Accepted Manuscript Masculinity and nursing care: A narrative analysis of male STUDENTS´ stories about care Kristin Jordal, Kristin Heggen PII:
S1471-5953(15)00082-7
DOI:
10.1016/j.nepr.2015.05.002
Reference:
YNEPR 1986
To appear in:
Nurse Education in Practice
Received Date: 13 March 2014 Revised Date:
5 May 2015
Accepted Date: 6 May 2015
Please cite this article as: Jordal, K., Heggen, K., Masculinity and nursing care: A narrative analysis of male STUDENTS´ stories about care, Nurse Education in Practice (2015), doi: 10.1016/ j.nepr.2015.05.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page
Total words: 4967 (excluding abstract, keywords and reference list)
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Authors:
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MASCULINITY AND NURSING CARE: A NARRATIVE ANALYSIS OF MALE STUDENTS´STORIES ABOUT CARE
Kristin Jordal (Corresponding author)
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Department of Nursing Science, Buskerud and Vestfold University College, P.O. Box 235, 3603 Kongsberg, Norway . Phone: 004733037543. Email: [email protected] Kristin Heggen
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Institute of Health and Society, Department of Health Sciences, Faculty of Medicine, University of Oslo, P.O. Box 1153 Blindern, NO-0318 Oslo, Norway. Phone: 004722845376 Email: [email protected]
ACCEPTED MANUSCRIPT MASCULINITY AND NURSING CARE: A NARRATIVE ANALYSIS OF MALE STUDENTS´ STORIES ABOUT CARE
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Abstract Nursing education programmes and the nursing curriculum have been criticised for
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presenting an outdated and feminised description of care, which has had the effect of
marginalising men, as well as hindering a more modern outlook for the profession. This
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article uses interview-based data from a qualitative study on Norwegian students’ experiences in the first year of training. Using a narrative analysis method, the paper explores how male nursing students use stories to describe care and shows how their storytelling illustrates a way for men to negotiate their role in a feminised profession. The
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paper aims to deepen our understanding of the ways in which male students can challenge this historically female profession to broaden itself by including male-based caregiving as part of nursing care. In addition, the paper highlights the potential of stories and storytelling
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as a teaching and learning strategy in nursing education.
Keywords: Nursing education, men, nursing care, narratives
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ACCEPTED MANUSCRIPT INTRODUCTION Professions are knowledge communities in which the participants develop a common understanding of the key concepts, theories and methodologies that form the basis of the
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practice of the profession (Grimen, 2008). Students are initiated into this community through education, and develop their identity as professionals (Heggen, 2008; Wenger,
1998). Care is a key concept in nursing education, which contributes to a student’s sense of
and Nelson, 2005; Rhodes et al., 2011) .
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identity and belonging to the profession (AACN, 2008; Brown, 2011; Clouder, 2005; Gordon
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The concept of care is at the core of nursing education and practice, but the understanding of care and the meanings given to the concept can vary over time and between cultural contexts (Clouder, 2005; England, 2005; Solbrække et al., 2012). Historically, the perception of nursing care was based on the role of a nun, a ‘virtue script’, which defines women as
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good, kind and self-sacrificing. This concept was used to recruit respectable women to the profession (Brown et al., 2000; Dufwa, 2006; Gordon and Nelson, 2005; Moseng, 2012;
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Svare, 2009). In Western society today, the public and professional understanding of nursing care is still closely associated with a female caregiving role (Abrahamsen, 2004; Brown et al.,
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2000; Stanley, 2008, 2012; Svare, 2009). This gendered understanding of nursing care has been exposed to criticism and debate. It is argued that it sends an archaic and sexist message, which not only stands in the way of a more modern, contemporary image of the nursing profession, but also marginalises men (Bakken, 2001; Christensen and Knight, 2014; Gordon and Nelson, 2005; Jorfeldt, 2006).
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ACCEPTED MANUSCRIPT Although the participation of men in nursing varies among European countries, in general, males nurses play a minority role in the profession (Bakken, 2001; Jorfeldt, 2006; Solbrække et al., 2012; Svare, 2009). This suggests that men who choose nursing as a career undergo a socialisation process into a female-dominated occupation where professional identity is
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based on a feminised understanding of nursing care (Abrahamsen, 2004; Brady and Sherrod, 2003; Gordon and Nelson, 2005; Simpson, 2004). Approximately 4,000 nursing students are admitted at bachelor degree level each year in Norway, but less than ten percent of this
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number are men. Statistics show that the drop-out rate among male nursing students is
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higher than among female students (Svare, 2009; Texmon and Stølen, 2009), a fact that is related to the socialisation process, role strain, and feelings of isolation and marginalisation as a minority in the training environment (Brady and Sherrod, 2003; Brandon and All, 2010; Christensen and Knight, 2014; MacWilliams et al., 2013; Paterson et al., 1996 ; Stott, 2007).
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Studies in nursing education also reveal that male students experience the study programme’s perception of care as feminine (Bakken, 2010; Christensen and Knight, 2014; MacWilliams et al., 2013; Paterson et al., 1995; Paterson et al., 1996 ). It is therefore
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suggested that men’s encounter with nursing education can represent a dual challenge
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because ‛not only must male students learn to think like nurses, they also often have to learn to think like women to be successful’ (Brady and Sherrod, 2003, p. 159). The concept of care has proved to be important for identification with the nursing profession for both male and female students (MacWilliams et al., 2013; Sellman, 2011; Tveit, 2008).
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ACCEPTED MANUSCRIPT In their study on male nursing students, Paterson et al. (1995) emphasise the importance of storytelling as a central strategy for male students to learn about nursing care. Accordingly, in this paper, we apply a narrative approach that is particularly well-suited for a grasp of the development of self-understanding through the analysis of participants’ stories and
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storytelling (Bruner, 2004; Holloway and Freshwater, 2007; Holstein and Gubrium, 2000). We direct a particular focus on the narrative dynamics that arise at the intersection of the
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male students’ stories and the profession’s discourse on care. The aim of the study is to describe how male nursing students use stories to talk about care, and how their storytelling
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can be understood as way for men to negotiate their role in a feminised profession. The low rate of male participation in nursing gives cause for concern in the context of the large and growing nursing shortage in Western society (AACN, 2014; Roksvaag and Texmon, 2012). This study presents findings that help shed light on men’s identification with nursing
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and their encounters with feminine perceptions of care in the profession. This is important knowledge both for the recruitment and retention of men in the profession. The findings
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may also help the development of a more contemporary and appropriate programme and
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curriculum for nursing education (Clouder, 2003; Clouder, 2005; MacWilliams et al., 2013). Gender perspectives
Considerable development has taken place in the understanding of gender since the beginning of the last century and up to today. Gender was previously defined within a biological perspective, where being born as a man or a woman was perceived as decisive for what you were or could be (Bondevik and Rustad, 2006; Jorfeldt, 2006; Svare, 2009). This viewpoint is related to what we currently call an essentialist understanding of gender, where female and male elements are regarded as given dimensions that set the terms for gendered 4
ACCEPTED MANUSCRIPT ways of behaving in society (Svare, 2009). In today’s social research, gender is to a great extent understood as being constructed and linked to specific contexts. Gender is thus perceived as something that is played out, within and between human beings, in cultural,
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historical and social frameworks (West and Zimmerman, 1987). Within this perspective, the relevant understanding of masculinity will at any given time be mobile and relationally formed since it varies between cultures, over time in the same
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culture, and throughout a person’s lifetime (Lorentzen, 2006, p. 126). When we emphasise today how different forms of masculinity, and femininity, are played out and formed in
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interaction with society’s structural conditions, gender is woven into active meaning-making and identity-creating work (Solbrække and Aarseth, 2006).
Following this line of thought, the professional discourse on care can be perceived as a structuring element that acquires importance for how male nursing students identify
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Simpson, 2004).
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themselves, as men, with the profession (Clouder, 2005; Gubrium and Holstein, 2009;
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Care as a gender-constructing power in nursing In spite of the fact that Norwegian men have gradually reached a high level of participation in the home arena and in the care of their own children, the labour market remains one of the most gender-segregated in the Western world (Solbrække, 2006). This is reflected in the nursing profession in which it is almost only women who nurse, who teach nursing and who write the textbooks and the curriculum (Brady and Sherrod, 2003; Jorfeldt, 2006). When a
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ACCEPTED MANUSCRIPT profession is culturally or historically linked either to masculinity or femininity to such a strong degree, the occupation can be defined as sex-typed (Crompton, 1987). In addition to the profession’s own prioritising of the care concept and the fact that nursing
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education was for a considerable time reserved for women (Moseng, 2012; Vike et al., 2002), a number of other historical social traits have contributed to the way that Norwegian nursing, in general, and care, in particular, have become a female domain. Bakken (2001)
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shows how nursing became a specifically feminine field based on a traditional dichotomybased mind-set, where the nurse is defined as a woman and the doctor as a man in mutual
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and complementary roles. Based on a model taken from the typical home environment, the doctor constituted a father figure, the nurse was linked to a maternal role and the patient was seen as a child who needed care. The feminine, maternal and caring elements were thus associated with nursing as a traditional female profession. According to Svare (2009),
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women also draw on a historical and cultural heritage in the form of practical housewifely competence and a monopoly of care and strength in interpersonal relationships. This ideal is characterised by the woman who takes care of the family with her knowledge of hygiene,
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nutrition and the ability to care. The woman was thus understood as naturally suited to care
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work – including in the public care arena (Kermode, 2006). As Florence Nightingale maintained: ‘every woman is a nurse’ (Svare, 2009, p. 43). The nursing occupation was thus perceived as the professionalisation of inherent qualities that all women should possess (Jorfeldt, 2006). Following this line of thought, men will always start with a handicap in nursing precisely because they are men. Svare confirms this with reference to a much-cited 1987 quotation from the President of the Norwegian Nurses Organisation:
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ACCEPTED MANUSCRIPT Of course I want to welcome more men into the ranks. Nevertheless, there will always be differences between men and women. The care professions will always be female-dominated, regardless of development. Women have innate advantages here which we can do little about (author’s translation) (2009, p. 45).
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The story of nursing as a feminine profession is also sustained and continued today both through public recruitment campaigns and the portrayal of the profession in films and the media (Dahlborg-Lyckhage, 2009; McLaughlin et al., 2010; Stanley, 2008, 2012). This outlook
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was clearly revealed in a recruitment campaign for Swedish nurses: ‛We need more women. We need more people. We also need men’ (Dahlborg-Lyckhage, 2009, p. 167). In addition to
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society’s portrayal of the profession, the nursing education syllabus also creates a picture of nursing and care that has strong feminine connotations (Bakken, 2010; Gordon and Nelson, 2005; Jorfeldt, 2006). Svare (2009) argues that women thus have power as models for the profession, and have therefore been able to define what is right and what is wrong, what is
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of falling short.
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good and what is bad in nursing. – a normative and excluding practice where men are at risk
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ACCEPTED MANUSCRIPT METHOD AND ANALYSIS This article forms part of a qualitative study of six female and three male nursing students’ experiences in the Norwegian nursing education programme. The study’s overall design
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included both individual interviews at the end of the first year and field work conducted in the students’ clinical practice in medical and surgical departments in the second year of the education programme. This paper is based on data from the interviews and adopts a
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narrative perspective both methodologically and analytically. More specifically, this entails gathering and analysing verbal and written stories (Creswell, 2013; Gubrium and Holstein,
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2009; Holloway and Freshwater, 2007; Riessman, 2008).
The first author conducted, recorded and transcribed the in-depths interviews. Each interview lasted about two hours and focused on topics linked to the students’ backgrounds, their interest in and perception of the profession, and their experiences from theoretical
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courses and specific patient situations in the first year of clinical practice. In line with a constructivist framework and a narrative working method, the first author used explorative
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and open questions to activate and facilitate the students' narrative resources (Creswell, 2013; Gubrium and Holstein, 2003; Holloway and Freshwater, 2007). For example, when a
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student talked about care in a general way, the first author might ask: ‘Can you tell me about an episode from your own life, or from clinical practice, where you experienced that someone got good care?’ In this way, the actual narrative production of the interview was a collaboration between the researcher and the participants directed by the research agenda of the study (Gubrium and Holstein, 2003; Holloway and Freshwater, 2007).
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ACCEPTED MANUSCRIPT Ethical considerations The students enrolled voluntarily as participants after finding out about the study through the university college website. The study was recommended by the Regional Research
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Committee and, in line with the application to the committee, the students who enrolled in the study received written information about the study objectives. It was made clear that all data from the study would be made anonymous. Accordingly, the names in this paper are
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fictitious. However, in a paper with a narrative approach, the extended use of the
participants’ stories will always reveal part of the students’ biography and background. This
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fact led us to invite the participants to read the paper during the writing process and to approve the use of their stories in it (Chase, 2013). Analytical approach
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Relating experience in a narrative form appears to be natural for human beings and is meaningful for the experience of our identity (Bruner, 2004; Holstein and Gubrium, 2000; McAdams, 1993). At the same time, an individual’s stories are considered to be very
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responsive to cultural, discursive, interpersonal and linguistic influence (Gubrium and
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Holstein, 2009; Holloway and Freshwater, 2007). Professions such as nursing offer significant narrative environments; (Gubrium and Holstein, 2009, p. 165) emphasise the need to identify how work-related resources and orientation shape narrative accounts. In line with this recommendation, the analytical work in this paper focuses both on how the students tell their stories and on what meanings they are up against in the nursing profession, which is understood as such a narrative environment (Gubrium and Holstein, 2009). Accordingly, the relationship between the students’ stories about care –a narrative structure with a specific content ‒ and their storytelling – the activity of telling these stories to others ‒ is viewed in 9
ACCEPTED MANUSCRIPT dynamic association with the narrative surroundings in which the stories are shaped (Creswell, 2013; Gubrium and Holstein, 2009). The actual analytical work took shape by a repeated reading of the interview data. This
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reading focused on the specific ways in which the men structured and arranged their experiences of good caregiving into narrative format. The stories of John and Christian were chosen because of their thematic content and the way they are structured as fully-formed
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narratives (Creswell, 2013; Labov, 1997; Riessman, 2008). Their stories have several common traits in terms of topics discussed and structural features. They reveal ‘Aha!’ moments of
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insight and change and seemingly broaden the men’s understanding of care (Paterson et al., 1995). The narratives in this paper therefore serve as optimised examples from the material on the male participants’ narration of what they perceived as good caregiving (Holloway and Freshwater, 2007). First, we conducted an internal structural analysis focused on the
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characters, on what`s at stake for whom in the stories, and the outcome. The initial exploration of the stories also focused on the developmental structure in the stories, identified as a fully-formed narrative in six stages: an abstract, orientation with regard to
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time, place and characters, a presentation of the story’s problem or crisis, an evaluation, the
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outcome of the story, and a final coda (Labov, 1997). After this initial analysis, we directed the analytical focus to the nursing profession as a cultural and discursive context (Gubrium and Holstein, 2009). The traditional and feminised discourse on care, as outlined in the introduction, was understood as structuring narrative circumstances that create specific conditions for how these nursing students described their masculinity. Qualifying for any form of professional practice is about identifying oneself with a particular occupational field and profession. At the same time, telling others about oneself
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FINDINGS
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profession (Gubrium and Holstein, 2009; Paterson et al., 1995).
John’s story
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John is in his early forties, is married and has children who live at home. After many years as a salesman and in a leadership position, John went through a crisis that ended with his taking a severance package and leaving his job. John had to make up his mind about what he wanted to do in the future and he therefore reviewed the jobs he had had. He found that
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being with other people was a common denominator. For a while, John considered becoming a prison officer and worked shifts in psychiatry to accrue enough credits for admission to the prison officer training programme. One day, when he was working in a
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psychiatric institution, he witnessed an incident that made him change his mind.
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I hadn’t thought about the professional background of nursing until I once saw a psychiatric nurse calming down a psychotic patient. The patient looked completely wild, and several people were involved. Then along came this nurse called David. He went up to the patient and held him like this round his shoulders [John demonstrates by holding me round my shoulders] since that’s an action that disarms people. Then he said ‘There’s nothing to worry about’ and ‛Just calm down’. So instead of being frightened of the patient he managed to turn the whole situation around. He knew that this psychotic
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ACCEPTED MANUSCRIPT patient was afraid of us all. He quite simply demonstrated care for the patient. So this was one of the situations that made me want to be a nurse.
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Christian’s story Christian is a married man in his late forties. His children had grown up and Christian had therefore reached a point where he needed to think carefully about how he wanted to
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spend the rest of his working life. He decided that he wanted to work with people in order to get more in line with his personal values. He is very motivated for this occupational change
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and says: ‛It’s about having the drive, the curiosity – like, I’ll fix this. To put it a bit flippantly: I’ll make a damn good nurse’. He then explores what being a ‘damn good nurse’ really means by talking about the male contact nurse he had for his practice period in a nursing home in
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the first year of his training:
He put things right for all kinds of patients – dementia patients and somatic patients. The approach he had towards them. [He had] a calming effect on the aggressive patients. He was what I would call an incredibly good all-round
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nurse, while at the same time he was professionally competent medically. Once there was a female patient who had very bad dementia, she started to
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get very aggressive, shouting abuse at the staff and the relatives. Some of them tried to restrain her, but she hit them and was absolutely desperate. He [Christian’s contact nurse] came to the rescue and calmed her down. She was crying and she was so distressed – she saw the devil in … she was very ill. He
really took his time, even though he was up to his neck in work. He gave the situation priority. He calmed things down. He crouched in front of her, held her hands – the closeness, met her gaze, she realised who he was. So he made her feel that ‘There’s nothing to worry about, this is quite OK’ without telling her off, but quite simply: ‘You can be angry. It’s OK’. He appealed to her ‘healthy’ side. He got her out of a difficult situation, pampered her a bit with 12
ACCEPTED MANUSCRIPT blankets and … he made her warm tea. It was great to watch him; it was really touching to see how he brought her back to normal. It was wonderful – in my eyes he was a damn good nurse. John and Christian’s stories start with an introduction that links them to the specific
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interview situation. They then develop their stories by introducing the main characters and the situation in which they find themselves. A male nurse is the main character in both stories. In narrative theory, this character is the protagonist (Frank, 2010). The main
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character of each story finds himself in an unstable and chaotic situation where the other staff have not managed to resolve the problems that have arisen. These male nurses are
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thus recognised by the students as having the particular skills of involvement and strength to calm and contain the situation. In our narrative perspective, they can be understood as saviours and heroes in the story, literary-inspired characters who are come to the rescue where others fall short (Frank, 2010). The patients in each story, the stories’ antagonists, are
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described respectively as ‛completely wild’, ‘psychotic’, ‛so distressed’ and ‘absolutely desperate’, which make us understand that these situations are very demanding. The patient
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is thus a challenger who through his or her way of behaving pushes the incident in the story to a decisive point – a climax where it can swing either one way or the other for the male
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nurses. The suspense is linked to whether they will manage to do what is necessary to save the situation and the patient (Frank, 2010). We note that both nurses are efficient and establish contact with the uncontrolled patients by holding them – holding their hands or putting their arms round their shoulders – showing connection and engagement skills. The male nurses contain the situation almost as if they are absorbing the patients’ chaos and loss of control, while at the same time they make the stories’ only statement: ‛There’s nothing to worry about’. In this way, these male nurses grasp the difficult situation while they also
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ACCEPTED MANUSCRIPT define it. The two stories have a common basic theme and a line of development that can be summarised as follows. A helpless or sick person needs help. Those present are not able to help. An effective male nurse understands the situation, takes action and does what is required to resolve the problem. In narrative analysis, this type of pattern is called the
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story’s plot and it is in the plot that we discover what the story is fundamentally about and what is at stake in the situation (Frank, 2010; Gubrium and Holstein, 2009). In these stories, the inherent risks are fear, helplessness and loss of control, provided by a strong other who
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is able to convey concern and connection. The stories of John and Christian emphasise how
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the male nurse understands the actual situation, grasps the problem and finds a solution. The result can be success or fiasco. In these stories the situation is resolved. In a sense we can view them as success stories that the two male students use to underline what good nursing care actually is.
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When we turn the analytic focus to nursing as the narrative environment in which John and Christian tell their stories about care, we enter a specific, professional and discursive arena where care is portrayed as feminised, physical, all-encompassing and emotional, based on
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altruism, compassion and inherent female qualities (Gordon and Nelson, 2005; Svare, 2009;
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Vike et al., 2002, p. 119). These stereotyped, heartfelt and feminine bodily perceptions of care are what John and Christian are up against as male nursing students. According to Connell (1995), hegemonic masculinity is the dominant and culturally-accepted way of being male in a society. This expression of masculinity is understood as hierarchically superior and directly opposed to femininity and homosexuality (Lorentzen, 2006).
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ACCEPTED MANUSCRIPT Svare (2009) describes how the masculine element in society is also linked to exceeding limits and to the ability to change and develop, along with archetypal portrayals of man as a hero who is willing to take risks in the battle against all types of enemies. Following this line of thought, we can see how the main characters in the men’s stories, with their resolute and
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firm intervention in a difficult situation, create alternative descriptions of care. This becomes clear when ‛all-round’ nurses ‘give priority’ to the situation, ‘come to the rescue’,
‘understand’ and ‛put things right’ for all kinds of patients. They ‘disarm’ conflicts and
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thereby get the patients out of a difficult situation. In this way, the male nurses in the stories
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intervene, define and resolve a challenging situation that nobody else appears to be able to cope with. They thus act out a culturally accepted and hegemonic masculinity that is associated with strength, power and dominance in the situation (Connell, 1995). When care is linked to this type of vigorous action, these male students do what we regard as practice-
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related and active masculinisation work, which also negotiates and stretches the understanding and perspectives of nursing care to include male caregiving. When their stories ‒ the way in which they structure the plot and present the characters ‒ are analysed
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in relationship to their narrative circumstances, we find that the storytelling can be
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interpreted as giving them space as men in a gendered profession such as nursing. Nonetheless, we also recognise the traditional discourse on care when the story’s male nurses create closeness and pamper patients. Care is thus interpreted by John and Christian as not only associated with hegemonic masculine features such as capacity, insight, decisiveness and action, but also with empathy and closeness. These men thus narrate their stories about care as a negotiation, both within and outside traditional masculine roles and the prevailing nursing discourse on care. As we see it, the story’s content and structure, as well as the work the story does for them, can be linked to the strategies that men, according 15
ACCEPTED MANUSCRIPT to Simpson, use ‘to bring the job more in line with dominant notions of masculinity’ (Simpson, 2004, p. 359). At the same time, the stories serve as part of their identification with the profession. The two men’s stories about care, perceived as masculinity at work
DISCUSSION
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experience, talk about, learn and perform nursing care.
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(Simpson, 2004), can thus contribute to highlighting and directing focus towards how men
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All professional fields mediate a value perception of what is right, appropriate and desirable in contrast to what is perceived as wrong, inappropriate and immoral (Jensen and Tveit, 2005). Hence, when care – as a key value of the nursing profession – is closely linked to an outdated perception of women’s nature, while also being communicated in stereotyped
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ways, it is problematic for several reasons.
First, the traditional discourse on care has been shown to exclude men and to push them out of the education programme and the profession (MacWilliams et al., 2013; Paterson et al.,
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1996 ; Stott, 2004, 2007). This is particularly worrying in the light of the huge recruitment
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challenges that the entire nursing profession faces in its encounter with a large and rapidlygrowing need for labour in the health sector (AACN, 2014; Roksvaag and Texmon, 2012). Studies show that male students experience alienation in their encounters with a professional field described as no man’s land (Bakken, 2001; Christensen and Knight, 2014; MacWilliams et al., 2013). John and Christian’s stories are examples of how such stories can serve as carriers of men’s experience. As we see it, these stories have the potential to give male students space as men in the nursing education programme. Men, as a minority, lack such masculine narratives to help them identify with the profession as well as to recognise 16
ACCEPTED MANUSCRIPT and learn about nursing care (MacWilliams et al., 2013). Paterson et al. (1995) found that storytelling was a key learning strategy among male students who actively sought narratives to determine the meaning of what it is to care as a nurse. The stories told by John and Christian are therefore in no way unique: these stories exist as part of men’s ‘tellable
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material’ (Gubrium and Holstein, 2009, p. 42). However, they are stories that do not often come to the surface in the nursing education programme, in the curriculum or the profiling
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of the nursing profession.
Secondly, the normative and traditional portrayal of nursing care can be said to trivialise and
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sentimentalise the profession. It stands in the way of updated and empirical descriptions of care understood as a complex nursing skill (Gordon and Nelson, 2005; Rhodes et al., 2011). We are of the view that stories such as those told by John and Christian stretch the understanding of nursing care and give it new perspectives. This is a useful contribution
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when seen in relation to the ongoing debate on how nursing education programmes and the curriculum should be renewed (Benner, 2010; Frenk et al., 2010). These stories can therefore be understood both as a masculine contribution to a feminised profession and as an
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example that highlights the need for a much greater variety and diversity in the way nursing
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care is conveyed in the curriculum.
Finally, we are of the view that the nursing education programme needs to take into account, to a much greater extent, the complex and diverse meaning-making and identification processes that all students go through when choosing the profession and undertaking their professional education (Heggen, 2008; Sandvik et al., 2014; Wenger, 1998). As we have discussed in this paper, stories have the capacity to link the students' own experiences with the theoretical content of the programme and are thereby key to critical
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ACCEPTED MANUSCRIPT reflection on nursing theory and practice (Gubrium and Holstein, 2009; Hunter, 2008; Paterson et al., 1995). This is emphasised by Hunter, who argues: For nurses, telling and listening to stories related to health and illness provide a vital means through which human experiences can be honored, as well as
to understanding the whole of nursing care (2008, p. 1).
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facilitate the integration of the essential patterns of knowing that are crucial
As a result, we believe helping students to share their own stories ‒ as well as to read,
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interpret and discuss a variety of updated curriculum stories ‒ has huge potential for nursing education (Benner, 2010; Holloway and Freshwater, 2007; Hunter, 2008; Paterson et al.,
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1995).
CONCLUSION
In this study, we analysed two male nursing students’ stories about care in light of the
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profession’s feminised and stereotyped discourse of care. We analysed the stories as a masculinisation of the care concept that gave the students space as men. The stories also serve as examples that highlight the need for updating the nursing curriculum. In summary,
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we are of the opinion that the renewal of the nursing programme must involve a teaching
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strategy that involves students telling their own stories, as well as developing a contemporary curriculum that offers diverse, experience-based stories about care to which today’s youth can relate. The overall objective must be for nursing to become a story that young people can identify with and want to be part of – regardless of class, ethnicity, religion or gender.
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ACCEPTED MANUSCRIPT References
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Holstein, J.A., Gubrium, J.F., 2000. The self we live by: narrative identity in a postmodern world. Oxford University Press, New York, NY. Hunter, L.A., 2008. Stories as Integrated Patterns of Knowing in Nursing Education. International Journal of Nursing Education Scholarship 5. Jensen, K., Tveit, B., 2005. Youth culture: A source of energy and renewal for the field of nursing in Norway, in: Dahl, H.M., Rask Eriksen, T., Larsen, K. (Eds.), Dilemmas of care in the Nordic welfare state: continuity and change. Ashgate, Aldershot, pp. 161-175. Jorfeldt, I., 2006. Vårdvetenskapen ur ett genusperspektiv [Gender perspectives on health and care], in: Strömberg, H., Eriksson, H. (Eds.), Genusperspektiv på vård och omvårnad. Studentlitteratur, Lund. Kermode, S., 2006. Is nurse education sexist? An exploratory study. Contemporary Nurse 22, 66-74. Labov, W., 1997. Some further steps in narrative analysis. J. Narrat. Life Hist. 7, 395-415. Lorentzen, J., 2006. Forskning på menn og maskuliniteter [Men and masculinities], Kjønnsforskning: en grunnbok. Universitetsforl., Oslo, pp. 121-135. MacWilliams, B.R., Schmidt, B., Bleich, M.R., 2013. Men in Nursing. American Journal of Nursing 113, 38-44. McAdams, D.P., 1993. The stories we live by: personal myths and the making of the self. W. Morrow, New York, NY. McLaughlin, K., Muldoon, O.T., Moutray, M., 2010. Gender, gender roles and completion of nursing education: A longitudinal study. Nurse Education Today 30, 303-307. Moseng, O.G., 2012. Framvekst og profesjonalisering [Development and professionalisation]. Akribe, Oslo. Paterson, B., Crawford, M., Saydak, M., Venkatesh, P., Tschikota, S., Aronowitz, T., 1995. How male nursing students learn to care. Journal of Advanced Nursing 22, 600-609. Paterson, B., Tschikota, S., Crawford, M., Saydak, M., Venkatesh, P., Aronowitz, T., 1996 Learning to Care: Gender Issues for Male Nursing Students Canadian Journal of Nursing Research 28, 25-39. Rhodes, M.K., Morris, A.H., Lazenby, R.B., 2011. Nursing at its Best: Competent and Caring. Online Journal of Issues in Nursing 16, 15-10. Riessman, C.K., 2008. Narrative methods for the human sciences. Sage Publications, Los Angeles, CA. Roksvaag, K., Texmon, I., 2012. Arbeidsmarkedet for helse- og sosialpersonell fram mot år 2035 [The labor market for health care personnel up to the year 2035], Rapporter Statistisk sentralbyrå, Oslo-Kongsvinger. 21
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Sandvik, A.-H., Eriksson, K., Hilli, Y., 2014. Becoming a caring nurse – A Nordic study on students' learning and development in clinical education. Nurse Education in Practice 2014. Sellman, D., 2011. Professional values and nursing. Medicine, Health Care, and Philosophy 14, 203-208. Simpson, R., 2004. Masculinity at Work: The Experiences of Men in Female Dominated Occupations. Work, Employment & Society 18, 349-368. Solbrække, K.N., 2006. Kjønn og arbeid[Gender and work], in: Mühleisen, W., Lorentzen, J. and Bondevik, H. Mühleisen, W., Lorentzen, J. and Bondevik, H. (Ed.), Kjønnsforskning: en grunnbok. Univeritetsforl., Oslo. Solbrække, K.N., Aarseth, H., 2006. Samfunnsvitenskapens forståelser av kjønn [Social sciences´ perceptions of gender], in: Mühleisen, W., Lorentzen, J. and Bondevik, H (Ed.), Kjønnsforskning: en grunnbok. Universitetsforl., Oslo. Solbrække, K.N., Fransson, E., Heggen, K., 2012. Italian male nurses stories of their profession. Sykepleien Forskning 7. Stanley, D., 2008. Celluloid angels: a research study of nurses in feature films 1900–2007. Journal of Advanced Nursing 64, 84-95. Stanley, D., 2012. Celluloid devils: a research study of male nurses in feature films. Journal of Advanced Nursing 68, 2526-2537. Stott, A., 2004. Issues in the socialisation process of the male student nurse: implications for retention in undergraduate nursing courses. Nurse Education Today 24, 91-97. Stott, A., 2007. Exploring factors affecting attrition of male students from an undergraduate nursing course: A qualitative study. Nurse Education Today 27, 325-332. Svare, H., 2009. Menn i pleie og omsorg: brødre i hvitt [Men in nursing care : brothers in white]. Universitetsforl., Oslo. Texmon, I., Stølen, N.M., 2009. Arbeidsmarkedet for helse- og sosialpersonell fram mot år 2030 [The labor market for health-care personnel up to the year 2030]. Statistics Norway, Oslo. Tveit, B., 2008. Ny ungdom i gammelt yrke: en studie av sykepleierstudenters motivasjon og fagidentitet i møte med en tradisjonstung utdanning [New youth in an old profession: a study of nursing students' motivation and identity in their encounter with a traditional education], Oslo and Akershus University College of Applied Sciences, Oslo, p. 289. Vike, H., Bakken, R., Brinchmann, A., Haukelien, H., Kroken, R., 2002. Maktens samvittighet: om politikk, styring og dilemmaer i velferdsstaten[Power and conscience: about politics , governance and dilemmas in the welfare state]. Gyldendal akademisk, Oslo. 22
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Wenger, E., 1998. Communities of practice: learning, meaning, and identity. Cambridge University Press, Cambridge. West, C., Zimmerman, D., H., 1987. Doing Gender. Gender and Society 1, 125151.
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ACCEPTED MANUSCRIPT Highlights:
• Male nursing students enter a profession with a feminised understanding of nursing care.
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• There is a lack of men`s stories about care in the education programmes, textbooks and in the profiling of the nursing profession
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• This paper explores how male students tell their stories about care and what meanings they are up against in the nursing profession.
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• We are of the opinion that the nursing programme must facilitate and inspire male students to share and reflect on their own stories, as well as developing a contemporary curriculum with a variety of experience-based and updated curriculum stories.
S1471-5953(15)00082-7
DOI:
10.1016/j.nepr.2015.05.002
Reference:
YNEPR 1986
To appear in:
Nurse Education in Practice
Received Date: 13 March 2014 Revised Date:
5 May 2015
Accepted Date: 6 May 2015
Please cite this article as: Jordal, K., Heggen, K., Masculinity and nursing care: A narrative analysis of male STUDENTS´ stories about care, Nurse Education in Practice (2015), doi: 10.1016/ j.nepr.2015.05.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page
Total words: 4967 (excluding abstract, keywords and reference list)
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Authors:
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MASCULINITY AND NURSING CARE: A NARRATIVE ANALYSIS OF MALE STUDENTS´STORIES ABOUT CARE
Kristin Jordal (Corresponding author)
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Department of Nursing Science, Buskerud and Vestfold University College, P.O. Box 235, 3603 Kongsberg, Norway . Phone: 004733037543. Email: [email protected] Kristin Heggen
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Institute of Health and Society, Department of Health Sciences, Faculty of Medicine, University of Oslo, P.O. Box 1153 Blindern, NO-0318 Oslo, Norway. Phone: 004722845376 Email: [email protected]
ACCEPTED MANUSCRIPT MASCULINITY AND NURSING CARE: A NARRATIVE ANALYSIS OF MALE STUDENTS´ STORIES ABOUT CARE
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Abstract Nursing education programmes and the nursing curriculum have been criticised for
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presenting an outdated and feminised description of care, which has had the effect of
marginalising men, as well as hindering a more modern outlook for the profession. This
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article uses interview-based data from a qualitative study on Norwegian students’ experiences in the first year of training. Using a narrative analysis method, the paper explores how male nursing students use stories to describe care and shows how their storytelling illustrates a way for men to negotiate their role in a feminised profession. The
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paper aims to deepen our understanding of the ways in which male students can challenge this historically female profession to broaden itself by including male-based caregiving as part of nursing care. In addition, the paper highlights the potential of stories and storytelling
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as a teaching and learning strategy in nursing education.
Keywords: Nursing education, men, nursing care, narratives
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ACCEPTED MANUSCRIPT INTRODUCTION Professions are knowledge communities in which the participants develop a common understanding of the key concepts, theories and methodologies that form the basis of the
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practice of the profession (Grimen, 2008). Students are initiated into this community through education, and develop their identity as professionals (Heggen, 2008; Wenger,
1998). Care is a key concept in nursing education, which contributes to a student’s sense of
and Nelson, 2005; Rhodes et al., 2011) .
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identity and belonging to the profession (AACN, 2008; Brown, 2011; Clouder, 2005; Gordon
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The concept of care is at the core of nursing education and practice, but the understanding of care and the meanings given to the concept can vary over time and between cultural contexts (Clouder, 2005; England, 2005; Solbrække et al., 2012). Historically, the perception of nursing care was based on the role of a nun, a ‘virtue script’, which defines women as
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good, kind and self-sacrificing. This concept was used to recruit respectable women to the profession (Brown et al., 2000; Dufwa, 2006; Gordon and Nelson, 2005; Moseng, 2012;
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Svare, 2009). In Western society today, the public and professional understanding of nursing care is still closely associated with a female caregiving role (Abrahamsen, 2004; Brown et al.,
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2000; Stanley, 2008, 2012; Svare, 2009). This gendered understanding of nursing care has been exposed to criticism and debate. It is argued that it sends an archaic and sexist message, which not only stands in the way of a more modern, contemporary image of the nursing profession, but also marginalises men (Bakken, 2001; Christensen and Knight, 2014; Gordon and Nelson, 2005; Jorfeldt, 2006).
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ACCEPTED MANUSCRIPT Although the participation of men in nursing varies among European countries, in general, males nurses play a minority role in the profession (Bakken, 2001; Jorfeldt, 2006; Solbrække et al., 2012; Svare, 2009). This suggests that men who choose nursing as a career undergo a socialisation process into a female-dominated occupation where professional identity is
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based on a feminised understanding of nursing care (Abrahamsen, 2004; Brady and Sherrod, 2003; Gordon and Nelson, 2005; Simpson, 2004). Approximately 4,000 nursing students are admitted at bachelor degree level each year in Norway, but less than ten percent of this
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number are men. Statistics show that the drop-out rate among male nursing students is
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higher than among female students (Svare, 2009; Texmon and Stølen, 2009), a fact that is related to the socialisation process, role strain, and feelings of isolation and marginalisation as a minority in the training environment (Brady and Sherrod, 2003; Brandon and All, 2010; Christensen and Knight, 2014; MacWilliams et al., 2013; Paterson et al., 1996 ; Stott, 2007).
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Studies in nursing education also reveal that male students experience the study programme’s perception of care as feminine (Bakken, 2010; Christensen and Knight, 2014; MacWilliams et al., 2013; Paterson et al., 1995; Paterson et al., 1996 ). It is therefore
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suggested that men’s encounter with nursing education can represent a dual challenge
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because ‛not only must male students learn to think like nurses, they also often have to learn to think like women to be successful’ (Brady and Sherrod, 2003, p. 159). The concept of care has proved to be important for identification with the nursing profession for both male and female students (MacWilliams et al., 2013; Sellman, 2011; Tveit, 2008).
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ACCEPTED MANUSCRIPT In their study on male nursing students, Paterson et al. (1995) emphasise the importance of storytelling as a central strategy for male students to learn about nursing care. Accordingly, in this paper, we apply a narrative approach that is particularly well-suited for a grasp of the development of self-understanding through the analysis of participants’ stories and
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storytelling (Bruner, 2004; Holloway and Freshwater, 2007; Holstein and Gubrium, 2000). We direct a particular focus on the narrative dynamics that arise at the intersection of the
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male students’ stories and the profession’s discourse on care. The aim of the study is to describe how male nursing students use stories to talk about care, and how their storytelling
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can be understood as way for men to negotiate their role in a feminised profession. The low rate of male participation in nursing gives cause for concern in the context of the large and growing nursing shortage in Western society (AACN, 2014; Roksvaag and Texmon, 2012). This study presents findings that help shed light on men’s identification with nursing
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and their encounters with feminine perceptions of care in the profession. This is important knowledge both for the recruitment and retention of men in the profession. The findings
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may also help the development of a more contemporary and appropriate programme and
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curriculum for nursing education (Clouder, 2003; Clouder, 2005; MacWilliams et al., 2013). Gender perspectives
Considerable development has taken place in the understanding of gender since the beginning of the last century and up to today. Gender was previously defined within a biological perspective, where being born as a man or a woman was perceived as decisive for what you were or could be (Bondevik and Rustad, 2006; Jorfeldt, 2006; Svare, 2009). This viewpoint is related to what we currently call an essentialist understanding of gender, where female and male elements are regarded as given dimensions that set the terms for gendered 4
ACCEPTED MANUSCRIPT ways of behaving in society (Svare, 2009). In today’s social research, gender is to a great extent understood as being constructed and linked to specific contexts. Gender is thus perceived as something that is played out, within and between human beings, in cultural,
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historical and social frameworks (West and Zimmerman, 1987). Within this perspective, the relevant understanding of masculinity will at any given time be mobile and relationally formed since it varies between cultures, over time in the same
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culture, and throughout a person’s lifetime (Lorentzen, 2006, p. 126). When we emphasise today how different forms of masculinity, and femininity, are played out and formed in
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interaction with society’s structural conditions, gender is woven into active meaning-making and identity-creating work (Solbrække and Aarseth, 2006).
Following this line of thought, the professional discourse on care can be perceived as a structuring element that acquires importance for how male nursing students identify
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Simpson, 2004).
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themselves, as men, with the profession (Clouder, 2005; Gubrium and Holstein, 2009;
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Care as a gender-constructing power in nursing In spite of the fact that Norwegian men have gradually reached a high level of participation in the home arena and in the care of their own children, the labour market remains one of the most gender-segregated in the Western world (Solbrække, 2006). This is reflected in the nursing profession in which it is almost only women who nurse, who teach nursing and who write the textbooks and the curriculum (Brady and Sherrod, 2003; Jorfeldt, 2006). When a
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ACCEPTED MANUSCRIPT profession is culturally or historically linked either to masculinity or femininity to such a strong degree, the occupation can be defined as sex-typed (Crompton, 1987). In addition to the profession’s own prioritising of the care concept and the fact that nursing
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education was for a considerable time reserved for women (Moseng, 2012; Vike et al., 2002), a number of other historical social traits have contributed to the way that Norwegian nursing, in general, and care, in particular, have become a female domain. Bakken (2001)
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shows how nursing became a specifically feminine field based on a traditional dichotomybased mind-set, where the nurse is defined as a woman and the doctor as a man in mutual
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and complementary roles. Based on a model taken from the typical home environment, the doctor constituted a father figure, the nurse was linked to a maternal role and the patient was seen as a child who needed care. The feminine, maternal and caring elements were thus associated with nursing as a traditional female profession. According to Svare (2009),
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women also draw on a historical and cultural heritage in the form of practical housewifely competence and a monopoly of care and strength in interpersonal relationships. This ideal is characterised by the woman who takes care of the family with her knowledge of hygiene,
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nutrition and the ability to care. The woman was thus understood as naturally suited to care
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work – including in the public care arena (Kermode, 2006). As Florence Nightingale maintained: ‘every woman is a nurse’ (Svare, 2009, p. 43). The nursing occupation was thus perceived as the professionalisation of inherent qualities that all women should possess (Jorfeldt, 2006). Following this line of thought, men will always start with a handicap in nursing precisely because they are men. Svare confirms this with reference to a much-cited 1987 quotation from the President of the Norwegian Nurses Organisation:
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ACCEPTED MANUSCRIPT Of course I want to welcome more men into the ranks. Nevertheless, there will always be differences between men and women. The care professions will always be female-dominated, regardless of development. Women have innate advantages here which we can do little about (author’s translation) (2009, p. 45).
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The story of nursing as a feminine profession is also sustained and continued today both through public recruitment campaigns and the portrayal of the profession in films and the media (Dahlborg-Lyckhage, 2009; McLaughlin et al., 2010; Stanley, 2008, 2012). This outlook
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was clearly revealed in a recruitment campaign for Swedish nurses: ‛We need more women. We need more people. We also need men’ (Dahlborg-Lyckhage, 2009, p. 167). In addition to
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society’s portrayal of the profession, the nursing education syllabus also creates a picture of nursing and care that has strong feminine connotations (Bakken, 2010; Gordon and Nelson, 2005; Jorfeldt, 2006). Svare (2009) argues that women thus have power as models for the profession, and have therefore been able to define what is right and what is wrong, what is
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of falling short.
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good and what is bad in nursing. – a normative and excluding practice where men are at risk
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ACCEPTED MANUSCRIPT METHOD AND ANALYSIS This article forms part of a qualitative study of six female and three male nursing students’ experiences in the Norwegian nursing education programme. The study’s overall design
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included both individual interviews at the end of the first year and field work conducted in the students’ clinical practice in medical and surgical departments in the second year of the education programme. This paper is based on data from the interviews and adopts a
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narrative perspective both methodologically and analytically. More specifically, this entails gathering and analysing verbal and written stories (Creswell, 2013; Gubrium and Holstein,
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2009; Holloway and Freshwater, 2007; Riessman, 2008).
The first author conducted, recorded and transcribed the in-depths interviews. Each interview lasted about two hours and focused on topics linked to the students’ backgrounds, their interest in and perception of the profession, and their experiences from theoretical
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courses and specific patient situations in the first year of clinical practice. In line with a constructivist framework and a narrative working method, the first author used explorative
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and open questions to activate and facilitate the students' narrative resources (Creswell, 2013; Gubrium and Holstein, 2003; Holloway and Freshwater, 2007). For example, when a
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student talked about care in a general way, the first author might ask: ‘Can you tell me about an episode from your own life, or from clinical practice, where you experienced that someone got good care?’ In this way, the actual narrative production of the interview was a collaboration between the researcher and the participants directed by the research agenda of the study (Gubrium and Holstein, 2003; Holloway and Freshwater, 2007).
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ACCEPTED MANUSCRIPT Ethical considerations The students enrolled voluntarily as participants after finding out about the study through the university college website. The study was recommended by the Regional Research
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Committee and, in line with the application to the committee, the students who enrolled in the study received written information about the study objectives. It was made clear that all data from the study would be made anonymous. Accordingly, the names in this paper are
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fictitious. However, in a paper with a narrative approach, the extended use of the
participants’ stories will always reveal part of the students’ biography and background. This
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fact led us to invite the participants to read the paper during the writing process and to approve the use of their stories in it (Chase, 2013). Analytical approach
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Relating experience in a narrative form appears to be natural for human beings and is meaningful for the experience of our identity (Bruner, 2004; Holstein and Gubrium, 2000; McAdams, 1993). At the same time, an individual’s stories are considered to be very
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responsive to cultural, discursive, interpersonal and linguistic influence (Gubrium and
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Holstein, 2009; Holloway and Freshwater, 2007). Professions such as nursing offer significant narrative environments; (Gubrium and Holstein, 2009, p. 165) emphasise the need to identify how work-related resources and orientation shape narrative accounts. In line with this recommendation, the analytical work in this paper focuses both on how the students tell their stories and on what meanings they are up against in the nursing profession, which is understood as such a narrative environment (Gubrium and Holstein, 2009). Accordingly, the relationship between the students’ stories about care –a narrative structure with a specific content ‒ and their storytelling – the activity of telling these stories to others ‒ is viewed in 9
ACCEPTED MANUSCRIPT dynamic association with the narrative surroundings in which the stories are shaped (Creswell, 2013; Gubrium and Holstein, 2009). The actual analytical work took shape by a repeated reading of the interview data. This
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reading focused on the specific ways in which the men structured and arranged their experiences of good caregiving into narrative format. The stories of John and Christian were chosen because of their thematic content and the way they are structured as fully-formed
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narratives (Creswell, 2013; Labov, 1997; Riessman, 2008). Their stories have several common traits in terms of topics discussed and structural features. They reveal ‘Aha!’ moments of
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insight and change and seemingly broaden the men’s understanding of care (Paterson et al., 1995). The narratives in this paper therefore serve as optimised examples from the material on the male participants’ narration of what they perceived as good caregiving (Holloway and Freshwater, 2007). First, we conducted an internal structural analysis focused on the
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characters, on what`s at stake for whom in the stories, and the outcome. The initial exploration of the stories also focused on the developmental structure in the stories, identified as a fully-formed narrative in six stages: an abstract, orientation with regard to
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time, place and characters, a presentation of the story’s problem or crisis, an evaluation, the
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outcome of the story, and a final coda (Labov, 1997). After this initial analysis, we directed the analytical focus to the nursing profession as a cultural and discursive context (Gubrium and Holstein, 2009). The traditional and feminised discourse on care, as outlined in the introduction, was understood as structuring narrative circumstances that create specific conditions for how these nursing students described their masculinity. Qualifying for any form of professional practice is about identifying oneself with a particular occupational field and profession. At the same time, telling others about oneself
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ACCEPTED MANUSCRIPT as a professional in a particular occupation is closely linked to self-understanding (Gubrium and Holstein, 2009; Heggen, 2008). Accordingly, the male students’ storytelling is analysed as masculine identification with ‒ and narrative meaning-making of ‒ nursing as a gendered
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FINDINGS
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profession (Gubrium and Holstein, 2009; Paterson et al., 1995).
John’s story
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John is in his early forties, is married and has children who live at home. After many years as a salesman and in a leadership position, John went through a crisis that ended with his taking a severance package and leaving his job. John had to make up his mind about what he wanted to do in the future and he therefore reviewed the jobs he had had. He found that
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being with other people was a common denominator. For a while, John considered becoming a prison officer and worked shifts in psychiatry to accrue enough credits for admission to the prison officer training programme. One day, when he was working in a
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psychiatric institution, he witnessed an incident that made him change his mind.
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I hadn’t thought about the professional background of nursing until I once saw a psychiatric nurse calming down a psychotic patient. The patient looked completely wild, and several people were involved. Then along came this nurse called David. He went up to the patient and held him like this round his shoulders [John demonstrates by holding me round my shoulders] since that’s an action that disarms people. Then he said ‘There’s nothing to worry about’ and ‛Just calm down’. So instead of being frightened of the patient he managed to turn the whole situation around. He knew that this psychotic
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ACCEPTED MANUSCRIPT patient was afraid of us all. He quite simply demonstrated care for the patient. So this was one of the situations that made me want to be a nurse.
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Christian’s story Christian is a married man in his late forties. His children had grown up and Christian had therefore reached a point where he needed to think carefully about how he wanted to
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spend the rest of his working life. He decided that he wanted to work with people in order to get more in line with his personal values. He is very motivated for this occupational change
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and says: ‛It’s about having the drive, the curiosity – like, I’ll fix this. To put it a bit flippantly: I’ll make a damn good nurse’. He then explores what being a ‘damn good nurse’ really means by talking about the male contact nurse he had for his practice period in a nursing home in
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the first year of his training:
He put things right for all kinds of patients – dementia patients and somatic patients. The approach he had towards them. [He had] a calming effect on the aggressive patients. He was what I would call an incredibly good all-round
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nurse, while at the same time he was professionally competent medically. Once there was a female patient who had very bad dementia, she started to
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get very aggressive, shouting abuse at the staff and the relatives. Some of them tried to restrain her, but she hit them and was absolutely desperate. He [Christian’s contact nurse] came to the rescue and calmed her down. She was crying and she was so distressed – she saw the devil in … she was very ill. He
really took his time, even though he was up to his neck in work. He gave the situation priority. He calmed things down. He crouched in front of her, held her hands – the closeness, met her gaze, she realised who he was. So he made her feel that ‘There’s nothing to worry about, this is quite OK’ without telling her off, but quite simply: ‘You can be angry. It’s OK’. He appealed to her ‘healthy’ side. He got her out of a difficult situation, pampered her a bit with 12
ACCEPTED MANUSCRIPT blankets and … he made her warm tea. It was great to watch him; it was really touching to see how he brought her back to normal. It was wonderful – in my eyes he was a damn good nurse. John and Christian’s stories start with an introduction that links them to the specific
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interview situation. They then develop their stories by introducing the main characters and the situation in which they find themselves. A male nurse is the main character in both stories. In narrative theory, this character is the protagonist (Frank, 2010). The main
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character of each story finds himself in an unstable and chaotic situation where the other staff have not managed to resolve the problems that have arisen. These male nurses are
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thus recognised by the students as having the particular skills of involvement and strength to calm and contain the situation. In our narrative perspective, they can be understood as saviours and heroes in the story, literary-inspired characters who are come to the rescue where others fall short (Frank, 2010). The patients in each story, the stories’ antagonists, are
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described respectively as ‛completely wild’, ‘psychotic’, ‛so distressed’ and ‘absolutely desperate’, which make us understand that these situations are very demanding. The patient
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is thus a challenger who through his or her way of behaving pushes the incident in the story to a decisive point – a climax where it can swing either one way or the other for the male
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nurses. The suspense is linked to whether they will manage to do what is necessary to save the situation and the patient (Frank, 2010). We note that both nurses are efficient and establish contact with the uncontrolled patients by holding them – holding their hands or putting their arms round their shoulders – showing connection and engagement skills. The male nurses contain the situation almost as if they are absorbing the patients’ chaos and loss of control, while at the same time they make the stories’ only statement: ‛There’s nothing to worry about’. In this way, these male nurses grasp the difficult situation while they also
13
ACCEPTED MANUSCRIPT define it. The two stories have a common basic theme and a line of development that can be summarised as follows. A helpless or sick person needs help. Those present are not able to help. An effective male nurse understands the situation, takes action and does what is required to resolve the problem. In narrative analysis, this type of pattern is called the
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story’s plot and it is in the plot that we discover what the story is fundamentally about and what is at stake in the situation (Frank, 2010; Gubrium and Holstein, 2009). In these stories, the inherent risks are fear, helplessness and loss of control, provided by a strong other who
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is able to convey concern and connection. The stories of John and Christian emphasise how
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the male nurse understands the actual situation, grasps the problem and finds a solution. The result can be success or fiasco. In these stories the situation is resolved. In a sense we can view them as success stories that the two male students use to underline what good nursing care actually is.
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When we turn the analytic focus to nursing as the narrative environment in which John and Christian tell their stories about care, we enter a specific, professional and discursive arena where care is portrayed as feminised, physical, all-encompassing and emotional, based on
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altruism, compassion and inherent female qualities (Gordon and Nelson, 2005; Svare, 2009;
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Vike et al., 2002, p. 119). These stereotyped, heartfelt and feminine bodily perceptions of care are what John and Christian are up against as male nursing students. According to Connell (1995), hegemonic masculinity is the dominant and culturally-accepted way of being male in a society. This expression of masculinity is understood as hierarchically superior and directly opposed to femininity and homosexuality (Lorentzen, 2006).
14
ACCEPTED MANUSCRIPT Svare (2009) describes how the masculine element in society is also linked to exceeding limits and to the ability to change and develop, along with archetypal portrayals of man as a hero who is willing to take risks in the battle against all types of enemies. Following this line of thought, we can see how the main characters in the men’s stories, with their resolute and
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firm intervention in a difficult situation, create alternative descriptions of care. This becomes clear when ‛all-round’ nurses ‘give priority’ to the situation, ‘come to the rescue’,
‘understand’ and ‛put things right’ for all kinds of patients. They ‘disarm’ conflicts and
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thereby get the patients out of a difficult situation. In this way, the male nurses in the stories
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intervene, define and resolve a challenging situation that nobody else appears to be able to cope with. They thus act out a culturally accepted and hegemonic masculinity that is associated with strength, power and dominance in the situation (Connell, 1995). When care is linked to this type of vigorous action, these male students do what we regard as practice-
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related and active masculinisation work, which also negotiates and stretches the understanding and perspectives of nursing care to include male caregiving. When their stories ‒ the way in which they structure the plot and present the characters ‒ are analysed
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in relationship to their narrative circumstances, we find that the storytelling can be
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interpreted as giving them space as men in a gendered profession such as nursing. Nonetheless, we also recognise the traditional discourse on care when the story’s male nurses create closeness and pamper patients. Care is thus interpreted by John and Christian as not only associated with hegemonic masculine features such as capacity, insight, decisiveness and action, but also with empathy and closeness. These men thus narrate their stories about care as a negotiation, both within and outside traditional masculine roles and the prevailing nursing discourse on care. As we see it, the story’s content and structure, as well as the work the story does for them, can be linked to the strategies that men, according 15
ACCEPTED MANUSCRIPT to Simpson, use ‘to bring the job more in line with dominant notions of masculinity’ (Simpson, 2004, p. 359). At the same time, the stories serve as part of their identification with the profession. The two men’s stories about care, perceived as masculinity at work
DISCUSSION
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experience, talk about, learn and perform nursing care.
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(Simpson, 2004), can thus contribute to highlighting and directing focus towards how men
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All professional fields mediate a value perception of what is right, appropriate and desirable in contrast to what is perceived as wrong, inappropriate and immoral (Jensen and Tveit, 2005). Hence, when care – as a key value of the nursing profession – is closely linked to an outdated perception of women’s nature, while also being communicated in stereotyped
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ways, it is problematic for several reasons.
First, the traditional discourse on care has been shown to exclude men and to push them out of the education programme and the profession (MacWilliams et al., 2013; Paterson et al.,
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1996 ; Stott, 2004, 2007). This is particularly worrying in the light of the huge recruitment
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challenges that the entire nursing profession faces in its encounter with a large and rapidlygrowing need for labour in the health sector (AACN, 2014; Roksvaag and Texmon, 2012). Studies show that male students experience alienation in their encounters with a professional field described as no man’s land (Bakken, 2001; Christensen and Knight, 2014; MacWilliams et al., 2013). John and Christian’s stories are examples of how such stories can serve as carriers of men’s experience. As we see it, these stories have the potential to give male students space as men in the nursing education programme. Men, as a minority, lack such masculine narratives to help them identify with the profession as well as to recognise 16
ACCEPTED MANUSCRIPT and learn about nursing care (MacWilliams et al., 2013). Paterson et al. (1995) found that storytelling was a key learning strategy among male students who actively sought narratives to determine the meaning of what it is to care as a nurse. The stories told by John and Christian are therefore in no way unique: these stories exist as part of men’s ‘tellable
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material’ (Gubrium and Holstein, 2009, p. 42). However, they are stories that do not often come to the surface in the nursing education programme, in the curriculum or the profiling
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of the nursing profession.
Secondly, the normative and traditional portrayal of nursing care can be said to trivialise and
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sentimentalise the profession. It stands in the way of updated and empirical descriptions of care understood as a complex nursing skill (Gordon and Nelson, 2005; Rhodes et al., 2011). We are of the view that stories such as those told by John and Christian stretch the understanding of nursing care and give it new perspectives. This is a useful contribution
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when seen in relation to the ongoing debate on how nursing education programmes and the curriculum should be renewed (Benner, 2010; Frenk et al., 2010). These stories can therefore be understood both as a masculine contribution to a feminised profession and as an
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example that highlights the need for a much greater variety and diversity in the way nursing
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care is conveyed in the curriculum.
Finally, we are of the view that the nursing education programme needs to take into account, to a much greater extent, the complex and diverse meaning-making and identification processes that all students go through when choosing the profession and undertaking their professional education (Heggen, 2008; Sandvik et al., 2014; Wenger, 1998). As we have discussed in this paper, stories have the capacity to link the students' own experiences with the theoretical content of the programme and are thereby key to critical
17
ACCEPTED MANUSCRIPT reflection on nursing theory and practice (Gubrium and Holstein, 2009; Hunter, 2008; Paterson et al., 1995). This is emphasised by Hunter, who argues: For nurses, telling and listening to stories related to health and illness provide a vital means through which human experiences can be honored, as well as
to understanding the whole of nursing care (2008, p. 1).
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facilitate the integration of the essential patterns of knowing that are crucial
As a result, we believe helping students to share their own stories ‒ as well as to read,
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interpret and discuss a variety of updated curriculum stories ‒ has huge potential for nursing education (Benner, 2010; Holloway and Freshwater, 2007; Hunter, 2008; Paterson et al.,
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1995).
CONCLUSION
In this study, we analysed two male nursing students’ stories about care in light of the
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profession’s feminised and stereotyped discourse of care. We analysed the stories as a masculinisation of the care concept that gave the students space as men. The stories also serve as examples that highlight the need for updating the nursing curriculum. In summary,
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we are of the opinion that the renewal of the nursing programme must involve a teaching
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strategy that involves students telling their own stories, as well as developing a contemporary curriculum that offers diverse, experience-based stories about care to which today’s youth can relate. The overall objective must be for nursing to become a story that young people can identify with and want to be part of – regardless of class, ethnicity, religion or gender.
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ACCEPTED MANUSCRIPT Highlights:
• Male nursing students enter a profession with a feminised understanding of nursing care.
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• There is a lack of men`s stories about care in the education programmes, textbooks and in the profiling of the nursing profession
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• This paper explores how male students tell their stories about care and what meanings they are up against in the nursing profession.
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• We are of the opinion that the nursing programme must facilitate and inspire male students to share and reflect on their own stories, as well as developing a contemporary curriculum with a variety of experience-based and updated curriculum stories.
