Intersectionality and Feminist Theory: A Framework for Understanding and Teaching Social Construct and Healthcare Policy

Nurses represent the largest portion of healthcare professionals in the United States (U.S.) at nearly four times the size of the physician workforce (National Academies of Sciences, Engineering, and Medicine, 2021). However, given the growing population and expanding roles/responsibilities of the profession, the current workforce is severely lacking. Due to numerous factors that influence the ingress and egress of nurses into the profession, nurses have long functioned with varying degrees of shortage. Even before the COVID-19 pandemic hit the U.S., factors such as retiring nurses, lack of nursing faculty, and economic conditions have pressured the profession to cope with the strain. However, with the onslaught of the COVID-19 pandemic, the critical need for registered nurses became a tidal wave, which served to worsen the long-standing, existing shortage and exposed workplace tribulations and inequities that nurses have faced for a long time (American Nurses Association, n.d.).

Although all areas of nursing, especially specialty areas, are facing critical shortages, leadership positions in nursing are among the highest need sections (Buerhaus, 2021). Over the next ten years, the number of experience years lost from nursing will exceed 2 million yearly (National Academies of Sciences, Engineering, and Medicine, 2021). Much of the loss of nursing Although all areas of nursing, especially specialty areas, are facing critical shortages, leadership positions in nursing are among the highest need sections leadership can be attributed to the retirement of Baby Boomer-era nurses, including those who returned to nursing to fill urgently vacant roles during the height of the pandemic. In fact, in the next five years, as many as half of the nurse managers, directors, and executives plan to leave their positions (Warden et al., 2021). This will undoubtedly lead to a profound loss of advocacy, experience, mentorship, and professional leadership (Buerhaus, 2021). Thus, it is imperative that graduate studies in nursing focus on preparing future nurse leaders for the vast demands of nursing leadership and the intersectionality that defines and shapes policy and healthcare.

Diversity and Marginalization

As with workforce shortage, diversity is a continuing battle in the nursing profession. Even though the U.S. is becoming ever more diverse, minorities continue to be underrepresented in professional arenas. Similarly, while the nursing profession has become more demographically diverse, persons of color are yet to be adequately represented. Likewise, although nursing continues to be a female-dominated profession, the healthcare community has failed to tackle the gender gap in healthcare leadership, which has resulted in gender biases that have produced a male-dominated leadership division (Aspinall et al., 2022). The World Health Organization (WHO, 2019) found that women comprise 70% of the world’s healthcare workforce but only 25% of leadership roles.

Unfortunately, healthcare is not the only arena where women remain underrepresented. In 2023, women represented approximately 41.9% of the world’s workforce; however, only 32.2% of senior leadership positions were occupied by women (World Economic Forum [WEF], 2023). Of particular concern beyond the healthcare arena is the significant lack of representation of women in the political sector, as at the current rate of progress, it will take 162 years to close the global political empowerment gender gap (WEF, 2023). The same is apparent in the American political sector. While the U.S. hails itself on constitutional equality, its progress toward gender equality has only made marginal improvements and ranks 43^rd in the world in the Global Gender Gap Index (WEF, 2023).

Furthermore, there continues to be a profound wage gap between men and women in the United States. In 2021, on average, a woman’s salary was only 83.1% of a man’s salary for the same position (U.S. Bureau of Labor Statistics [BLS], 2023). When looking at the educational system, the wage-difference percentage drops to 78.6% and even more to 77.5% in management positions (BLS, 2023). Furthermore, the disparity is even more significant among women of color. While white women’s wages have grown by 44% from 1979 to 2021, Black and Hispanic women’s wages have only grown by 31% (BLS, 2023).

Again, this is not an isolated issue to the United States; according to the WEF (2023), no country in the world has yet to achieve gender parity, and with the current rate of progress, gender parity will not be possible for approximately 131 years. Focus on women and minority participation in business and government are critical factors in addressing broader aspects of health, gender, and racial disparities. With this continued gender and racial gap, along with the recent backward slide of bodily autonomy rights in the United States, future nurse leaders need to be prepared to advocate for and attend to controversial issues facing society and the nursing profession.

Justice Ruth Bader Ginsberg (2016) once said in an interview with the Academy of Achievement, “I don’t say women’s “rights” say the constitutional principle of the equal citizenship stature of men and women.” Although these sentiments, and much of what Justice Ruther Bader Ginsberg achieved, are inspirational to women across the globe, one does not need to be a Supreme Court Justice to fight for equality. The fight to ensure constitutional equality begins with the everyday hero. It starts with a seat at the table. Leaders of all professions, especially nursing, must cultivate awareness, education, and enthusiasm that focuses on the values long engrained in American history: dignity, equality, justice, law, truth, reason, and religious freedom. However, in doing so, leaders must understand the intersectionality of power relationships that underscore the political system.

Background and Recent Policy Changes

The marginalization of women and people of color that continues today has been ingrained in the country since the inception of constitutional democracy. The time of our forefathers was not rooted in social equality, but rather, it was contrived of white men who fought to ensure that power and rights stayed with white men (Lithwick, 2022). Indeed, women and people of color are abundantly aware, especially in light of recent political events, that although much progress has been made over the last century in the pursuit of social equality, many of these seemingly inalienable rights can be quickly taken away (Lithwick, 2022).

In one of the largest challenges to women’s health, autonomy, and personhood, the recent overturning of the 1973 Supreme Court of the United States (SCOTUS) landmark case of Roe v. Wade has sent a surge of debate across the country. Regardless of the stance on the philosophical and moral debate of when life begins, the decision made in the Dobbs v. Jackson Women’s Health Organization SCOTUS case in June 2022 undoubtedly has profound effects on how the healthcare industry can treat women’s health issues. It is not just abortion care that is being affected, but rather, the access to care in many areas of women’s healthcare.

In a country where the elected legislative officials are purported to ratify the will of the people they represent, many state and federal legislators have missed their mark. A recent Gallup poll in May 2022 found that 85% of Americans believe that abortions should be legal in some or all circumstances. However, states such as Texas, Arizona, Mississippi, Florida, and others have enacted laws that vastly restrict a woman’s right to proper health care in most, if not all, circumstances. For example, even before the Dobbs v. Jackson Women’s Health Organization opinion was filed, Texas had enacted Senate Bill (S.B.) 8, also known as Texas Heartbeat Act (2021), which enabled private civil right of action if a physician “knowingly perform[s] or induce[s] an abortion on a pregnant woman if the physician detected a fetal heartbeat for the unborn child…or failed to perform a test to detect a fetal heartbeat…[except when] a physician believes a medical emergency exists” (S.B. 8, 2021). Furthermore, after the reversal of Roe v. Wade (1973), Texas went further to pass House Bill 1280 (H.B., 2021), also known as Texas’ so-called “trigger law”, which created “a second degree felony offense for a person who knowingly performs, induces, or attempts an abortion and to provide for the enhancement of that penalty to a first degree felony if an unborn child dies as a result of the offense” with the only exception being if the pregnancy or the birth is going to threaten the life of the pregnant woman or cause significant bodily harm (H.B. 1280, 2021).

Moreover, international human rights groups recognize that the mistreatment of women seeking reproductive health services can cause immense physical and emotional suffering (United Nations General Assembly [UNGA], 2013). In fact, “The Committee against Torture has repeatedly expressed concerns about restrictions on access to abortion and about absolute bans on abortion as violating the prohibition of torture and ill-treatment” (UNGA, 2013).

Furthermore, the WHO (2022a) emphasized the following:

Decisions whether to have children or not, while preferably made in consultation with a spouse or partner, must not be limited by spouse, parent, partner, or Government… Women, adolescents, girls and all persons capable of becoming pregnant have a right to make informed, free and responsible decisions concerning their reproduction, their body and sexual and reproductive health, free of discrimination, coercion and violence. This right, which is anchored on the rights to bodily autonomy and self- determination, guarantees all persons capable of becoming pregnant meaningful control over whether or not to reproduce. (pp. 39-40)

Much of the debate on whether access to an abortion should be a constitutional right is based on a false dichotomy. Pro-life activists suggest that they are the stark opposite of pro-choice advocates. However, this is not the case. Being “pro-choice” does not necessarily equate to “pro-abortion”. It simply purports that women have a right to bodily autonomy, which is the very argument centered in this debate. Does the Constitution provide women the right to medical autonomy? As such, the inherent question remains: should the government be able to govern the decisions of women’s health care, or should the conversation of what is suitable for a woman’s body belong to only her and her healthcare team?

However, the debate on women’s medical autonomy extends far beyond the central issue of abortion. Medical access to care such as in vitro fertilization (IVF) and contraceptives have also been brought into question. According to the American Society of Reproductive Medicine (ASRM, 2022), although the opinion in the Dobbs v. Jackson Women’s Health Organization (2022) does not necessarily restrict access to assisted reproductive technology procedures, such as IVF, it is essential to understand the intricacies of state laws, as overly general statutes, ...the debate on women’s medical autonomy extends far beyond the central issue of abortion. whether purposeful or not, affect the availability of such procedures. This has the potential to severely restrain the ability of healthcare providers to deliver high-quality, patient-centered maternal health care (ASRM, 2022).

Across the United States, in the few short months since the Dobbs v. Jackson Women’s Health Organization decision, there have been numerous examples of the hindrance to healthcare for women. For instance, in Ohio, a 10-year-old rape victim was denied an abortion due to the state’s abortion law that prohibits abortions after six weeks of gestation. The 10-year-old girl was, in fact, six weeks and three days pregnant (DeLaney, 2022), which forced the girl to cross state lines to seek care with an obstetrician-gynecologist (OBGYN) in Indiana. The state of Ohio, in this case, failed to consider the potential physiologic and psychologic dangers of forcing a 10-year-old to carry her rapist’s embryo. According to the WHO (2022b), adolescent pregnancy results in distinctly known severe health, social, and economic consequences. For example, teenage pregnancy has a higher rate of complications, such as preeclampsia, eclampsia, postpartum and antepartum hemorrhage, obstructed labor, premature rupture of membranes, gestational diabetes, emotional trauma, and even death (Amoadu et al., 2022).

There have been numerous examples of failing to provide high-quality patient-centered maternal health care across the country post- Dobbs v. Jackson Women’s Health Organization (2022). For example, a woman with an ectopic pregnancy had to cross state lines to receive life-saving treatment (an abortion) at the University of Michigan when the doctor in her home state feared repercussions from acting due to a fetal heartbeat present (Sellers & Nirappil, 2022). What advocates for sweeping legislation banning abortion fail to consider is circumstances such as these, where the medical, ethical, moral, and legal implications of care do not necessarily coincide. At a House Reform and Oversight Committee hearing in July 2022, Representative Ayanna Pressley questioned Erin Hawley, senior counsel for Alliance Defending Freedom, about life-saving treatment for an ectopic pregnancy. Hawley stated, “Abortion is not health care…the treatment for them [ectopic pregnancies] is not an abortion” (Hawley, 2022). Even though the medical definition of an abortion is the spontaneous or induced termination of a pregnancy before viability (Abortion, 2021), this is the exact opposite of what Hawley said. The dangers of having non-medical persons interjecting opinions and legislation on medical procedures is, at minimum, a violation of privacy and autonomy, but in reality, it is dangerous, especially for women and people of color.

The inability of medical providers to provide high-quality reproductive healthcare will undoubtedly lead to unnecessary patient harm, especially in populations where systematic inequities already exist (Joint Statement from Maternal Health Specialists on Dobbs v. Jackson Women’s Health Organization, (2022). Women of color, young women, women who have lower income, live in rural areas, and/or are in abusive relationships are disproportionately affected by restrictive laws that restrict reproductive rights (Gostin, 2022). Without further advocacy, political action, and protection, many marginalized women will be forced to make healthcare decisions beyond abortion that are not based on evidence-based practice. In such, restriction in care options could increase the already high maternal mortality rate in the U.S. while simultaneously worsening the intersectional disparities currently noted in maternal mortality (The PLOS Medicine Editors, 2022).

Medical Paternalism

The dangers of returning to harsh regulation of women’s rights are numerous, but how did America come to this point after nearly 50 years of protection of bodily autonomy? Unfortunately, medical paternalism has a long-standing in American history. The SCOTUS believes that when deciding whether a fundamental right equates to constitutional right, they must rely on “whether the right is deeply rooted in [our] history and tradition and whether it is essential to our Nation’s scheme of ordered liberty" (Dobbs v. Jackson Women’s Health Organization, 2022, p. 12). However, this opinion implies that our founding fathers knew what was just at the time of the writing of the Constitution, a time before many of the discoveries of modern science, and when people of color and women were not considered in decision-making (Lithwick, 2022).

Justice Alito wrote in the Dobbs v. Jackson Women’s Health Organization opinion, “The eminent common-law authorities (Blackstone, Coke, Hale, and the like) all describe abortion after quickening as criminal” (Dobbs v. Jackson Women’s Health Organization, 2022, p. 17). However, the eminent authorities on common law Alito refers to, such as Blackstone and Hale, were deeply rooted in misogyny and racism. For example, Sir Matthew Hale was a 17^th-century lawyer who presided over a trial in which two women were executed for witchcraft (Krueger, 2010). Furthermore, Hale regarded crimes such as infanticide, sorcery, and rape as crimen exceptum, which demanded a lower standard of proof for conviction, by which these all have gender in common (Krueger, 2010). Sir William Blackstone also noted that “the very historical precedent of witchcraft, its ubiquity in the records of past civilizations, and its enshrinement in Scripture demanded that the reality of witchcraft could not be denied” (Krueger, 2010, p. 83). These experts on common law seem to have not only believed that witchcraft was enshrined in Christian Scripture, but also that because crimes such as infanticide, sorcery, and rape were dependent mainly on the testimony of women, that the standard of proof for conviction in such cases was not as high as if a man was on trial. This suggests the female body and its abilities to produce other bodies is an existential threat to preponderant authority and domination (Hernández & Upton, 2018).

Like Justice Alito relying on 17^th-century thinking to base the SCOTUS Dobbs v. Jackson Women’s Health Organization (2022) opinion, medical paternalism is the foundation by which the idea that the interference in one’s autonomy is justifiable. According to Sándor et al. (2018), examples of medical paternalism, especially gendered medical paternalism, can still be found worldwide. This gendered medical paternalism reflects social and cultural ideologies that incite restriction of female autonomy. Furthermore, Sándor et al. (2018) stated that although reproductive rights are asserted to be empowering, women are treated differently than men due to deeply ingrained gender biases.

Intersectionality and Feminist Theory

The grassroots of contemporary feminist scholarship are the identification of multiple identities and experiences of subordination (Davis, 2008). It is unfathomable in today’s feminist theology that significant attention would not be paid to race, religion, class, age, and heteronormativity, as well as gender (Davis, 2008). Thus, intersectionality is vastly intertwined with feminist ideology, whereas both intersectionality theory and feminist theory can be used to understand and advocate for policy and change.

Intersectionality, a term first used by Crenshaw (1989), was pioneered to focus on the fact that the singularity of feminist or racial activist discussion did not adequately address experiences of women of color. Davis (2008) further defined the concept of intersectionality as “the interaction between gender, race, and other categories of difference in individual lives, social practices, institutional arrangements, and cultural ideologies and the outcomes of these interactions in terms of power” (p. 68).

The discussion of intersectionality invites the prospects of discussing concerns about power, inequality, justice, and social action (Grzanka, 2020). According to Lapalme et al. (2020), intersectionality theory asserts that power relationships that produce social inequalities are comprised of (1) intersecting systems of power, such as hetero-patriarchy, white supremacy, and capitalism, and (2) intersecting social groups that experience privilege and/or oppression as a result of social structures shaped by the intersecting powers. In contrast to other social theories, intersectionality theory emphasizes multidimensional power relationships. For instance, as Grzanka (2020) noted, instead of focusing on a single relationship between the patriarchy and women’s oppression, intersectionality theory asserts there are multiple intersecting systems of power, such as patriarchy and white supremacy and Black women’s oppression. Thus, solving social issues, such as those relating to reproductive rights, within any context requires the analysis of various complexities within power structures, which is the basic premise of intersectionality theory.

By studying intersectional thought, nurse leaders can perform a self-analysis and understand their own complex social construct. This can lead to further understanding of how to make decisions based on the multiple systems of privilege and oppression that frame individuals’ lives (Collins et al., 2021). Further, by understanding others’ identities, leaders can understand By studying intersectional thought, nurse leaders can perform a self-analysis and understand their own complex social construct. that the differences in identity are not points of division but points of solidarity (Osman, 2018). When multiple groups come together in solidarity, they can create inclusive and inspirational movements capable of enduring social change. In light of recent legislative backslides, conversations based on varying systems of power and how they interact to create social inequalities are crucial to protecting women’s healthcare and the continuance of a profession of which the vast majority are women.

Educating Future Nurse Leaders

Across the globe, the lack of women, especially women of color, in leadership positions in health care has resulted from vast power imbalances, gender stereotyping, discrimination, and patriarchal structures that allow for one gender to excel. At the same time, the other remain in subservient roles (WHO, 2019). The lack of women-led healthcare systems results in a lack of knowledge from the female perspective. According to the WHO (2019), the intersectionality, or the compounding factor of possessing more than one marginalized identity of gender, race, religion, class, and ethnicity, is responsible for the limited opportunity for women to enter leadership roles. This lack of female leadership in healthcare fields leads to a decrease in sexual and reproductive health rights, which has a significant negative effect on women’s health (WHO, 2019).

A recent leadership theory that has gained momentum in the nursing profession, quantum leadership, asserts that the whole is greater than the sum of its parts (Albert et al., 2022). Like quantum theory, intersectionality assumes the same and provides a holistic approach to examining social inequities that cannot be separated into singular causes. Understanding various social identities and how they are influenced is essential to culturally relevant and responsive leadership. Additionally, critically examining emancipatory ways of knowing using intersectionality theory could be vital in addressing and advocating for policy changes in today’s political environment.

Nurse leaders need a specific set of knowledge, skills, and abilities to be a competent practitioner and advocate for the profession. According to the American Organization for Nursing Leadership (2015), this set of competencies includes communication and relationship management, professionalism, knowledge of the healthcare environment, and business skills and principles. Many of the attributes are informed by power relations and social context. Social context, which is not a static entity, is a crucial concept of intersectionality (Ruiz et al., 2021). Context, in relation to intersectionality, is understood to be specific to time and place, and thus, it is ever-changing based on history, economy, culture, politics, and social structures (Ruiz et al., 2021). Examining context through the lens of intersectionality forms a basis for leaders to succeed, grow, and impact health and health outcomes.

Nurse leaders need a specific set of knowledge, skills, and abilities to be a competent practitioner and advocate for the profession.

For example, utilizing intersectionality theory to understand the context and capacity of leaders cannot focus solely on the intersectionality of gender and race but instead also needs to focus on other factors, such as their sexual identity, religion, resilience, oppression and/or privilege, and stereotyping and how they all shape their identity as a leader. Teaching about leadership from an intersectional theory perspective emphasizes crucial factors regarding one’s ability to effectively lead, such as (in)visibility and silencing, authenticity, and the role of shifting contexts based on the intersection of social identities and power dynamics (Jones, 2016).

Designing An Assignment to Teach Future Nurse Leaders

In a Master of Nursing Science program at a university in the United States, two assignments were introduced into a course designed to teach students leadership skills within organizational systems and structure. These assignments were introduced to ascertain whether students could learn about power, influence, diversity, and intersectionality about workforce equity and healthcare opportunities.

In the first assignment, students were asked to read the article entitled “Intersectionality and Nursing Leadership: An Integrative Review” by Aspinall et al. (2022) and then write a short paper discussing diversity, intersectionality, equity, and inclusion about healthcare organizations’ policies on workforce equity and opportunity. In the second assignment, students were asked to read Hill Collins’ (2017) entitled, “The Difference that Power Makes: Intersectionality and participatory democracy.” Then, the students were asked to discuss (1) power, influence, diversity, and intersectionality about workforce equity and opportunities; (2) the historical and contemporary power relationships that feed healthcare leadership and policy today; and (3) utilize the Domains-of-Power Framework (Hill Collins, 2017) to explore power, privilege, and influence in nursing leadership.

Overall, students felt the course assignments were informative and interesting and allowed them to delve deeper into the ideals of power and influence in healthcare leadership. Students stated that the assignment allowed them to not only learn about the subject matter but also reflect on their own personal power, influence, diversity, and intersectionality and how that may play a role in the context of future leadership positions. The assignment proved integral to learning various subjects on diversity, equity, and inclusion that are vastly important in today’s political and healthcare environments.

Implications for Nursing Education

Undoubtedly, the nursing profession will reach a critical point shortly in which a new generation of nurse leaders will need to take the reins on leadership in healthcare, advocacy in policy and political downstream consequences, and shift the context through which leaders see the rights and work of women and minorities. The connection between diversity in leadership and the perpetuation of various health disparities is undeniable (Iheduru-Anderson, 2021). Instead, educating future nurse leaders on issues such as medical paternalism and intersectionality can open the discussion on attributes perpetuating negative cultural divides.

Assignments in leadership courses, such as the ones mentioned previously, aim to use feminist theory and the intersectional lens to start the discussion of the impact of socially constructed or contextualized identities on social structure, healthcare opportunities, career progression, and political ideologies. By beginning to understand and evaluate power and privilege from the multiplicities of what make humans what they are today, nurse leaders can be prepared to fight for and treat cultural divides, health disparities, and political ideologies that risk marginalized populations' health.

Conclusion

Context is the concept by which nurse leaders can most impact nursing, health, and health policy. Understanding the dynamic struggle in the intersections of power is vital to voicing concerns about the direction of current policy and advocating for lasting change. The current resurgence of patriarchal, racial, and religious extremism, especially about gender norms and roles, has placed a considerable tax on both the justice and healthcare system. Leaders in healthcare need to be prepared to discuss the power relationships that feed healthcare policy and know how to circumvent the historical context by which current policy is entrenched.

Nurse leaders need to have a vision of a future that advocates for policies that denounce the idea that the law is based on blind tradition. Our historical founding fathers were not infallible. Instead, they were also subject to their social context; thus, their power dynamics and ideologies reflected a society that did not value diversity. However, just because sexism, racism, and various other forms of discrimination are “deeply rooted in our Nation’s history” does not necessarily make it just to continue it in today’s context. As Lithwick (2022) stated, in countries grounded in stories of kings and magic, the power lies with the powerful; however, in a constitutional democracy, power belongs to the people who step up to the fight. To create a country that genuinely represents all its people, leaders, including nurse leaders, must closely examine their beliefs on intersectionality and power relationships to strive for moral progression and gender/ racial equality.

Author

Erin J. Dy, PhD, MSN, BA, RNC-MNN, CNE
Email: edy@chamberlain.edu
ORCID ID: 0000-0001-6560-7485

Erin J. Dy, PhD, MSN, BA, RNC-MNN, CNE is an Assistant Dean/Assistant Professor at Chamberlain University College of Nursing. She earned her doctorate in education from Capella University and earned an MSN, BSN, and BA in organizational communication and women’s studies. Dr. Dy is a certified maternal-newborn nurse and certified nurse educator who is passionate about preparing future nurse educators and leaders.