Perception of power among dietitians

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Perception of power among dietitians ELLEND. MANDEL, MPA, RD; JENENE G. GAREY, PhD, RD

IITRCT: Power is a new concept in the field of nutrition that has increasing relevance for the survival of the profession in the 1990s. This study reports on dietitians' perception of power. A survey questionnaire was mailed to all members of the New Jersey State Dietetic Association (1,969 members). Usable responses were obtained from 521 dietitians (a response rate of 27%). The majority of respondents were female, married, and younger than 40 years of age; 37% were in clinical positions and 62% had completed internship and master's degree programs. Respondents rated power as very important (30%) or important (44%), and the terms accomplishments, control, intelligence, and connections were key descriptors of power. Power was felt to be acquired through knowledge, education, and position/title. The positions of department head, chief clinical dietitian, and nutrition support dietitian ranked in the middle of a power hierarchy. The top positions were chief executive officer and physician, and the bottom position was tray-line worker. Responses to "power" scenarios showed greater professional concern (60%) than personal concern (35%) over a clinical scenario (loss of control of the nutrition formulary) than a managerial scenario (threatened layoffs) (38% and 32%, respectively). Dietitians need to focus on and understand the concept and realistic use of power in the workplace. Initially, basic concepts and skills related to power must be incorporated into dietetics and continuing education using a gender-focused teaching approach. JAm Diet Assoc. 1993; 93:423-428.

he business literature from as early as the 1960s contains articles on the concept of power and its role in motivating managers (1-4). That body of literature, though small, includes motivational factors relevant to the field of nutrition. Parks and Moody (5) have challenged dietitians to understand how to manage the organization in which they work so that the nutrition profession can survive in the 1990s; in other words, they asked dietitians to address the issue of power. The environment in which dietitians work is responding to recessionary times with hospital closings, corporate layoffs, less discretionary income, and changes in Medicare reimbursement. The survey research presented here examines how a specific group of dietitians perceive power in the workplace. Because there is almost no information on power and the field of dietetics, this article begins with a review and discussion of research findings on the concept of power with an emphasis on behavior related to the organizational setting. RESEARCH FINDINGS ON POWER In an organizational setting McClelland and Burnham (2) define power as "the need to exert influence over the actions of others." They found that successful managers work for the well-being of the entire organization by influencing the behavior of others. Researchers (2,4,6) have shown that managers were not motivated by personal aggrandizement or by the need to be liked by subordinates. Good managers wanted power, but managers usually do not consciously consider power when directing activities. Pfeffer (6) describes power as being transformed into authority and as an influence on events: "politics involves those activities or behaviors through which power is developed and used ... " He states that, in organizations, power and the accompanying political strategies are inherent in improving performance. Pfeffer concludes that the "politicization of organizations" will become the norm of power and politics as a result of today's business environment. Although the business environment is dominated by men, the nutrition and dietetics profession is dominated by women. It is important, therefore, to understand that perceptions and applications of power in a corporate setting may differ by gender. Researchers have found that differences exist between men's and women's expressions of power (7,8). Men tend to be more task oriented and women more people oriented. Women's power-related behavior stresses subtlety of interaction and attention to the whole picture rather than the tasks at hand (ie, women are generalists), whereas men adopt a direct style that emphasizes the analytical and manipulative (7). More specifically, Kanter has studied the area of women and issues of power. Kanter (8) links power to the ability to produce J G. Garey (corresponding author) is an associate professor in the Departmentof Nutrition, Food, and Hotel Management, New York University, New York, NY 10003. E. D. Mandel is a nutrition/life-style consultant in private practice in Berkeley Heights, NJ JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 423

REeRoH*

Table 1 Demographic characteristics of respondents (n = 521) Characteristic

No.

%

Gender Female Male NAa

383 11 127

73.5 2.1 24.4

Age (y) <25 26-30 31-40 41-50 >50 NA

47 113 182 84 84 11

9.1 21.7 34.9 16.1 16.1 2.1

Marital status Married Single Divorced, other, NA

368 118 35

70.6 22.6 6.8

Route to dietetic registration Master's degree Internship Traineeship Coordinated undergraduate program PhD NA

143 181 51 48 6 92

27.4 34.7 9.8 9.2 1.2 17.7

Area of professional emphasis Clinical nutrition/dietetics Research Outpatient services Education Management/administration Consulting/private practice Sales/marketing Other NA

193 8 21 38 94 75 9 30 43

37.0 1.5 4.0 7.3 18.0 14.4 1.7 5.8 10.2

Years working In nutrition/diletetics Up to 3 3-6 >6-12 >12-20 >20 NA

88 73 177 97 67 19

16.9 14.1 34.0 18.6 13.0 3.7

Salaries <$15,000 $15,000-24,999 $25,000-34,999 $35,000-44,999 $45,000-54,999 -$55,000

77 112 192 58 14 12

14.8 21.5 36.9 11.1 2.7 2.3

aNA= no answer

and the capacity to mobilize people and resources. In her books Kanter (8,9) documents that women currently perceive a lack of power and ability to produce change in the corporate setting. She describes power as originating in different forms: personal, social, and organizational. Her description of organizational power, which is relevant because most dietitians work in some type of organization, has four elements: (a) information, including knowledge; (b) political intelligence and expertise; (c) resources, including funds, materials, space, staff, and time; and (d) support, including endorsement, backing, approval, and legitimacy (8). Nutrition professionals can learn from Kanter's research on organizations and from other female-dominated professions such as nursing, which is beginning to explore the issue of power. Editorials and researchers' findings about power show 424 / APRIL 1993 VOLUME 93 NUMBER 4

that nurses are not comfortable with the concepts of power, authority, and responsibility. Smith (10) asserts that proposed change from traditional roles and uncertainty about domain boundaries (Pfeffer's term is environment) cause the nurse to "step aside," making room for other health care professionals to step in. The result, Smith fears, is that nurses may walk away from power if it is offered in an unfamiliar package. In addition, Smith criticizes professional nursing practice for not socializing nurses to challenge the traditional model. Sovie (11) states that for the nurse to move forward in the changing health care environment nursing practice needs to be restructured; it must focus on problem solving to empower the professional nurse to deliver high-quality care while controlling costs. The advice is similar to that of Parks and Moody (5) and Insull (12) in the dietetics literature. Power was the major determinant of job satisfaction in a research study (13) of nurses at large, small, private, nonprivate, and teaching hospitals. Bush (13) defines job satisfaction as the extent to which nurses and nurse executives believe they have autonomy and power in professional practice. Nurse executives, who are higher on the job hierarchy, scored higher on power and autonomy scales than first-level managers. Nurses with more power had higher job satisfaction scores and felt that control over others is necessary to maintain power. In the nutrition profession, information related to power is sparse, but there are warnings about the future similar to those in the nursing field. Finn and Martin (14) write of the "shifting balance of power: a new decade of decision for dietitians" in which nutrition professionals must demonstrate cost-effectiveness, interact with existing powers, and build grass-roots support. These ideas are similar to those of Kanter (8), Pfeffer (6), Parks and Moody (5), and Insull (12). Dietitians' concern over image and role may be interfering with or may inhibit opportunities for power in the organization. Research findings (15) show that dietitians who manage the nutrition care of renal patients experience role disparity. In that study dietitians and physicians identified the primary decision makers for nutrition prescriptions: dietitians felt they were primary decision makers more than 50% of the time, whereas physicians felt dietitians were the primary decision makers less than 10% of the time (15). The dietitians aspired to have more autonomy in decision making than the physicians were willing to grant in traditional areas of the dietitians' domain (eg, energy supplements and progression of diet). Two other studies (16,17) had contrasting results. In a study of consultant dietitians (16), perceptions by other long-term health care professionals (eg, medical directors and dietary managers) were compared with dietitians' self-perceived image and role. The medical directors rated the consultant dietitians higher than the dietitians rated themselves in the areas of "necessary, important, and vital" and "helpful and cooperative." In another study (17), rankings by dietitians, administrators, and physicians rated the nutrition support dietitian as more competent and knowledgeable than the clinical dietitian. In both studies responses to the role of the dietitian were positive and indicate an improvement in image and self-image during the past 5 years. Dietetics and allied health professionals are just beginning to explore the subject of power and authority For our research, we built on findings about power in the corporate world. Kanter provides insight to power, masculine and feminine roles, networking, promotions, and obstacles to women in her extensive studies of major corporations. Kanter's work, in conjunction with the work of other major researchers (2-9), provided the content for our research, which examines dietitians' perceptions of power.

METHOD AND DATA ANALYSIS In an effort to understand how dietitians perceive power, we mailed survey questionnaires to a cross-section population of dietitians. The questionnaire consisted of a previously tested instrument and questions and scenarios developed from the literature on power, management, and leadership.

Table 2 Responses to management and clinical scenarios Question/response

Sample The population included members of the New Jersey State Dietetic Association, which represents large urban and rural populations and dietitians employed in clinical dietetics, community dietetics, and dietetics management, private practice, and teaching and research. We sent all 1,969 state members a cover letter and questionnaire with a postage-paid envelope for returning the questionnaire.

Instrument The mailing consisted of a cover letter and a questionnaire that included demographic information and three other sections. Content and clarity of the original letter and questionnaire were tested in a graduate research seminar comprising dietitians and other hospitality professionals. A revised questionnaire was then sent to a sample of expert dietetics practitioners in leadership positions to validate content. Revisions were made before the final letter and questionnaire were sent to all members of the state association. The New York University Committee on Activities Involving Human Subjects reviewed and approved the study The demographics section of the survey asked questions that included route to dietetic registration, position, work setting, and salary. The next section of the questionnaire presented two scenarios: Scenario 1. Your facility is beginning to show signs of financial problems. The hint of future layoffs is in the air As the manager of a department, respond to questions below. Scenario 2. You are a dietitian working in a hospital. Currently, your foodservice department is responsible for evaluating and maintaining the hospital's nutrition tube feedings and supplements. Recently, the hospital pharmacy has gone beyond friendly advice about these tube feedings and supplements. The pharmacy is showing signs of wanting responsibility for maintaining and deciding nutrition supplements. Respond to the questions below The same group of questions was asked after each scenario. The questions sought to determine the degree of action or extent of involvement in preventing a layoff in the department (management scenario) and in preventing takeover of the nutrition formulary by the pharmacy (clinical scenario). These questions required participants to indicate whether, how, and to whom they would communicate their concerns and how important involvement was both professionally and personally The third section of the questionnaire, titled Entrepreneur Questions, asked questions designed to test the respondent's locus of control. The concept of locus of control was developed by Rotter (19), and the questions are based on work initiated by McClelland (1) and from research validated and conducted by Rao (18) with management professionals. These researchers' findings show that entrepreneurial individuals have an internal locus of control as a primary characteristic. This characteristic is present in individuals who act as change agents. Findings from this section of the questionnaire are not reported here. The last section of the questionnaire asked respondents about their perception of power in the workplace. The first three questions covered importance of power to a nutritionist and dietitian, means to acquire power, and words to describe power. The last question asked respondents to rate the amount of power for 16 job titles at a health-related organization.

Management scenario (n=513)

Clinical scenario (n = 519) No.

%

94.6 3.8

509 10

97.7 1.9

494 4

94.8 0.8

504 2

96.7 0.4

27 450 4 6 1

5.2 86.4 0.8 12 0.2

65 412 4 5 1

12.5 79.1 0.8 1.0 2.1

286 210 1

54.9 40.3 0.2

216 279 4

41.5 53.6 0.8

412 63

79 1 121

431 60

82.7 11.5

7 24 163 217 22

13 46 31.3 41.7 42

10 50 159 189 29

1.9 9.6 30.5 36.3 5.6

195 197 39

37.4 37.8 7.5

313 106 25

60.1 20.3 4.8

17

3.3

8

166 181 73 25

31.9 34.7 14.0 4.8

84 162 80 25

No.

%

493 20

Would you respond to situation? Yes No

Would you communicate with someone in your organization? Yes No

With whom would you communicate initially? Coworker Immediate boss Boss's boss Very top Other

What form would your initial response take? Verbal only Verbal and written Written only

Ifyou received no response initially,would you pursue the issue? Yes No

How far would you pursue the issue? Coworker Immediate boss Boss's boss Verytop Other

How important Is recognition of your involvement in the issue professionally? Very important Important Somewhat important

Not important How important is recognition of your involvement in the Issue personally? Very important Important Somewhat important Not important

1.5 35.3 31.1 15.4 4.8

RESULTS A total of 527 (27%) dietitians responded to the survey; all but six responses were usable. The demographic profile, as well as all the other analyses, were obtained using the Statistical Package for the Social Sciences software program (release 3.1, 1988, SPSS, Chicago, I1) (20). The demographic characteristics of the respondents are shown in Table 1. Responses to the management scenario and to the clinical scenario showed small differences between respondents to each scenario (Table 2). For both scenarios, the largest number of respondents would communicate their concerns to their boss: in verbal form for the management scenario and in both verbal and written form for the clinical scenario. Respondents indicated they would pursue the issue to the top of the organization to get an answer. The greatest difference in the responses between the two scenarios was to the question of JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 425

RESEIRCH

Table 3

Importance of power to nutritionists/dietitians (n= 503) Response

Very important Important Somewhat important Not important

Overall No.

%

157 221 104 21

30.2 43.9 20.7 4.2

Clinical (n=188)

Research (n=8)

Outpatient (n =20)

Education (n=37)

Management (n= 90)

Consulting (n = 73)

Sales/Marketng (n=8)

Other (n=79)

24.9 49.7 20.2 2.6

25.0 37.5 25.0 12.5

28.6 38.1 28.6 0.0

38.8 39.5 18.4 2.6

37.2 35.1 17.0 6.4

29.3 41.3 24.0 2.7

33.3 33.3 0.0 22.2

30.0 36.7 23.3 10.0

Table 4

Words to describe power by route to dietetic registration and within areas of professional emphasis Response

Overall No.

%

%within selected route to registration (n=429) Master's

Intern

frainee

CUP,

%within selected area of professional emphasis (n =468) Clinb

Reach

Outpat

Educ

Mgmt

Cons

S/mkt

Accomplishments Control Intelligence Connections

435 360 354 290

83.5 69.1 67.9 55.7

82.5 72.0 65.0 55.9

84.5 70.7 70.7 58.0

88.2 76.5 64.7 60.8

70.8 60.4 64.6 58.3

81.3 72.5 72.5 53.9

75.0 50.0 37.5 75.0

90.5 66.7 71.4 66.7

81.6 55.3 63.2 60.5

84.0 70.2 66.0 55.3

85.3 69.3 58.7 53.3

88.9 77.8 66.7 55.6

Important Money Acquired Masculine

251 218 195 30

48.2 41.8 37.4 5.8

51.0 47.6 35.0 6.3

45.9 41.4 38.7 7.2

64.7 43.1 31.4 9.8

52.1 33.3 39.6 2.1

48.2 39.9 37.3 6.2

50.0 50.0 37.5 12.5

33.3 33.3 38.1 0.0

50.0 44.7 39.5 7.9

48.9 34.0 45.7 4.3

46.7 50.7 28.0 5.3

44.4 44.4 0.0 0.0

27 16 16 14

5.2 3.1 3.1 2.7

5.6 2.1 1.4 2.8

3.3 4.4 5.0 1.7

5.7 0.0 2.0 5.9

6.3 4.2 6.3 2.1

6.7 3.1 3.6 1.0

12.5 12.5 12.5 12.5

14.3 0.0 4.8 0.0

5.3 2.6 0.0 5.3

3.2 4.3 2.1 1.1

2.7 1.3 4.0 2.7

11.1 0.0 0.0 0.0

Inherited Abusive Scary Unimportant

aCUP = coordinated undergraduate program. bClin = clinical. Resch = research. Outpat = outpatient. Educ =education. Mgmt = management. Cons= consulting. S/mkt = sales/marketing.

how important recognition of involvement was professionally and personally. Whereas 60% said that recognition of involvement in the clinical issue was very important professionally, only 37% felt that recognition of involvement in the managerial issue was very important professionally, and 38% rated it important. The importance of personal recognition was similar for both scenarios. The respondents believed clinical issues were more important, both professionally and personally, than managerial issues. Table 3 shows respondents' answers to this question: How important is power to nutritionists/dietitians based on your perception of power in the workplace? Overall, 44% checked important, and only 30% checked very important. The respondents working in the areas of management and education checked "very important" in higher proportions than respondents working in other areas. Table 4 lists the key words that respondents identified as describing the concept of power. Of the 12 words listed, the top 5 in descending order were accomplishments, control, intelligence, connections, and important. Respondents' answers categorized by area of professional emphasis or route to registration resulted in the same order of ranking, except for dietitians employed in education, outpatient, and research. 426 / APRIL 1993 VOLUME 93 NUMBER 4

These groups may be different because of their heightened need to rely on connections and intelligence for grants, publications, funding, and tenure. Table 5 indicates how dietitians feel power is acquired; instructions asked them to rank the top five ways. Information or knowledge (33%) and position or title (19%) shared the top ratings, followed in descending order by education, association with others, and risk taking. Table 6 shows perception of power based on the respondents' independent ranking (not in relation to the other listed titles) of 16 position titles. The titles most frequently ranked highest were chief executive officer, physician, financial director, personnel director, and department head. Eighty-seven percent of the respondents ranked the position of physician as either 5 or 4. The chief clinical dietitian and the nutrition support dietitian were ranked the highest of the dietitian positions; for each, the ranking was 40% for the number 3 rating and 28% and 18%, respectively, for the number 4 ranking. DISCUSSION A comparison of the demographics of our respondents and the 1990 membership database of The American Dietetic Association (ADA) (21) showed the percentages by area of practice,

Table 5 How does one acquire power?a Responses

4

5b

2

3

1

Mean ranking

No.

%

No.

%

No.

%

No.

%

No.

%

173 98 51

33.2 18.8 9.8

105 74 79

20.2 14.2 15.2

72 71 82

13.8 13.6 15.7

42 65 61

8.1 12.3 11.7

33 62 58

6.3 11.9 11.1

3.8 3.2 3.0

Association with others Risk taking Friends in right places

43 30 19

8.3 5.8 3.6

69 51 26

13.2 9.8 5.0

78 65 21

15.0 12.5 4.0

98 83 34

18.8 15.9 6.5

60 77 59

11.5 14.8 11.3

2.8 2.6 2.5

Having money "Control" of others Mentoring

20 15 12

3.8 2.9 2.3

21 20 15

4.0 3.8 2.9

27 23 22

5.7 4.4 4.2

30 19 29

5.8 3.6 5.6

41 30 41

7.9 5.8 7.9

2.6 2.7 2.4

Information or knowledge Position or job title Education

aNumber of respondents = 461. b5 =the strongest. Only the top five words were ranked. Table 6 Rankings for perception of power for each position b

Position

5

4

3

2

Mean ranking

1

No.

%

CEO,C president, director

426

81.8

34

6.5

6

1.2

3

Physician Finance director

0.6

1

0.2

328 234

4.9

62.8 44.9

125 195

24.0 37.4

13 32

Personnel director

2.5 6.1

3 4

0.6 0.8

128

24.6

0 2

0.0 0.4

202

4.7 4.4

38.8

105

20.2

24

4.6

6

1.2

3.9

Department head Nurse, head Chief clinical dietitian Pharmacist

77 45 48 24

14.8 8.6 9.2 4.6

255 198 148 98

48.9 38.0 28.4 18.8

121 183 209 214

23.2 35.1 40.1 41.1

16 35 53 110

3.1 6.7 10.2 21.1

0 5 7 15

0.0 1.0 1.3 2.9

3.8 3.5 3.4 3.0

Nutrition support dietitian Consulting nutritionist Educator/trainer Department supervisor

10 19 16 33

1.9 3.6 3.1 6.3

94 73 63 119

18.0 14.0 12.1 22.8

212 173 191 119

40.7 33.2 36.7 38.2

123 143 151 105

23.6 27.4 29.0 20.2

24 54 38 7

4.6 10.4 7.3 1.3

2.9 2.7 2.7 3.2

Clinical dietitian Nurse, staff Technician Tray-line worker

10 14 2 5

1.9 2.7 0.4 1.0

33 32 14 2

6.3 6.1 2.7 0.4

167 155 52 10

32.1 29.8 10.0 1.9

213 212 209 37

40.9 40.7 40.1 7.1

40 50 187 409

7.7 9.6 35.9 78.5

2.5 2.5 1.8 1.2

No.

%

No.

%

No.

%

No.

%

aNumber of respondents= 521. b5= the highest.

CCEO = chief executive officer

age, gender, salary, and years in practice to be similar. In other words, our limited population appears to be a representative cross section of the ADA membership. Additionally, it is noteworthy that only 4% of our respondents indicated they were divorced, a very small number given the national average. Our 27% response rate came from one mailing without a follow-up. Hence, we believe our respondents are those who were most interested in power, and they could represent a cross section of the profession who consider themselves empowered. The responses to the scenario questions demonstrate some interesting differences based on area of practice. The question about format of the initial response to the management (layoffs) and clinical (takeover by pharmacy) scenarios shows differences between the two. In the management scenario most respondents would start with a verbal inquiry, then follow with a written inquiry. In the clinical scenario most respondents would inquire in both written and verbal form first. Initially more than 94% of the survey respondents indicated they would

respond to both scenarios; however, if they did not receive a response to the first query, only 79% would pursue the management issue and 83% would pursue the clinical issue. Of this group, the largest percentage, 42%, would pursue the management issue to the very top level of management, whereas only 36% would do so on the clinical issue. These responses indicate a high level of professional self-esteem. Pfeffer (6) states that employees rarely exercise their power to withhold services and information or quit. Gender differences (6,7,22,23) in management style based on leadership characteristics and the differing approaches to managing and leading also explain the answers. We did not ask the respondents to identify their managerial responsibilities; however, research findings in the nursing literature indicates that the managerial level affects the orientation to power. Schwartz (23) points out that women are still underrepresented among managers in corporations. Power was not considered a priority by our respondents. Other researchers' findings about the issue of power and JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 427

women are similar to ours (7-9,22). Researchers have found that for their respondents, affiliation and cognitive development are more important motivators than achievement and power. Our question dealing with the issue of describing and acquiring power found that respondents highlighted accomplishments and information or knowledge. Our respondents did not feel that power was acquired by control of others, mentoring, friends in the right places, or having money. Words they used to describe power were information, education, and accomplishments. Rosener (22) studied men and women leaders and found that employees need to participate and share power and information to feel powerful and that power comes from hard work. Ruffing-Rahal (24) explains how factors related to gender may be incorporated into the graduate nursing curriculum. Schwartz (23) makes some important points on how women can function more effectively than men; perhaps as women and men recognize their differences and work to minimize them power will be viewed differently. Our respondents understood the importance of power, but they did not see themselves as having or using power. Our respondents did not describe power as abusive, scary, masculine, or unimportant-words associated with power in early research (4,7). Other answers to our survey reinforced gender-related findings. Respondents most frequently used 3 as the ranking for their perception of the power of any of the dietitian positions (see Table 6). In contrast, the physician was ranked 5 (top rating) by 63% of the respondents. It is interesting to consider whether dietitians rated their position as a 3 as an overall feeling about power or as the result of how they use their positions. Again, the findings in the nursing literature support differences in perceptions of power based on the management level of nurse managers (their power base). Heineken and Wozniak (25) stated that the lack of a firm power base was the single most limiting factor in the achievement of overall potential by that profession. Three political strategies documented by nursing researchers are negotiation, compromise, and coalitions-concepts that have not been stressed in materials for dietitians. Future research should examine the responsibility and accountability of the dietitian's position and the orientation of dietitians to power. Shifts in power and authority occur regularly as a result of the changes in the environment. One example of change of power resulted from the advent of diagnosis related groups (DRGs) and subsequent changes in the health care regulatory and financing environment (26). The power, importance, and authority of hospital accountants have increased since the implementation of DRGs. This shift in authority occurred with little change in the accountants' responsibilities. APPLICATIONS Nutrition is a field that is growing in importance as the health status of the nation changes. The nutrition professional must be ready to use power in the 1990s in order to survive. Recent findings (27) indicate that there may be shortages in dietetics staffing, and subsequently other health care practitioners may be substituted. In this research study we sought to understand the perception of power by dietetics professionals. Our respondents appear to share similar opinions about power, undifferentiated by areas of practice or experience, and this includes a perception that dietitians generally lack power in the work environment. Nursing graduate education curriculums (24) discuss the issues of powerlessness and lack of activism in a patriarchal health care system. Nursing education is working to correct the nurse's present self-image to empower the profession. To survive, the dietetics profession needs to begin 428 / APRIL 1993 VOLUME 93 NUMBER 4

similar efforts by educating current and future practitioners to better understand, acquire, develop, and enhance power in the professional setting and to focus on gender differences. · The authors acknowledge M. Mareanforstatistical assistance.

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