Nursing and Health Sciences (2014), ••, ••–••
The image of nursing, as perceived by Iranian male nurses Leila Valizadeh, PhD,1 Vahid Zamanzadeh, PhD,1 Marjaneh M. Fooladi, NP, PhD,2 Arman Azadi, PhD,1,3 Reza Negarandeh, PhD4 and Morteza Monadi, PhD5 1 Department of Nursing, Tabriz University of Medical Sciences, Tabriz, 4Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, 5Faculty of Education and Psychology, Alzahra University, Tehran, 3Department of Nursing, Ilam University of Medical Sciences, Ilam, Iran and 2WWNSN, El Paso, Texas, USA
The stereotypical public image of nursing is a major concern for male nurses around the world. In this study, we explored how Iranian male nurses perceived the public view of nurses, and their perceptions of themselves. A qualitative descriptive design and content analysis were used to obtain data from 18 purposely-selected male hospital nurses with a baccalaureate nursing degree in Tabriz, Iran. Semistructured interviews were conducted and analyzed. Two main themes emerged: (i) the outsider’s view of nursing, which referred to the participants’ perceptions of their public image; and (ii) the insider’s view, which related to the male nurses’ perceptions of themselves. Results included personal transition into a positive professional self-image through the educational process, and continued public perception of nursing as a female profession ill-suited for a man. Strategies to improve the insider’s and outsider’s views of nursing are listed to help recruit and retain more Iranian male nurses.
Iran, male nurse, nursing image, public image, self-perception.
INTRODUCTION Although the number of men entering the nursing profession is on the rise, the gender imbalance continues to exist for men in nursing, because more males than female nurses leave the profession (Evans & Frank, 2003; Stott, 2007; MacWilliams et al., 2013). Studies have shown that male nurses leave nursing to study other fields and change careers (Lou et al., 2007). It has been reported that male nurses have twice the rate of turnover of females, and on average, leave nursing early in their careers (Evans, 2002; Duffin, 2006). Barriers for men seeking to enter nursing and for those already working as nurses are the public perception of nursing profession, social values, professional organization, nursing culture, and patient preferences (Whittock & Leonard, 2003; Meadus & Twomey, 2007; Mooney et al., 2008). One of the major obstacles dissuading men from choosing nursing as a career is its traditional female image (Evans, 1997; Roth & Coleman, 2008). The prevailing feminine nature of nursing with a caring image has been symbolized as the epitome of femininity (O’Lynn, 2004). The public perception of nursing is not only a job for women but as one who have no skills and are valued less compare to male career, mainly medicine (Evans, 1997; Roberts & Vasquez, 2004). Men who choose a traditional female-oriented career are perceived as socially demoted, in contrast to women who Correspondence address: Arman Azadi, Students’ Research Committee, Nursing Department, Tabriz University of Medical Sciences, Tabriz, Iran. Email: [email protected]
Received 14 May 2013; revision received 12 September 2013; accepted 29 September 2013.
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pursue a conventionally male-oriented occupation and are perceived as being socially promoted (Evans, 2004). Similar to men in nursing, women in engineering or blue-collar jobs, experience gender bias and stereotypes and their abilities or competencies are questioned, and their performance undermined (McMurry, 2011). The public perception of the nursing profession is complex and difficult to describe; media portrayal of nurses are often harmful to the professonal image of nurses (Tzeng, 2006; Cabaniss, 2011). They portray nursing contrary to the way nurses perceive themselves and their profession. Media nurses are often single, white women under 35 years of age (Fletcher, 2007), and despite the fact that men are not new to nursing (Mackintosh, 1997), media male nurses are often depicted as misfits or those who chose the wrong profession (Cabaniss, 2011). Our understanding of the image of nursing has been mainly based on others’ perspectives, such as the public or media, rather than nurses themselves (Fletcher, 2007). The negative public perception of male nurses is often dismissive, hurtful, and discouraging, which leads to job dissatisfaction and subsequent departure (Ellis et al., 2006; Meadus & Twomey, 2011). Researchers have found that the public’s view of nursing influences nurses’ perceptions of themselves, their self-concept, collective self-esteem, job satisfaction, and job performance (Takase et al., 2002).
Image of male nurses in Iran The Iranian nursing profession began in 1915 with the enrolment of female nursing students (Salsali, 2000). Fooladi doi: 10.1111/nhs.12101
(2003) noted that, before the Islamic revolution in Iran, there were few men in nursing, and patients expected genderappropriate nursing care. According to Nikbakht Nasrabadi and Emami (2006), many patients are surprised when a male nurse walks in to care for them. Hajbaghery and Salsali (2005) stated that, in a patriarchal Iranian society, people have a poor image of nursing. Nurses often feel frustrated, hopeless, and confused about their professional image and social identity (Nasrabadi et al., 2003; Nikbakht Nasrabadi & Emami, 2006). Even today, most Iranians believe nurses are simply a physician’s assistant (Vaismoradi et al., 2011). Nasrabadi et al. (2003) reported that many Iranian students, particularly males, aspire to pursue a university degree, and few consider nursing. Once in a nursing program, male students have more emotional conflicts and burnout than females. Job dissatisfaction and turnover among male graduates are considerably greater (Zarea et al., 2009).
Iranian higher-degree system There is a gatekeeping mechanism in Iran called “concoor”, where high school graduates have to earn high scores on a national entrance exam to be admitted to a university. Entrance acceptable scores are different for each major in a government-funded or private university. Candidates select a few majors, and the system assigns their earned score to the major, with consideration for social needs. Candidates learn their fate through the internet and media. Those who marked medicine as their first choice feel disappointed when they find out that nursing is their major (Fooladi, 2003). Students who enter the program must finish the degree plan, and those who decline to enter the program have to wait two consecutive years before reapplying. The government-funded programs are contractual degrees and are non-negotiable, because the Iranian Government pays for the students’ tuitions, and in part for housing, food, and other expenses, with an expectation that graduates will work at an assigned government-sponsored hospital until the educational debt has been paid. Often male and female students develop a dislike for nursing, but have to remain in the program and graduate. Private universities are noncontractual and less restricted (Fooladi, 2003). The public image of nursing as a profession has been well published, but few, especially in Iran, have focused on how male nurses perceive their public image and themselves. Therefore, in this study, we highlighted the public and personal perceptions of male nurses in Iran, with the aim of improving recruitment, admission, transition, job satisfaction, and retention.
METHODS Design and participants A qualitative descriptive design was used to explore the image of nursing as perceived by Iranian male nurses and their perceptions of public understanding of nursing. Participants were recruited through purposive sampling. The inclusion criteria were: (i) being a male nurse; (ii) graduated from © 2014 Wiley Publishing Asia Pty Ltd.
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a four year baccalaureate nursing program; (iii) having worked as a clinical nurse for at least one year in Iran; and (iv) willingness to enrol in the study. Of the 27 male nurses approached, 18 from different Iranian provinces with a variety of clinical experience met the criteria and agreed to participate. Participants were employed full time at five different government hospitals in Tabriz and Tehran, Iran, and held various clinical positions, which helped capture a broad range of perspectives and experiences.
Data collection Data were collected through in-depth, semistructured interviews lasting between 45 and 60 min. Interviews were recorded after obtaining verbal consent, and transcribed verbatim for analysis before conducting the next interview. Field notes were recorded to help subsequent analyses, thus allowing the researchers to highlight non-verbal aspects of the interview. The interview guide was generated from an extensive literature review. Based on the primary researcher’s experiences as a male nurse, and in consultation with two nursing experts, interview questions were formulated: “Please tell me why you decided to be a nurse”, “When you entered the nursing program, what was the general reaction?”, or “Tell me about your perception and the public image of nursing at work or in general”. As data collection progressed, participants answered follow-up questions. We explored the gendered educational and healthcare system in Iran. Notes from interviews were summarized at the end of each session to find common patterns. Interviews were carried out according to each participant’s available time and place of choice. The preferred places of choice were hospital conference rooms, nurses’ lounges, education rooms, libraries, or their offices for interviews. The participants had one interview session, with the exception of three participants who had two rounds of interviews.
Data analysis Audio-taped data were recorded in the participant’s native language and transcribed in Farsi (Persian). Common patterns and themes were coded according to the participants’ real experiences and Graneheim and Lundman’s (2004) content analysis guide.
Trustworthiness of the study To enhance the rigor of our findings, several strategies were employed, including participants being asked to verify the themes that emerged following each step of data analysis (Graneheim & Lundman, 2004). Data credibility was established by two experts in qualitative nursing research and peer reviewers. The researchers developed an audit trail, which is a systematic collection of materials and documentation reviewed by an independent auditor to confirm and approve the process (Polit & Beck, 2008).
Ethical considerations This study was approved by the research council affiliated with Tabriz University of Medical Sciences in Tabriz, Iran.
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All participants provided informed consent for voluntary participation in the study. Data were stored on a passwordprotected private computer at the researcher’s (AA) office. Hardcopy records and interview materials were securely stored. Participants were assured of their privacy, confidentiality, and autonomy to openly express their views.
RESULTS Eighteen Iranian male nurses aged between 22 and 45 years (mean: 32.8 ± 6.6) were interviewed. Twelve were married, and all had graduated from a four year baccalaureate degree program. Their clinical experiences ranged from two years to 18 years (mean: 8.5 ± 5.3) in specialized areas of coronary care, psychiatry, emergency care, operating room, surgery, and internal medicine. Data analysis revealed two main themes: (i) outsider’s view (participants’ perceptions of public nursing image); and (ii) insider’s view (participants’ self-perceptions of nursing).
Outsider’s view From this theme, five subthemes emerged: (i) nursing as a feminine and physician-subordinate career; (ii) unreasonable expectations of nurses; (iii) professional competency; (iv) maid duty image evoked by the term “nurse”; and (v) nursing as an unrecognized career for men.
Nursing as a feminine and physician-subordinate career Participants stated that the most important factor hindering men from wanting to be a nurse was the public’s image of nursing as a female occupation, and being perceived as a physician’s subordinate: My previous boss laughed when I told him my major was nursing. He said: “How does a man become a nurse?” (ridiculing). If this is the perspective of an office manager about male nurses, what can we expect of the general public or our family members? Even aunts and uncles put you down when you introduce yourself as a nurse. (Participant 3, 43 years old) They (the public) think nurses only obey and blindly follow doctors’ orders. When I was accepted into nursing, my friend asked me and marveled: “Why do you want to study nursing for four years and be a doctor’s assistant?”. (Participant 15, 34 years old) Participants believed that as long as the community perceives nursing as a female profession, and a nurse as someone governed by a doctor, it would be difficult to recruit and retaining males in nursing. Nursing is the last option by those who are not accepted into other fields, such as medicine, dentistry, pharmacy, or physiotherapy.
Unreasonable expectations of nurses The public has a better understanding of disciplines other than nursing, because they meet nurses in emergency situa-
tions. In emotionally-charged events, physicians and nurses are judged unfairly and expected to perform miracles when outcomes could be unpredictable under extreme job stress. Unfortunately, participants reported that less experienced nurses would lose temper in crisis situation instead of keeping calm, when attending to the patient’s needs and/or comforting family members. The outsider’s views are influenced by nurses’ behaviors: I understand their (patients’ relatives) anxiety, but they expect everything to be done instantly when they bring their patient to the emergency room. If a doctor arrives late . . . nurses are blamed. (Participant 4, 33 years old)
Professional competency According to the participants, public perceptions stem from nurses’ unprofessional behaviors. Female nurses are considered inadequately prepared, less knowledgeable, and less skilled, especially based on the way physicians treat them. The participants found female nurses’ behaviors unacceptable when they used family obligations to escape from professional responsibilities, and subsequently damaged the nursing image. The poor public image of nursing was attributed to comments nurses made in response to patients’ questions about their condition and were told: “Ask your doctor, I don’t know about that”. Thus, patients perceive nurses as inadequately prepared or incompetent. Physicians design protocols for standards of care, which offer Iranian nurses limited autonomy: Most female nurses have family obligations (uncommon for males to share household chores), with less time to review and update their knowledge. They do routine nursing care and follow doctors’ orders. (Participant 5, 28 years old)
Maid duty image evoked by the term “nurse” The Farsi term “parastar”, meaning “nurse” in English, defines anyone who provides any type of care, such as a ward orderly, hospital attendant, nursing assistant, or someone caring for children or the elderly at home. Iranians view “parastar” as someone with limited or no education. The participants strove to redefine themselves in specialized areas alongside physicians to improve their social status and public image: I think part of the poor nursing image is due to the term “parastar”. Patients call anyone in uniform “parastar”. I think this term is too broad and unprofessional for an educated nurse. (Participant 4, 33 years old)
Nursing as an unrecognized career for men A distorted media image of nursing has influenced the public perception. In the participants’ view, it was not only the media, but also the school system–especially school counselors – who have failed to increase awareness and © 2014 Wiley Publishing Asia Pty Ltd.
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introduce nursing as a gender-neutral profession. The public’s view of nursing has discouraged men to pursue nursing, and male nurses find it difficult to remain positive: They (the public) have a media image of a nurse as a woman who obeys the doctors’ orders and for that . . . men hesitate to consider nursing as a career. Iranian men who enter nursing have a hard time coping . . . because they have broken the social rules. (Participant 11, 27 years old)
Insider’s views The male nurses’ perceptions of nursing profession are categorized as the insider’s view, with six subthemes: (i) nursing as a gender-neutral profession; (ii) discovering nursing as an academic profession; (iii) improved perceptions through clinical skills; (iv) career concealment; (v) lack of mutual respect among nurses; and (vi) male nurses’ opportunities within nursing.
Nursing as a gender-neutral profession The participants unanimously disagreed with the notion that nursing is most suitable for women, especially in a country, such as Iran, where gendered nursing care requires male and female nurses to care for male and female patients, respectively. They did not perceive caring as an inherently feminine trait, and suggested that male nurses can be as caring as females. However, they said that fast-paced, high-tech, and less skin contact jobs were better suited to them. I disagree with the public perception. I think we need both men and women nurses, because we have male and female patients who have different needs. (Participant 2, 40 years old)
feminine traits. The participants agreed that providing compassionate care is important, but they wanted the public to understand that nursing is a serious profession. The participants believed compassionate care was a part of professional competency. Challenging clinical skills that were perceived to be closer to those of a medical doctor’s were more satisfying for participants: I felt that anyone could do what a staff nurse does on the surgical floor. I wanted to work in specialized units with more autonomy. The position you hold in the system is important. For example, in surgery, when a doctor sees that the patient’s INR (international normalized ratio) is elevated, he would ask the nurse if the patient was given warfarin, rather than Nitrocontin, but in a specialized unit, doctors do not have to ask or tell the nurses what to do . . . in that setting, doctors and nurses are equal partners. (Participant 4, 33 years old)
Career concealment As students, the participants avoided revealing their career as they were embarrassed to be perceived as feminine. After graduation, they would introduce themselves as a supervisor or medical staff instead of a nurse in order to be respected. Once revealed, participants felt obliged to explain why they chose nursing: I gradually realized that nursing was not what movies portrayed. I increasingly felt more confident. When I was a nursing student, I didn’t publically disclose my major; for example, in a taxi. (Participant 5, 28 years old) When I go to my child’s school, I introduce myself as a nursing supervisor to be more respected by the school principal. (Participant 1, 29 years old)
Lack of mutual respect among nurses Discovering nursing as an academic profession As students, the participants held an outsider’s view of nursing, and were disappointed with their major due to lack of knowledge. Nursing was viewed as less valued than medicine, but over the course of their education, the participants discovered the program’s intensity, developed clinical competencies in various specialties, and performed bedside nursing skills. Didactic and clinical knowledge helped the participants better appreciate nursing as a profession:
The insider’s view was that female nurses often had more respect for male nurses than their female counterparts. The participants blamed female nurses for excessive catering to physicians’ demands. Male nurses had mutual respect and supported each other, and physicians were more cordial with male nurses than female nurses. Professional disharmony and subservient behavior toward physicians by female nurses reached a point where a participant requested to be transferred to a unit with more male nurses:
After more involvement in clinical aspects of nursing, I realized what nursing was all about. I learned that nursing is very different from what they (the public and media) have perceived. Nursing is a discipline that gives nurses professional satisfaction. (Participant 5, 28 years old)
All female nurses exhibit excessive and unreasonable regard for physicians, and fail to respect each other. In some cases, they gossiped and created an unpleasant work atmosphere. (Participant 9, 36 years old)
Male nurses’ opportunities within nursing Improved perceptions through clinical skills In the public’s view, cleaning a patient does not require expertise, doing repetitive routine tasks does not define a profession, and a man in nursing is unattractive. The outsider’s view of nursing is of a compassionate person with © 2014 Wiley Publishing Asia Pty Ltd.
The participants acknowledged having great career opportunities in nursing, with the majority holding senior positions across the country. The Iranian patriarchal healthcare system helps male nurses move up the ladder through support they receive from physicians, and offer them unique career
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insights with higher pay. The participants said that nursing offered them a secure and promising future compared to other professions: I think we (males) are in a good place, (as we are) very few and get great offers . . . most of the male nurses I know are holding a well-paying position in management or specialized areas. (Participant 1, 29 years old)
DISCUSSION In this study, we explored and compared Iranian male nurses’ self-perceptions of nursing and their perceptions of others’ understanding of nursing. We found that only three of 18 participants chose nursing as a first career option, and that all experienced significant personal, family, and community resistance to entering a female-dominated profession. Participants shared their previous and others’ reactions to their nursing major as a diametrically-opposing and unimaginable job for a man. We discovered a positive evolution in the self-perception of nurses as compared to the public. Professional growth and socialization helped the study participants, which is similar to the findings of Takase et al. (2002), who found that nurses attain intrinsic values and professional identity through specialized knowledge and skills. Our findings, which were also similar to Tzeng (2006), showed that the public image of nursing stems from nurses’ self-image and perceptions. The public view of nursing as a feminine and caring profession merely shows limited public understanding of nursing. Roberts and Vasquez (2004) asserted that public misperception was fueled by media, which gave credit to medicine, and portrayed nurses as handmaidens to physicians. Currently nurses’ work mostly limited to secondary and tertiary care in which they are governed by physicians and this often overshadows their role in primary health care. The outsider’s view led participants to conceal their career, which is similar to male nurses in Ireland, who were also unable to publically disclose their career and felt powerless (Mooney et al., 2008). In contrast, Evans (2004) found that male nurses in Canada, the UK, and the USA thrived in a patriarchal healthcare culture with a gendered division of labor and disproportionate assignment of male nurses to a masculine-congruent administrative role in specialized areas. Also supporting our findings, Nasrabadi et al. (2003), and Vaismoradi et al. (2011) showed that the public image of Iranian nurses as physician subordinates or technicians is not culturally unique, because researchers in England, Canada, and China have reported similar results (Brodie et al., 2004; Fletcher, 2007; Wang et al., 2011). However, we found that education had a positive influence on male nurses’ self-views. The Farsi term “parastar” troubled participants, as it is ambiguous. According to Vaismoradi et al. (2011), for Iranians, any uniformed healthcare worker is a “parastar”, and as MacWilliams et al. (2013) noted, the feminine image of a “nurse” is a potential barrier for men considering a career in nursing. Similarly, Evans and Frank (2003) stated that men
find nursing to be a threat to their masculine perceptions, and is perceived as defying the prevailing gender norms that are often defended in career choices. The eight male nurses from Nova Scotia and Canada shared similar experiences in a nontraditional role as participants in this study. Although nurses can be administrators, educators, researchers, or direct providers of care, the public maintains the stereotype a nurse. According to Roberts and Vasquez (2004), nurses themselves minimize their importance in the system and do too little to improve their image. Fletcher (2007) suggested that it might be necessary to overtly articulate various nursing roles to inform the public, and warned that denial of previous stereotypes must not merely result in finding an improved new one. Roberts and Vasquez (2004) and Tzeng (2006) support a supplement to the traditional role by creating an even more honorable and worthwhile profession to advance the quality of health care with efficient patient care. A rigid Iranian education system disallows college students to first examine and then commit to their major without penalty. According to Fooladi (2003), male nurses resolve the gender issue by assuming “masculine” roles in management, armed forces, and emergency and intensive care. Stott (2007) also found that male nurses gravitate toward technical, nonclinical, or high-acuity areas in order to cope with the role strain in nursing. The participants in this study excelled in high-tech “masculine” roles, and female nurses chose “feminine” fields in pediatrics, postpartum care, or community health nursing in order to manage family and career (Fooladi, 2003). Our findings of patriarchal support between physicians and male nurses were congruent with the findings of Ellis et al. (2006). Improved self-perceptions helped the participants understand that caring is not an inherently feminine trait and that being sensitive to a patient’s needs exhibits professional competency. In a UK study, Whittock and Leonard (2003) reported that male nurses can be as caring as female nurses. Male nurses often struggle with the caring aspect of nursing. Rafael (1996) recognized the existing tension in the opposition between power and caring, and offered the concept of “empowered caring” to reduce discomfort with the notion of power (Rafael, 1996). To change the public perception of nursing, Iranian nurses need to inform the public of their academic knowledge, skills, and professional commitment (Fooladi, 2003; Adib Hajbaghery & Salsali, 2005; Varaei et al., 2012). Tzeng (2006) found that a positive professional image leading to expert power is often shaped by skills, knowledge, and credibility. According to Evans (1997), male nurses distance themselves from traditional nursing roles to avoid feminine perceptions. However, male nurses in Iran can provide gender-appropriate care and achieve their goals. The public view of male nurse in Iran is in transition, because with regard to being in a patriarchal society and obligation of gendered care by Islamic perspective they are not faced with much social discrimination. In fact, the majority of tenured administrative positions in colleges and hospitals are held by male nurses, which is a testimony to this claim, regardless of © 2014 Wiley Publishing Asia Pty Ltd.
public views (Nasrabadi et al., 2003; Vaismoradi et al., 2011; Rezaei-Adaryani et al., 2012). In this study, we identified gender issues in Iran with respect to nursing, and recommend the following to improve male nurses’ self-perceptions and their perceived public view of nursing: (i) encourage media directors to display a professional view of male and female nurses, with an emphasis on their knowledge and skills; (ii) offer an in-service to address gender issues and promote autonomy in nursing leadership; and (iii) introduce nursing as a potential career to male and female high school students. In this study we struggled to explore male nurses’ perception of the image of nursing, however as a limitation of this study further research is recommended on how patriarchal society has influenced the public views of nursing profession.
Conclusions Iranian male nurses have learned to adjust to a femaledominated profession and cope with being “out of one’s element” in a patriarchal society, such as Iran. Knowledge and skills have a positive influence on male nurses’ perspectives of the nursing profession. The public views of men in nursing require comprehensive public education and community awareness to recognize nursing as a profession and improve its image. Nurses themselves play a key role in professional identity, job satisfaction, and career stability. Social change requires time, effort, and commitment. Male nurses’ views of nursing and their professional outlooks can directly influence job performance, patient satisfaction, and the professional image over time. A positive image of the nursing profession can improve future recruitment and the retention of male nurses.
ACKNOWLEDGMENTS This is a report of a database from thesis entitled “Socialization of men to nursing profession” approved by Tabriz University of Medical Sciences. The authors wish to acknowledge all of the male nurses, whose contribution enabled the production of this article.
CONTRIBUTIONS Study Design: LV, VZ, AA, RN, MM. Data Collection: AA. Data Analysis: AA, LV, VZ. Manuscript Writing: MF, AA.
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