The Lived Experiences of Fijian Male Student Nurses - School of Nursing - Fiji National University: A Mixed Method Study

Osea Masilaca^*
*Correspondence: Osea Masilaca, College of Medicine, Nursing & Health Sciences, Fiji National University, Princess Road, Tamavua, PMB, Suva, Fiji, Tel: +679 9791868, Email: ,

Keywords

Male nurses • Lived experience • Perceptions • School of nursing • Fiji • Gender equity

Introduction

The gender divide in nursing education has been an area of concern for a long time despite an increase in recruitment The United States has a three million nursing workforces where only 6.6% are males, in European countries like Austria, Denmark, Iceland, Estonia, Hungary, Norway, Poland and Spain between 5% to 10%, while China is at 1% [1] in Nigeria 5.2% to 5.8% of the total student population. The highest percentage of males in nursing is reported in Saudi Arabia at 32% and Italy at 21% [1].

Gradual increase in men entering nursing is apparent suggesting that perceptions of becoming a male student nurse in a predominantly female profession may play a role in this. Male nursing students perceive inequalities in how they are treated in practice and regarding the lack of gender diversity in the nursing profession [2] Compared to professions such as medicine and engineering, which have minimized their gender gap by including more females. Younas, Sundus, Zeb and Sommer alluded that nursing is the health profession with the widest gender discrepancy. This is in contrast to massive campaigns from women's organizations seeking equal participation at all levels, men are under-represented in nursing.

Background

Historically, nursing began with males in India - 250BC where the first known nursing institution was established and only men were admitted because “women were not considered pure enough to serve in this role”. This was followed by the ancient nursing era, pre-Christian era; the Christian era (1 – 400AD); the birth of medieval nursing (500 -1500D); the reformation and the renaissance era; finally the Florence Nightingale era (1800AD) who reformed nursing to the extent that she wanted it to be an all-female profession. In support, alluded the view that nursing belongs to the female gender is a recent phenomenon because men in nursing can be traced to the era Before Christ (BC) where those who cared for the sick during the time of Hippocratic in ancient Greece were men who were supervised by male physicians.

The slow increase in recruiting males may suggest that nursing education may play a role in this decline as Fister stipulated that gender discrimination is prevalent in nursing education; followed by society’s stereotyping of nursing as for females only, lackof positive male role models in academia [3] gender biases of the curriculum, challenges faced during nursing education [3] uncertainty about public and professional identity [4] and uncertain future for males in the nursing profession [5].

Male student nurses faced challenges when choosing nursing as their career as they had their masculinity threatened, they were judged by their families, friends and society and stigmatization by their association as gay male-feminist stereotypes along with the feeling that their gender identity is being threatened (Rudman) if they become nurses. Thus, the notion that males joining nursing could be considered out of line leading to their marginalization in nursing, which viewed to belong to the female gender only recently. Despite this era of human rights advocating where male nurses are being permitted the education and employment equity, they are still stereotyped and ridiculed for their desired profession – nursing [5]. A plethora of studies on the lived experiences of male nurses exist wherein the impact on male student nurses is highlighted. Meadus and Twomey found the lived experiences of male nurses were centered on i) choosing nursing, (ii) becoming a nurse, (iii) caring within the nursing role, (iv) gender-based stereotype and (v) being visible or invisible.

Hill insisted that male student’s nurses felt isolated, challenged and devalued in their roles while Bartfay and Bartfay conceded that feeling of seclusion and loneliness, lack of emotions and caring, the feminized culture of nursing and feeling of stress and vulnerability were some of the experiences of the male student nurses while Smith added client’s refusal to be treated by male nursing students as demoralizing. Recent studies by Gao, Cheng, Madani and Zhang reported that male nurses did not give a voice to their experience and a lack of role models and clinical values for male student nurses contribute to their negative lived experiences while Ndou and Moloko-Phiri, alluded that the negative lived experience began before entering nursing school due to the societal constructs expressed by family, friends and internal manifestation by the male nurse. These negative lived experiences result in a decreased sense of self-worth due to its impact on self-esteem and also influences of cultural beliefs about nursing [6] while in an earlier study Wood asserted that the non-application of role theory, social network and social support theory aggravated these negative lived experiences. Nursing education needs to provide a conducive learning environment for male student nurses, teaching methodologies required being re-evaluated awareness on gender biases and there was a need to promote a positive image for male nurses. Buthelezi and colleagues agree that the need for ‘male nurse awareness’ and nurse educators needed to be knowledgeable of gender differences to provide a neutral learning environment for both genders. The lived experiences of male student nurses have some common grounds considering the different study settings.

Al-Momani MM [7] found that the attitudes of patients towards male nurses in a revealed the themes (i) societal and cultural image of male nurses - that nursing was not for males because of its “low social prestige and value” (ii) engagement in nursing - challenges that student male nurses face are gender discrimination, lacking in interpersonal communication, mostly student males were left out during handovers or meetings and (iii) discriminatory policies and training hours were also found to be barriers by male student nurses within the clinical environment. Bleich, MacWilliams and Schmidt, found that the aspect of touching female patients in obstetrics wards created fear in male nurses. However, “touch” was perceived by female patients as professionally therapeutic and not sexual. Also, it has been highlighted men who were enrolled in nursing programmes were classified as “finders or seekers” or “settlers”. The attitude towards male student nurses has cascaded over the years that have affected males joining the nursing profession. Therefore, the need to change this attitude should the responsibility of all relevant stakeholders, so that male student nurses get their fair share in nursing. Kirk, O’Lynn and Ponton found that anti-male remarks in the class were most common in the online programs highlighting rudeness, impoliteness and vulgarism towards male student nurses apparent, which echoed the findings of Marchiondo, (Marchiondoand Lasiter) where authors claim that incivility from faculty resulted in increased numbers of male nursing students leaving the program, which also mentioned by O'Lynn in a separate study.

Earlier studies found that because they were a minority, there was a lack of avenues for male student nurses to raise concerns regarding ill-treatment while studying to be a nurse and there is a paucity of studies that specifically addresses strategies that are in place for male student nurses to access in a predominant female education system; lack of encouragement from career counselors that caused male student nurses to have a feeling of selfdoubt and being overwhelmed; while Al-Momani MM [7] alluded that career classes needed to be the vehicle to create awareness and help improve the community’s’ perceptions of males entering nursing.

Nursing education has failed to provide an appealing learning environment that would retain and train males for the nursing profession with an understanding of coping mechanisms to overcome stress by minority male. Additionally, career classes in school should be utilized to help improve the community and high school male student’s perception of male nurses while Al-Momani MM [7] insisted on the need to use gender neutral language and for male nurses to be cautious when performing nursing care. McLaughlin and colleagues asserted that nursing faculty was responsible for providing a conducive learning environment for male student nurse’s academic experience while Hung and colleagues posited that they should develop male student nurses caring behavior and professional image and reduce gender friendliness barriers. Additionally, Male student nurses need opportunities to share their concerns Smith which faculty should facilitate with lessons on the history of men in nursing needs to be discussed in nursing schools as this not only addressed the barriers buts also the attrition rates. Meadus suggests that nursing should break and correct barriers in nursing; where affirmative action is needed to balance the gender gap in the female-dominated profession while added the need to portray a positive image of male nurses where male student nurses need to be treated as nurses.

In summation, the aforementioned findings are peculiar to a particular location for example the study done in China is with a Chinese context, hence the need to address lived experiences of male student nurses for a particular setting in this instance The Republic of Fiji due to its unique workplace environment and culture needs to be considered. In The Republic Of Fiji (ROF), males entering nursing education is negligible as evident that not one time a fifty percent (50%) males and fifty percent (50%) females are recruited in a class, as there is always more than eighty percent (80%) of the female gender. The plethora of studies that inform on males in nursing education has been done in overseas countries. Hence, this study explored the lived experiences of male student nurses from the Fijian context and to the authors knowledge this is the first study done on this phenomenon in The Republic of Fiji (ROF) where the findings elucidated the reasons of the slow increase in males entering nursing, with their lived experiences in nursing education.

Methodology

Research design

This study used a mix -method design Creswell & Creswell where quantitative data analysis centered the phenomenon of interest and qualitative aspect refined and explained the quantitative results thru In-depth exploration.

Research setting

The research setting was the School of Nursing – College of Medicine Nursing & Health Sciences – Fiji National University from June – September 2021.

Target population

The target population in this study was male student nurses enrolled in the Bachelor of Nursing & Health Sciences program at the School of Nursing – College of Medicine Nursing and Health Science, Fiji National University.

The sample for the quantitative phase was purposive sample male student nurses of Fijian nationality studying in a nursing program at the School of Nursing, College of Medicine, Nursing & Health Science and Fiji National University. There were thirty (30) male nurses selected in this phase of study. A purposive sample which implies intentionally selecting individuals knowledgeable about the issue under study to learn to understand the central phenomena was used. Purposeful sampling is commonly used in qualitative research and it involves selecting research participants according to the needs of the study where the researchers choose participants who give rich information that are suitable for detailed research. A purposive sample of ten (10) male student nurses was selected and the idea was to purposively select informants who would best answer the research question with rich information.

Methods and tools

Quantitative data collection – Instrument: The Inventory of Male Friendliness in Nursing Programs (IMFNP-S) developed by O’Lynn was used to gather quantitative data. Content validity was for the IMFNP-S, alpha ranged from 0.80 to 0.84 and the reliability test reading - Cronbach’s alpha was .56. The IMFNP-S is a Likert –type scale with a weighting from 0 – 4. A high mean indicated a high level of the variable measured. The levels were then categorized as low-level (0 – 1.33); moderate-level (1.34 – 2.67); and highlevel (2.68 – 4.00). The overall score of the IMFNP-S ranged from 0 – 68 and were categorized as low-level (0 – 22.66); moderate level (22.67 – 45.33); and high-level (45.34 – 68.00).

Qualitative data collection: A Focus Group Discussion (FGD) was used to collect qualitative data.

Data analysis procedure

Phase 1: Descriptive Statistics was used to calculate frequency, percentages mean, range and standard deviations were calculated to provide information. For this study, a high mean indicated a high level of the variable measured. The levels were then categorized as low level, moderate level and high level for a better understanding. The SPSS (Version 21) software was used in data analysis.

Phase 2: Qualitative data analysis utilized thematic analysis according to the process popularized by Braun V and Clarke V [8]. The six-step process included: (i) familiarization; (ii) coding; (iii) generating themes; (iv) reviewing themes ; (v) defining and naming themes; and (vi) writing up.

Protection of human subject/ethical consideration

This research proposal and ethical component was viewed and approved by College of Humanities and Education - Associate Dean Research and Chair College Higher Degree & Research Committee - College of Humanities and Education and institutional approval was given by Dean College of Medicine Nursing and Health Science.

Results

Quantitative data

Response rate: Twenty-eight (28) of the thirty (30) questionnaires were returned resulting in a response rate of 93.33%.

Demographic data: Table 1 shows that more than half (53.60%) of the participant were enrolled in 2018, followed by 2019 (28.60%) then 2020 (17.90%) (Table 1).

The ethnic distribution in Table 2 shows that there were more Itaukei (53.60%), followed by Fijians of Indian descent (39.30%) then Fijian of Others(s) decent (7.10%) who participated (Table 2).

Descriptive statistics

Table 3 displays the total score for the IMFNP-S 37.39 which was at a moderate level. Table 4 shows the itemized score in descending order and the level attained as per male student nurses’ responses. The range for each item was between 0 – 4 and it is noted that most of the items were at a highlevel followed by moderate- level then low-level. (N.B The number in brackets () beside each item refers to the number the item was in the questionnaire (Tables 3 and 4).

Qualitative results

Data analysis revealed there (3) themes: (i) Being Singled Out, Societal and cultural image of male student nurses and (iii) Educational environment and educational content.

Theme 1: Being singled out

Most the participants mentioned they were singled out (marked) because they were male student nurses. They mentioned it was always easy for the lecturers to cite males when there were disciplinary issues to highlight. For example, if there was a breach in uniform codes even though the females were noted to be in breach it was the male student nurses that were reprimanded. One participant explained this as:

• In times of discussing disciplinary issues – they use males to send the message across.

Another participant explained provided an example of being signaled out as:

• Sometimes when we go for clinical – they (lecturers) stress about the uniform code - It’s unfair – that they will always pick on the male student nurses even though the female student nurses were not in the proper uniform code too.

The participants also discussed that during clinical attachment, even though they were allocated a patient to look after – the doctor coming to attend to the patient would single out the male student nurse and prefer a female student nurse to assist him / her (doctor) in attending to the patient.

Theme 2: Societal and cultural image of male student nurses

The participants overwhelmingly stated that they were to some extent prone to negative attitudes from peers and family members which to some extent did affect them emotionally. As one participant stated:

► For me they (friends) were surprised – from high school they didn’t know I was going to join nursing - they thought I was going to do something else.

Being made fun of or teased by family members and relatives was also discussed in the group even when the offer letter for a placement at the School of Nursing was received. One male student nurse stated that:

► They were kind of teasing type – ‘like that’s a girl’s profession’ – one of my uncles said no matter how much you study you will get a lady’s job.

They spoiled me even until the day I got the offer letter. Another student reflected on his family and father’s apprehension of him joining the School of Nursing as a male student nurse mentioned:

► My family wanted me to become a doctor not a nurse. My dad was worried that this this profession (nursing) will change me to be more feminine.

Theme 3: Educational environment and educational content

The participants mentioned some discrepancies in the educational environment and content that did affect them. Participants discussed the curriculum was not conducive to male nursing students as per practicum purposes and also the nursing program as a whole was poorly planned and disorganized that did affect their learning. Three informant’s iterations were as follows:

• I think so far we didn’t have that in the curriculum – teaching of how males should attend to females.

• They have not specifically mentioned how a male should look after a female patient. The only they have taught in school is communication. So, once you establish your therapeutic relationship with your patient.

• I am still anxious about being cited of sexual advances at practical – as they (patients) can always change their story.

On the curriculum / nursing program as a whole, two informants claimed that:

• The planning of the program was not organized well – plenty changes.

• Planning of the program was disorganized. Like changes to not having classes all of a sudden – or prolonged classes the next.

Discussion

This study identified some difficulties and challenges that male student nurses experienced. The male student nurses highlighted the negative portrayal of male nurses by family friend and friends regarding it as a female profession and would impact on their masculinity being impacted to their becoming feminine in nature. This finding resonates with that of Bartfay WJ and Bartfay E [3] who affirmed the negative portrayal of male nursing students and being ridiculed for being a male in the nursing profession existed. This would lead to male student nurses being emotionally impacted and could result in less males taking up nursing as a profession. However, it can be assumed that the lack of awareness of males taking up nursing as a profession and the history that nursing began with males not being stressed could have resulted in this. Furthermore, male student nurses faced challenges in that of stereotype comments from family, peers and culture has been widely mentioned in the literature [9,10].

One important finding that could be regarded as harassment or discrimination in nursing education is the report of being singled out because of being a male student nurse. Al-Momani MM [7] posited that male student nurse were left out during clinical attachment in his study, similar to the iterations of the participants in this study, that they were singled out or not considered by the doctors to assist them during clinical attachment. It would be fair to say that at times male student nurses are not considered to assist a male doctor if the patient being attended to is a female for ethical reasons. However, policies ought to be in place to cater for the learning experiences of male student nurses in that if they miss out on certain competencies due to being singled out. The highlighting of being picked on in instances of disciplinary issues by the participants in this study, echoes the sentiment of O’Lynn who posited that nursing education has failed to provide a conducive environment to prepare males in the nursing profession. Furthermore, McLaughlin and colleagues attested that nursing academics needed to create a friendly environment for male student nurses to enjoy their academic experience and improve on their nursing care [11-17].

Findings on the educational environment and educational content was discussed by the participants as not specifically addressing male nursing students and disorganized on the whole. Evans iterated there was a need to be gender neutral; and opportunities needed be made available for male student nurses to raise their concerns especially in the area of caring for female patients. As the participant mentioned that there were times when they were anxious about being cited of sexual advances towards female patients Hung and colleagues suggested that there was a need to reduce gender friendliness barriers.

Finally, the quantitative aspect of this mix-method study scored highly in most areas; the items that were least scored were the ones that were reversed and overall score for the Inventory of Male Friendliness in Nursing Programs – Short was at a moderate level. It is noticeable that the qualitative design that followed did not affirm the finding of the quantitative aspect, since the qualitative design was to explore more or probe more or confirm the findings of the quantitative design. However, since this was a sequential explanatory design (QUANT --> qual), where the purpose of the qualitative study is to better understand the results from the quantitative study.

Limitations in this study were:

• The sampling technique was convenience sampling limiting its generalizability.

• Time was a factor that led the researcher to hasten the data collection due to the design being a mix-method one.

• The interviewer’s previous experience as being a student once and also a former nursing lecturer may have influenced the nature of the questions.

Conclusion

The lived experiences of male student nurses from the participants of the quantitative and qualitative designs. Themes elicited were (i) Being singled out, (ii) Societal and cultural image of male student nurses and (iii) Educational environment and educational content that the participants stressed were challenges to their becoming student nurses. The Inventory of Male Friendliness score was at a moderate level for this study – suggesting that more should be done to raise the level male friendliness of nursing programs to a higher level. The study also revealed that the stereotype thinking that nursing was only females, male’s nurses being victimized (singled out) and made a mockery of for choosing nursing as a career still persists are some serious issues that need addressing in nursing education in general. There is a need for improved portrayal and awareness of male’s student in nursing by relevant stake holders to alleviate the negativity towards those males who chose nursing as a career.

Recommendation

Caution must be applied in generalizing the findings of this study as this study pursued a convenience sampling technique. Future research should seek a more diverse sample and sampling technique, like using random sampling technique and also including male student nurses from other nursing institutions as Sangam Nursing School and University of Fiji then compare result for a better understanding of the phenomenon of interest. Finally, a sequential exploratory design (QUAL --> quant) to be implemented whereby after the qualitative aspect, an instrument / survey questionnaire can be developed to suit the local context.

Expected Benefits/Implications of the Study

• Implications for education: The results of this study will assist educators in planning strategies to recruit and to acclimatize male student nurses into nursing education; be informed on how the nursing education curriculum could be tailored to be male student considerate.

• The implication for future research: The results of this study will provide baseline information on the lived experiences of male student nurses and where future research could take its cue from.

• Policymakers: Stakeholders could use results to collaboratively tailor policies to address the challenges experienced by male student nurses, thus promoting a change in perception of male student nurses and boost male nursing student numbers during enrolment.

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