1987, p. 185). If the educators of future nurses are truly concerned about improving health and providing nursing care developed from a holistic perspective, we must challenge existing notions about women and health. We must make room in the curriculum for alternative views. It is my view that women's health care is an excellent place to begin this challenge. Women's health courses should be developed to incorporate feminist theory. Although this is happening in some instances, it must become a concerted effort in all schools of nursing. Women themselves are demanding change. It would be unfortunate if nursing did not take advantage of such an opportunity. REFERENCES Andrist, L. (1988). A feminist framework for graduate education in women's health. Journal of Nursing Education, 27 (2), 66-70. Ashley, J. A. (1980). Power is structured misogyny: Implications for the politics of care. Advances in Nursing Science, 2, 3-22.
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Clement, C. (1987). Women and health. Health Promotion, 25 (4), 5-8. Fee, E. (1983). Women and health: The politics of sex in medicine. New York: Baywood. Fogel, C , & Woods, N. (1981). Health care of women: A nursing perspective. St. Louis, MO: Mosby. Griffith-Kenny, J. (1986). Contemporary women's health: A nursing advocacy approach. Reading, MA: Addison-Wesley. Kirkham, M. (1986). A feminist perspective in midwifery. In C. Webb (Ed.), Feminist practice in women's health care (pp. 35-51). Chichester, UK: Wiley. MacPherson, K. (1985). Osteoporosis: Analysis of the social construction of a syndrome. Advances in Nursing Science, 7(4), 11-22. McBride, A. B., & McBride, W. L. (1981). Theoretical underpinnings for women's health. Women's Health, 6(1/2), 37-55. Orr, J. (1986). Feminism and health visiting. In C. Webb (Ed.), Feminist practice in women's health care (pp. 69-93). Chichester, UK: Wiley. Orr, J. (Ed.). (1987). Women's health in the community. Chichester, UK: Wiley. Saunders, R., & Taylor, R. (1985, March-April). Women's health: Developing a course for open enrollment. Nurse Educator, pp. 25-30. Webb, C. (1985). Gynaecological nursing: A compromising situation. Journal of Advanced Nursing, 10, 47-54. Webb, C. (Ed.). (1987). Feminist practice in women's health care. Chichester, UK: Wiley. World Health Organization. (1984). Women as providers of health care. Chronicle, 31 (1), 18-21.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Time for a change: Women's health education in Canadian university schools of nursing Elizabeth I. Hagell M.Ed., B.N., R.N. To cite this article: Elizabeth I. Hagell M.Ed., B.N., R.N. (1990) Time for a change: Women's health education in Canadian university schools of nursing, Health Care for Women International, 11:2, 121-131, DOI: 10.1080/07399339009515883 To link to this article: http://dx.doi.org/10.1080/07399339009515883
Published online: 14 Aug 2009.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=uhcw20 Download by: [University of Sydney Library]
Date: 13 November 2015, At: 14:11
TIME FOR A CHANGE: WOMEN'S HEALTH EDUCATION IN CANADIAN UNIVERSITY SCHOOLS OF NURSING Elizabeth I. Hagell, M.Ed., B.N., R.N.
Downloaded by [University of Sydney Library] at 14:11 13 November 2015
Red Deer College, Red Deer, Alberta, Canada
As a group, women are the major users of the health care system, both directly, in terms of their own health, and indirectly, as the custodians of their family's health. In the past 10 years, there has been a growing awareness of the particular health concerns of women. One of the results of this increased awareness has been the development of courses that address these concerns. Most have been offered through Women's Studies programs. Recently, a growing awareness of these issues has developed among nurses and nurse educators. However, as Saunders and Taylor (1985) point out, "Nurse educators have been slow to develop courses that address women's health issues" (p. 25). My purpose in conducting this study was to survey university schools of nursing in Canada to discover if topics relating to women's health are incorporated into the nursing education curricula. I found that nursing education curricula tend to present women's health issues in a traditional, medically defined manner, focusing on childbearing and reproductive issues. The important problems of women and poverty, the social construction of diseases, and the social context of women's health were addressed much less frequently.
Fogel and Woods (1981), writing about nursing at the beginning of the 1980s, exemplify the optimism and enthusiasm of the time: Because the nursing profession is able to alter its approach to practice to reflect the health needs of designated populations, because it is concerned with the well being of the total person, because it is committed to fosterHealth Care for Women International, 11:121-131, 1990 Copyright © 1990 by Hemisphere Publishing Corporation
121
122
E. I. Hagell
Downloaded by [University of Sydney Library] at 14:11 13 November 2015
ing the active participation of clients in health promotion and maintenance and because the profession is comprised almost entirely of women, it is likely that nursing will emerge as the profession most responsive to women's health needs (p. 59). Nursing as an occupation was becoming more and more confident in its practice and research. Nurses were demanding to be part of health care policy decisions. At the same time the women's movement wanted to provide input into social policy formation. These two groups seemed natural allies. Both were composed of women asking to be heard and making creative suggestions for alternative ways of organizing social institutions. Although there has been some integration of these two groups, nursing has not been as responsive to women's health concerns as might have been hoped in 1981. Certainly there has been some progress. For example, there has been a movement within nursing, especially in the United States and the United Kingdom, similar to that within the women's movement, to examine and critique the existing system of medical care and to discuss social factors associated with women's health (Ashley, 1980; GriffithKenny, 1986; Webb, 1987; Orr, 1986). Also, more nursing research is focusing on women and their particular health needs and more articles on women's health issues are being published in nursing journals. Nurses have also become more active in terms of practice, especially in self-help and mutual aid groups. Despite these activities, however, there continues to be evidence that many nurses, practitioners, and educators are unaware of the health care needs of women (Kirkham, 1986; Orr, 1986). Webb (1987), commenting on a research project she conducted in 1983 involving women undergoing a hysterectomy, found that "women in our study did not get the kind of help they needed from nurses while in hospital" (p. 53). In a related study by the same researcher (Webb, 1985) it was found that "negative attitudes toward women as patients were expressed by the majority of nurses" (p. 50). Orr (1987), discussing nursing practice in the community, concluded that Nurses still place insufficient emphasis on the community specifically as it affects women. Many health visitors are involved in organizing mother and toddler groups but it could be argued that the function of these groups is little more than a reflection of middle class values and views of women, (pp. 181-182) In my own research, I received responses such as, "Issues listed here [in the questionnaire] are discussed in regard to all persons—not only in
Downloaded by [University of Sydney Library] at 14:11 13 November 2015
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relation to females," and "We do not discuss by sex but relate to the individual and family." It seems, then, that although some nurses are aware of the importance and uniqueness of women's health care issues and of the potential for nursing to create positive changes in women's health care, many are not. The question that must be asked is "Why have nurses been slow to become aware of and involved in women's health care issues?" As a nurse educator, it seemed to me that one answer for this lack of awareness might be that nursing education programs do little to expose student nurses to the issues and concerns relating to women's health. There is, in fact, a dearth of information on nursing education and women's health altogether. A study of student health care workers' perceptions of women, conducted in the United Kingdom, indicated little questioning of sex-role stereotyping. "There was little awareness of the social divisions within society, let alone any awareness of the degree of sexual inequality . . . there was little evidence of any other perspective being presented" during the education program (Orr, 1986, p. 75). Andrist's (1988) statement about graduate nursing education could be applied to undergraduate education as well: Graduate nursing education, in the preparation of nurses for advanced practice in areas of women and their health, has concentrated on specialities in childbearing. Although innovative programs in women's health exist, the majority of programs are titled Maternal-Child or Parent-Child, (p. 66) In other words, when such programs do exist, they focus on a narrow definition of women's health. Orr (1987) stated that there is very little emphasis given to any critical examination of women's health in professional education. In terms of nursing education specifically, she noted, "At present, little is taught which is particularly relevant to women and much of the social sciences are, in fact, grounded in and derived from the experiences, perceptions and beliefs of men" (p. 185). Given that there is a lack of information relating to nursing education and women's health, I felt that an initial step would be to explore which aspects of women's health are incorporated into nursing education programs. Specifically, in this study I attempted to examine which issues are being incorporated and which are excluded. The data collected from this study provide preliminary information about the quality and quantity of nursing course content relating to women's health. Before discussing the methodology, data, and data analysis, I will explore the meaning of women's health and why it deserves special attention in nursing education.
124
E. I. Hagell
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WOMEN'S HEALTH McBride and McBride (1981) stated that women's health is related not just to the diseases of women or their childbearing function, but to the overall experience of women as women. It is about the interdependence of physical and psychological well-being. It is about the social, economic, political, and environmental context in which women live and which have an impact on women's health. Poor housing, sexism, violence against women, and the medical care system itself, for example, all have an impact on women's health. Women's health should be given special consideration for a number of reasons. First, because women share common health experiences in their lives, regardless of race or class (although these, too, have their own particular impact on health), women as a group have particular health needs. Unfortunately, these needs have frequently been overlooked, ignored, or distorted. Another argument to be made in support of giving special consideration to women's health relates to women's role as health guardian in the home: Nurses are one group of workers who should be most concerned about women's health issues, both as providers and recipients of the service. Women take most responsibility for the maintenance of family health in terms of nutrition, safety, and nursing of family members. (Orr, 1987, p. 2) By improving women's health, it is possible to improve family and community health. The World Health Organization's Chronicle (1984) stated, "Since women are the principle providers of health care it is they who most need health education programmes so they can improve their own health and that of their families and communities" (p. 19). This is of interest to nurses, as health promotion has received increasing attention and is now seen as an important area of nursing practice. A final, and very powerful, argument for giving women's health special attention is the fact that women are now demanding health care that is much more responsive to their needs than that provided by the existing medical care system. In the past few years, many individuals and groups have become increasingly aware of the problems created by the medical care system and the particular interests it serves. The system has come under increasing scrutiny, and it is women who have made the most cogent criticisms and who have offered the most creative alternatives. I want to examine in detail some of these criticisms because they have important implications for nursing.
Women's Health Education
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WOMEN AND THE MEDICAL CARE SYSTEM As a group, women are the major consumers of medical care, both directly, in terms of their own needs, and indirectly, as the custodians of family health. Women use medical services approximately 25% more than men do (Clement, 1987, p. 6). This does not mean that women are ill more often than men are. There are other factors that must be examined to understand the significance of this statistic. The first is that many normal female functions have been defined as inherently pathological—menstruation, pregnancy, childbirth, and menopause, for example—and, therefore, subject to medical intervention. These interventions have ranged from imposed rest to clitorectomies and hysterectomies, and although these procedures are less common today, there is ample evidence that a distorted view of women continues to exist in medical practice. The high rate of prescriptions for estrogen/progesterone supplements and mood-altering drugs (especially for elderly women) and the ever increasing use of technology in childbirth are present day manifestations of this attitude. These interventions have many associated risks, often doing more to create ill health than to cure the "problem." Nor do these interventions acknowledge the social aspects of many women's health concerns. As Clement (1987) noted, "The major health concerns, especially for women, are social problems" (p. 6). Prescribing mood-altering drugs to an elderly woman living alone in poverty is an example of how the medical model cannot deal with many women's health issues. Indeed, this removal of women's problems from their larger context works to silence women. By labeling a problem as a disease, it becomes isolated in that individual, it becomes their problem, and they have to change or adapt. If a problem is identified as a social concern, the onus shifts to society, others with the same problem are identified, and they may come together to create change outside the medical system, threatening the control of physicians. One other aspect of the medical system that is important to examine, in terms of women's health, is the social construction of disease. MacPherson (1985), using a feminist framework, examined the role of science, medicine, and drug companies in the construction of the disease labeled osteoporosis and the promotion of hormone replacement therapy despite the associated risks and the availability of alternative therapies. This is only one example of how diseases are constructed. It is important to recognize that much of what has been labeled as scientific truth is actually a reflection of the beliefs of society. Fee (1983, p. 11) stated that science is socially contingent, and scientific information is constituted in the context of class and gender. Medical
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knowledge cannot be separated from the group that produces it, legitimates it, and profits from it. Historically and today, that group is predominated by white middle class men. Feminists have been among the first to point out the excessive disease orientation and curative focus of modern medicine. Emphasis has been placed by feminists on educating women about themselves and their bodies as well as about the historical, social, and political roots of women's health concerns. This new focus leads to the empowerment of women and the possibility of creating change within the existing system as well as creating alternative services. In recent years, there has been a steady growth in health care groups created and controlled by women. Some provide educational materials only, others provide support and counseling services, and still others act as advocacy groups. The movement for the legalization of midwifery in Canada, and the theoretical critiques of the medical care system and its treatment of women are additional examples of the potential for women to understand and control their own health. It is evident that women are becoming less and less satisfied with the present system and that they will create alternatives with or without the help of health care workers such as nurses. It is imperative, therefore, that nurses become cognizant of women's concerns about their health. The question I address here is whether these issues constitute a part of the nursing education curriculum. METHOD Since there is very little information on women's health content in nursing education curricula, I decided to conduct a survey of all university schools of nursing in Canada, focusing on the basic degree program. Four questionnaires were sent to the dean or chairperson of each school of nursing where English is the language used. The dean or chairperson was asked to distribute the questionnaires to someone teaching in each of the four years of the basic degree program who would know the general course content or someone with an interest in women's health, who would be aware of the issues being addressed. The selected person would then complete the questionnaire. A total of 68 questionnaires were sent out. The questionnaire design was similar to one used by Russell and Gregory (T. Gregory, personal communication, November 1987) in a study of curriculum content relating to transcultural nursing. Descriptive data were collected pertaining to location (Atlantic, Central, Western, and Pacific). Respondents were also asked to identify the
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number of students enrolled in the program as well as the year of the program in which they taught. In terms of curriculum content, the questionnaire identified eight major topics relating to women's health. The topics were selected from a review of the women's health literature and were deemed to be the most frequently discussed. Each major topic had four subcategories. For each of the eight major topics, respondents were asked to identify (a) which of the subcategories were included in the curriculum, (b) the course title and level of the discussed subcategories, (c) the resources used in teaching, and (d) whether nonnursing courses dealing with these subjects were offered. The questionnaire was reviewed by three people with experience in nursing research. Minor changes were suggested and incorporated. DATA ANALYSIS Before examining the data in detail, it is important to note that because of the integrated nature of baccalaureate program curricula, obtaining information relating to specific content is extremely difficult. Therefore, it should be kept in mind that where an item is noted as discussed it may mean it was mentioned briefly or examined in a student seminar. To discern the amount of time allocated to particular topics would require a detailed examination of course materials. To do so was beyond the scope of this project. The purpose of this research was, instead, to obtain general information about which topics relating to women's health are included in degree programs in nursing education. Of the 68 questionnaires sent out, 38 were returned (55%), representing 44 respondents (63%). Unfortunately, because of inaccurate reporting, it was not possible to categorize data according to location, enrollment, or year of teaching responsibility. It was possible to identify the extent to which the identified topics were addressed in the nursing program curriculum. The data collected (see Figure 1) reveal that nursing education programs continue to emphasize the reproductive role of women and to address other issues to a lesser extent. The combination of issues that came under the heading of reproductive health were discussed to the greatest extent (total = 101). The major topic heading that came closest to this was female sexuality (total = 83). It is interesting to compare these two with the topics that were discussed the least. They are mental health issues (total = 58) and diet and nutrition (total = 59). The topic social aspects of health was among the bottom three categories (total = 67).
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It is also useful to examine individual issues in terms of how frequently they are discussed in the nursing education curriculum. The women's health movement, for example, was discussed by only 7 respondents (15.9%). All of the issues under the heading of mental health issues were discussed by 25 to 36%, with an examination of prescription drug use by women as the least discussed category. Fashion trends and the cosmetic industry were discussed by few (9%), whereas body image was the topic discussed by the largest number of respondents (63.3%). Eating disorders was a topic that was examined by more than half of the respondents (54.5%). As noted earlier, reproductive health issues was the category most frequently discussed, and this held true for all of the subcategories under this heading. Other individual topics included elderly women and poverty, which was discussed by less than one half of the respondents (40.9%). Under the heading of social aspects of health, more than half discussed violence against women (52.2%), whereas poverty and health, and women, work, and health were examined by slightly more than a third of the respondents (38.6% and 36.3%, respectively). Environmental issues were discussed by 25% of the respondents. In analyzing the data, it is important to note that in addition to the difficulties presented by an integrated curriculum, there were also problems with reporting that may have related to the questionnaire design and length. Although this study does not present any major conclusions regarding women's health content in nursing education programs, it does raise many important questions. For example, why were body image and eating disorder cited by such a large number of respondents, while examination of the cosmetic and fashion industries was essentially ignored? One answer might be that these two categories can be discussed as diseases existing in an individual rather than as problems developing out of a social context. As individual, medically defined problems, they require individual treatment; as social problems they require social change. And why were mental health issues relating to women cited by so few of the respondents? Given the fact that women are prescribed mood-altering drugs twice as frequently as are men, it would seem an area worthy of examination in the nursing education curriculum. And what about the problem of women and poverty? This is a major concern for women today, and it has an enormous impact on the health of women. In addition to questions about how women's health concerns are being addressed within nursing education programs, an even larger issue is raised by this data. That is the question of whether a holistic approach is being incorporated in nursing education. From the data collected, it appears that, despite the rhetoric of holism, it is in effect the medical
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model that predominates, as social and mental health issues take a back seat to topics that focus on illness.
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CONCLUSIONS AND RECOMMENDATIONS To conclude, the one noteworthy finding from this research is that nursing education curricula seem to present women's health issues in a traditional, medically defined manner focusing on childbearing and reproductive issues. The important problems of women and poverty, the social construction of diseases, and the social context of women's health were addressed much less frequently. Although this emphasis on medically defined concerns is not new, it does suggest that nursing education has not challenged a narrow definition of women's health (or indeed a narrow definition of health in general). There does not seem to be an overall awareness of the variety of women's health issues for nurses as women and as health care providers. One possible reason for the continuance of the traditional view is the lack of a feminist perspective in nursing education. The women's movement has been examining these issues for the past 15 years. Orr (1987) stated, "the growing body of feminist literature identifies women's issues in relation to health care and provides insights about women's role which are crucial to those providing health care" (p. 2). It is time for nursing education to utilize and build on this work more effectively. This requires "a critical examination of what happens in education and a recognition of the value and beliefs which underpin much of existing practice" (Orr, 1987, p. 185). If the educators of future nurses are truly concerned about improving health and providing nursing care developed from a holistic perspective, we must challenge existing notions about women and health. We must make room in the curriculum for alternative views. It is my view that women's health care is an excellent place to begin this challenge. Women's health courses should be developed to incorporate feminist theory. Although this is happening in some instances, it must become a concerted effort in all schools of nursing. Women themselves are demanding change. It would be unfortunate if nursing did not take advantage of such an opportunity. REFERENCES Andrist, L. (1988). A feminist framework for graduate education in women's health. Journal of Nursing Education, 27 (2), 66-70. Ashley, J. A. (1980). Power is structured misogyny: Implications for the politics of care. Advances in Nursing Science, 2, 3-22.
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Clement, C. (1987). Women and health. Health Promotion, 25 (4), 5-8. Fee, E. (1983). Women and health: The politics of sex in medicine. New York: Baywood. Fogel, C , & Woods, N. (1981). Health care of women: A nursing perspective. St. Louis, MO: Mosby. Griffith-Kenny, J. (1986). Contemporary women's health: A nursing advocacy approach. Reading, MA: Addison-Wesley. Kirkham, M. (1986). A feminist perspective in midwifery. In C. Webb (Ed.), Feminist practice in women's health care (pp. 35-51). Chichester, UK: Wiley. MacPherson, K. (1985). Osteoporosis: Analysis of the social construction of a syndrome. Advances in Nursing Science, 7(4), 11-22. McBride, A. B., & McBride, W. L. (1981). Theoretical underpinnings for women's health. Women's Health, 6(1/2), 37-55. Orr, J. (1986). Feminism and health visiting. In C. Webb (Ed.), Feminist practice in women's health care (pp. 69-93). Chichester, UK: Wiley. Orr, J. (Ed.). (1987). Women's health in the community. Chichester, UK: Wiley. Saunders, R., & Taylor, R. (1985, March-April). Women's health: Developing a course for open enrollment. Nurse Educator, pp. 25-30. Webb, C. (1985). Gynaecological nursing: A compromising situation. Journal of Advanced Nursing, 10, 47-54. Webb, C. (Ed.). (1987). Feminist practice in women's health care. Chichester, UK: Wiley. World Health Organization. (1984). Women as providers of health care. Chronicle, 31 (1), 18-21.
