Evolution, evidence and enterprise: women in leadership in the Australian healthcare industry.

Evolution

The evolution of the profession of dietetics in Australia, has many parallels with the development of women in leadership in this country. This is not surprising, as dietetics is a female dominated profession. A question I was recently asked is:

Is it a good thing to have a female dominated profession?

First, there are a number of elements that define a profession, that separate it from being a technical, vocational or craft based occupation. One of these elements is the ability to advocate on behalf of the constituents for whom it provides its services. Nursing has used the advocacy role as a major element in its strategy to move the status of nursing from a vocational to a professional level.

Adopting the view that advocating on diet and nutrition issues for constituents in public health, community health, food services, food industry, government, and clinical services is the responsibility of the profession, the Association (as the representative body) and the individuals within the various sectors of the profession, suggests an extremely broad and onerous responsibility. It is also possible to extend the scope beyond local boundaries to consider national, regional and global responsibilities.

There exists a second dimension to this issue, which I refer to only in passing as the impact of the medical model on dietetics. The medical model continues to be patriarchal, hierarchical, with a culture of apportioning power on the basis of position and status. It is important to acknowledge the medical model as providing the foundations for establishing nutrition and dietetics as a profession, a foundation we all agree is imperative to the future. In order for the dietetics profession to effectively advocate in the future, it needs to develop more flexible and responsive models and culture.

The vision and mission of the Dietitians Association of Australia (DAA) is consistent with the view of advocacy and the curriculum within the dietetic training establishments also aligns to better health outcomes for all. However, there are implications for dietetics as a female dominated profession, which in turn, has implications for its role as advocate on issues of diet and nutrition.

This brings me to the second point of female dominance in the profession. The annually honoured and recognised pioneering women of the dietetics profession are mostly characterised as powerful individuals, with formidable personalities, each upholding a vision of a strong profession, recognised for its pursuit of excellence, knowledge and practice in the field of nutrition and dietetics. Barbara Chester, Jo Rogers and Joan Mary Woodhill were all pioneering women, who did not see barriers, only obstacles to be overcome.

In more recent times we acknowledged the power of our contemporary pioneers such as Rosemary Stanton, the first 'celebrity' dietitian, Sandra Capra, the first dietitian holding a Chair of Nutrition and Dietetics, and Peter Williams the first male President of DAA. I adopt the word pioneers intentionally, as they have paved the way forward for others to follow, whether it be into private practice, academia or politics. And indeed, each of these pioneers had to deal with a level of rejection or criticism from peers and associates for taking a less traditional path. This enduring foundation, created a profession, which today is recognised for the diversity of careers and businesses, from traditional to non-traditional, from the public hospital sector to running thriving food service businesses, consultancies and private practices. In each of these sectors, women still experience less access to capital, the decision making table and the network that male colleagues have available.

At a time when we are seeing an increased awareness of the economic and social impact of diet and nutrition related health disorders, such as obesity and diabetes, dietitians must assume the power required to make a difference, to lead the debate. The dialogue must concern the issues, the evidence, the most effective strategies to act on the evidence, the effective monitoring of the interventions, and the imperatives for future research to better understand cause and effects. I cannot think of one other discipline that is better able to unite the scientific dilemmas of research and practice in managing nutrition related issues. Although the first question is not yet answered, the question, in this context, may be rephrased.

Is the profession's ability to fulfill its obligations as advocates affected by the largely female based membership?

As a profession, we have a responsibility to ensure that the political power and in the case of the medical model, the positional status, is available to successfully advocate for our constituents. The barriers to successfully acting upon beliefs and values inherent in the dietetic profession, must be identified and addressed, including those resulting from the community and business perceptions of women.

Power and influence are synonymous when used in the context of leadership. I take my definition of power from Helen Lynch, one of Australia's top five business women, who 12 years ago defined power as all about achievement and the opportunity to influence change.

Evidence

To this end, I reviewed the structures of power and influence within the broader business community and a little more closely in the health services sector.

Working within the health services sector, with its majority female workforce, it is easy to believe that inequality for women does not exist. As we take a broader view of the Australian employment landscape, a very different picture emerges. The inaugural census of women in business (released in 2002) surveyed the top 152 companies listed on the Australian Stock Exchange and reported that women held 8.4% of executive management positions, 52.6% of companies had no women executive managers, only 17.8% of companies have two or more women executive managers, and women held just 5% of all line positions. At the Board Director level, women held 8.2% of directorships but 46.7% of companies had no women directors, and 9.9% of companies had two or more women directors. Not surprisingly, given the small numbers of women in core executive positions, just two of Australia's top 200 listed companies employed a woman as CEO (1). The census itself has enabled focus to be created, and will ensure the trend is positive when we next measure the number of women in senior roles.

The main employers of dietitians, such as State and Commonwealth governments and their agencies, self-employed dietitians, those engaged in the church and charitable sector, and private companies, were not represented in this sample. Although it is recognised that the participation of women at the senior executive ranks in health related and government fields is higher than in its private sector counterparts, it is evident that organisations in all market sectors are a long way from capitalising on the talent available in their female workforce. The representation of women at the executive level in health service organisations remains lower than the overall percentage of women participating in the health service workforce. A quick look at some of the 'firsts' for women in the health sector suggests there is still some distance to travel.

I can also add to this that many recipients within the Telstra Business Women's Award, specifically in the community and government sector are very successful health sector managers and leaders. The evidence suggests that women have an impact on the executive decision making ranks within the private and public health sectors. However, a review of executive management roles in the hospital and aged care sector indicates most positions are held by men (2).

The power and influence women exert is growing. In his book Women that roar, Tom Peters argues that 'women's increasing power-leadership skills and purchasing power--is the strongest and most dynamic force at work in the American economy today' (3).

The growth in women's power and influence is driven by external factors such as increasing consumerism, changing household sizes and family dynamics, and economic imperatives lead by the retiring baby boomer generation. The need for full employment to maintain GDP growth (especially as the percentage of the population in the workforce is reducing) is driving government policy and industry diversity and equity initiatives.

Therefore, while recognising dietitians require political power to successfully fulfill their professional responsibility, and that female health professionals are still behind their male counterparts in achieving that positional power in the executive ranks, and acknowledging that sociological and economic pressures act as a catalyst to increase women's power and influence, I ask the next question.

Does the dietetic profession need equity for women?

To achieve positional power and status dietitians need equity--we cannot wait for the winds of change to occur, because they may not blow in our direction, or with the outcomes we seek to achieve. Therefore, when considering these questions, the profession has a dilemma.

The difference between management and leadership as defined by Fons Trompenaars (4), the world's leader in building cross cultural competence, is that managers make decisions on issues, high performing leaders reconcile dilemmas. Trompenaars determined seven dimensions on which the values of diverse cultures vary. These concepts use highly abstract terms, as a large number of 'family resemblances' are included within each concept. The variance between the concepts represent dilemmas, i.e. two propositions in apparent conflict. In other words a dilemma describes a situation whereby one has to choose between two good or desirable options. So a dilemma describes the tension that is created due to conflicting demands.

On the one hand, as professionals, we seek to advocate for our constituents, while on the other hand, as professionals in a female dominated profession, we may seek to create a base of equity and influence for women in the health sector, and indeed women in general. As with all dilemmas we may achieve one without the other, or indeed compromise both outcomes and achieve half the benefits--which is where I suggest the dietetics profession sits today. The challenge for the profession is to use the tension created due to the conflicting demands of each dimension as an opportunity to reconcile the differences and create a high level resolution.

Through the evolution of dietetics a number of dilemmas present themselves for the profession. Table 2 represents a number of the potential dilemmas as applied to the Trompenaars 2002 model.

Two of these dimensions are discussed below as an illustration of the divergent cultural issues currently being managed by the profession.

Individualism vs communitarianism 

We are well aware that less than half of the profession now practices in the traditional hospital setting. The majority of dietitians work for themselves in private practice, or in associated industries, especially the food industry. A number of dietitians are exceedingly entrepreneurial starting their own businesses, or moving into senior bureaucratic and managerial roles. In fact, the trend may possibly be toward greater individual effort, and less collective public health advocacy. This may in part explain the apparent unwillingness to nominate for the DAA presidency, a role that has certainly personified the profession's increasing advocacy role.

Inner directed vs outer directed

This dilemma was evidenced in the Letters to the Editor in the April 2003 DAA Newsletter. The DAA's Statement on Television Advertising of Food to Children was criticised, and reflected the DAA's dilemma of seeking to be outer directed to engage the public debate, while individuals within the profession are seeking a harder line. Both propositions are correct. Traditionally, the Association has sought to compromise between the two forces. However, this no longer serves the position of both groups, and DAA needs to reconcile the two.

I argue the profession does need equity for women, so we are able to reconcile the dilemma between the individuals within the profession having to choose between their personal careers and their professional obligations as advocates.

In essence we need to achieve success in both dimensions, most probably in a sequential manner by achieving the power available through leadership, and adopting an advocacy role through positional power.

Enterprise

Leadership

As individuals it also means we need to create behaviours and an environment that models and rewards leadership. So, what are the characteristics of leaders, how will we recognise them, and how as individuals will we develop the attributes and competence that enables us to be leaders? How will we resolve the dilemma impacting upon the profession, and really advocate for our constituents in the field of nutrition and dietetics?

In the text Good to great, published in 2001, and considered the most detailed investigation into attributes of successful public companies, a consistent pattern emerged among the great companies leaders (5). They were defined as:

   Level 5 leaders channel their ego needs away from themselves and
   into their larger goal of building a great company. It's not that
   Level 5 leaders have no ego or self interest. Indeed, they are
   incredibly ambitious--but their ambition is first for the
   institution, not themselves.

Level 5 leaders blend extreme personal humility with intense professional will.

Collins' research compared the great companies with companies competing in the same market with similar products. 'In over three quarters of the comparison companies, we found executives who set their successors up for failure or chose weak successors, or both' (5)

Other findings were:

* Level 5 leaders look out the window to attribute success to factors other than themselves. When things go poorly, however, they look in the mirror and blame themselves, taking full responsibility.

* Level 5 leaders exist all around us, if we just know what to look for, and that many people have the potential to evolve into Level 5 leaders.

* Ten of 11 good to great CEOs came from inside the company.

* The researchers of Good to great were not looking for Level 5 leadership in their research, but the data was overwhelming and convincing. It is an empirical, not an ideological, finding.

In order for dietetics to be a great profession, it now has the challenge of resolving the leadership dilemma in nutrition and dietetics.

What are the attributes of leadership? In an overview Levey et al. (6) conclude that leaders need to:

* Have a vision and share it.

* Challenge the status quo.

* Encourage and participate in debate.

* Be persistent and hard working.

* Be team builders.

* Be interested in developing others.

* Become active decision makers.

* Be risk takers and risk managers.

* Be results oriented.

Many of these leadership behaviours are perceived as strengths for men. Within health and science much of the perception of a great leader is male, medically or scientifically qualified.

The women in business census demonstrates the number of women in leadership roles has not changed markedly for over ten years (1). This may well be the case in the health industry also. The reasons are varied, but my own observations are:

* During selection processes, people generally recruit people like themselves.

* Stereotypes continue to reinforce the male scientist vs the female dietetic professional.

* Women are reluctant to publicly debate feminist issues e.g. why are women under represented in positions of power within the health industry?

* There is a lot at stake for people currently with the power, to change the order or nature of giving and sharing power.

Raising the dialogue, individually and collectively

I suggest dietitians have a professional obligation to address issues of equity, power and leadership to successfully advocate for their constituents. In order to make progress, and create the leadership the profession is capable of achieving, I suggest a few simple actions.

Engage men in the dialogue

Until the people with power seek to change the status quo, and believe there is a sound business, social or cultural imperative to do so, it will not change. Engage in the dialogue regarding women and through the Equal Opportunity for Women in the Workplace Agency (EOWA) to measure women in the health sector.

Engage women in the dialogue

Other health professions, frequently male dominated, often compete with the dietetics profession for power and influence. Therefore, we need to align the agenda and collaborate, and not dilute the effort. I suggest we should start with the other female dominated professions that share these issues.

Build the financial case

Highlight the risks and opportunities associated with the health imperatives, and indicate the importance of addressing leadership dilemmas.

Collaborate

Building enduring and diverse relationships, both personally and professionally creates significant value when seeking to break through barriers. I am continuously amazed at the lack of recognition given to the value created through public and private sector partnerships--there is significant noise about why they fail--but very little interest in taking the lessons learned, and creating opportunity. There is a wealth of knowledge and capacity to be leveraged--if we open our eyes to the possibility.

Prioritise 

The greatest asset we each have is our time and attention. Our greatest problem is that individually and collectively we are squandering time and resources on the wrong things.

Support the risk takers

Leaders will take risks, and most likely stumble along the way. Offer a helping hand when they need it the most.

Create opportunities

To quote Julie Hulcombe (7):

   Dietetics provided me with skills which provided the platform to
   work in a number of areas. Finally, opportunities always seem to
   arise during times of change, take on the challenge, try something
   new and learn. Take a risk, the rewards are worth it.

Conclusion

The answers to the questions raised lie in successfully advocating for our constituents and recognising as a society we are truly capitalising on the talents and attributes of women, and the dietetics profession. As Dr Faith Ottery claimed (8), to sit at the table nutritionists need to be equal or better than, those sitting at the table today, and to achieve this we need the evidence. The profession of nutrition and dietetics will be judged by turning the inequality in the health system today into an opportunity. To better advocate for our constituents through reconciling the cultural dilemma will need the support of the male and female members of the profession, because the barriers to our fulfilling our professional obligations as advocates is a matter for the entire profession. The dietetic profession can be proud of achievements to date. The challenges ahead are also great, and the need for equity, leadership and advocacy is even greater.

Table 1. Milestones in senior female appointments

Year                         Event

1905    First female surgeon
1990s   First female Area Health Service CEO (NSW)
1990s   First female CEO, in the church and charitable sector
2002    First female Director General of Health (NSW)
          First female Deputy Director General (Queensland)
2002    First female President Australian College of Health
          Service Executives
2002    First female recipient of ACHSE Gold Medal
2003    First Dietitian held Chair of Nutrition and Dietetics

Table 2. Conflicting propositions creating dilemma for practice

                                        Cultural concepts

Universalism                            Particularism

Women seek a level playing field        We need affirmative action to
                                          overcome the existing gender
                                          imbalance

Individualism                           Communitarianism

Pay for performance                     Performance of the profession
                                          evaluated in terms of public
                                          health outcomes

Neutral                                 Affective

Professional image                      Engaging and enthusiastic

Specific                                Diffuse

Deliver individual and group results    Leading collaborative industry
                                          and government initiatives

Achieved status                         Ascribed status

Merit based recruitment and selection   Hierarchical, positional power
  processes

Sequential time                         Synchronous time

Win the Race                            Shorten the course

Inner directed                          Outer directed

Driven by conscience and conviction     Responsive to outside
                                          influences

References

(1.) Equal Opportunity for Women in the Workplace Agency. Australian Census of Women in Leadership. Sydney: EOWA; 2002.

(2.) 2003 Hospital and health services yearbook. Brisbane: ASPN Big Business Information Group; 2003.

(3.) Peters T. Women roar. The new economy's hidden imperative. New York: Select Books Inc; 2001.

(4.) Trompenaars F, Hampden-Turner C. 21 leaders for the 21st century: How innovative leaders manage in the digital age. New York: McGraw Hill; 2002.

(5.) Collins J. Good to great. London: Random House Business Books; 2001.

(6.) Levey S, Hill J, Greene B. Leadership in health care and the leadership literature. J Ambulatory Care Management 2002;25:68-74.

(7.) Hulcombe J. Queensland Director profile. Dietitians Association of Australia Newsletter 2003;(4):21.

(8.) Dietitians Association of Australia. 21st National Conference. Cairns: DAA; 9 May 2003. Ottery F. Evidence: using evidence to get your just desserts.

This paper is based on the Lecture in Honour of Barbara Chester presented on 10 May 2003 at the 21st Dietitians Association of Australia National Conference 8-10 May 2003. The Lecture in Honour is presented as an opinion, and as such, this paper has not been subject to the Journal's usual peer review process.

Eurest Australia

S. Evans, BSc, Corporate Development Director

Correspondence: S. Evans, 737 New South Head Road, Rose Bay NSW 2029. Email: [e-mail]