Over the past three decades, more men are pursuing careers in nursing because they are attracted by some of the same benefits and opportunities that have drawn women to the profession, such as job security, attractive salaries, job satisfaction, respect, and, primarily, to make a difference in the health and the well-being of people’s lives (Meadus ; Twomey, 2011). However, even with the increase in males entering nursing and the opportunities in the field of nursing, male nurses are still significantly underrepresented in nursing schools and in the nursing workforce. The Barbadian population has seen a considerable increase of people from various cultural, racial, and ethnic backgrounds; yet, the diversity of the nursing workforce does not mirror the nation’s diversity. In order to provide the care that will meet the cultural, racial, or gender needs of the population, the nursing workforce will have to become more diverse.
For over a century, nursing has been categorized as a female profession, and that categorization continues in the 21st century in spite of the appeal for gender diversity in health care, especially in nursing. While the need for health care becomes more complex with a growing diverse population, it is crucial to ensure that there is an adequate and diverse supply of registered nurses (RNs) to meet the health care needs of people both nationally and globally. The recruitment and retention of men in nursing education are considered important components that will increase the supply of nurses in the workforce as well as provide care for the diverse population.
Even though the number of male nurses is expected to increase, gender parity still lags.
Additionally patient health outcomes are linked to the quality of nursing care, which in turn is linked to adequacy of nurse staffing. Changing population and nurse demographics are anticipated to exacerbate the current nursing shortage. Men are underrepresented in nursing, and enhanced recruitment of men has been identified as a possible solution to the shortage. However, research has suggested that men face gender-specific challenges in nursing and other gender-atypical occupations, which may influence the low recruitment and high turnover of male nurses.
This study employed an ethnographic approach to explore and describe how male nurses perceive and describe this phenomenon. For this study, nine male nurses who practiced at the bedside were interviewed. Data were obtained using a bio-demographic questionnaire, semi-structured interviews, and participant observation. Measures to ensure study rigor and trustworthiness included credibility, fittingness, and auditability (Beck, 1993; Lincoln & Guba, 1985).
Findings so far revealed that men in nursing experience gender-specific challenges during three timeframes: choosing to become a nurse, becoming a nurse, and being a nurse. During the first timeframe, choosing to become a nurse, the men decided whether nursing was a fitting profession for them. Three factors positively affected men’s decisions to become nurses: a) exposures to nurses, especially males; b) understanding the benefits of a career in nursing; and c) support from family and friends. Social influences, such as stereotypes about nursing and men in nursing, negatively impacted men’s decisions to become a nurse. During the second timeframe, becoming a nurse, the participants’ primary focus was to survive the often rigorous nursing program. Participants experienced both supportive and stereotypic responses to their career choice, and they began to learn ways in which to process stereotypic responses. Although the men continued to experience gender-specific challenges during the third timeframe, being a nurse, they felt confident and comfortable with themselves as men and as nurses. Study findings have implications for the recruitment and retention of men in nursing, nursing practice, nursing education, and theory development.
The historical context of men in nursing at the present time must begin with the history of nursing itself. Florence Nightingale established modern nursing in the 1800s as a profession for women. Such gender specialization in the work force at that time was not uncommon; in fact, law and medicine-were established as professions for men. Nightingale expected nurses to “show total commitment to work and total submission to authority” (Schirger, 1978, p. 13), and the profession has traditionally projected a stereotypical image of non-assertiveness, malleability, self-effacement and self-sacrifice in the Nightingale tradition (Schirger, 1978). Although there have been many efforts to change the image, vestiges of the past are still present (Hamilton and Kiefer, 1986).
Throughout the history of nursing there has been a tradition of altruism that interfered with the professional autonomy and development of the nurse.
Roles for women are changing, however, and many attribute this to the women’s movement. The impact of this movement on nurses is difficult to gauge. Nurses have not been actively involved in the women’s movement despite the fact that a few nursing leaders predicted that involvement would help them gain the power and influence needed to affect the quality of health care and working conditions (Ashley, 1976).
There is still a feminist disdain for nursing as a career (Baer, 1992). The lack of nurse’s involvement in the women’s movement is not always advantageous for men. The sense of empowerment and the enhancement of self-esteem associated with the women’s movement lead to a more egalitarian work environment. Perhaps the men in the nursing world need to acquire insight into a different culture of women.
The structure, images, and traditions assigned to an occupation have a profound effect on an individual’s selection of that occupation as a career (Lieb, 1978). Modern nursing is, and always has been, a sex-typed profession. Stein (1980) noted that the characteristics of sex and occupational role are related to inequality and are a part of a male-female, doctor-nurse game. Can this game be perpetuated when the roles and sexes of the actors are reversed? It is an important question. Stein (1990) examined this issue a decade later and noted many changes in the hospital. He suggested that some changes were due to the women’s movement. There are no studies, however, that examine how a man fits into the culture of nursing. There is no research that examines what type of socialization is occurring for the male nurse in Barbados.
Male nurses are identical to or equal with their female counterparts in at least one important dimension. They must give quality care to all patients. However, since nursing is perceived to be a female profession, confusion can occur when a patient is cared for by a male nurse, when a physician interacts with a male nurse, or even when another female nurse interacts with a male nurse. As a result, when providing patient care, men in nursing face barriers due to stereotyping (Turnipseed, 1986). The nurse who is a woman has a clearly articulated pattern to follow as she is socialized into the profession.
This research identifies the mechanism that exists for the socialization of men into the nursing profession.
Chapter 1: Research Question and Approach
This chapter describes and illustrates a symbolic interactionist approach to ethnographic research within nursing. An eclectic approach to interpretive sociological research is developed and explicated. It is anticipated that this approach will offer the potential for new and additional insights into the phenomena of the occupational socialization of men in nursing. An exploration of the symbolic nature in which male are socialize to the role of the professional nurse is presented.
This study therfore examines gender and its impact on the socialization of Barbadian men to the nursing profession. The discussion begins with how gender plays out in everyday life and the influence of gender on occupations. A brief summary of the status of males within the nursing profession and the issues males face as a minority, as well as the problems that arise when choosing work counter to the expectations of society due to its gendered nature, is presented.
The purpose, research questions, theoretical framework, and significance of the problem follows. The chapter concludes with definitions of key terms, as well as the limitations of the study.
Background to Problem
Gender is socially constructed whereas sex is biologically defined. With reference to gender in the Caribbean, (Barriteau 2000) states that we need to know more about what informs the content of the content of the concept of masculinity.
Gender- being a man or a woman; masculinity or femininity; acting like a man or behaving like a lady; a “man’s man” or a “girly-girl” soft man – these are some examples of phrases we use to delineate and define the two sexes. Gender is ingrained in everything we do. Gender influences how we interact and communicate, how we dress, even the type of hygiene products we use. In labour and delivery rooms across the nation, the first question asked is whether it’s a boy or a girl, even prior to determining the physiological stability of the child. In fact, many times parents opt to find out the sex of the child prior to its birth so that they can prepare for the new arrival by purchasing pink decorations and clothing for girls and blue if it will be it will be a boy. At the time of birth, a pink cap is placed if it is a girl, and blue if it is a boy; a symbolic gesture representing the child’s sex. From this moment on, the future of the individual, from what types of play they engage in to what career they choose is heavily based on this qualifier (Goffman, 1977; Leaper & Friedman, 2007). After a child is born, friends and family will come to visit. If this is a first boy for the parents after having more than one girl, this comment may be made: “You finally did it right this time and got a boy” or if the situation is reversed: “Did you have another child so that you could “get” a girl this time?” Often parents will make plans for the child. A parent will dream of their son becoming a football hero, or their daughter becoming the homecoming queen, further symbolizing gender roles more so than simply a sex category ref. Gender is the trait we associate with the two sex categories of male and female. Important to this concept is sex. Sex is not the same as gender; however, there are many assumptions about a person’s gender, and their role in society, based on their sex (Leaper & Friedman, 2007). Gender becomes much more complex to define, as it has a meaning which goes beyond the physical characteristics of being a boy or girl. From a sociological viewpoint, the definition of gender is the totality of meaning attached to the two sex categories (Kramer, 2005). Gender is the delineation of roles, traits and characteristics assigned to each of the sex categories which humans take on as they are socialized. It also influences behaviors and one’s sense of identity (Howard & Hollander, 1997; Leaper & Friedman, 2007). Socialization to a gender is facilitated through a number of channels. Parents, society, and popular culture all reinforce what is considered appropriate gendered behavior for each of the sexes (Leaper & Friedman, 2007). With regards to toys a boy may be given a trucks while the girl is given a tea set. Appropriately gendered behavior would include males as football players and girls as netballers and this influence flows into the eventual choice of one’s vocation.
Males are encouraged to become engineers, doctors, auto mechanics, and all occupations that build and repair. The practice of medicine, although a helping profession, has a strong emphasis on healing or repairing of the body, sharing this masculine association. Although times are changing, jobs in teaching, secretarial work, social work, child care and nursing are traditionally associated with females. Nursing, which often is referred to as an offshoot of medicine, focuses not on curing illness, but rather on four major areas: 1) promoting health and wellness, 2) preventing illness, 3) restoring health, and 4) caring for the dying (Berman, Snyder, Kozier & Erb, 2008). Noticeably, these occupations emphasize caring and nurturing. Therefore, certain occupations have been defined as “gendered,” such as nursing (Williams, 1989, 1993, 1995). This gendering of an occupation tends to lead to an occupational appeal to only one-half of the population.
Nursing is predominantly a female profession, resulting in a feminine gender orientation (Fagin and Diers, 1983). Because nursing has been experiencing a crisis in recruiting qualified individuals, the profession has been actively encouraging men to join its ranks. The research problem that is addressed concerns how the nursing profession socializes male nurses.
The transition from student nurse to graduate nurse is an area that has received considerable attention in the nursing literature. This transition has been described as a time of great turmoil for the new nurse and a critical period in his or her career development (Kramer, 1974). No published studies have looked specifically at how the male nurse becomes socialized to the culture or professional hospital work in Barbados.
This study addresses the problem of professional socialization of new male nurses. In conducting such a study, it was necessary to identify the behaviours developed by male nurses to cope with their new roles as professional registered nurses. An examination of the sociocultural knowledge influencing new male nurses and their perspectives regarding this knowledge can generate a comprehensive and accurate depiction of relationships and events. This knowledge can he used by administrators to tailor an orientation period that specifically meets the needs of male nurses.
This study generates questions that challenge educators preparing the male nurse and it illuminates the issues involved in role development for a man desiring a nursing career. The profession is reaching out to this new population, and it is imperative that the norms, values, and taboos or the culture or nursing and their interrelationships with the subculture of man be explored. In this and the following chapters the researcher presents an ethnographic study that will assist the reader to develop an understanding of the complex environment in which male nurses become a part.
The development of professional role conception in nursing has been studied by many researchers (Davis and Olsen 1963; Kramer, 1974: Schmalenberg and Kramer, 1979). These studies found that differences in role conception were related to socialization patterns, particularly the type of education the female nurse received. Davis and Oleson (1963) focused specifically on initiation into a women’s profession and found that the new nurse had great difficulty integrating this new role with the emerging identity of adult womanhood.
Nursing as a Gendered Profession
Nursing became one of the professions along with teaching, secretarial work and others known as appropriate work for females. The women’s movement of the 1960’s changed the traditional prescribed roles for women, opening doors to fields that were once closed. Many women started to move into various fields once dominated by men. Unfortunately, the trend did not go in reverse for men entering traditionally women’s fields. Although currently considered a “woman’s profession,” historically, care of the ill was performed by males within the monastery systems of the early Catholic church. The monastery system is the religious communities of men and women in the form of monks, Christian brothers and religious sisters. Due to social and political changes associated with the Protestant reformation, resources for the education of health-care providers shifted to medicine (curing) and away from nursing (caring). Salvage There were two major elements involved with this shift in perspective: the growth of the scientific method and the decline of church social capital in England. The growth of scientific method moved the focus away from caring of the ill and toward the cure of disease process and hence, to the science of medicine (Jensen, 1950; Seymer, 1933 & 1954). Medicine, based on the scientific method, was taught in the university, and was considered to be a role fit for educated men only. savage Women, who were educated during this time, were instructed in the arts and humanities, but not math or science. The decline in church capital came about as a result of the political activities of Henry VIII in England. When the Roman Catholic Church refused his divorce from his first wife, Catherine of Aragon, Henry VIII joined in the Protestant reformation, acquiring church property in England and destroying six hundred monasteries (Jamieson & Sewall, 1944). As a consequence of the destruction of these monasteries, the inns and hospitals that cared for the sick also were destroyed (Jamieson & Sewall, 1944).
This trend continued until the advent of formalized training of nurses, which was facilitated by Florence Nightingale. Nightingale, who came from an upper-class background, was one of the few women of her time to be educated in math and science as well as the humanities. This focus on math and science was due heavily to the influence of her parents. With her educational background, Nightingale was able to utilize statistical data to validate the importance of environmental conditions on the health of individuals. Nightingale essentially founded modern nursing education. Her philosophical stance was that nursing was an extension of a woman’s role (Nightingale 1859/1991), thus setting the stage for what in modern times has been considered a women’s profession. From Nightingale’s time to present, the image of the nurse has bee 5 Males and the Nursing Profession Ironically, males maintained an active role in the health-care professions, although their roles have been distinctively different. Males who entered nursing in the early 1900’s, for instance, were segregated into nursing programs designed exclusively for the training of male health-care providers (O’Lynn, 2007). Therefore, the expectation was that if males did enter the field, their roles and education would be distinctively different from their female counterparts. The men who did enter the nursing profession faced a myriad of stereotypes, ranging from questions of their sexual orientation, intellectual abilities, masculinity and moral character, to name a few (Blankenship, 1991; Evans, 2002; Evans ; Blye, 2003; O’Lynn, 2004). These stereotypes are still evident today. The nursing profession is currently suffering from what is considered by many a critical shortage of registered nurses. In order to correct this problem, the profession has turned to recruiting from some atypical populations. The word atypical is used because in the last 200 years, nursing has been dominated and exclusively thought of as a women’s profession. In order to remedy the problem of the nursing shortage, the profession has turned to focusing a large part of recruitment efforts toward attracting more men as well as minorities. Currently, men make up less than 6% of nurses (Yurkovich, 2006). Adding to the nursing shortage is the fact that an estimated 7.5% of newly graduated male nurses will leave the nursing profession within the first four years of graduation, as compared to 4.1% of female graduates (Yurkovich, 2006).
Aims of the Research:
The aim of my research is to examine the nature of the occupational socialization of male nursing staff within a Psychiatric Hospital in Barbados, drawing on the templates offered by the ethnographic traditions and the way of representing ethnographic accounts. With this piece of research I aimed to conduct a “realist account” (Van Maanen 1988) of the experiences and perceptions of male nurses in relation to their adjustment to the realities of working in a Psychiatric Hospital in Barbados. I sought to understand how staff makes sense of the range of training and learning opportunities available to them and how they embed them in their practice.In addition an exploration into what are the mechanism that influences the practice of nursing for males? What role does gender and culture play? As such this research is concern with the subjective dimension of this experience and the perspectives of the staff as to how their practices are shaped.
This thesis examines the occupational socialization of a group of student nurses in a four-year nursing programme. It demonstrates the strength of the relationship between professional training and occupational demands through an examination of the teaching and learning arrangements needed to prepare students for work within the profession of nursing. The aims of the research are to describe and analyse the ‘official curriculum’ of nurse preparation and to examine and explore how candidates form a nursing school in Barbados receive, respond to and make sense of their education and training, which is needed to prepare them for the world of work. The research is concerned with the ways in which these nursing students become part of the ‘professions” social world. As such, the central focus of this thesis is the subjective dimension of this experience and the perspectives of the trainees and staff. Pseudonyms are used throughout this work for staff, students and the names of places (IRB, 2014).
‘Exploring Different Worlds’: choosing a title.
The idea for this piece of research and the process began with what was for me a significant encounter with a nurse whom I was mentoring. In the course of our interactions the subject of being a student nurse and the expectation of the developmental and training opportunities arose. This student was in module 6 and on placement at the unit for two months. The three year programme is divided into 9 modules; the first module introduces the student to the concepts and themes that underpin nursing practice. In module 2 the student looks at the role of the nurse in care across the lifespan. In this module the student observe other professional roles e.g. Midwifery, Pediatrics etc. Other modules examine the psychosocial context of health (level 3). Module 4 is designed to enable student to successfully make the role transition to a student in mental health and introduces the major theoretical issues related to mental health nursing. Module 5 is designed to develop the students’ personal and professional understanding of themselves through the provision of relevant theories and experiences; as well as to demonstrate application of relevant theory to practice in terms of one to one care of clients and therapeutic relationships. During their forensic placement students in module 6 they are expected to develop and maintain professional working relationships with clients, their careers and families. This module also prepares the student for module 7 which is design to enable the student to function as an effective member of the multidisciplinary team and to develop skills in the management of clients and case load, Module 8 is designed to enable the student to employ sociological insight towards their greater understanding of mental health care and to critically view mental health policy and practice. This is followed by module 9 which is developed to enable the student to function effectively as a newly registered staff nurse in their chosen clinical area. A primary focus of the students’ placement in module 6 is also to enable them to develop transferable skills, knowledge and attitudes appropriate to work with a forensic client group. It is expected that students demonstrate that they fulfill learning objectives and have achieved the learning criteria laid down by the Nursing and Midwifery Council (NMC). As the mentor and a senior staff nurse on the ward my role was to enable pre-registration nurses to recognize the salience of their theoretical sessions and what they have learnt from reading. For the student their placement experiences on the wards are intended to help them learn how to utilize this formal and practical knowledge when caring for people, how to become proficient in its use how to manage their time effectively and how to become part of each inter¬professional team of practitioners they meet during their placement. My role was therefore to help students with these learning activities as well as planning their learning, document their progress and to develop learning plans and providing day to day support for the student collaborative working. During our weekly meetings the student and I reflected on our practice and discussed the expectation of her training programme opportunities and the support needed for her to advance in her career.
Upon reflection, her response to my questions; “How do you keep abreast of current practices, technologies and theories in nursing”? generated a discomfort within me. Her responses were ‘I do not know what to expect…….. I do some reading, but I hope to learn as much as possible whilst on my placement’. She added that she learns a lot on the job especially from her mentors. I reflected on the encounters I had with student nurses and surmised that pre¬registered nurses, have different attitudes and expectations towards education, training and development within the unit and clinical settings. In theory, the qualified professional is distinctive, having been transformed into a “participating effective member or the organization”. (Nelson and Quick, 1994.p449) and responsible for their own professional development, so how do they learn? Whom do they learn from? This made me appreciate that in my previous practice encounters, I had never explored how post¬-registration nurses learn and how the environment contributes to, or hinders this process. I therefore decided to focus my research on post- registered nurses in a mental health unit, but I will include voices from pre-registration nurses as well as service users in order to offer a thick description (Geertz 1976) of post registration professional learning, and to contrast the range of learning experiences in the unit with the way in which the service user perceives the outcome of these.
The choice of title for this work was arrived at quite unexpectedly. During the early stages of developing my proposal, I met Amy, one of the first year students whom I mentored during her placement at the Hospital, outside a local library. My completely ‘innocent’ question of ‘So how are things going with you?’, elicited a lengthy description of the problems she was having in combining the demands of life in the nursing college with the requirement to study for a degree in nursing at the college:
It’s just very difficult coping with what’s required of us in college as well as all of the academic stuff. It’s like living in different worlds …. When things really get going it’s going to be difficult to fit everything in. (Research Diary entry)
I also remembered that Amy had responded similarly while on her clinical placement at the Hospital. This was now a further source of motivation to explore the issue of nurse socialization. It seemed to me that the concept of encountering and experiencing ‘different worlds’ had profound resonances across the foci of this piece of research. As Amy explains in the extract above, at one level the staff and students described in this study inhabit the two very different worlds – the Hospital and the training institution, and world of their family and personal life, and at times this relationship could be a strained one. Secondly, the purpose of the nursing school is to prepare men and women to both live and mediate in the ‘real world’ of nursing. The research represented in this thesis problematizes and renders strange the process of professional preparation for these students through contrastive and ‘wise reading’ (Delamont, 1992; Todd, 1996) that draws on parallel occupational settings and trajectories (e.g. teachers (Lortie, 1975; Lacey, 1970; 1977; Zeichner et al., 1990; Salisbury, 1994); doctoral students (Delamont et al., 1994; 1997); medical students (Becker et al. 1961 ; Atkinson, 1981 ); nurses (Melia, 1987; Davies, 1988); journalists (Parry. 1988); accountants (Coffey, 1993); social workers (Pithouse, 1994); and estate managers (Greed, 1991 ). However, what makes this setting distinct is the fact that ‘vocation’ is expressed literally as a both ‘calling’ and a “caring profession”, which implies that a certain set of “skill” and “qualities” are needed in order for students to function as a member of the profession. This often sparks a question for me of whether caring can be taught…a niggling question I hope to examine during this research. Finally, as a novice researcher, I will be able to move relatively easy between the lived realities of the student due to my own occupational biography and my familiarity with the world of the college. Hence, I will be also experiencing something of the different world that comprise the context of this piece of work.
Lofland and Lofland (1995) write of ‘starting where you are’ in the production of ethnographic, empirical accounts, as well as the role played by ‘remote biography’ and ‘personal history’. This advice in no small way influenced my initial and subsequent choice of research topic and setting. At the time my initial proposal was developed, I was working as a nurse and had been responsible for mentoring several students whilst they were undertaking their formal nurse practice. In addition, as a student in my own nurse training. I was also deeply interested in using my ‘sociological imagination’ (Wright Mills, 1959) to focus a critical gaze on, and render ‘strange’ and ‘problematic’ (Becker. 1971; Delamont, 1992; Delamont and Atkinson 1995) my own recent occupational preparation and working life. Alongside this interest was my reflection and questions about my own responses to the training process I had undergone. I had experienced a profound realization of the palimpsest nature of my identity an occupational identity shaped and forged in the training process and expressed as a set of personal, social and professional roles performed for 20 years, however it felt like these roles had been almost completely erased and ‘written’ over. Training to be a nurse had undoubtedly changed me, but beyond nursing, traces of that particular identity remain a part of me. How had some of the features and social processes of the training process I had experienced come to be irrevocably written on my senses of self?
Initial searches of the literature revealed the ‘gap’ in empirical data specifically in this area. However, the earlier work and research on nursing students in the UK by (Melia, 1984) seemed like a good starting point.
As with some other researchers (Parry, 1888; Salisbury, 1994), the idea and research were chosen deliberately since they would offer the opportunity to research within the ethnographic tradition and to triangulate using a range of qualitative methods (Denzin, 1976), as well as sewing my own ‘apprenticeship’ in the practice and development of ethnographic research skills. While studying Sociology as a student nurses I had been profoundly interested in and ‘turn on’ to this research paradigm as a result of reading examples of published ethnographic work (eg. Humphreys. 1970; Delamont. 1976; Lacey, 1977; Ball, 1981; and Mac and Ghaill, 1988). I discovered through an increasing familiarity with this type of work and writing that “qualitative data are sexy’! (Miles and Huberman, 1994). Hence, it was considered that this type of project would sustain my interest throughout the arduous research process and the ‘lonely voyage’ of writing-up.
Questions to be addressed by the research:
Towler and Coxon (1979)in justifying their own research projects focusing on clergy recruitment and training, argue that: ‘knowledge about the training given to clergy tells us what sort of specialists the Church aims to have: what
skills they should possess, what knowledge they need, what attitudes and values should characterise them. What the clergy are supposed to be like will become clear through an examination of their…training…’ This rationale also provides the justification for the work presented in this thesis in that it clearly maps out and anticipates a strong relationship between the relative intimacy of the training institution, the process and environment experienced by the trainee nurses. An articulation of this with the more formal and formalised demands of ‘the professional or occupational group is needed.
Key research questions or ‘sensitizing concepts’ (Blumer, 1954) were initially generated as a result of a number of strategies. These included:
? Critical reflection on and ‘interrogation’ of previous personal experience of training in nursing for example, revisiting personal diaries that I had written at the time;
? Initial literature review work/contrastive reading (Delamont et al., 1997) on parallel occupational preparations and trajectories; and an access interview with a key gatekeeper.
Once initial access has been negotiated, I will use the period of induction for the new trainees and their first term at the nursing college to observe both routine and key events in college. These observation data also helped to refine, as well as generate new questions to frame of the research. This ‘progressive focusing’ (Hammersley and Atkinson, 1995) will become a feature of the ongoing fieldwork.
Key research questions:
a) What factors / experiences have influenced the choice of this ‘career’ for the trainees?
b) ” unofficial constructs” shape the perceptions of the trainees prior to and during formal training?
c) How does the process of selection operate? What criteria are operationalized in the selection process? (Is there a construct of the ‘ideal candidates’?)
d) What are the candidates’ expectations of their training and clinical placement and how do they respond to the ‘reality shock’ of life at the Nursing School)
e) What is the nature of the education and training regime at the Nursing School? How is it monitored / evaluated / inspected?
f) What significant variations, heterogeneities, roles and typologies exist and can be ethnographically mapped?
– married / singles
– age and previous experience
– The role and experiences of wives/husbands/partners/children in the journey to professional status.
– gender and nursing students
– range of academic background and academic programme followed
g) How do these heterogeneities shape and influence experiences and expectations?
h) What perceptions and understandings do the trainees have of each other?
What groupings or subcultures occur?
j) What are the forms and outcomes of assessment /surveillance /discipline /normalisation processes?
k) What is the significance of time management and temporal structures within the institution?
I) What is the nature and transmission of ‘professional knowledge’ and therefore, institutional/ occupational culture or ‘habitus’?
m) What is the relationship between this institution and external professional bodies, organisations and people?
The ‘open ended nature’ of ethnographic research (Measor and Woods, 1991) meant that as fieldwork progressed, further questions were generated and tested as theory was developed and grounded (Glaser and Strauss, 1967).
Value of the research:
This piece of work contributes to the expanding literature and empirical work on Occupational Socialization and the Sociology of the Professions.
Theoretical and Methodological Frames:
The interactionist tradition provides a dominant structuring and theoretical framework for this piece of work since this approach facilitates a closer exploration and also serves as an avenue for the discovery of the ‘passage from the layman’s estate to that of the professional’, with attention to the crises and dilemmas of role which arise (Hughes, 1958). What is presented throughout represents a conscious attempt to be ‘theoretically eclectic’ (Salisbury. 1994) In order to make sense or the complex social processes involved in the training of student nurses.
As Atkinson and Housley (2003: 1-33) argue, the story of interactionism is a complex one and is bound up with the story of sociology at the University of Chicago (the ‘Chicago School’) in the 1920s and 1930s and its association with the development of qualitative field research and the emerging sociological tradition of ethnographic empirical work. Atkinson and Housley (2003), drawing on the work of Fisher and Strauss (1978, 1978) describes two different theoretical/methodological strands and institutional contexts within the tradition (the Park – Thomas tradition of empirical sociological research inspired by the city around them and, secondly, the social philosophy and psychology of George Herbert Mead and codified by Herbert Blumer). As Atkinson and Housley (2003) argue:
‘There are points of contact, and some individual scholars have been influenced by both traditions. Others have worked much more in one or another. Yet others. Fisher and Strauss suggest, probably cannot tell the difference, having been socialized into a generalist ‘interactionist’ perspective.’
The Park-Thomas tradition took inspiration from Chicago’s growing and spatially segregated multi-ethnic and cultural composition and has resulted in numerous empirical explorations of the distinctive neighbourhoods that characterised the different areas of the city. The methodological developments that accompanied these ‘urban ethnographies’ represented advances in both qualitative and quantitative techniques and were formulated in order to describe and analyse the complex processes of social and spatial evolution at the frontiers of different zones of the city. As Atkinson and Housley (2003) state:
‘The Park-Thomas strand of thought was significant in the development of interactionist sociology. It stressed the centrality of social change. In doing so, the sociology of Chicago reflected the times: the manifest turmoil of the end of the nineteenth century and the early decades of the twentieth. The transformations of an urban and industrial society, increasingly characterised by ethnic and cultural diversity, provided the backdrop and the subject matter of the sociological programme. The sociologists saw themselves, and acted as, public intellectuals, actively engaged in shaping social transformations, and in the creation of a well-informed public.’
Mead (1932, 1934, and 1938) developed a view of social change that was congruent with the sociologists, but that was embedded in the view that such change was associated with the distinctive human characteristic of language and its consequences and the ways in which language can transcend the concrete limitations of stimulus-response reactions.
‘Language allows for the creation of culture, in that human social actors can exchange experiences, cumulate experiences and share meanings.’ (Atkinson and Housley, 2003: 6)
Language can permit a dialogue either between actors or allow for a form of internal dialogue so that the human actor can also act reflexively on herself or himself. The actor has a dual character in that it can treat herself or himself as a form of ‘other’ and aspects of ‘the self can be regarded as being constituted through the interactions of this dual character the ‘l’ (the origin of action) and the ‘Me’ (the object of self-awareness). In a sense, the ‘I’ can be regarded as a form of ‘ego’, and the ‘Me’ as a reflexive ‘looking glass self (Cooley, 1902). These dual aspects have been expressed as tensional: the impulsive and creative impulse versus the socialized internalization of social mores.
‘This general capacity therefore permits the human actor to take the role of the other in being able to imaginatively grasp how another actor is stimulated. One can, therefore, monitor and adapt one’s conduct in the light of others’ perceived perceptions and judgements. The process of socialization also means that actors internalize not merely the judgements of concrete, specific others; they also develop a sense of the ‘generalized other, so that they come into a fully socialized awareness of the social milieu in which they are placed.’ (Atkinson and Housley, 2003)
Blumer (1969) explicitly linked the sociological work of the Park Thomas stand with Mead’s social psychology and in doing so established a number of important principles:
a. the concern of sociology is social action;
b. individual and group action is meaningful.
In stressing the relationship and importance of action and meaning, he emphasised the ‘symbolic’ function involved in human beings acting on the basis of their interpretations and understandings. Thomas (1923) formulated this as the ‘definition of the situation’: situations are real insofar as they are defined as real and are real in their consequences.
The interactionist tradition has methodological implications in that:
‘the most important premise is that enquiry must be grounded in the empirical world under study. By the ’empirical social world’ is meant the minute-by-minute, day-to-day social life of individuals, as they develop understandings and meanings …… Research methods are the means to discover that reality…’ (Woods, 1996: 37)
Hence the emphasis in this research is on ‘naturalism’ and “grounded theory” (Glaser and Strauss,1967), in an endeavour to keep faith with the empirical world under scrutiny. Blumer (1969) advocated the use of ‘sensitizing concepts’ (heuristic ideas, or ‘directions along which to look’) that reflect the relative indeterminacy of research ideas and runs counter to ideas that suggest that productive and valid research can only be conducted if research hypotheses and variables are specified with complete precision (Atkinson and Housley, 2003). These ideas were further developed with the empirical social research of the second Chicago School (Fine, 1995) and associated with, for example, Everett Hughes, Blanch Geer, Howard Becker, Anselm Strauss, Rue Bucher, Leonard Schatzman and Virginia Olesen. Key empirical themes in their work involved a focus on work and occupations (individual careers. trajectories and the constraints of social institutions), a rejection of the notion of ‘professions’ as a category that display distinctive traits and value systems that differentiate them from other occupational groups and, in particular, occupational and professional socialization and the development of collective perspectives on and responses to shared experiences.
Occupational socialization, for Hughes and his colleagues, was a matter of situated learning: more a series of coping strategies and survival tactics than a smooth internalization of knowledge and values …… such coping mechanisms became part of a self-sustaining culture and had practical consequences for the conduct of education and work. Socialization was thus seen as a process of mutual adaptation between the institution and its members.’ (Atkinson and Housley, 2003).
This has significance for this study of the nurses in Barbados and their occupational preparation and socialization since they cannot be regarded as ‘passive receptors’ of a process ( e.g. Becker et al 1961) or occupational culture but are agents active in shaping and negotiating their very public identities. The emphasis is, therefore, placed on the process of the construction of ‘identity’ and the importance of ‘impression management’ (Goffman. 1959) in social situations. Multiplicities of meaning and interpretation in relation to identity are regarded as being developed in particular contexts and as a result of complex processes of interaction (Mac and Ghaill. 1994).
Following Schutz and Luckmann (1974), this project also draws where relevant on a social phenomenological perspective, in that it seeks to describe the ways in which the trainees perceive and make sense of their “categories of reality’ through the ‘reflective glance’ and in doing so how collective
‘life-worlds’ are constructed. In this way, interactionism and Schutzian phenomenology both inform and enable the ethnographic ‘mapping’ and ‘thick description’ of the multi-faceted and layered relationships and meanings of the complex community of this nursing college.
Denzin and Lincoln (1994: 2) argue that:
‘the qualitative researcher-as-bricoleur uses the tools of his or her methodological trade, deploying whatever strategies or methods, or empirical materials are at hand …… The choice of research practices depends upon the questions that are asked…what is available in the context, and what the researcher can do in that setting.’
While recognising the inherent problems of constructing monolithic methodological categorisations or paradigms, the research represented in this study adopted an ethnographic approach, using qualitative methods of observation, informal, semi-structured interviews, and documentary analysis (the “ethnographic triptych’, Sanger, 1996), as well as a focus group with the male trainees at the Nursing College and a consideration of relevant secondary data. These methods were chosen in order to facilitate ‘getting close’ to the participants’ perspectives and culture, and ‘capturing’ the individual’s point of view. Through triangulation, these strategies of data collection have been proven successful in securing ‘rich descriptions’ (Denzin and Lincoln, 1994) of the social worlds of the participants, as well as offering the possibility of producing reflexive and complex ‘tales of the field’ (Van Maanen, 1988).
Thus, the socially situated researcher with an identity and history that impact on those who have been researched, is located within all stages of the research process, including the interpretation of data and the generation of ethnographic fiction’ (Atkinson. 1990; Coffey, 1996). In writing of the ‘fifth and the sixth moments’ of ethnography, or
ethnographic, interpretive writing, ‘in the twilight years or the twentieth century (Denzin, 1997), argues that ethnographic inquiry is concerned with the production of ‘messy texts’ that
‘focus on those events, narratives, and stories that people tell one another as they attempt to make sense of the epiphanies or existential taming-point moments of their lives.’
He goes on to claim that:
“messy texts are many sited, open ended. they refuse theoretical closure, and they do not indulge in abstract, analytic theorizing. They make the writer a part of the writing project…they attempt to reflexively map multiple discourses that occur in a given social space. Hence, they are always multi
voiced, and no given interpretation is privileged.’
Although not all ethnographers would uncritically accept Denzin’s somewhat linear account of the history of ethnography (e.g. Atkinson at al. 1999), his ideas have become associated with what has been termed ‘the crisis of representation’ in ethnography and is associated with postmodernist and post-structuralist agendas (Clifford and Marcus,1986; Denzin and Lincoln. 2000). These agendas imply a rejection of the principles of “realist ethnographic narrative’ and recognise that all borders are ‘fuzzy’, in that the ‘boundaries between the self and other, researcher and researched, sex and gender, text and topic are all overthrown’ (Delamont, 1997). At the very least, it has been argued that such developments imply more reflexive self-conscious research and texts that draw on new conceptual frameworks of aesthetic understanding and more complex considerations of authorship and audience (Atkinson et al.. 2003. In response to these developments, in this thesis I adopt the view that all accounts are ‘partial’ and do not assume that the social world is an ‘objective reality’ capable of being ‘captured’ or ‘truthfully represented by the ‘aloof researcher (Taraborrelli, 1996). Rather, in this thesis I seek to celebrate the ‘multiple realities’ (Hammersley and Atkinson, 1995) of multifarious social settings in offering a tapestry of accounts that are ‘anchored in the worlds of lived experience’ (Denzin, 1997) within a nurse training programme in Barbados. This piece of work, therefore, stresses the socially constructed nature of reality for the staff and trainees described in it, as well as the ‘intimate’ relationship between these participants and myself as researcher.
This piece of work does not contain a discrete section that critically considers the existing literature relevant to the study. Informed by the work of Atkinson (1981), Van Maanen (1988) and Lofland and Lofland (1995), and some other examples of published ethnographic studies (Salisbury. 1994; Taraborrelli, 1996), I shall:
‘weave’, ‘blend’ and ‘interpenetrate’ the analytic frame and the qualitative data to produce an ‘eventful’ ethnographic account. (Salisbury, 1994)
Throughout the main body of this work, therefore, the various literatures are used and referred to when they illuminate the qualitative data collected during fieldwork.
Review of the Literature
Broadly, socialization is a process by which one learns the norms of a particular group (Adams & Coltrane, 2005). Each of us encounters numerous socialization processes throughout life. With respect to the socialization into nursing. Nurse educators and Nursing Schools initiate socialization as students are taught the traditions and knowledge the “technical know-how” of nursing, and then guide the students as they develop their abilities to think and behave as nurses. After school, graduates are socialized into specific work settings through orientation and preceptor programs.
The concept of socialization indicates the systemic effects of the old to the new generation, in order to develop those characteristics that society deems necessary for the integration of young people in this new world. The professional socialization is a developmental process in adult socialization and is of central importance to the replication of the community culture.
Education is therefore a specialized form of socialization that is normally exercised by entities outside of the family and has as its content the transmission of knowledge, skills and form of energies or conduct (Weidman, Twale and Stein 2001). Education prepares young people for entry into society and is thus a form of socialization. Haralambos and Holborn wrote that “in its broadest sense, education is simply one aspect of socialization: it involves the acquisition of knowledge and the learning of skills. Whether intentionally or unintentionally, education often helps to shape beliefs and moral values” (Haralambos and Holborn 2000).
Durkheim saw the major transmission of society’s norms and values through education. Durkheim believed schools were the primary socialization agent for the production of future adults. This is reflected in his work on moral education, which places the development of consensus and solidarity in society in the hands of the school. Durkheim pronounced education as a challenged social institution in society. One that establishes and upheld social consensus and solidarity through its socializing function (secondary socialization).
Socialization is a process controlled by the community (society) (Luhmann 1995), and according to Berger (1983) is the process through which the child/individual learns how to become a member of society, internalizing the social world. The same process occurs whenever an adult enters in a new social context or in a new social group (Berger 1983).
Socialization fulfills a clear role in society, because due to this process, people endure the pressure of their social environment, since the internal structure is determined by the rules, values and orientations of the society in which they live (Vanderstraeten 2000). According to Berger (1983) the society forces and creates. So the individuals seeking entrance to a particular group, instills those attributes, and learn the behaviours that are common among group members. The members of society or group themselves want to posses the mannerisms, deportment and behaviour which represents and replicate those characterictics and values which society expects from them, because society determines not only what makes a person but eventually what constitutes those essential elements and behaviours that should be replicated by society members.
The psychologist Baumeister (1996) conceders, on the one hand, the freedom of the will which the individual has, but on the other hand admits that no one can develop his/her identity by ignoring the socio-cultural context. In this sense the way a person grows and changes depends on the social systems of which they are a member (family, peer group, school class, professional group, etc.). This “self” construction and reconstruction is a continuous process of social interactions and relationships. (Berger 1983, Anderson & Goolishian 1988).
The professional socialization is a developmental process in adult socialization and is of central importance (Howkins & Ewens 1999) in contributing to the ongoing production cycle of young professionals practicing their skills in the labor market (Du toit 1995). Treated as a lifelong process in which a person learns to become functional member of a group (Faison 2003). Merton et al (1957) refers to it as “the process by which the individual selectively acquires the values, attitudes, and behaviours, interests, skills and knowledge and the dominant culture group of which he is, or seeks to become a member”.
According to Du Toit (1995), professional socialization is a process that takes place during the time of life and consists of three stages: a) the stage of the pre—socialization corresponding to the secondary education and is associated with the values and attitudes of adolescents and important for them persons and the image that exists in society for the profession (b) the stage of formal socialization corresponding vocational training and (c) the stage of post-socialization corresponds to the period of career until retirement (Du Toit 1995).
The socialization into the profession is a process of transforming a beginner to a professional, and is treated as a process of integration during which the values, the norms of behaviour and the symbols of the profession is internalized (Du Toit 1995), and the newcomers adopt ethical standards and even the lifestyle of the team which the individual is seeking to become a member of”(Hardy ; Conway 1988, Melia 1984). This internalization of behavioural norms and standards leading to the formation of a sense of identity and commitment to a professional ?eld” (Weidman, Twale & Stein 2001).
The process of professional socialization and the construction of professional identity is a dialectical relationship (Jenkins 1996). (Gregg et al 2001, Fitzpatrick, While & Roberts 1996) points out that, socialization aims to develop a professional identity and the adoption of a particular professional role. Waugman and Lohrer (2000) also consider that during the socialization the individual adopts social group’s mission, organizational goals and underpin knowledge, learning technology, the language of the profession, and ?nally integrates the professional role in identity.
The educational system is the official institution in which society disseminates – instills- perpetuates the prevailing values and conceptions, creating citizens and professionals needed for maintenance operations and meeting its needs. Training is provided mainly at secondary and tertiary level. The years of undergraduate education usually coincides with post adolescence age and therefore is time for reconstruction of identity because of the significant events that occur in this stage of life. Speci?cally, the age is considered to be critical because most students in adulthood embark on other aspects of life, while at this time the foundations of professional identity is laid. This coincides with other important aspects of their lives, such as, separation from parents, developing their relationships with the opposite sex and sometimes for some the beginning of their individual family. They identify professions as a pre requisite for advancement within the society (Ryynanen 2001).
Role of Nursing Instructors
Nursing instructors have been cited as an important influence on male nurses’ choice of career paths within the profession as well as reinforcing male privilege, and disadvantages (Evans & Blye, 2003; O’Lynn, 2004; Soerlie, Talseth & Norberg, 1997; Stott, 2003). The instructor of nursing is an influential person in the socialization of the student to the professional role, and the direction students take in their careers (Soerlie, Talseth, & Norberg). As part of this socialization process, the instructor is charged with finding learning opportunities that will assist the student to develop professionally. The literature refers to the professional responsibilities of the instructor on the clinical unit as necessitating that the instructor forms a close working relationship with the student (Tang, Chou & Chiang, 2005). The effectiveness of nursing instruction is based on the instructor’s attitudes toward the student. This attitude can have a significant influence on the student’s feelings of success or failure in their ability to be clinically successful. Unlike the classroom setting, in which most communication is one-way with the teacher standing in front of a classroom full of students and speaking while the student passively participates as the observer, listener, and recipient of information, the clinical setting involves more one-to-one, intimate dialogue and interaction between student and instructor. As part of this close relationship between student and instructor, students look toward instructors to point out their strengths as well as weaknesses in a way that is supportive and displays a positive attitude toward the student (Tang, Chou & Chiang, 2005). With this aspect of instruction in mind, men have reported a lack of knowledgeable advisors to guide them in career decision-making (Gilchrist & Rector, 2007). Men have been encouraged and expected to not just go into the high-tech areas, but to also fulfill roles in the clinical area such as dealing with the aggressive patients and doing most of the heavy lifting (Gelchrist & Rector). These are just some examples which have led to an encouragement for female nurses, especially instructors, to engage in some “gender awareness training” to develop an awareness of the male student’s needs (Gelchrist & Rector, 2007; O’Lynn, 2004). Having accurate information from an instructor could 8 make the difference in a male choosing a field such as pediatrics, rather then intensive care. In order for an instructor to determine the true strengths and weaknesses of the student, the instructor must assign the student to a variety of patient care situations. This cannot occur if the instructor has underlying assumptions or biases regarding a student’s capability due to their gender. An example of this would be not assigning a male student to a female patient, or not assigning males to patients who require a great amount of personal care. Favoring or insisting that male students be assigned strictly to male patients or female patients who are relatively independent in their ability to meet their activities of daily living (ADL’s) is counter-,productive and places restrictions on students experiences’, limiting the opportunities that the student has to develop their skills. Challenges to the Nursing Instructor The importance of examining the socialization of males to nursing is two-fold. The first issue addresses the goals of educational experiences for males as well as females. Dickson, Walker and Bourgeois (2006) speak to the agreed-upon perspective throughout the nursing literature as to the goals of the clinical experience: “skill acquisition, integration of theory with practice, application of problem solving skills, development of interpersonal skills, socialization to the informal and formal norms of the profession, acclimatization to the protocol and expectation of professional practice and exposure to the socio-political health care area (p. 417).” The clinical instructor, therefore, becomes a facilitator of the learning experience, through providing time with a student as well as focusing the interaction and guiding the process of education (Dickson, Walker & Bourgeois, 2006; Lambert, 2005). The second issue deals with professional development. “Male students look to faculty to provide opportunities and support for learning” (Anthony, 2006, p. 228). Types of clinical 9 experiences do not solely reinforce theoretical information, but also expose the student to various types of nursing care. This becomes important to the student in formulating an idea of what type of nursing they may desire to engage in after graduation. Students should be encouraged to go into areas that complement their strengths, not those that fit into what is assumed will be their area of strength because of their gender. Not only does the instructor aid the student by pulling together theoretical information and pointing out its use in the clinical setting, but also in assisting the student nurse in identifying his or her place within the profession. A person finding their “place” within a profession is strongly influenced by the individual who is instructing them to the role. Within nursing, this person is primarily an instructor found in the clinical setting. Part of what is influential on a student’s socialization is the student’s positionality within the larger group. The next section of this paper describes what is meant by positionality and how this concept affects the teaching-learning environment. Positionality of Male Nursing Students The adult education literature is replete with literature regarding the topic of student positionality and its effect on the learning environment (Brown, Cervero, Johnson-Baily, 2000; Johnson-Baily & Cervero, 1998; Merriam, Johnson-Baily, Ming-Yee, Kee, Ntseane & Muhamad, 2001). Positionality refers to existing social structures and how those structures affect the student in the learning environment. For example, males are the outsiders within nursing educational programs. This has been referred to as the insider/outsider status when discussing student positionality within adult education (Merriam, Johnson-Baily, Lee, Kee, Ntseane & Muhamad). Insider/outsider status exists when one’s positionality in terms of gender, class, race, sexual orientation, and/or religion offer one either advantages or disadvantages, depending on how this individual is similar to or different from the dominant group. In terms of gender to the nursing profession, being a female provides a student “insider” status and a male “outsider” status within the classroom and clinical situations. The student-teacher relationship, as far as the social location of the student in terms of gender, has been studied to some extent within the adult education field (Brown, Cervero & Johnson-Baily, 2000). Brown, Cervero & Johnson-Baily (2000) found that the social location of a teacher impacts the dynamic in the teaching and learning process. Nursing offers a unique look at the concept of overall social privilege and how it can spill over into environments where those who hold power in society (men) are now the minority and those who hold lesser social status (women) are now those within positions of power. Do social factors of what is considered masculine and feminine affect the way in which nursing instructors interact with and socialize the male student? How does a female react when placed in a position in which they have authority over males? Does the social status of men affect the way in which instructors interact, advise, and utilize corrective action in the clinical setting?
Recruitment of men into the nursing profession is considered to have two positive impacts. The first is to relieve the nursing shortage by marketing the profession to 50% of the population who, otherwise, may not have considered the profession due to the female image associated with the profession. Secondly, the influx of men in nursing is felt to raise the professional value of nurses within the health-care field. Men are thought to bring with them a certain amount of power and prestige, which in turn will help raise nurses’ salaries and improve working conditions within the field (Yurkovich, 2006). In addition to the impact on salaries, men’s participation in nursing education and the nursing profession has been studied from many different viewpoints. Throughout the research it is clear that when men enter the nursing profession, they face advantages as well as disadvantages (Anthony, 2004; Brady & Sherrod, 2003; Evans, 2004; Kelly, Shoemaker & Steele, 1996; Okraniec, 1994; O’Lynn, 2004; Soerlie, Talseth & Norberg, 1997, Williams, 1989, 1993, & 1995). What has been concluded from this research is that men, while in nursing education, do face marginalization due to their gender. This comes across in nursing texts when the nurse is always referred to as “she,” or instructors address their classrooms as “ladies,” instead of ladies and gentlemen. Men have also found that although they are on the margins as far as numbers, they also enjoy privilege in the form of being elevated to positions of status in the profession. The elevated status of men, therefore, does not begin as they enter the working environment but rather starts within nursing educational programs. Men who participate in nursing education programs report being nominated and elected to leadership by their female student colleagues (Soerlie, Talseth & Norberg 1997). The female colleagues, who are in the majority, tend to step aside for this minority population, allowing them to take over as the leaders.
The history of nursing suggests that men might possess contradictory norms than those that have evolved for women in the profession. Merton (1968) studied reference groups and explored the ramifications of membership in multiple groups with divergent or contradictory norms and standards. He identified the concept of deprivation, defined as a functional type, and examined a variety of group behaviors in the armed forces. Although these studies only looked at men in military service, they were significant to this reviewf literature since they identified an area that has been fruitfully explored by other professionals.
In a study of 220 new nurse graduates, Kramer (1968) identified the need of new graduates to resolve bureaucratic role conflict by studying the ways that the novice nurse works toward developing competence in the work setting. Krammer and Schmalenberg (1976) wrote a manual for nurses entering the profession basing their advice on material drawn from this study. They used, as examples, diaries and letters of new or recent graduates from both the United States and Canada.
These authors identified the phenomenon of “reality shock”, defined as the time “when an individual moves out of a subculture in which he is competent and feels comfortable and into a new subculture” (Kramer and Schmalenberg, 1976, p. 21). Kramer and Schmalenberg also noted that to “become interpersonally competent in the new work subculture…one must be able to interpret accurately a given situation from the point of view of someone well adapted to the work subculture” (p. 22).
Banner (1984) applied the Dryfus model or skill acquisition to individuals entering nursing. Twentyone pairs at nurses, one new to the profession and one with experience, were interviewed separately to O’Toole (1991), can be divided into several broad categories: sex role stereotyping and career choice, recruitment, role strain, male nursing student experiences and empathy. The literature associated with each of these areas is discussed in the following sections.
Sex Role stereotyping and Career Choice
The choice of an occupational role is a significant task for the young adult. Merton (1968) discussed the importance of anticipatory socialization in the selection and implementation of an occupational role, other literature suggests that the small number of males who choose nursing as a career can be attributed to the portrayal of nursing as an exclusively feminine profession (Aldag & Christensen, 1967; Vaz, 1968; Aldag, 1970; Minnigerode, KayserJones, & Garcia, 1978; Egeland & Brown, 1988: Pontin, 1988).
Vaz (1968) was very interested in young boys’ attitudes toward nursing. The purpose of her study was to determine some of the factors that underlie male selection or rejection of nursing as a career. In this study, 506 high school senior boys from six public high schools in the Northeast responded to an attitudinal scale and check list designed by the researcher. Students were asked to rate which of seven occupations would be most acceptable to them. “Masculinity was the dimension of primary interest in the research” (p. 535). The results revealed that nursing “was clearly ranked at the lower end of the masculinity scale as defined by 315 observed cases” (p. 536).
Aldag and Christensen (1967) were interested in the personality characteristics of male nursing students. They designed a study to investigate how this group compared to three other groups: male junior college students, female junior college students and female nursing students. Each group contained 29 subjects. The short form of the Minnesota Multiphasic Personality Inventory (MMPI) was used to determine if male nursing students were more similar to female nursing students than to other groups. The questions asked related to whether female college students would show similar personality characteristics to students who chose nursing or to all students in the general college population. “In essence both analyses asked whether vocational interest or sex-linked interest were primary in predicting personality characteristics” (p. 375).
The findings indicated that male nursing students were more similar to female nursing students than to male junior college students. “Nursing students, regardless of sex, had significantly greater ‘femininity’ scores than junior college students” (Aldag and Christensen, 1967, p. 376). In addition, nursing students of both sexes demonstrated a unique set of personality attributes. These included responsibility and generosity with a passive dependent character structure. One weakness of this study, however, was the reliance on a sample from one Midwestern junior college. _
In a later study, Aldag (1970), utilizing the Strong Vocational Interest Blank (SVIB), randomly surveyed 145 students in each of four groups: female, nursing students, male nursing students, male college students and female college students, to compare the occupational and non-occupational interests of male nursing students to the other groups. The researcher’s hypothesis was that “male nurses would have more feminine interests than college males” (p. 533). The findings supported the researcher’s hypothesis that male nursing students appeared to have interests characterized as “more feminine than college males” (p. 533). However, all nursing students were characterized as having more feminine interests. This study therefore supported Vaz’s conclusion that “nursing is a feminine occupation” (p. 533).
In a later study, Mlott, Rust, Assey and Doscher (1986) examined the “personality structure of men who chose nursing as a career” (p. 372) by comparing them to a control group of men comparable in years of education, marriage and socioeconomic status. The MMPI, the Barksdale Self-Esteem Inventory and the Imaginal Process Inventory were used to gather data.
A sample of fifteen male nursing students responded to all three instruments. A matched group of male college students was used for comparison. Although the sample size was small and drawn from the same Southern collegiate school of nursing. It is interesting to note that the men were found to be comparable to other men in their personality traits. This is particularly significant since the indicator of feminine characteristics on the MMPI is an interest in nursing.
The findings also revealed that men entering nursing possess “adequate self-concept, level of ego strength, self-esteem, and male sexuality” (Mlott et al., 1986, p. 371). Additionally, they appeared to rely less on fantasy in their day to day functioning than the comparison group.
The authors postulated that the reason for the difference between their findings and similar research studies may be attributed to a change in the type of individual who was considering nursing as a career choice at that time or the changes were attributed to design flaws in the study’s methodology. The passage of time from studies performed in the sixties and seventies to more contemporary studies with the accompanying changes in health care systems supports the first thesis.
As times changed, so did some of their research tools and particular foci of the studies. Of particular interest during the late 1960’s and 1970’s was a redefinition of sex roles. In nursing, Minnigerode, Kayser-Jones and Garcia (19l8) were specifically interested in examining the implications of the redefinition of sex roles and how individuals would describe the ideal nurse.
One hundred and eighty-six nursing students completed the Personal Attribute Questionnaire (PAQ) developed by Spence and colleagues. This scale presumes that masculinity and femininity are independent of each other and that high scores on both masculine and feminine items shows psychological androgyny.
0f the 186 subjects who participated, 75 were female undergraduate nursing students from the ‘University of San Francisco, 62 were female undergraduate nursing students from the University of California at San Francisco, and 14 were males from both the undergraduate and graduate nursing programs from both institutions. The findings revealed that the ideal nurse was described as someone capable of displaying both masculine characteristics such as independence, competitiveness, self-confidence, and decision making, as well as the traditionally female characteristics of warmth, understanding, gentleness, helpfulness, and kindness. Based on these findings, the researchers concluded that both male and female characteristics are important in nursing and that sex typing of the profession should end.
Culkin, Tricarico, and Cohen (1981) examined sex role orientation of male (n= 20) and female (n= 48) nursing students who were attending a community college in the Northeast. The Ben Sex Role Inventory was used to collect data. According to Ben’s theory, this scale would “predict that men who enter a traditionally female field would tend to be androgynous, in part because the androgynous person is less likely to perceive the world of work in terms of sex typed areas”(p. 949). This study, however, did not support Ben’s theory. Males in this study were not more androgynous than their female counterparts, and both groups were equally likely to be sex typed. The researchers suggested that the findings of this study be viewed cautiously. The Ben Scale may not have been an appropriate choice of instrument for this study because the sample consisted of volunteers who had previously been employed and were older than the mean age of college students.
A related study of male and female nurses was conducted by Dentin (1988) in the United Kingdom. He was interested in determining whether male nurses were psychologically androgynous. In this study, the Bem Sex Role Inventory (BSRI) was used with a sample of 23 nurses. Thirteen of the nurses returning the inventory were female and ten were male. The findings revealed male nurses do exhibit a degree of androgyny with regard to sex role orientation (p.722). “Female nurses, too, are seen to be androgynous…” (p.773).
An interesting corollary of this study is found in a study conducted by Powell and Jacobs (1984) that noted occupations in England tend to be less gender specific. A study using both male nursing students and male practicing nurses was undertaken by Manino (1963), who was interested in discovering why men entered the field of nursing. The sample consisted of 516 male graduates and student nurses. Although the author attempted to solicit data nationwide, the sample was predominantly drawn from the Pennsylvania Hospital School of Nursing for Men (n=394).
A questionnaire was created by analyzing essays written by students at the Pennsylvania Hospital School of Nursing for Men. It consisted of 16 statements on why men choose nursing as a career. The last statement asked the respondents to offer other choices not available in the 16 forced choice responses. Additionally, demographic information solicited input on a variety of variables including marital, job, and military status as well as whether they would recommend nursing as a career to other men.
According to Mannino (1963), the results of this study showed that the first five reasons for selecting nursing as a career were: (1) “because I like people and enjoy helping them” (p. 186), (2) financial inability to pursue medicine as a career, (3) increase in status, (4) humanitarian motives, and (5) security. Demographic data from this group revealed that the median age was 37 years old, married with children, with previous military service. Approximately 61% responded that they had been previously employed in another occupation before choosing nursing. More than 70% stated they would suggest nursing as a career, primarily because it was viewed as “a good stepping stone to other fields”(p. 186). Of note relative to this statement is that most of the men surveyed were children of individuals who listed their occupations as skilled and semiskilled workers.
Williams (1973) was interested in discovering the characteristics of men who selected nursing as a career. For this study, 384 male nursing students from 13 states and 32 nursing programs that comprised the Western Interstate Commission for Higher Education were mailed a three part questionnaire. Two hundred and seventy-three questionnaires (71%) were returned.
The questionnaire used for this study was developed by Auster and Luster (1970). The first part of the questionnaire requested demographic data and background characteristics. The second part examined the reasons for choosing nursing as a career. The final section asked for information specific to goals.
The findings revealed that most respondents came from middle class environments. The fathers of one half the respondents were identified as skilled craftsmen, managers, or members of a profession. Fifty-eight percent of the subjects were married, and
of these, 30% were married to nurses. Eighty-one percent responded that the most important reason for entering nursing was to “help people.” “Nearly….90% indicated that they would probably or definitely “choose nursing again if given the choice” (Auster and Auster, 1970, p. 522). Approximately two-thirds perceived their chances of getting ahead were better than most of their male friends. One-third viewed nursing as a career with good opportunities for upward mobility.
A recommendation offered by Garvin (1976) was that the findings be used to recruit more men into nursing. This section of the literature review addressed the importance of the conceptualization of men as individuals rather than exceptions within the profession. As a group they present characteristics that suggest the man’s socialization pattern may differ from a woman’s.
Several reports have been generated throughout the years that suggest one way to curtail nursing shortages is to recruit more men into the discipline (0.5. Public Health Service, 1963: National Commission for the study of Nursing and Nursing Education, 1970). This suggestion continues to be offered as one solution to the present shortage. Although the number of men who participate in the profession has remained somewhat stable, Johnson (1974) reported that a significant change in the proportion of men recruited into nursing occurred in 1972. In that year, the percentage of men nearly doubled from those admitted in 1969. Current figures illustrate a slight decline to 5.8% from the number of males admitted more than 20 years ago (Rosenfeld, 1989).
Johnson, Goad, and Canada (1984), were interested in investigating the differences in attitudes toward nursing as a career by men in selected majors. The study consisted of a sample of 247 male non-nursing majors and 94 male nursing students attending a community college in Texas. These individuals responded to the Attitudes Toward Nursing Scale (ATNS) developed by the researchers.
Demographic data collected for this study were consistent with those reported by other researchers. Male nursing students are generally older, married, and have previous military experience. Forty-three percent of college males not studying nursing at the time of this inquiry expressed an interest in nursing as a career if they were unsuccessful in their chosen fields. Students majoring in the humanities were more accepting of nursing as a possible career option than were students in the sciences.
The majority of nursing student respondents reported that the choice of nursing as a career did not require any loss of male characteristics. Responses by non-nursing majors were more supportive of nursing as a career choice for females only.
Kippenbrock (1990) looked specifically at factors that contributed to the success of recruiting men into nursing programs. The population surveyed included National League for Nursing-accredited baccalaureate schools. Two hundred and seventy-nine schools responded to the survey, a return rate of 66%. The tool used to gather the data was a combination of multiple choice, open ended questions, and Likert-type items developed by the investigator.
Seventy percent of the schools reported no efforts to recruit men. Multiple regression analysis revealed significant positive relationships in male application rates (r= .14) and male enrollments (r=.13) in schools with male faculty members. Room and board as well as tuition costs for particular schools demonstrated a significant relationship to enrollment rate. Only one recruitment strategy was noted as significant in recruiting males, the invitation of high school personnel to the campus. Stepwise multiple regression analysis showed that the combined independent variables of high ratio of doctorally prepared faculty per male
students and the number of gifts and endowments had a 23
multiple r of .23 and accounted for 23% of the variance in male applications and enrollments.
The findings of the studies dramatically illustrate the need for ethnographic study of men in nursing. Which variables are spurious? When men are successfully recruited, how are they socialized?
The status of nursing as a predominantly female profession has led to a body of research examining the concept of role strain for men who entered the nursing profession. Greenberg and Levine (1971) specifically looked at this topic in a preliminary investigation. Role strain for the male was defined as the conflict that was experienced when it was “difficult to reconcile one’s role as a man with one’s role as a nurse”(p. 419). Nine male nurses from Philadelphia and six from the Baltimore area were interviewed using the focused interview technique as developed by Merton, Fiske, and Kendall (1956). The ages of the interviewees ranged from 25 to 65. They were employed in a variety of settings and represented several
nursing specialties. Analysis of the interviews indicated that role strain did exist. Specifics of the interviews were reported in detail and provided insight into how male nurses dealt with role strain.
The men who were studied reported that certain specialties within nursing lessened role strain. These specialties were identified as those that did not require the “need to touch” (Greenberg and Levine, 1971, p. 421). The practice areas included were psychiatric nursing, accident and emergency, and administration. In addition, these specialities were perceived to be higher in status than other nursing specialties. It was also noted that a non-nursing garb was acceptable when functioning in these areas. Historical factors were suggested to have played a role in the tradition of men choosing psychiatric nursing since many men during these years received their training at a psychiatric hospital in Massachusetts. All 15 nurses in this study identified financial considerations as the primary reason for entering nursing. Men from the Depression Era noted that nursing school, with room and board, was free at the time. Nine of those interviewed were interested in medicine but could not afford medical school. Two said they did not have the ability to enter medicine.
Effeminate group in male nursing.
They shared their perception that this group did exist, but they were not a part of it.
In a related study, Bush (1976) examined role identity. This study focused on a small sample of six male nursing students and four male registered nurses. Consistent with the other reported studies, the male nursing students in this sample were older and married. When asked why they entered nursing, three primary reasons emerged: job security and opportunity, an interest in the biological sciences, and a desire to work in a humanistic field. Only one respondent said that he chose nursing because he was unable to enter medical school. Previous exposures to nursing, either through military service or a hospital experience, were reported as being helpful in the selection of nursing.
The interviewees stated that they received less negative comments than anticipated when they discussed their career choice with others. In fact, respondents said they felt advantaged. To illustrate the point, male nursing students have held a disproportionately high percentage of elected positions in the National Student Nurses’ Association. Similar to Greenberg and Levine’s (1971) study, the coping mechanism that frequently identified job availability as the primary reason they chose nursing while the female students expressed a humanitarian motivation. The men placed salary as the third most common response and working conditions fifth. These factors were not in the top five reasons for the female students.
When polled about plans, the men identified a strong preference for critical and acute care settings. Anesthesia, which has traditionally been rated high, was the fifth choice. The authors attributed this to the following:
Men entering nursing are more liberated, more willing to be identified as nurses. As male liberation develops concurrently with women’s liberation, it may become easier for men to allow themselves to be identified with nurses within the mainstream of nursing (Schoenmaker and Radosevich, 1976, p. 300).
Auster (1979) did a comparative analysis offth occupational attitudes and values of male and female nursing students. The sample consisted of 335 men and 508 women enrolled in 32 associate and diploma nursing programs. A questionnaire was used to collect initial data and was supplemented by 80 individual interviews with male nursing students.
According to Auster (1979), sex related role strain was found to be significant. Male respondents noted that the “rules and regulations of nursing school were ‘too strict'” (p. 23). The author did note, however, that most of this criticism came from students enrolled in diploma programs. When the students responded to the question, “What is your opinion about the difficulties of nurse’s training compared to what you had expected?” (p. 22) there was a significant sex difference (p