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Nurse Education in Practice 15 (2015) 409e414

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Nurse Education in Practice


journal homepage: www.elsevier.com/nepr

Masculinity and nursing care: A narrative analysis of male students0


stories about care
Kristin Jordal a, *, Kristin Heggen b, 1
a
Department of Nursing Science, Buskerud and Vestfold University College, P.O. Box 235, 3603 Kongsberg, Norway
b
Institute of Health and Society, Department of Health Sciences, Faculty of Medicine, University of Oslo, P.O. Box 1153 Blindern, NO-0318 Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Nursing education programmes and the nursing curriculum have been criticised for presenting an
Accepted 6 May 2015 outdated and feminised description of care, which has had the effect of marginalising men, as well as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 article uses interview-based data from a
Keywords: qualitative study on Norwegian students' experiences in the rst year of training. Using a narrative
Nursing education analysis method, the paper explores how male nursing students use stories to describe care and shows
Men
how their storytelling illustrates a way for men to negotiate their role in a feminised profession. The
Nursing care
paper aims to deepen our understanding of the ways in which male students can challenge this his-
Narratives
torically 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 as a teaching and learning strategy
in nursing education.
2015 Elsevier Ltd. All rights reserved.

Introduction today, the public and professional understanding of nursing care is


still closely associated with a female caregiving role (Abrahamsen,
Professions are knowledge communities in which the partici- 2004; Brown et al., 2000; Stanley, 2008, 2012; Svare, 2009). This
pants develop a common understanding of the key concepts, the- gendered understanding of nursing care has been exposed to crit-
ories and methodologies that form the basis of the practice of the icism and debate. It is argued that it sends an archaic and sexist
profession (Grimen, 2008). Students are initiated into this com- message, which not only stands in the way of a more modern,
munity through education, and develop their identity as pro- contemporary image of the nursing profession, but also margin-
fessionals (Heggen, 2008; Wenger, 1998). Care is a key concept in alises men (Bakken, 2001; Christensen and Knight, 2014; Gordon
nursing education, which contributes to a student's sense of iden- and Nelson, 2005; Jorfeldt, 2006).
tity and belonging to the profession (AACN, 2008; Brown, 2011; Although the participation of men in nursing varies among
Clouder, 2005; Gordon and Nelson, 2005; Rhodes et al., 2011). European countries, in general, males nurses play a minority role in
The concept of care is at the core of nursing education and the profession (Bakken, 2001; Jorfeldt, 2006; Solbrkke et al.,
practice, but the understanding of care and the meanings given to 2012; Svare, 2009). This suggests that men who choose nursing
the concept can vary over time and between cultural contexts as a career undergo a socialisation process into a female-dominated
(Clouder, 2005; England, 2005; Solbrkke et al., 2012). Historically, occupation where professional identity is based on a feminised
the perception of nursing care was based on the role of a nun, a understanding of nursing care (Abrahamsen, 2004; Brady and
virtue script, which denes women as good, kind and self- Sherrod, 2003; Gordon and Nelson, 2005; Simpson, 2004).
sacricing. This concept was used to recruit respectable women Approximately 4000 nursing students are admitted at bachelor
to the profession (Brown et al., 2000; Dufwa, 2006; Gordon and degree level each year in Norway, but less than ten percent of this
Nelson, 2005; Moseng, 2012; Svare, 2009). In Western society number are men. Statistics show that the drop-out rate among
male nursing students is higher than among female students
(Svare, 2009; Texmon and Stlen, 2009), a fact that is related to the
* Corresponding author. Tel.: 47 31009297.
E-mail addresses: kristin.jordal@hbv.no (K. Jordal), k.m.heggen@medisin.uio.no
socialisation process, role strain, and feelings of isolation and
(K. Heggen). marginalisation as a minority in the training environment (Brady
1
Tel.: 47 22845376. and Sherrod, 2003; Brandon and All, 2010; Christensen and

http://dx.doi.org/10.1016/j.nepr.2015.05.002
1471-5953/ 2015 Elsevier Ltd. All rights reserved.
410 K. Jordal, K. Heggen / Nurse Education in Practice 15 (2015) 409e414

Knight, 2014; MacWilliams et al., 2013; Paterson et al., 1996; Stott, Care as a gender-constructing power in nursing
2007). Studies in nursing education also reveal that male students
experience the study programme's perception of care as feminine In spite of the fact that Norwegian men have gradually reached a
(Bakken, 2010; Christensen and Knight, 2014; MacWilliams et al., high level of participation in the home arena and in the care of their
2013; Paterson et al., 1995, 1996). It is therefore suggested that own children, the labour market remains one of the most gender-
men's encounter with nursing education can represent a dual segregated in the Western world (Solbrkke, 2006). This is re-
challenge because not only must male students learn to think like ected in the nursing profession in which it is almost only women
nurses, they also often have to learn to think like women to be who nurse, who teach nursing and who write the textbooks and the
successful (Brady and Sherrod, 2003, p. 159). curriculum (Brady and Sherrod, 2003; Jorfeldt, 2006). When a
The concept of care has proved to be important for identication profession is culturally or historically linked either to masculinity or
with the nursing profession for both male and female students femininity to such a strong degree, the occupation can be dened as
(MacWilliams et al., 2013; Sellman, 2011; Tveit, 2008). In their sex-typed (Crompton, 1987).
study on male nursing students, Paterson et al. (1995) emphasise In addition to the profession's own prioritising of the care
the importance of storytelling as a central strategy for male stu- concept and the fact that nursing education was for a considerable
dents to learn about nursing care. Accordingly, in this paper, we time reserved for women (Moseng, 2012; Vike et al., 2002), a
apply a narrative approach that is particularly well-suited for a number of other historical social traits have contributed to the
grasp of the development of self-understanding through the anal- way that Norwegian nursing, in general, and care, in particular,
ysis of participants' stories and storytelling (Bruner, 2004; have become a female domain. Bakken (2001) shows how nursing
Holloway and Freshwater, 2007; Holstein and Gubrium, 2000). became a specically feminine eld based on a traditional
We direct a particular focus on the narrative dynamics that arise at dichotomy-based mind-set, where the nurse is dened as a
the intersection of the male students' stories and the profession's woman and the doctor as a man in mutual and complementary
discourse on care. The aim of the study is to describe how male roles. Based on a model taken from the typical home environment,
nursing students use stories to talk about care, and how their sto- the doctor constituted a father gure, the nurse was linked to a
rytelling can be understood as way for men to negotiate their role in maternal role and the patient was seen as a child who needed
a feminised profession. care. The feminine, maternal and caring elements were thus
The low rate of male participation in nursing gives cause for associated with nursing as a traditional female profession. Ac-
concern in the context of the large and growing nursing shortage in cording to Svare (2009), women also draw on a historical and
Western society (AACN, 2014; Roksvaag and Texmon, 2012). This cultural heritage in the form of practical housewifely competence
study presents ndings that help shed light on men's identication and a monopoly of care and strength in interpersonal relation-
with nursing and their encounters with feminine perceptions of ships. This ideal is characterised by the woman who takes care of
care in the profession. This is important knowledge both for the the family with her knowledge of hygiene, nutrition and the
recruitment and retention of men in the profession. The ndings ability to care. The woman was thus understood as naturally
may also help the development of a more contemporary and suited to care work e including in the public care arena (Kermode,
appropriate programme and curriculum for nursing education 2006). As Florence Nightingale maintained: every woman is a
(Clouder, 2003, 2005; MacWilliams et al., 2013). nurse (Svare, 2009, p. 43). The nursing occupation was thus
perceived as the professionalisation of inherent qualities that all
Gender perspectives women should possess (Jorfeldt, 2006). Following this line of
thought, men will always start with a handicap in nursing pre-
Considerable development has taken place in the understanding cisely because they are men. Svare conrms this with reference to
of gender since the beginning of the last century and up to today. a much-cited 1987 quotation from the President of the Norwegian
Gender was previously dened within a biological perspective, Nurses Organisation:
where being born as a man or a woman was perceived as decisive
Of course I want to welcome more men into the ranks. Never-
for what you were or could be (Bondevik and Rustad, 2006; Jorfeldt,
theless, there will always be differences between men and
2006; Svare, 2009). This viewpoint is related to what we currently
women. The care professions will always be female-dominated,
call an essentialist understanding of gender, where female and
regardless of development. Women have innate advantages
male elements are regarded as given dimensions that set the terms
here which we can do little about (author's translation) (2009, p.
for gendered ways of behaving in society (Svare, 2009). In today's
45).
social research, gender is to a great extent understood as being
constructed and linked to specic contexts. Gender is thus
perceived as something that is played out, within and between The story of nursing as a feminine profession is also sus-
human beings, in cultural, historical and social frameworks (West tained and continued today both through public recruitment
and Zimmerman, 1987). Within this perspective, the relevant un- campaigns and the portrayal of the profession in lms and the
derstanding of masculinity will at any given time be mobile and media (Dahlborg-Lyckhage, 2009; McLaughlin et al., 2010;
relationally formed since it varies between cultures, over time in Stanley, 2008, 2012). This outlook was clearly revealed in a
the same culture, and throughout a person's lifetime (Lorentzen, recruitment campaign for Swedish nurses: We need more
2006, p. 126). When we emphasise today how different forms of women. We need more people. We also need men (Dahlborg-
masculinity, and femininity, are played out and formed in interac- Lyckhage, 2009, p. 167). In addition to society's portrayal of
tion with society's structural conditions, gender is woven into the profession, the nursing education syllabus also creates a
active meaning-making and identity-creating work (Solbrkke and picture of nursing and care that has strong feminine connota-
Aarseth, 2006). tions (Bakken, 2010; Gordon and Nelson, 2005; Jorfeldt, 2006).
Following this line of thought, the professional discourse on care Svare (2009) argues that women thus have power as models for
can be perceived as a structuring element that acquires importance the profession, and have therefore been able to dene what is
for how male nursing students identify themselves, as men, with right and what is wrong, what is good and what is bad in
the profession (Clouder, 2005; Gubrium and Holstein, 2009; nursing e a normative and excluding practice where men are at
Simpson, 2004). risk of falling short.
K. Jordal, K. Heggen / Nurse Education in Practice 15 (2015) 409e414 411

Method and analysis narrative surroundings in which the stories are shaped (Creswell,
2013; Gubrium and Holstein, 2009).
This article forms part of a qualitative study of six female and The actual analytical work took shape by a repeated reading of
three male nursing students' experiences in the Norwegian nursing the interview data. This reading focused on the specic ways in
education programme. The study's overall design included both which the men structured and arranged their experiences of good
individual interviews at the end of the rst year and eld work caregiving into narrative format. The stories of John and Christian
conducted in the students' clinical practice in medical and surgical were chosen because of their thematic content and the way they
departments in the second year of the education programme. This are structured as fully-formed narratives (Creswell, 2013; Labov,
paper is based on data from the interviews and adopts a narrative 1997; Riessman, 2008). Their stories have several common traits
perspective both methodologically and analytically. More specif- in terms of topics discussed and structural features. They reveal
ically, this entails gathering and analysing verbal and written Aha! moments of insight and change and seemingly broaden the
stories (Creswell, 2013; Gubrium and Holstein, 2009; Holloway and men's understanding of care (Paterson et al., 1995). The narratives
Freshwater, 2007; Riessman, 2008). in this paper therefore serve as optimised examples from the
The rst author conducted, recorded and transcribed the in- material on the male participants' narration of what they
depths interviews. Each interview lasted about two hours and perceived as good caregiving (Holloway and Freshwater, 2007).
focused on topics linked to the students' backgrounds, their interest First, we conducted an internal structural analysis focused on the
in and perception of the profession, and their experiences from characters, on what's at stake for whom in the stories, and the
theoretical courses and specic patient situations in the rst year of outcome. The initial exploration of the stories also focused on the
clinical practice. In line with a constructivist framework and a developmental structure in the stories, identied as a fully-formed
narrative working method, the rst author used explorative and narrative in six stages: an abstract, orientation with regard to time,
open questions to activate and facilitate the students' narrative place and characters, a presentation of the story's problem or
resources (Creswell, 2013; Gubrium and Holstein, 2003; Holloway crisis, an evaluation, the outcome of the story, and a nal coda
and Freshwater, 2007). For example, when a student talked about (Labov, 1997).
care in a general way, the rst author might ask: Can you tell me After this initial analysis, we directed the analytical focus to the
about an episode from your own life, or from clinical practice, nursing profession as a cultural and discursive context (Gubrium
where you experienced that someone got good care? In this way, and Holstein, 2009). The traditional and feminised discourse on
the actual narrative production of the interview was a collaboration care, as outlined in the introduction, was understood as structuring
between the researcher and the participants directed by the narrative circumstances that create specic conditions for how
research agenda of the study (Gubrium and Holstein, 2003; these nursing students described their masculinity. Qualifying for
Holloway and Freshwater, 2007). any form of professional practice is about identifying oneself with a
particular occupational eld and profession. At the same time,
Ethical considerations telling others about oneself as a professional in a particular occu-
pation is closely linked to self-understanding (Gubrium and
The students enrolled voluntarily as participants after nding Holstein, 2009; Heggen, 2008). Accordingly, the male students'
out about the study through the university college website. The storytelling is analysed as masculine identication with e and
study was recommended by the Regional Research Committee and, narrative meaning-making of e nursing as a gendered profession
in line with the application to the committee, the students who (Gubrium and Holstein, 2009; Paterson et al., 1995).
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 cti-
Findings
tious. However, in a paper with a narrative approach, the extended
use of the participants' stories will always reveal part of the stu-
John's story
dents' biography and background. This fact led us to invite the
participants to read the paper during the writing process and to
John is in his early forties, is married and has children who live
approve the use of their stories in it (Chase, 2013).
at home. After many years as a salesman and in a leadership po-
sition, John went through a crisis that ended with his taking a
Analytical approach
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
Relating experience in a narrative form appears to be natural for
reviewed his previous jobs. He found that being with other people
human beings and is meaningful for the experience of our identity
was a common denominator. For a while, John considered
(Bruner, 2004; Holstein and Gubrium, 2000; McAdams, 1993). At
becoming a prison ofcer and worked shifts in psychiatry to accrue
the same time, an individual's stories are considered to be very
enough credits for admission to the prison ofcer training pro-
responsive to cultural, discursive, interpersonal and linguistic in-
gramme. One day, when he was working in a psychiatric institution,
uence (Gubrium and Holstein, 2009; Holloway and Freshwater,
he witnessed an incident that made him change his mind.
2007). Professions such as nursing offer signicant narrative envi-
ronments; Gubrium and Holstein (2009, p. 165) emphasise the I hadn't thought about the professional background of nursing
need to identify how work-related resources and orientation shape until I once saw a psychiatric nurse calming down a psychotic
narrative accounts. In line with this recommendation, the analytical patient. The patient looked completely wild, and several people
work in this paper focuses both on how the students tell their were involved. Then along came this nurse called David. He
stories and on what meanings they are up against in the nursing went up to the patient and held him like this round his shoul-
profession, which is understood as such a narrative environment ders [John demonstrates by holding me round my shoulders]
(Gubrium and Holstein, 2009). Accordingly, the relationship be- since that's an action that disarms people. Then he said There's
tween the students' stories about care ea narrative structure with a nothing to worry about and Just calm down. So instead of
specic content, and their storytelling e the activity of telling these being frightened of the patient he managed to turn the whole
stories to others, is viewed in dynamic association with the situation around. He knew that this psychotic patient was afraid
412 K. Jordal, K. Heggen / Nurse Education in Practice 15 (2015) 409e414

of us all. He quite simply demonstrated care for the patient. So showing connection and engagement skills. The male nurses
this was one of the situations that made me want to be a nurse. 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
Christian's story way, these male nurses grasp the difcult situation while they also
dene it. The two stories have a common basic theme and a line of
Christian is a married man in his late forties. His children had development that can be summarised as follows. A helpless or sick
grown up and Christian had therefore reached a point where he person needs help. Those present are not able to help. An effective
needed to think carefully about how he wanted to spend the rest of male nurse understands the situation, takes action and does what is
his working life. He decided that he wanted to work with people in required to resolve the problem. In narrative analysis, this type of
order to get more in line with his personal values. He is very pattern is called the story's plot and it is in the plot that we discover
motivated for this occupational change and says: It's about having what the story is fundamentally about and what is at stake in the
the drive, the curiosity e like, I'll x this. To put it a bit ippantly: I'll situation (Frank, 2010; Gubrium and Holstein, 2009). In these
make a damn good nurse. He then explores what being a damn stories, the inherent risks are fear, helplessness and loss of control,
good nurse really means by talking about the male contact nurse provided by a strong other who is able to convey concern and
he had for his practice period in a nursing home in the rst year of connection. The stories of John and Christian emphasise how the
his training: male nurse understands the actual situation, grasps the problem
and nds a solution. The result can be success or asco. In these
He put things right for all kinds of patients e dementia patients
stories the situation is resolved. In a sense we can view them as
and somatic patients. The approach he had towards them. [He
success stories that the two male students use to underline what
had] a calming effect on the aggressive patients. He was what I
good nursing care actually is.
would call an incredibly good all-round nurse, while at the same
When we turn the analytic focus to nursing as the narrative
time he was professionally competent medically. Once there
environment in which John and Christian tell their stories about
was a female patient who had very bad dementia, she started to
care, we enter a specic, professional and discursive arena where
get very aggressive, shouting abuse at the staff and the relatives.
care is portrayed as feminised, physical, all-encompassing and
Some of them tried to restrain her, but she hit them and was
emotional, based on altruism, compassion and inherent female
absolutely desperate. He [Christian's contact nurse] came to the
qualities (Gordon and Nelson, 2005; Svare, 2009; Vike et al., 2002,
rescue and calmed her down. She was crying and she was so
p. 119). These stereotyped, heartfelt and feminine bodily percep-
distressed e she saw the devil in she was very ill. He really
tions of care are what John and Christian are up against as male
took his time, even though he was up to his neck in work. He
nursing students.
gave the situation priority. He calmed things down. He crouched
According to Connell (1995), hegemonic masculinity is the
in front of her, held her hands e the closeness, met her gaze, she
dominant and culturally-accepted way of being male in a society.
realised who he was. So he made her feel that There's nothing to
This expression of masculinity is understood as hierarchically su-
worry about, this is quite OK without telling her off, but quite
perior and directly opposed to femininity and homosexuality
simply: You can be angry. It's OK. He appealed to her healthy
(Lorentzen, 2006).
side. He got her out of a difcult situation, pampered her a bit
Svare (2009) describes how the masculine element in society is
with blankets and he made her warm tea. It was great to
also linked to exceeding limits and to the ability to change and
watch him; it was really touching to see how he brought her
develop, along with archetypal portrayals of man as a hero who is
back to normal. It was wonderful e in my eyes he was a damn
willing to take risks in the battle against all types of enemies.
good nurse.
Following this line of thought, we can see how the main characters
in the men's stories, with their resolute and rm intervention in a
John and Christian's stories start with an introduction that links difcult situation, create alternative descriptions of care. This be-
them to the specic interview situation. They then develop their comes clear when all-round nurses give priority to the situation,
stories by introducing the main characters and the situation in come to the rescue, understand and put things right for all kinds
which they nd themselves. A male nurse is the main character in of patients. They disarm conicts and thereby get the patients out
both stories. In narrative theory, this character is the protagonist of a difcult situation. In this way, the male nurses in the stories
(Frank, 2010). The main character of each story nds himself in an intervene, dene and resolve a challenging situation that nobody
unstable and chaotic situation where the other staff have not else appears to be able to cope with. They thus act out a culturally
managed to resolve the problems that have arisen. These male accepted and hegemonic masculinity that is associated with
nurses are thus recognised by the students as having the particular strength, power and dominance in the situation (Connell, 1995).
skills of involvement and strength to calm and contain the situa- When care is linked to this type of vigorous action, these male
tion. In our narrative perspective, they can be understood as sav- students do what we regard as practice-related and active mascu-
iours and heroes in the story, literary-inspired characters who are linisation work, which also negotiates and stretches the under-
come to the rescue where others fall short (Frank, 2010). The pa- standing and perspectives of nursing care to include male
tients in each story, the stories' antagonists, are described respec- caregiving. When their stories e the way in which they structure
tively as completely wild, psychotic, so distressed and the plot and present the characters e are analysed in relationship to
absolutely desperate, which make us understand that these situ- their narrative circumstances, we nd that the storytelling can be
ations are very demanding. The patient is thus a challenger who interpreted as giving them space as men in a gendered profession
through his or her way of behaving pushes the incident in the story such as nursing. Nonetheless, we also recognise the traditional
to a decisive point e a climax where it can swing either one way or discourse on care when the story's male nurses create closeness
the other for the male nurses. The suspense is linked to whether and pamper patients. Care is thus interpreted by John and Christian
they will manage to do what is necessary to save the situation and as not only associated with hegemonic masculine features such as
the patient (Frank, 2010). We note that both nurses are efcient and capacity, insight, decisiveness and action, but also with empathy
establish contact with the uncontrolled patients by holding them e and closeness. These men thus narrate their stories about care as a
holding their hands or putting their arms round their shoulders e negotiation, both within and outside traditional masculine roles
K. Jordal, K. Heggen / Nurse Education in Practice 15 (2015) 409e414 413

and the prevailing nursing discourse on care. As we see it, the stories have the capacity to link the students' own experiences with
story's content and structure, as well as the work the story does for the theoretical content of the programme and are thereby key to
them, can be linked to the strategies that men, according to critical reection on nursing theory and practice (Gubrium and
Simpson, use to bring the job more in line with dominant notions Holstein, 2009; Hunter, 2008; Paterson et al., 1995). This is
of masculinity (Simpson, 2004, p. 359). At the same time, the emphasised by Hunter, who argues:
stories serve as part of their identication with the profession. The
For nurses, telling and listening to stories related to health and
two men's stories about care, perceived as masculinity at work
illness provide a vital means through which human experiences
(Simpson, 2004), can thus contribute to highlighting and directing
can be honored, as well as facilitate the integration of the
focus towards how men experience, talk about, learn and perform
essential patterns of knowing that are crucial to understanding
nursing care.
the whole of nursing care (2008, p. 1).
Discussion
As a result, we believe helping students to share their own
All professional elds mediate a value perception of what is stories e as well as to read, interpret and discuss a variety of
right, appropriate and desirable in contrast to what is perceived as updated curriculum stories e has huge potential for nursing edu-
wrong, inappropriate and immoral (Jensen and Tveit, 2005). Hence, cation (Benner, 2010; Holloway and Freshwater, 2007; Hunter,
when care e as a key value of the nursing profession e is closely 2008; Paterson et al., 1995).
linked to an outdated perception of women's nature, while also
being communicated in stereotyped ways, it is problematic for Conclusion
several reasons.
First, the traditional discourse on care has been shown to In this study, we analysed two male nursing students' stories
exclude men and to push them out of the education programme about care in light of the profession's feminised and stereotyped
and the profession (MacWilliams et al., 2013; Paterson et al., 1996; discourse of care. We analysed the stories as a masculinisation of
Stott, 2004, 2007). This is particularly worrying in the light of the the care concept that gave the students space as men. The stories
huge recruitment challenges that the entire nursing profession also serve as examples that highlight the need for updating the
faces in its encounter with a large and rapidly-growing need for nursing curriculum. In summary, we are of the opinion that the
labour in the health sector (AACN, 2014; Roksvaag and Texmon, renewal of the nursing programme must involve a teaching strat-
2012). Studies show that male students experience alienation in egy that involves students telling their own stories, as well as
their encounters with a professional eld described as no man's developing a contemporary curriculum that offers diverse,
land (Bakken, 2001; Christensen and Knight, 2014; MacWilliams experience-based stories about care to which today's youth can
et al., 2013). John and Christian's stories are examples of how relate. The overall objective must be for nursing to become a story
such stories can serve as carriers of men's experience. As we see it, that young people can identify with and want to be part of e
these stories have the potential to give male students space as men regardless of class, ethnicity, religion or gender.
in the nursing education programme. Men, as a minority, lack such
masculine narratives to help them identify with the profession as References
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