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Nursing & Health Journal Articles Nursing & Health

September 2008

Men's clinical career pathways: Widening the understanding

Thomas Harding
NorthTec, New Zealand; University College in Buskerud, Norway, tharding@northtec.ac.nz

Recommended Citation
Harding, Thomas, "Men's clinical career pathways: Widening the understanding" (2008). Nursing & Health Journal Articles. Paper 16. http://www.coda.ac.nz/northtec_nh_jo/16

This Journal Article is brought to you for free and open access by the Nursing & Health at coda. It has been accepted for inclusion in Nursing & Health Journal Articles by an authorized administrator of coda.

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Mens clinical career pathways: Widening the understanding

This article, drawn from a larger study, reports on the factors which have influenced the choice of a group of New Zealand male nurses clinical career pathways. Using discourse analysis, interview data from 18 participants were analyzed and related to existing literature on male nurses. The analysis reveals that the predominance of men in selected areas of nursing can be attributed to multiple factors including: socialisation pressures that are grounded on gender stereotyping, a desire for challenge, homosocial tendencies, and the belief that multiple work experience equips them to be better nurses. The results challenge essentialist readings of masculinity within the context of nursing and identifies challenges for the nursing education and the profession to enable men to contribute more widely to nursing. Keywords discourse analysis, gender stereotypes, men, nursing, work force issues

Thomas Harding

Fag og kn

Introduction
This article reports on one aspect of a larger study which used discourse analysis to critically explore the social construction of men as nurses. It draws upon the literature pertaining to gender and nursing and upon interviews with 18 New Zealand men to describe how socio-political factors impact on and maintain the subculture of male nurses. It considers the overrepresentation of men in selected areas of nursing such as intensive care, emergency department, psychiatry, and administration and discusses how these areas have been labelled islands of masculinity (1, p. 265). It offers alternative explanations to those commonly found in existing literature.

Background
With respect to men in nursing, two prominent themes emerge in existing literature: (i) Men are attracted to the more high-status and prestigious

aspects of nursing such as emergency department (ED) and critical care areas (2 p. 173); and, (ii) men have more advantages with respect to career promotion (3-5). As nursing is strongly associated with womens work, it has been argued that men distance themselves from its feminine core (6) and the emotional labour of nursing (7). It has been contended also that they seek promotion in order to protect their masculine status (2, 5) or chose to work in speciality areas which emphasise the need for either technical aptitude or physical strength. These so-called speciality areas have also been delineated as high status and it is argued that men work in such environments in order to separate themselves and their masculine sex role identities from their female colleagues and the feminine image of nursing itself (3 p. 226). Such theorizing is underpinned by the proposition that men suffer from role strain: identity conflict as a consequence of being in a female profession (1, 8, 9). This is postulated as resulting from difficulty in reconciling the script of normative masculinity with the feminine role of the

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nurse: In order to reduce this conflict in role obligations, a man nurse may choose certain areas of specialization, and within these areas, his perception of his status tends to minimize the role strain (10 p. 419).

The Study
Aim The current study investigates whether the themes described in existing literature accurately reflect the reality for men who inhabit these discourses. Philosophical and methodological assumptions Arguing that conceptions of normative identity emerge from the cultural conversations within which society is embedded (11 p. 220), this study was underpinned by a social constructionist challenge to knowledge taken for granted. Social constructionist research is grounded in one or more of the following tenets: (i) a critical approach to knowledge taken for granted; (ii) knowledge is culturally and historically located; (iii) knowledge is created and sustained through social processes; and (iv) knowledge and social action go together (11,12). It argues the centrality of language in the construction of identity, social life, and in mediating the relationship between the individual and society. Thus, discourse analysis is an appropriate method (14). Method Discourse analysis is an umbrella for a variety of research practices with different aims and theoretical backgrounds; however, two broad categories can be identified. One approach, where the present work is situated, is concerned with issues of identity, selfhood, personal and social changes, and power relations (12 p. 47). Here, the focus is on language as central to structuring and constrain-

ing meaning and on the use of interpretive styles of analysis. The second approach is less concerned with issues of selfhood and the subjectivity of power, but more orientated towards the use of language: How the accounts are constructed, the rhetorical devices used, and how they are deployed (15). Given the different approaches not one of the different methods of discourse analysis can be said to be the right one. However, theoretical considerations are relevant to its application in a research context (16). Of particular significance to this study are the understandings that: (i) language has a variety of functions and consequences; (ii) language is both constructed and constructive; (iii) the same phenomenon can be described in a number of different ways; and (iv) there will be considerable variation in accounts (12, 13). Parkers approach to discourse analysis was adopted to perform the actual analysis (17). His ten criteria do not form a specific methodology for discourse analysis: They are guides.

Participants The participants were selected using purposive and snowball sampling. Four were enrolled in university programmes; two in Bachelor of Health Science (Nursing) degrees and two in Master of Health Science (Nursing) degrees. All but one had received their nursing education or were currently studying nursing in New Zealand. Several were purposively selected based on previous knowledge of their nursing experience. Discussions with colleagues and participants led to the inclusion of other participants. The workplace of the participants included clinical nursing, education, administration, midwifery, mental health, and the armed forces. This career distribution provided responses from those positioned differently, and to investigate any differences related to age and career length, the participants ranged from those who had recently commenced or completed their nursing education to a person retiring after 40 years in the profession.

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The decision to limit the number of participants to 18 was not based on a sense that the data were sufficient with respect to whether anything new was to be learned, but more on manageability in terms of being able to conduct a thorough analysis of the data within the time available for the study.

Data collection The study utilised a variety of literature, which can be divided into two categories:
1. Existing literature on gender and nursing. This included writings, both academic and nonacademic, and two films. 2. 20 transcribed interviews conducted in 2004 with 18 New Zealand male nurses. A number of key themes emerged from the literature related to men and nursing, and relevant to this study are: (i) the clustering of men in areas of speciality nursing; and (ii) men choosing specialities to avoid the emotional labour of nursing and to maintain masculine status. The interviews were undertaken to explore these themes from a male perspective. In-depth interviews with the participants were conducted in 2004. They were semi-structured, and the participants were able to relate their experiences as they chose. The interviews provided 278 pages of data. As the interviews were read and reread, thematic notes were made and allocated keys which had been identified during the earlier literature analysis. Further reading and reflection identified subthemes which were also allocated keys. The expanded keys were noted alongside the pertinent sections of the material which was photocopied and the marked bits of text cut out. These were then sorted into collections according to the keys; organizing (or coding) the material by thematic keys was a precursory act to the actual process of discourse analysis and deconstruction. The analysis per se necessitated reading and rereading the groups of text pieces while simultaneously engaged in the conceptual work required by deconstructive discourse analysis.

Ethical considerations Approval and permission to undertake the main study was obtained from the University of Auckland Human Subjects Ethics Committee. The number of men who are nurses in New Zealand is relatively small; therefore, it is possible even after taking appropriate measures to ensure anonymity that there may be readers who think they can identify a particular participant. This was discussed with all participants, and each one stated his comfort with this, and on receiving a copy of their transcripts, no one withdrew or asked for any aspect to be deleted. In the following discussion texts from the participants is denoted by use of pseudonym, quotation marks or indented excerpts. While the findings presented here may provide further understanding into the experience of male nurses, they are not generalizable.

Findings
Four themes emerged from the interview data: 1. 2. 3. 4. The persistence of nursing as womens work; The pressure of gender appropriate nursing; The desire for career development; and The feeling of isolation.

The persistence of nursing as womens work Only four of the participants stated that they had any thoughts of becoming a nurse while at school, and all described its association with womens work as a potent barrier. Allan described his initial experience at a career seminar in the early 1980s:
I was interested in becoming a nurse and went to a careers day at City Tech; I was nervous that day. It was a sort of multi-career option day, and my plan was to be there for the nursing component. When they asked the nurses, the

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people interested in nursing, to get up and go to another room, I watched more than a hundred young women do so and stayed in my seat, and when they asked for accountants or something, I got up with that group and went home there were no men in the nursing group. Charles, who left school several years after Allan, talked about his teenage belief that nursing was not a viable career option for men: 1 It sort of started about 1996, I started to think about nursing yeah, but, it wasnt really something that I thought of to do as a male. It was something that when you do career options at 5 school, it is never offered. It is never presented to males. It is always a girly thing to do. Interviewer: Do you think that if it had been presented at school when you thinking about career options that it would have interested 10 you? Charles: It would have interested me, but I dont know whether I would have done it at that stage. Interviewer: Why not? 15 Charles: Because, I guess, it is stepping away from mainstream a little bit. Interviewer: Mainstream? Charles: Mainstream, in taking on a career that a male would not normally take on. Charles described nursing as being away from the mainstream (line 16) which is the discourse of a male hierarchy which subjugates the interests of women to those of men and marginalises women and their work. Charles not only categorized nursing as a female occupation but he also linked it to the word girly (line 6). This can be interpreted in three ways; first as denoting something that is typically female in character. Second it also suggests a patronising and dismissive attitude to both women and nursing. Third there is the association of the word with sexually provocative magazines, the girly magazine. It is not possible to accurately infer a sexual connota-

tion from his words, and no other utterance during his interview sexualised nurses. It is possible, however, to infer that, at the very least, he has assimilated popular notions of nursing as womens work and is trivialising it by the use of the word girly. His relationship with nursing is ambivalent. There was a congruence between the respondents with respect to the association of nursing with womens work as this surfaced in all the interviews. Robert held this belief so strongly that he thought a man would not be even allowed to apply: Going through high school, I thought about it, and because it was a job that women did I thought I would be excluded from it, even though I wanted to do it. Edward, who was in his early 20s when he entered nursing school in the mid 1980s, looks back on it as being an unusual choice. He elaborated: 1 I look back on it as being a excuse the generalization but as a rugby [playing], outdoors person it just didnt seem to fit the context of a male and going and making and doing that 5 change Interviewer: Are you saying that there is some association with it as being womens work? Edward: Oh, I think it is very much a feminine role. In this extract, not only is there the link to nursing as womens work, but in line 2, the illusion of the dominant stereotype of the New Zealand man: the sport-loving, outdoors man surfaces. In line 9, Edward used the word feminine, and he returned to this at a later point: Theres times that I have fought, to my embarrassment, fought that feminine side of nursing and being seen as feminine. In using the word fought, he articulated his struggle with the discourse that by entering a womans profession he becomes, by association, less of a man: being seen as feminine. Charles also alluded to this when he commented: They as-

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sume that for you to be a nurse, you must have female traits somewhere. Even in light of the re-evaluation of gender roles that was instigated by feminist scholarship and protest, all the respondents believed the notion that general nursing is womens work remains prevalent. When asked why there are still so few men entering the profession, Mathew responded: 1 Oh, I think because of a number of reasons. There is the stereotypical reason to start with that nursing is still seen as a female role, and that its paid accordingly. I mean, we dont get 5 as much money as equivalent services. Police and teaching are doing better than us so its not attractive, its not a big money earner and, I guess, the other stereotypical beliefs about the role. I dont think males are necessarily drawn 10 to the idea of bed baths or cleaning bedpans and that sort of stuff. Theyre all sort of female roles arent they? (laughs). Obviously, were talking stereotypically here. A relationship between women, domesticity, and nursing emerges (lines 10 and 11). Robert, when asked the same question, stated simply: I suppose its because the old attitude still prevails: its womens work.

study, George encountered a similar experience when denied time in gynaecology as a student: They said they would give me more orthopaedics to compensate. The exclusion of men during their nursing education from gynaecology was common and remains so today according to an academic staff member responsible for students clinical placements at a New Zealand School of Nursing, (J. Phillips, personal communication, November 2, 2006). Although it did not interest him, Carl felt pressured to apply for an administrative role by a family member:Ive got an Aunt who would just love me to apply for a Charge Nurses job. But no, Madge, its not going to happen so get over it! Other studies have also shown that such pressure to move up comes from colleagues as well. For example the experience of Thompson Charles who was contentedly working as a clinical nurse has been described: But lots of people have asked: Why havent you moved up the ladder when you are capable of doing so? I usually hear it from the staff nurses and sisters, he says. They always give the impression that I am wasting my time. I think they are comparing me with what they see as the norm for male nurses. (18 p. 31)

The pressure of gender appropriate nursing It has been proposed that both men and women in nursing are channelled into specialities that are considered more appropriate to their gender (5). From both the literature and the interviews, it is evident that such pressure comes from the profession, both education and practice, and also from family and friends. For example, in another study (5), the experience of Bill, who worked in neonatal intensive care, was cited; although he wanted to work in obstetrics and gynaecology, this was not allowed while at nursing school. If he wanted to work with women and neonates, then it was only perceived as appropriate in the intensive care environment. In this

The desire for career development For the men in this study, four factors emerged which influenced their choice to work in a speciality area: gaining experience, the variety of work and its challenge, more autonomy, and acquiring experience to support career goals. For Edward, it was part of developing himself as an expert clinician:
It was really a conscious choice; I developed my career as an expert clinician not from career progression. So I would work in a ward till I had learned as much as I could. And that was a conscious choice because I wanted to be an expert clinician, and I wanted to work in an area where I could get those demands. I worked in ICU, CCU.

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Bruce described his work in Coronary Care as looking to expand my horizons, and from there, he went on to work in primary health care with an international volunteer organisation. Bruce and Allan described a humanitarian impulse: the desire to be of service in countries with impoverished health care. They perceived the experience they gained in CCU, and ICU and ED respectively as developing clinical expertise to enhance their prospects for recruitment by aid agencies. Edward also saw this environment as more demanding intellectually and clinically. He described the challenge of working in a unit in which there was no full-time medical cover and the responsibility that devolved to the nurses. He found it to be an environment where he developed the ability to give expert care, but where he was also stimulated academically. Paul talked about the variety of work and enjoyed the way nurses participated more directly in patient care.

Discussion
Ensuring masculine status or seeking a place to work? It has been suggested that men create islands of masculinity within the profession as a stratagem to maintain masculine status through separation from female colleagues (1, 3, 10). Psychiatric nursing, intensive care, and nursing administration are most often cited as such enclaves. Several issues arise from this notion of masculine enclaves. First historical analysis reveals that many avenues in nursing were closed to them. Thus, men have not created enclaves to support their masculinity, but found employment where they could. For many years, in New Zealand and in other countries such as the United Kingdom and the United States men were denied entry into general nursing schools and were not welcomed into professional nursing organisations. In the early years of psychiatric nursing, they were wanted for their physical strength, and in order to ensure reasonable pay and conditions of employment, they had to align themselves with the trade union movement (20). Thus, they established mechanisms which have contributed to the differential between the average pay of men and women in nursing. This has been described as a secondary benefit from masculine specialization (enhanced prestige is the other) (5), yet given the number of psychiatric nurses who are female, it would appear that women benefit also. Second if areas such as psychiatric nursing are masculine in their ethos then what motivates women to work there? There is a paradox: Men are accused of creating enclaves that benefit them, yet no one questions the motives of women who choose such work. It is not suggested, as has been alleged of men, that they choose to separate themselves from the feminine image of nursing itself (3 p. 226). While enhanced pay may well be an inducement for many mens career decisions, especially given the persistence of a discourse that constructs men as the bread winner, this also needs to be understood in light of the fact that they will probably

The feeling of isolation A number of the participants thought working predominantly with women could be challenging. For example, according to Luke, it was very difficult working in a predominantly female workforce. I dont think it was necessarily a sexist issue; it was just difficult being one against a mass of others. Men have been described as tending to withdraw from small talk with female colleagues: Its nice to share things with men. You have a professional attitude toward both, but when it comes to small talk The women only want to talk about babies and periods (19 p. 118). Men sometimes participate in this small talk; they arent excluded, but they dont enjoy talking about the same things as their female colleagues all the time. Edward described a similar experience and related how during morning and afternoon tea breaks, he preferred to spend time talking with the patients: I would still socialise, but I wouldnt spend those protracted periods of time talking about family and boyfriend and all that other stuff.

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earn less than their male colleagues in what is traditionally considered mens work, such as police work. It is also illogical to presume that many contemporary women would not choose better-paid work. The world-wide shortage of nurses may well be partly attributable to this fact. It has been argued that the specialism of critical care attracts large numbers of men because of the technological focus (2, 5, 21). Men who work in a technically specialised area are accused of focusing on the machinery in order to avoid intimate physical and emotional contact with patients. This is an incomplete understanding of ICU nursing, which demands physical intimacy with the patient and often an intense emotional relationship with the patients significant others. Intimacy cannot be avoided, nor can female colleagues: The majority of the nursing workforce is female, even in the speciality areas. Thus, men cannot separate themselves from female colleagues; as the respondents argued: They either accept this or leave.

cal patients perceived levels of embarrassment with physical and psychological care given by nurses of both genders revealed that men may be met with suspicion about their motives: 1 I cant help wondering what would make a male nurse undertake duties involving intimate care of females e.g., curiosity? Males obviously lack understanding because of their gender. 5 Probably very sick people may well not feel embarrassed; being helped by anyone is appreciated in those circumstances. However, human nature being what it is I feel careful vetting would be needed to prevent the recruiting of 10 perverted personnel by that I mean people who seek gratification from certain aspects of their work. I believe we should be broad minded, and over the years embarrassment will ease, but at the moment I still wonder what at15 tracts men to the intimate side of nursing females. (23 p. 900) The comment about mens lack of experience and understanding (line 4) is salient. Given that men work as obstetricians and gynaecologists that childless women work as midwives, and acceptance that it is normal for a man to be cared for by women then it would appear that male nurses are subject to an extra layer of discrimination. A 90-year-old woman in the same study was able to articulate this anomaly: Ive nearly always had male GPs, and a lot of doctors in the hospital are male, and this does not cause me any embarrassment. A lot would depend on the attitude and training of male nurses. Male patients are frequently attended to by female nurses after all. (23 p. 899) The right to demand a particular type of caregiver is problematic. On the one hand, a patient refusing a nurse because of race would be considered discrimination. On the other hand, common sense suggests that the preference for intimate care from a member of ones own sex is reasonable within a

Gender role stereotyping in nursing

An influential development in a contemporary social science of masculinity has been role theory and the concept of gender roles: the patterns of social expectation for the behaviour of men and women which are a widely-held part of everyday life. For men, their gender is a potent barrier for them in their roles as caregivers. Two discourses intersect to discriminate against men as carers. First the belief that women prefer a member of their own gender as care provider, and that they are entitled to choose the gender of their nurse partly because one would want to defend the right of women who need care to be cared for by another woman, not by men (22 p. 54). Men, on the other hand, are assumed to be comfortable with a nurse of either gender. Second, there is a discourse that problematises male sexuality as a threat. A study of gynaecologi-

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discourse that has constructed genitalia to be shameful, private, and the locus of considerable vulnerability. Men who are nurses are caught between these two discourses: the threat posed by their sexuality and questions of their appropriateness in providing intimate care for women. Subsequently, they face discrimination based upon their gender, not upon their ability to provide competent care. Western culture stereotypes gender traits in terms of binary oppositions (24). Masculinity has become categorized by instrumental behaviours such as achievement orientation, assertiveness, and decision-making ability whereas women are characterized by expressive and communal behaviours, including affiliation, deference, passivity, and nurturance (25). The gender-typing of nursing has been investigated by questioning 384 nursing students in the United Kingdom (26). A 7-point Likert-type scale was used to rate the gender appropriateness of 19 nursing specialities. No area was rated as male sextyped so it can be inferred that the specialities considered most appropriate for men are those ranked gender-neutral: nurse manager, general surgical, nurse consultant, theatre, learning disability, accident and emergency, and mental health. Predictably, those viewed as most appropriate for men, or at least gender-neutral, such as mental health and learning disabilities, have traditionally had larger numbers of male nurses; areas, which at the time of the study suffered the most severe nurse shortages in the UK. The authors suggested that the fact that women do not consider these areas as career options exacerbate recruitment problems. They did not explore the reasons for this. A number of inferences can be made, including (i) that women do not choose these areas because of the predominance of men, but more likely, (ii) the work itself is not attractive. With respect to this study, the second inference is worth further consideration. The form of mental disability that some people experience may make them liable to physically aggressive impulses; therefore the physical strength of men has tradi-

tionally been valued in situations requiring calming and restraint (27, 28). A paradox emerges then in that men have historically been channelled into mental health and disability care, but the construction of men as sexual predators means they are not encouraged to work with children in schools, in general practice or in paediatric wards. The corollary is that children with a learning disability must then be constructed as children of less value if men are deemed suitable to be their caregivers. Another interesting feature of men working in mental health and with disabled people is that it contradicts the claim that men strategize to protect their masculine status. It ignores the fact neither psychiatric nursing nor care for the disabled are considered high status. As Rune Bakken commented in an interview with the Norwegian nursing journal Sykepleien in 2004: [F]or det er ikke entydig at menn fordi de er menn streber oppover i hierarkier. Psykiatrien er lavt rangert, men der er det mange menn (29 p. 15). It is not clear that because men are men, they climb up the hierarchy. Psychiatry is low-ranked, but there are many men in this field.

The homosocial impulse Observation of society reveals that men and women enjoy the company of members of their own gender at times. It provides the opportunity to participate in interests that members of the opposite sex may not share. Thus, an aspect of the creation of islands of masculinity may be a homosocial impulse: the desire to be with members of your own gender:
Im around women all the time. I feel like I need to sort of escape from that a certain while and be with my male friends and do male things Just to establish a bit of balance. (19 p. 118)

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A study of nurses interactions in two small US hospitals found that men were often absent from female colleagues informal networks (30). This study of tokenism revealed that the dominant group exaggerates similarities with one another and their differences with the token group: Observations indicated that the typical conversations of female nurses revolved around female topics Male nurses were not included in these conversations, and the female nurses made no attempt to include them. Only once were two female nurses observed to change their topic of conversation when a male nurse was present. (p. 932) Rather than men segregating themselves from the lot of nurses in general (19 p.119), they are excluded by the dominant female group which does not introduce conversational themes of mutual interest to all group members. Mens otherness in what continues to be a womans world is reinforced.

It is likely that for some men protecting themselves against nursings over-identification as womens work plays a role, albeit unconscious, in career decisions; however, mens career choices are predicated on multiple factors including socialisation pressures arising from notions of gender appropriate work, a desire for challenge, and the perception that multiple work experience equips them to be better nurses, homosocial tendencies, and seeking those roles in nursing which are better paid. Within a global context of nursing shortages, these findings have implications for the recruitment and retention of men. It is timely to refocus on dismantling those aspects of a traditional female culture of nursing which place barriers in the way of men (and women) to the pursuit of satisfying nursing careers.

Acknowledgement The author would like to acknowledge the men who participated in this study for their generosity with respect to making themselves available for interviews so readily and for their willingness to talk so freely about their experiences.

Conclusion
This study highlights some contradictions between different perspectives on mens experiences as nurses. It offers challenges to given assumptions about men and nursing and the opportunity of a new understanding of the experience of men in nursing. To explain the predominance of men in the speciality areas of nursing as a strategy to protect status and to avoid the emotional labour of nursing is an essentialist reading of masculinity which is inadequate to explain the complexity of the male experience in nursing. Equally, it is arguable that the traditional emphasis on the domestic aspects of nursing, particularly in general nursing, has enabled generations of nurses, male and female, to avoid or to have little time for the emotional and relational aspects of nursing.
Thomas Harding, PhD Programme Manager Nursing and Health NorthTec New Zealand Associate Professor II Institutt for helsefag/Department of Health Science Hgskolen i Buskerud Grnland 40B 3045 Drammen NORWAY Tel: + 47 32 20 64 00 Fax: + 47 32 20 64 10 Thomas.Harding@hibu.no

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