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The 1990s: A Decade for Change in Women's Health Care Policy
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The 1990s:A Decade for Change in Women’sHealth Care Policy Sylvia H. Wood, RN, CNM, MSN, Victoria J. Ransom, RNC, MSN
4s the 1990s usher in the era of reform, nurses and advocates for women’s health must work together to elevate and integrate the concept of caring throughout the new health care system. Nurses must develop strategies to empower and educate women and communities to take charge of their health. To accomplish this, nurses must recognize the impact of health care policy on their profession and practice and activate their political power to make needed changes.
H
ealth care policy changes proposed recently in Congress have shifted the focus toward a relatively “silent” group of health care consumers, women and children. While women represent fifty percent o f the world’s population, they perform nearly two-thirds of all working hours, receive only one-tenth of the world income and own less than one percent of world property (Fraser, 1984, p. 57).
Historical Highlights The evolution of women’s health issues, much like the profession of nursing, has shadowed the women’s movement toward equality. In fact, the United States government’s involvement in health care only marginally addressed women’s health needs until after Universal Suffrage was enacted in 1920. Until that time, most US health care policies reflected concern for soldiers, sailors, and others who fell outside the “family care” system of health care. The Maternity and Infant Act, the first policy that specifically addressed a women’s health issue, was passed by Congress in 192 1 to provide grants for the development of health services for mothers and children (Litman & Robins, 1984). In 1921, Margaret Sanger established the Birth Control League (a forerunner of Planned Parenthood), but Congress failed to enact a bill removing the prohibition
February 1774
against contraceptives and information on contraceptives until several years later. The Social Security Act, passed in 1935, provided grants-in-aid for maternal and child care (Litman & Robins, 1984). Although many women took active roles in both world wars, medical services to female veterans were essentially ignored, a practice that continues. Legislation enacted in the 1950s and 1960s that affected women’s health care included passing of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) to provide care for military dependents and amending the Social Security Act to provide medical assistance to the poor through Medicaid. The 1970s brought the Supreme Court decision that declared outlawing abortion unconstitutional, and the government began paying for abortions for poor women under the Medicaid program. With the Hyde Amendment and its revisions in 1981, Medicaid funding for abortion was limited to cases in which the mother’s life was endangered. The Ommibus Budget Reconciliation Act (OBRA) of the early 1980s included funding for nurse-midwifery services, family health education, rape crisis centers, and maternal and child health care. In 1989, Congress enacted, through OBRA, mandatory coverage for mammography under Medicare.
The New Decade The 1990s ushered in new opportunities for directing national attention toward health care policy to meet the needs of women and children. In December 1989, the Congressional Caucus for Women’s Issues was formed, and the appalling inequities in funding for research on women’s health, including poor representation of women in clinical study populations, were elevated to the nation’s attention. These inequities were discovered when the Caucus requested an audit by the General Accounting Office (GAO) to evaluate to what extent the National Institutes of Health (NIH) had incorporated its 1987 policy of encouraging the inclusion of women in clinical study populations (Schroeder, 1992).
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The report of this audit, published in June 1990, revealed some shocking facts that began a new movement to bring gender equity to research in women’s health. A disproportionately small amount (13.5%) of the NIH budget was found to have been committed to research on women’s health, and women were “routinely and purposely left out of clinical trials and other medical studies conducted by the NIH” (Mink, 1992). The GAO audit revealed that even the Physician’s Health Study, which investigated the preventive effects of aspirin on coronary disease, included only male subjects (Schroeder, 1992). Upon the release of these findings, the Caucus, headed by Representatives Patricia Schroeder and Olympia Snowe, introduced to Congress the Women’s Health Equity Act of 1990. This bill came with 20 provisions that included the establishment of the Office of Research on Women’s Health at the National Institutes of Health. In April 1991, the Society for the Advancement of Women’s Health Research was formed. The group brought together care-givers and consumers to plan a woman’s health research agenda that they agreed “must acknowledge the diversity of women and focus not just on disease intervention but on prevention of disease, freedom from violence, access to health care, and overall wellness” (Bass & Howes, 1992, p. 5). The passage of the NIH Reauthorization Act of 1992 heralded the largest women’s health initiative in the history of Congress. In addition to permanently authorizing the Office of Research on Women’s Health, money was allocated to support and encourage research on women’s health and to include women and members of minority groups in study populations. Funding was increased for research on cancers effecting women and for conditions such as heart disease and osteoporosis, the effects of which had been previously studied only in men. The Family and Medical Leave Act of 1992 was passed by Congress but vetoed by then-President George Bush. With Congress unable to muster the two-thirds vote needed to override the veto, the measure failed (Fisher, 1993). Passage of the Family Leave bill was one of the first policy moves of the Clinton administration in 1993, but implementation of the legislation remains uncertain.
shifting Women’sRhes Although the social and political development of womankind has been painfully slow during the past century, there is no question that the pace of our progress has been steadily increasing during the past several decades. Women have made giant strides in their efforts to achieve equality in job opportunity, compensation, and representation in male-dominated professions and government. This shift in the role of women from subordination and dependency to self-determination and autonomy has been brought about by desire and necessity and will change the fabric of our society. Already, women make up half of the world’s population, and it is predicted that by the year 2000 more than 80% of women 25-54 years of age in the United States will be in the country’s work
140 J O G N N
force. However, these women will remain in the role of the family’s principal caretaker (Aberndorf, 1992). The impact of the dual role of women on success of business and families in our country undoubtedly will influence our society and our government. Politics and practices that “potentiate” women as employees and employers and support their roles as wives, mothers, daughters, and caretakers will become commonplace. Perhaps we will no longer be known as “the only developed country in the world, except for South Africa, without universal family supports” (Johnson, 1992, p. 660). As women achieve more equitable levels of representation in the political system, characteristics such as caring, nurturing, and avoidance of conflict may begin to affect policy making, legislation, and government.
caring in the 1990s Health care and other governmental policies are based on the accepted values of a society. When a society undervalues caring in an industrialist and technological atmosphere oriented toward mass productivity (Pepin, 19921, caring becomes invisible work (Diers, 1992). The vital work traditionally done by women becomes unrecognized, unpaid, and underresearched. Passage of such legislation as the Family Leave Act forces government and business institutions to value caring by recognizing the economic cost of “love and labor” (Pepin, 1992). Leininger (1988) identifies caring as “the essence of nursing” and defines it as “actions directed towards assisting, supporting, or enabling.” Caring interventions affirm the subjectivity of persons and lead to positive change for the welfare of others (Watson, 1988). Although caring values may be the essence of nursing, the profession does not hold the monopoly on assisting, supporting, or enabling others. A critical purpose of nursing care and of political action by nursing on behalf of women should be to “ameliorate or improve a human condition.” Bringing the value of caring to the political forefront becomes a critical role for professional nursing. Because learning to nurture is part of the experience of being a woman (Pepin, 1992), nurses who provide and promote women’s health care must ensure that caring becomes neither invisible nor undervalued.
Access to care It was not until the early 1900s that medical care was shown to be of benefit to patient outcomes (Grodin, 1993), so access to health care is a fairly new issue. However, the subject now pervades the medical and nursing literature and has become a popular topic in public and political arenas. Within the past decade, particular emphasis has been placed on women’s access to health care. Perhaps this came about because of the escalation in the battle for reproductive rights or the country’s sensitivity to the increasing infant mortality that caused our nation to decline in world position from 20th in 1980 to 23rd in 1988 (US DHHS, 1993). However, this increase in the prominence of women’s health care issues probably
Volume23, Number 2
A Decadefor Change in Women’sHealth Care Policy
came about because of the “effects of the gender gap on the election outcomes since 1980” (Archer, 1985, p. 70). Whatever the reason, women came to be identified and marketed to as the doorway to family health care more frequently and regularly than did men because women take the responsibility for seeking care for their families (Chapin & Pereles, 1992). Factors that were found to determine women’s access to health care included real and perceived needs of health care services, ability to obtain services, and accept:ibility of services available (Chapin & Pereles, 1992). Although we will need to continue to focus our efforts on the “simpler” issues of availability and ability to obtain health care services, the 1990s will be confronted with the deeper, more difficult problems of perceived needs and acceptability of services. The complexity of dealing with women’s multifaceted roles will be a challenge to any plan for health care reform. Addressing women’s values, attitudes, priorities, and cultural differences will be difficult and demanding. Dealing with these issues will require more than money, resources, and time. It will require caring, commitment, and empowerment of the community to address their health care needs.
Empowerment Nurses can be resource mobilizers (Jones & Meleis, 1993) who empower people to assert control over factors affecting their health. If the goal of nursing is health, the profession and discipline must influence prevailing social policies to help change a disease-oriented system of care to a true health care system. Schorr (1993) asserts that the term “health care,” rather than “medical care,” should be used in policy making discussions because nursing, medicine, and other allied disciplines all make up health care. Current politics of health care are funded on illness care, rather than health care. The World Health Organization definition of health (Jones & Meleis, 1993) focuses on the positive condition of physical, mental, and social well-being, rather than the absence of disease; it challenges nurses to become strong advocates for the empowerment of individuals to mobilize resources. Empowerment enables a person to take charge of life, deliberately making choices and believing that the future can be influenced (Zerwekh, 1992). Empowering strategies affirm individual responsibility and capacity for autonomy, which promotes client choice and self-determination. Four strategies described by Zerwekh (1992) for fostering family choices can be used as a model of care to influence health care policy. First, we must believe that people have choices and help them believe they do. Second, policy makers must listen to consumers of health care (the elderly, growing families, industry) to help them discover and articulate what they want. Third, the vision of realistic possibilities should be expanded to include health- and illness-oriented care. Finally, politically active nurses should give feedback on the reality of new policies via professional organizations and the me-
February 1934
dia. As consumer advocates, policy advisors, and care providers, nurses can examine the effectiveness of policies and suggest additional changes when needed.
Education As we continue to move forward into the next decade,
nurses must look to the future and educate each other, our clients, and our children to improve the health of America’s people. If we ensure the health and well-being of women and children, we enhance the future of our whole society. Although nursing is far from an exclusively female profession, the learning model presented by Belenky, Clinchy, Goldberger, and Tarule (1986) can provide important insights for educating people who find the ethic of responsibility more “natural” than the ethic of rights. The “connected” teaching model described in Women’s Ways ofKnowing (Belenky et al., 1986), is problemposing, helping people move toward community, power, and integrity. The “midwife” teacher is one who helps articulate and expand latent knowledge, drawing out what people know, rather than depositing information in their heads. The teacher poses questions and listens, recognizing that others need to be accepted as people and not oppressed or patronized. Belenky tells us to watch carefully, listen with patience, and to feel related despite our differences. Women’s issues can be helped to develop if connection is emphasized over separation, understanding and acceptance over assessment, and collaboration over debate, with respect for knowledge that comes from experience. Keohane (1991) describes four factors that must be imparted when educating women: a sense of self-confidence, communication skills, a sense of connectedness with other women, and a commitment to action. Education should bolster self-confidence when it is regularly challenged or undermined by an existing power system. Communication skills will ensure that women get their messages across to a skeptical, if not hostile, world. Women need a sense of connectedness to provide the support and sisterhood that empowers people to make changes. A commitment to action promotes the importance of service to others and of the power of men and women to change the world for good.
Action Perhaps the most important outcome of women’s health care policy during the last decade is that it has enlightened women to the work that remains to be done. Recognizing the inequities that exist in government policies and practices, women and those who advocate for them have begun to organize. N o longer subjugated to roles and positions that lack power and influence, women today have a greater impact on business, politics, and communities. They bring with them strengths, values, problems, and needs that are unique to their gender and critical to our society. Nursing, as a predominately female profession, JOG”
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shares many of the same issues and concerns as women and their families. As advocates for women a n d children, our profession, and ourselves, w e play a vital role in the advancement of women and of women’s health care policies. The dual role of nurses as advocates for the profession and the consumer should never b e seen in conflict (Sprayberry, 1993). “Indeed, nurses must place such high value o n what they have to contribute to society and health care that they recognize that advocating for their own interests will serve society as well” (Vance, Talbott, McBride, & Mason, 1992, p. 25). This is particularly important to remember as w e move into the ‘‘newera for a family-friendly America” (Schroeder, 1993, p. 2931, while we are confronted with the challenges of health care reform. As nurses and consumer advocates for women, we must use the advantage of our large numbers, established credibility, and political position to elevate and integrate the concept of caring throughout our n e w “health care” system. We must plan strategies that empower women and communities to take charge of their health care and ensure that models and systems of education are designed to benefit both genders. As advocates for our profession and health care providers in a system that will undergo major reform in this decade, we should heed warnings from the past. “It is absolutely imperative that nurses become assertive at once. The emerging health planning movement along with the impending maternal health insurance program that is sure to become law in the near future will have the effect of redefining role prescriptions and authority among health care workers” (Kalisch & Kalisch, 1977). This prediction, made almost 2 decades ago, is upon us, but has not taken nursing by surprise. Nursing’sAgenda forHealth Care Reform (American Nurses Association), introduced in 1991, has quickly found wide support from organized nursing a n d from consumers (Sprayberry, 1993). However, the direction the country will take is impossible to predict. As the controversy of health care reform grows larger a n d more consuming each minute, the media addresses health care issues every day. Questions include: What is health care? Do w e have a health care system? What are w e going to reform? As the largest single group of health care providers in the nation, nurses must play a visible role in providing answers. We must recognize our ability to speak as experts o n health care and our responsibility to “change what is wrong with t h e s+tem a n d reward a n d promote what is right” (Morse. 1993, p. 16).
Conclzcsion There is little question that the 1990s will b e remembered as the era of health care reform in our country. Equally predictable is the emergence of women’s health care issues into t h e public eye a n d professional arena. As we move toward the next millennium, we are entering a new era that should give each of us, as women’s health
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care providers, a sense of hope and optimism about the future. Nursing must use its considerable power to influe n c e health care policy for the benefit of those w h o are among the most invisible, women and children. Our nation’s future depends upon the policies made today.
References American Nurses Association. (1991). Nursing‘s agenda for health care reform. Kansas City, M O : American Nurses Association. Archer, S. E . (1985). Politics and the community. In D. J . Mason &S. W. Talbott (Eds.), Politicalaction handbook fornurses (pp. 67-77). Menlo Park, California: Addison Wesley. Bass, M., & Howes, J . (1992). Women’s health: The making of a powerful new public issue. Women S Health Issues, 2,3-5. Belenky, M. F., Clinchy, B. M., Goldberger, N. R . , & Tarule, J. M . (1986). Women’s Ways of Knowing. New York: Basic Books. Chapin, J . L., & Pereles, S. A. (1992). Women’s access to the health care system. In J.A. Horton (Ed.), The Women’s Health Data Book: A Profile of Women’s Health In the UnitedStates (pp 93.1071, Washington, D.C.: Elsevier. Diers, D. (1992). On the dangers of invisibility. Image: Journal ofNursing Scholarship, 24, 170. Fisher, R. W. (1993). Labor legislation. The 1993 World Book YearBook (pp. 271). Chicago: World Book, Inc. Fraser, A. S. (1984). Looking to the future: Equalpartnership between women and men in the 21st century. University of Minnesota, H. N. Humphrey Institute of Public flairs,
Women, Public Policy, and Development Project. Grodin, M. (1993). The evolution of informed consent: Beyond an ethics of care. Women S Health Issues, 2, 11. Johnson, M. (1992). A universal agenda for women and their families. Vital Speeches of the Day, 58,660-662. Jones, P. S., & Meleis, A. (1993). Health is empowerment. AdvancedNursing Science, 15, 1-14.
Kalisch, B. J., & Kalisch, P. A. (1977). An analysis of the sources of physician-nurse conflict.Journal ofNursingAdministration, 7, 50-57. Keohane, N . 0. (1991). Educating women for leadership. Vital Speeches of the Day, 57,605-608. Leininger, M. M. (1988). Leininger’stheory of nursing: Cultural care diveristy and university. Nursing Science Quarter&, I , 152- 160. Litman, T. J., & Robins, L. S. (1984). Healthpolitics andpolicy. New York:John Wiley and Sons. Mink, P. (1992, Summer). NIH reauthorization legislation is landmark for women’s health research. Women’s Issues Heport.
Morse, M. (1993). Nurses must be visible in political arenas. The American Nurse, 25, 16. Oberndorf, M. E. (1992). The changing role of women in the 21st century: Building self esteem in our daughters. Vital Speeches of the Day, 58,751-754. Pepin, J. I. (1992). Family caring and caring in nursing. Image: Journal ofNursingScholarshi$, 24, 127-131. Schorr, T. M. (1993). The term is ‘health care.’ Nursing &Health Care, 14, 294. Schroeder, P. (1992). Women’s health: A focus for the 1990’s. Women’s Health Issues, 2, 1.
Schroeder, P. (1993). We’ve come a long way, maybe: Women’s health and the 103rd Congress. Nursing G Health Care, 14, 292-293.
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Sprayberry, L. D. (1993). Nursing’s dual role in health care policy. Nursing &Health Care, 14, 250-254. US Department of Health and Human Services (DHHS). (1993). Infant mortality: United States, 1990. Morbidity aiid Mortalitji Weekly Report, 42, 161-163. Vance, C., Tdlhott, S . W., McBride, A. B., B Mason, D. J . (1992). Coming of age: The women’s movement and nursing. In D. J. Mason B S. W. Talhott (Eds.), Political action handbookfor muses (pp. 23-35). California: Addison-Wesley. Watson, J. (1988). Nursing: H u m a n scieiices a n d h u m a n care. A theory ofnursirzg. New York: National League for Nursing. Zerwekh, J. V. (1992). The practice o f empowerment and coer-
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DecadeeJbrChange in Womens Heulth Cure Policy
cion by expert public health nurses. Image: Journal of Nursing Scholarshzp, 24, 101-105.
Addressfor correspondence: Sylvia H. Wood, RN, CNM, MSN, 13305 129th Street East, Puyahp, WA 98374. Sylvia H. Wood is an assistant professor in the School ofNursing at PaciJic Lutheran University in Tacoma, Washington. Victoria J. Ransom Is a clinical nurse specialist in the Maternal. Child Health Nursing Section, Department of Nursing at Walter Reed Army Medical Center in Washington, DC.
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The 1990s:A Decade for Change in Women’sHealth Care Policy Sylvia H. Wood, RN, CNM, MSN, Victoria J. Ransom, RNC, MSN
4s the 1990s usher in the era of reform, nurses and advocates for women’s health must work together to elevate and integrate the concept of caring throughout the new health care system. Nurses must develop strategies to empower and educate women and communities to take charge of their health. To accomplish this, nurses must recognize the impact of health care policy on their profession and practice and activate their political power to make needed changes.
H
ealth care policy changes proposed recently in Congress have shifted the focus toward a relatively “silent” group of health care consumers, women and children. While women represent fifty percent o f the world’s population, they perform nearly two-thirds of all working hours, receive only one-tenth of the world income and own less than one percent of world property (Fraser, 1984, p. 57).
Historical Highlights The evolution of women’s health issues, much like the profession of nursing, has shadowed the women’s movement toward equality. In fact, the United States government’s involvement in health care only marginally addressed women’s health needs until after Universal Suffrage was enacted in 1920. Until that time, most US health care policies reflected concern for soldiers, sailors, and others who fell outside the “family care” system of health care. The Maternity and Infant Act, the first policy that specifically addressed a women’s health issue, was passed by Congress in 192 1 to provide grants for the development of health services for mothers and children (Litman & Robins, 1984). In 1921, Margaret Sanger established the Birth Control League (a forerunner of Planned Parenthood), but Congress failed to enact a bill removing the prohibition
February 1774
against contraceptives and information on contraceptives until several years later. The Social Security Act, passed in 1935, provided grants-in-aid for maternal and child care (Litman & Robins, 1984). Although many women took active roles in both world wars, medical services to female veterans were essentially ignored, a practice that continues. Legislation enacted in the 1950s and 1960s that affected women’s health care included passing of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) to provide care for military dependents and amending the Social Security Act to provide medical assistance to the poor through Medicaid. The 1970s brought the Supreme Court decision that declared outlawing abortion unconstitutional, and the government began paying for abortions for poor women under the Medicaid program. With the Hyde Amendment and its revisions in 1981, Medicaid funding for abortion was limited to cases in which the mother’s life was endangered. The Ommibus Budget Reconciliation Act (OBRA) of the early 1980s included funding for nurse-midwifery services, family health education, rape crisis centers, and maternal and child health care. In 1989, Congress enacted, through OBRA, mandatory coverage for mammography under Medicare.
The New Decade The 1990s ushered in new opportunities for directing national attention toward health care policy to meet the needs of women and children. In December 1989, the Congressional Caucus for Women’s Issues was formed, and the appalling inequities in funding for research on women’s health, including poor representation of women in clinical study populations, were elevated to the nation’s attention. These inequities were discovered when the Caucus requested an audit by the General Accounting Office (GAO) to evaluate to what extent the National Institutes of Health (NIH) had incorporated its 1987 policy of encouraging the inclusion of women in clinical study populations (Schroeder, 1992).
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The report of this audit, published in June 1990, revealed some shocking facts that began a new movement to bring gender equity to research in women’s health. A disproportionately small amount (13.5%) of the NIH budget was found to have been committed to research on women’s health, and women were “routinely and purposely left out of clinical trials and other medical studies conducted by the NIH” (Mink, 1992). The GAO audit revealed that even the Physician’s Health Study, which investigated the preventive effects of aspirin on coronary disease, included only male subjects (Schroeder, 1992). Upon the release of these findings, the Caucus, headed by Representatives Patricia Schroeder and Olympia Snowe, introduced to Congress the Women’s Health Equity Act of 1990. This bill came with 20 provisions that included the establishment of the Office of Research on Women’s Health at the National Institutes of Health. In April 1991, the Society for the Advancement of Women’s Health Research was formed. The group brought together care-givers and consumers to plan a woman’s health research agenda that they agreed “must acknowledge the diversity of women and focus not just on disease intervention but on prevention of disease, freedom from violence, access to health care, and overall wellness” (Bass & Howes, 1992, p. 5). The passage of the NIH Reauthorization Act of 1992 heralded the largest women’s health initiative in the history of Congress. In addition to permanently authorizing the Office of Research on Women’s Health, money was allocated to support and encourage research on women’s health and to include women and members of minority groups in study populations. Funding was increased for research on cancers effecting women and for conditions such as heart disease and osteoporosis, the effects of which had been previously studied only in men. The Family and Medical Leave Act of 1992 was passed by Congress but vetoed by then-President George Bush. With Congress unable to muster the two-thirds vote needed to override the veto, the measure failed (Fisher, 1993). Passage of the Family Leave bill was one of the first policy moves of the Clinton administration in 1993, but implementation of the legislation remains uncertain.
shifting Women’sRhes Although the social and political development of womankind has been painfully slow during the past century, there is no question that the pace of our progress has been steadily increasing during the past several decades. Women have made giant strides in their efforts to achieve equality in job opportunity, compensation, and representation in male-dominated professions and government. This shift in the role of women from subordination and dependency to self-determination and autonomy has been brought about by desire and necessity and will change the fabric of our society. Already, women make up half of the world’s population, and it is predicted that by the year 2000 more than 80% of women 25-54 years of age in the United States will be in the country’s work
140 J O G N N
force. However, these women will remain in the role of the family’s principal caretaker (Aberndorf, 1992). The impact of the dual role of women on success of business and families in our country undoubtedly will influence our society and our government. Politics and practices that “potentiate” women as employees and employers and support their roles as wives, mothers, daughters, and caretakers will become commonplace. Perhaps we will no longer be known as “the only developed country in the world, except for South Africa, without universal family supports” (Johnson, 1992, p. 660). As women achieve more equitable levels of representation in the political system, characteristics such as caring, nurturing, and avoidance of conflict may begin to affect policy making, legislation, and government.
caring in the 1990s Health care and other governmental policies are based on the accepted values of a society. When a society undervalues caring in an industrialist and technological atmosphere oriented toward mass productivity (Pepin, 19921, caring becomes invisible work (Diers, 1992). The vital work traditionally done by women becomes unrecognized, unpaid, and underresearched. Passage of such legislation as the Family Leave Act forces government and business institutions to value caring by recognizing the economic cost of “love and labor” (Pepin, 1992). Leininger (1988) identifies caring as “the essence of nursing” and defines it as “actions directed towards assisting, supporting, or enabling.” Caring interventions affirm the subjectivity of persons and lead to positive change for the welfare of others (Watson, 1988). Although caring values may be the essence of nursing, the profession does not hold the monopoly on assisting, supporting, or enabling others. A critical purpose of nursing care and of political action by nursing on behalf of women should be to “ameliorate or improve a human condition.” Bringing the value of caring to the political forefront becomes a critical role for professional nursing. Because learning to nurture is part of the experience of being a woman (Pepin, 1992), nurses who provide and promote women’s health care must ensure that caring becomes neither invisible nor undervalued.
Access to care It was not until the early 1900s that medical care was shown to be of benefit to patient outcomes (Grodin, 1993), so access to health care is a fairly new issue. However, the subject now pervades the medical and nursing literature and has become a popular topic in public and political arenas. Within the past decade, particular emphasis has been placed on women’s access to health care. Perhaps this came about because of the escalation in the battle for reproductive rights or the country’s sensitivity to the increasing infant mortality that caused our nation to decline in world position from 20th in 1980 to 23rd in 1988 (US DHHS, 1993). However, this increase in the prominence of women’s health care issues probably
Volume23, Number 2
A Decadefor Change in Women’sHealth Care Policy
came about because of the “effects of the gender gap on the election outcomes since 1980” (Archer, 1985, p. 70). Whatever the reason, women came to be identified and marketed to as the doorway to family health care more frequently and regularly than did men because women take the responsibility for seeking care for their families (Chapin & Pereles, 1992). Factors that were found to determine women’s access to health care included real and perceived needs of health care services, ability to obtain services, and accept:ibility of services available (Chapin & Pereles, 1992). Although we will need to continue to focus our efforts on the “simpler” issues of availability and ability to obtain health care services, the 1990s will be confronted with the deeper, more difficult problems of perceived needs and acceptability of services. The complexity of dealing with women’s multifaceted roles will be a challenge to any plan for health care reform. Addressing women’s values, attitudes, priorities, and cultural differences will be difficult and demanding. Dealing with these issues will require more than money, resources, and time. It will require caring, commitment, and empowerment of the community to address their health care needs.
Empowerment Nurses can be resource mobilizers (Jones & Meleis, 1993) who empower people to assert control over factors affecting their health. If the goal of nursing is health, the profession and discipline must influence prevailing social policies to help change a disease-oriented system of care to a true health care system. Schorr (1993) asserts that the term “health care,” rather than “medical care,” should be used in policy making discussions because nursing, medicine, and other allied disciplines all make up health care. Current politics of health care are funded on illness care, rather than health care. The World Health Organization definition of health (Jones & Meleis, 1993) focuses on the positive condition of physical, mental, and social well-being, rather than the absence of disease; it challenges nurses to become strong advocates for the empowerment of individuals to mobilize resources. Empowerment enables a person to take charge of life, deliberately making choices and believing that the future can be influenced (Zerwekh, 1992). Empowering strategies affirm individual responsibility and capacity for autonomy, which promotes client choice and self-determination. Four strategies described by Zerwekh (1992) for fostering family choices can be used as a model of care to influence health care policy. First, we must believe that people have choices and help them believe they do. Second, policy makers must listen to consumers of health care (the elderly, growing families, industry) to help them discover and articulate what they want. Third, the vision of realistic possibilities should be expanded to include health- and illness-oriented care. Finally, politically active nurses should give feedback on the reality of new policies via professional organizations and the me-
February 1934
dia. As consumer advocates, policy advisors, and care providers, nurses can examine the effectiveness of policies and suggest additional changes when needed.
Education As we continue to move forward into the next decade,
nurses must look to the future and educate each other, our clients, and our children to improve the health of America’s people. If we ensure the health and well-being of women and children, we enhance the future of our whole society. Although nursing is far from an exclusively female profession, the learning model presented by Belenky, Clinchy, Goldberger, and Tarule (1986) can provide important insights for educating people who find the ethic of responsibility more “natural” than the ethic of rights. The “connected” teaching model described in Women’s Ways ofKnowing (Belenky et al., 1986), is problemposing, helping people move toward community, power, and integrity. The “midwife” teacher is one who helps articulate and expand latent knowledge, drawing out what people know, rather than depositing information in their heads. The teacher poses questions and listens, recognizing that others need to be accepted as people and not oppressed or patronized. Belenky tells us to watch carefully, listen with patience, and to feel related despite our differences. Women’s issues can be helped to develop if connection is emphasized over separation, understanding and acceptance over assessment, and collaboration over debate, with respect for knowledge that comes from experience. Keohane (1991) describes four factors that must be imparted when educating women: a sense of self-confidence, communication skills, a sense of connectedness with other women, and a commitment to action. Education should bolster self-confidence when it is regularly challenged or undermined by an existing power system. Communication skills will ensure that women get their messages across to a skeptical, if not hostile, world. Women need a sense of connectedness to provide the support and sisterhood that empowers people to make changes. A commitment to action promotes the importance of service to others and of the power of men and women to change the world for good.
Action Perhaps the most important outcome of women’s health care policy during the last decade is that it has enlightened women to the work that remains to be done. Recognizing the inequities that exist in government policies and practices, women and those who advocate for them have begun to organize. N o longer subjugated to roles and positions that lack power and influence, women today have a greater impact on business, politics, and communities. They bring with them strengths, values, problems, and needs that are unique to their gender and critical to our society. Nursing, as a predominately female profession, JOG”
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shares many of the same issues and concerns as women and their families. As advocates for women a n d children, our profession, and ourselves, w e play a vital role in the advancement of women and of women’s health care policies. The dual role of nurses as advocates for the profession and the consumer should never b e seen in conflict (Sprayberry, 1993). “Indeed, nurses must place such high value o n what they have to contribute to society and health care that they recognize that advocating for their own interests will serve society as well” (Vance, Talbott, McBride, & Mason, 1992, p. 25). This is particularly important to remember as w e move into the ‘‘newera for a family-friendly America” (Schroeder, 1993, p. 2931, while we are confronted with the challenges of health care reform. As nurses and consumer advocates for women, we must use the advantage of our large numbers, established credibility, and political position to elevate and integrate the concept of caring throughout our n e w “health care” system. We must plan strategies that empower women and communities to take charge of their health care and ensure that models and systems of education are designed to benefit both genders. As advocates for our profession and health care providers in a system that will undergo major reform in this decade, we should heed warnings from the past. “It is absolutely imperative that nurses become assertive at once. The emerging health planning movement along with the impending maternal health insurance program that is sure to become law in the near future will have the effect of redefining role prescriptions and authority among health care workers” (Kalisch & Kalisch, 1977). This prediction, made almost 2 decades ago, is upon us, but has not taken nursing by surprise. Nursing’sAgenda forHealth Care Reform (American Nurses Association), introduced in 1991, has quickly found wide support from organized nursing a n d from consumers (Sprayberry, 1993). However, the direction the country will take is impossible to predict. As the controversy of health care reform grows larger a n d more consuming each minute, the media addresses health care issues every day. Questions include: What is health care? Do w e have a health care system? What are w e going to reform? As the largest single group of health care providers in the nation, nurses must play a visible role in providing answers. We must recognize our ability to speak as experts o n health care and our responsibility to “change what is wrong with t h e s+tem a n d reward a n d promote what is right” (Morse. 1993, p. 16).
Conclzcsion There is little question that the 1990s will b e remembered as the era of health care reform in our country. Equally predictable is the emergence of women’s health care issues into t h e public eye a n d professional arena. As we move toward the next millennium, we are entering a new era that should give each of us, as women’s health
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care providers, a sense of hope and optimism about the future. Nursing must use its considerable power to influe n c e health care policy for the benefit of those w h o are among the most invisible, women and children. Our nation’s future depends upon the policies made today.
References American Nurses Association. (1991). Nursing‘s agenda for health care reform. Kansas City, M O : American Nurses Association. Archer, S. E . (1985). Politics and the community. In D. J . Mason &S. W. Talbott (Eds.), Politicalaction handbook fornurses (pp. 67-77). Menlo Park, California: Addison Wesley. Bass, M., & Howes, J . (1992). Women’s health: The making of a powerful new public issue. Women S Health Issues, 2,3-5. Belenky, M. F., Clinchy, B. M., Goldberger, N. R . , & Tarule, J. M . (1986). Women’s Ways of Knowing. New York: Basic Books. Chapin, J . L., & Pereles, S. A. (1992). Women’s access to the health care system. In J.A. Horton (Ed.), The Women’s Health Data Book: A Profile of Women’s Health In the UnitedStates (pp 93.1071, Washington, D.C.: Elsevier. Diers, D. (1992). On the dangers of invisibility. Image: Journal ofNursing Scholarship, 24, 170. Fisher, R. W. (1993). Labor legislation. The 1993 World Book YearBook (pp. 271). Chicago: World Book, Inc. Fraser, A. S. (1984). Looking to the future: Equalpartnership between women and men in the 21st century. University of Minnesota, H. N. Humphrey Institute of Public flairs,
Women, Public Policy, and Development Project. Grodin, M. (1993). The evolution of informed consent: Beyond an ethics of care. Women S Health Issues, 2, 11. Johnson, M. (1992). A universal agenda for women and their families. Vital Speeches of the Day, 58,660-662. Jones, P. S., & Meleis, A. (1993). Health is empowerment. AdvancedNursing Science, 15, 1-14.
Kalisch, B. J., & Kalisch, P. A. (1977). An analysis of the sources of physician-nurse conflict.Journal ofNursingAdministration, 7, 50-57. Keohane, N . 0. (1991). Educating women for leadership. Vital Speeches of the Day, 57,605-608. Leininger, M. M. (1988). Leininger’stheory of nursing: Cultural care diveristy and university. Nursing Science Quarter&, I , 152- 160. Litman, T. J., & Robins, L. S. (1984). Healthpolitics andpolicy. New York:John Wiley and Sons. Mink, P. (1992, Summer). NIH reauthorization legislation is landmark for women’s health research. Women’s Issues Heport.
Morse, M. (1993). Nurses must be visible in political arenas. The American Nurse, 25, 16. Oberndorf, M. E. (1992). The changing role of women in the 21st century: Building self esteem in our daughters. Vital Speeches of the Day, 58,751-754. Pepin, J. I. (1992). Family caring and caring in nursing. Image: Journal ofNursingScholarshi$, 24, 127-131. Schorr, T. M. (1993). The term is ‘health care.’ Nursing &Health Care, 14, 294. Schroeder, P. (1992). Women’s health: A focus for the 1990’s. Women’s Health Issues, 2, 1.
Schroeder, P. (1993). We’ve come a long way, maybe: Women’s health and the 103rd Congress. Nursing G Health Care, 14, 292-293.
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Sprayberry, L. D. (1993). Nursing’s dual role in health care policy. Nursing &Health Care, 14, 250-254. US Department of Health and Human Services (DHHS). (1993). Infant mortality: United States, 1990. Morbidity aiid Mortalitji Weekly Report, 42, 161-163. Vance, C., Tdlhott, S . W., McBride, A. B., B Mason, D. J . (1992). Coming of age: The women’s movement and nursing. In D. J. Mason B S. W. Talhott (Eds.), Political action handbookfor muses (pp. 23-35). California: Addison-Wesley. Watson, J. (1988). Nursing: H u m a n scieiices a n d h u m a n care. A theory ofnursirzg. New York: National League for Nursing. Zerwekh, J. V. (1992). The practice o f empowerment and coer-
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cion by expert public health nurses. Image: Journal of Nursing Scholarshzp, 24, 101-105.
Addressfor correspondence: Sylvia H. Wood, RN, CNM, MSN, 13305 129th Street East, Puyahp, WA 98374. Sylvia H. Wood is an assistant professor in the School ofNursing at PaciJic Lutheran University in Tacoma, Washington. Victoria J. Ransom Is a clinical nurse specialist in the Maternal. Child Health Nursing Section, Department of Nursing at Walter Reed Army Medical Center in Washington, DC.
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