Swimming against the malestream: men choosing nursing as a career.
Abstract: This article reports on one aspect of a larger study, which used qualitative methods to critically explore the social construction of men as nurses. It draws upon literature pertaining to gender and nursing, and interviews with 18 New Zealand men to describe the factors underpinning decisions to turn away from malestream occupations and enter a profession stereotyped as "women's work'. Five thematic groupings are revealed to be significant with respect to the decision-making process: formative experiences, the Call, expediency, personal acquaintance with a nurse and personal fulfilment. These factors, however, do not necessarily operate in isolation. The reasons for becoming nurses are complex and multifactorial.

In comparison to the experiences reported in the international literature, the men in this study were more focused on human caring and the transformational potential for personal fulfilment rather than a focus on the barriers to their engagement with nursing.

Key Words: Nursing, men, gender, "women's work', qualitative research.
Article Type: Report
Subject: Men nurses (Surveys)
Men nurses (Beliefs, opinions and attitudes)
Nursing (Surveys)
Nursing (Demographic aspects)
Author: Harding, Thomas
Pub Date: 11/01/2009
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2009 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: Nov, 2009 Source Volume: 25 Source Issue: 3
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291894325
Full Text: Introduction

This article describes the factors which underpinned the decisions of a group of New Zealand men to turn away from malestream occupations and become nurses; a profession stereotyped as 'women's work'. Hearn (1999) described malestream organisations as "the main political arenas by which men maintain power in the public worlds and the main areas of accumulation of men's resources in the public worlds" (p. 3). Thus, malestream occupations can be understood as those in which a dominant male hierarchy subjugates the interests of women to those of men and in doing so marginalises women and the work they do.

This paper draws upon one aspect of a larger work (Harding, 2005), which used qualitative research methods to explore the experiences of men who are nurses in Aotearoa New Zealand. It presented a critical discussion of a number of facets of significance to the understanding of men as nurses. These included the construction of masculinity, the construction of images of the nurse, the reaction to men who are nurses, sexuality issues, career development, and men and caring. The themes related to entering nursing identified in the earlier work will be presented and discussed within the context of findings from the international literature.

It is the first published New Zealand study of the factors influencing men to become general nurses and, as such, may offer useful insights to those wishing to recruit more men into nursing.

Background

While at secondary school, in the early 1970s, I considered career options and given the strength of the prevailing belief that nursing was women's work, it is not surprising that it was not my first career choice. I was not alone; according to LaRocco (2007) "at the present time, men in our society are not encouraged to become nurses" (p. 121). Thus, few men consider nursing as an option during their school years and are more likely to enter the profession later in life (Armstrong, 2002; Johnson, Goad & Canada, 1984; Mannino, 1963; Marsland, Robinson & Murrell, 1996; Okrainec, 1994).

A number of factors have been put forward in the nursing literature to account for men's low entry into nursing. For example, it is argued that the low economic value of nursing has kept men out of nursing; thus, the low pay of nursing coupled with the traditional male role as a breadwinner are suggested as barriers to men's participation (Halloran & Welton, 1994; Meadus, 2000; Poliafico, 1998; Villeneuve, 1994). However Hemsley-Brown and Foskett (1999) contended pay is not a significant factor, arguing that by late primary school most young people have rejected jobs based on negative perceptions about the occupation. Others also reported the importance of attitudes to nursing as a significant factor in young people's motivation to choose nursing (for example: Grossman & Northrop, 1993; Mendez, 1991; Vaz, 1968).

A significant generator of negative attitude might be the belief that men in nursing are homosexual. For example, a report in the Australian Nursing Journal ("Where are all the male nurses?" 2001) stated, "The main reason men were not entering nursing was not because of poor pay, shift work or a lack of career advancement but because they fear being branded as effeminate or gay by their peers and families" (p.35). This stereotype has been challenged (Harding, 2005) and the processes by which this social construction occurs have been described (Harding, 2007). Nevertheless, it has been presented by a number of authors as a significant factor which may keep men out of the profession (for example: Armstrong, 2002; Isaacs & Poole, 1996; Williams, 1995).

Given that most of the literature pertaining to men's choice of nursing (in fact with respect to all areas of research on men and nursing) relates to the experience of men outside New Zealand, it is timely that research from a New Zealand perspective is presented.

This article investigates those factors which have influenced a group of New Zealand men to become Registered Nurses and identifies differences between their experience and that reported internationally.

Methods

The findings presented here are derived from an exhaustive search of the literature pertaining to men in nursing and from a larger project (Harding, 2005) which used qualitative methods--thematic analysis and discourse analysis--to research written and visual texts and data captured in interviews with 18 New Zealand men who are nurses.

This study utilised a variety of texts that can be divided into two categories:

1. Pre-existing texts about gender and nursing.

2. 20 transcribed interviews conducted in 2003-2004 with

18 New Zealand men who were nurses.

The face-to-face interviews were conducted by the researcher at mutually agreed locations. The interviews, which lasted between 4090 minutes, were audiotaped. The interviews were semi-structured and the participants were able to relate their experiences as they chose. Two participants were interviewed twice owing to the amount of information they wished to share.

The thematic analysis, which occurred for this aspect of the project, was undertaken in a three-step process:

* all interviews were transcribed verbatim by the researcher;

* the narratives were read and re-read to obtain deeper understanding of the phenomenon; and

* descriptive phrases were noted and organised into common themes.

Participants

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. All the participants identified as Pakeha/New Zealand European.

Participants' workplaces 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 someone retiring after 40 years in the profession.

Trustworthiness

According to Lincoln and Guba (1985) with respect to trustworthiness the basic issue is simple:

Using the criteria outlined by Lincoln and Guba (1985; 2000) of credibility, transferability, dependability, confirmability and authenticity, a variety of measures were undertaken during the larger project to establish trustworthiness. These included: prolonged engagement with the topic, persistent observation, reflection, peer debriefing, member checks and negative case 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 that there will be some readers who may be able to identify, or at least assume they know the identity of, a particular participant. This was discussed with those participants for whom the possibility of such disclosure could occur and each one stated his comfort with the possibility of identification. Upon receiving a copy of the transcript no one withdrew or asked for any aspect to be deleted.

In the discussion that follows text 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 men who are nurses, they are not generalisable.

Findings

Analysis of the transcripts identified five thematic groupings with respect to the decision-making process: formative experiences, the Call, expediency, personal acquaintance with a nurse and personal fulfilment.

Formative Experiences

Mathew was adamant that his childhood experience of his father was a significant factor in choosing nursing. His father was "abusive, physically and emotionally" and Mathew considered this shaped him as a sensitive person with a strongly formed belief in the importance of advocacy:

He articulated quite clearly "the defining moment" when he decided to become a nurse. He was 18 years old, on the dole, with no ambition other than to play music and surf "for the rest of my life." He took a job as an aide in a psychopaedic hospital because the dole was not providing him with enough money:

Grant identified the death of his wife four years before he entered nursing school as a factor in the decision-making process, "I thought, well maybe I could because of Carla's death and family bereavements." He described himself as having "an affinity with death--people who have terminal illnesses." He was sure that these experiences were why he chose a career pathway that eventually led him into nursing and hospice work. Several others also described personal experience with death and illness. Carl's parents died the year preceding his entry into nursing school, during a period in which he was "exploring what he wanted to do in the long term." Ian's father died when he was seventeen and he saw this, along with being hospitalised as a child, as influential.

The physical and spiritual attributes of the hospital also had impact for some. According to Ian, when describing sitting with his dying father, "you sort of get some idea of the mystique, I suppose, about the wards." His use of the word mystique is evocative and one that Luke echoed in describing the psychiatric hospital in which he trained: "There was always that kind of mystique about it, [a] kind of aura." Allan also alluded to the mystique or allure of the hospital as part of the influence in his choice of nursing: "I had a historic knowledge that I wanted to work in a hospital in that physical building and the image it held for me.

I was never clear what role that might involve."

The hidden processes, or mysteries, that went on in hospitals caught the imagination of these men and drew them to nursing.

The "Call": Nursing as Vocation

Although Bruce had friends and a sister who were nurses, the most salient factor appeared to be what he termed "a Call", which entailed "a sense of duty, a way to make a difference, [to do] something meaningful in the world." Although not using the word call, Allan was clearly motivated by a sense of altruism: "I can clearly remember that for a long time I had some connection to relief and disaster work in third world countries and that always held interest for me that I wanted to pursue."

This theme, altruism or being of use to humanity, coupled with the deaths of his parents, was part of the motivation for Carl. He turned to nursing after several years as an accountant: "I thought about what I wanted to do and I was thinking VSA--Volunteer Service Abroad--I was quite keen on [that] and I thought nursing would be a good way to get into that." Carl also described nursing as a way "to feel useful", a statement that is congruent with Grant's comment that it enabled him to put "something back into society."

Expediency

Bart described the type of motivation discussed in the preceding section as a "very ideal, soul-saving sort of notion." His description of what then happens to such people when they entered into psychiatric nursing in his era suggests that considered such motivation to be naive:

Bart's viewpoint could be considered a cynical one, but it can also be interpreted as realistic given the milieu of psychiatric nursing in the 1970s:

For Bart such conflict between idealism and reality was never an issue. His description of the circumstances leading up to his entry into psychiatric nursing suggests that his decision was expedient:

One of the most unusual reasons for choosing nursing was provided by Andrew, who thought nursing would be a way in which he could avoid being sent to war: "I had this amazing obsession, if you like, with war and hostilities and I knew that people who had valid, good, professional qualifications, as a rule, don't get marched off to the front line and shoot people."

He also perceived nursing as "something that I did quite consciously as a means to get me some sort of qualification in a small country town." He subsequently went on to become a registered nurse and then a midwife.

Personal Acquaintance with a Nurse

Although nursing is popularly seen as a women's occupation it is likely that the barrier this creates to men entering the profession is diminished by personal acquaintance with nurses. Eleven of the men who participated in this study were personally associated with (female) nurses either through friendship or kinship before they became nurses. Of these eleven, three had personal or family friends who were nurses, while the others were related to nurses.

It might be assumed that given close links with nurses these men became nurses because they were encouraged to do so. While some described positive or at least neutral reactions from family members, this was not necessarily the case. Three of the men received a negative reaction from family members. For example, Grant's two daughters were both nurses and he received encouragement from one and not the other; although the disapproval may have had more to do with his age and lack of educational qualifications rather than his gender.

Nursing as fulfilment

A common theme through most of the narratives of the men who participated in this study was that nursing provided fulfilment through greater work satisfaction. For example, as Charles said about his former job as a technician, "I was finding it very boring. I was finding there was nothing; I wasn't getting anything out of it at all". Jock was "stuck in a rut and I decided to move on ... I really wanted to get a better qualification". Ian, at 21, "didn't quite know where I was heading", while Grant was "disenchanted". Carl summarised the feelings these men expressed when he labelled his former job, a "dead end". Paul, on the other hand, worked as an orderly while completing an undergraduate degree in psychology, but also found at completion that he wanted to become a nurse because of the greater possibilities he thought would be available to him.

Discussion

Sensitisation to Nurturant Abilities

The notion that formative experiences might sensitise men to nurturant abilities has been reported in the literature. For example, Phillips (1997) investigated whether the psychodynamic findings of "reparation" and "compulsive caring" were motivating factors for entering nursing. She found that nursing students had a significantly greater number of "recollected adverse experiences" (p. 42) in their childhood and teenage years. More importantly to understanding men who choose nursing, when males and females were analysed separately there was a higher level of significance obtained for the males.

Arguably, in line with Phillips' (1997) proposal, Mathew was experiencing a sense of reparation, or compensation, for the difficulties encountered in his relationship with his father. Mathew revealed that he has striven throughout his career to not be like his father, a "classic male figure", i.e., more authoritarian and less caring than the mother. According to Miers (2000) the traditional father figure in Western society has been constructed as an authority figure, emotionally distant from the work of caring; his fathering duties limited to being the household provider and to educating children to control their feelings and to accept behavioural control based on rational feelings. It is arguable that this construction of masculinity provides a potent barrier to men's entry into nursing and is one of the reasons why school counsellors have been reported to be consistently nonsupportive when male students have inquired about nursing (Boughn, 1994; Kelly, Shoemaker & Steele, 1996). This was also noted by several of the participants in this study; for example, according to Charles, "It was something that when you do career options at school, it is never offered. It is never presented to males. It is always a girly thing to do."

As in Carl's and Grant's experience in this study, Lemkau (1984) argued that the loss of someone close sensitises men to their nurturing abilities. Her study investigated why some men choose atypical occupations rather than sex-typical occupations. Lemkau (1984) listed representatives of sex-typical occupations as including: accountants, architects, engineers, farm managers, pharmacists, clergy and financial officers. Those in atypical occupations were physical and occupational therapists, nurses, dieticians, librarians, elementary school teachers and day care workers. The results indicated that in comparison to those employed in sex-typical fields (S's) those employed in atypical professions (A's) demonstrated lower adherence to traditional sex-role expectations with respect to sex-typical household responsibilities and greater "tender-minded emotional sensitivity" (p. 110). The A's also more frequently reported having had working mothers, distant relationships with their fathers and having been positively influenced in their career choices by women. They also had more frequently experienced death of a first-degree relative, parental divorce or separation and frequently mentioned such stresses as sensitising them to their nurturing and emotional capabilities. While Lemkau did not specifically investigate men who are nurses, the study is relevant to understanding men who are nurses.

Personal acquaintance

As noted above, Lemkau (1984) also described the influence of women on men's atypical career choices and the impact of knowing other nurses--usually a female family member--was described by a number of the men in this study. This finding has been reported elsewhere (for example: Ellis, Meeker & Hyde, 2006; LaRocco, 2007). While several of the men in this study and men in other studies reported favourable reactions from friends and family, there were also those who experienced negative reactions, as has also been found elsewhere (for example: Bush, 1976; Skevington & Dawkes, 1988). LaRocco argued that more positive reactions found today may be indicative of a change in social attitudes over the last 20 years. However, it is apparent that negative reactions persist, as found in this study, and elsewhere (for example: Isaacs & Poole, 1996; Bullough, 1997). The men reported in this and other studies have been able to resist the negative pressure against their career choice exerted by family, friends and society in general; but there has been little investigation into those who were considering nursing but were dissuaded by such pressures. It could be argued that men having a tendency to enter the profession later in life (Bush; Galbraith, 1991; Marsland, Robinson & Murrells, 1996; Okrainec, 1994; Perkins, Bennett & Dorman, 1993) or be more likely to have had a previous career (Mannino, 1963, Marsland et al.; Okrainec) has allowed them to develop the personal resources with which to resist pressure against their choice of nursing as a career.

Nursing as a Vocation

Some of the participants employed the phrase of use in their narratives, which implies a sense of subscription to the idea of nursing as a vocation dedicated to the service of mankind. Bruce's use of "the Call" has considerable spiritual resonance and in the Christian world is often used to denote a feeling of God requiring one's service. So for some of these men the language they used to describe their relationship with nursing is connected very closely with that image of nursing which emphasises the attributes of spirituality and self-sacrifice. It could be argued, therefore, that for these men what Crawford, Nolan and Brown (1998) described as the "link between the spiritual life and caring work" (p. 212) is an important factor in their decision-making.

Seeking security

It has been reported that some men enter nursing because they perceive it as offering financial security. For example, in Perkins, Bennett and Dorman's (1993) study of men in the US who chose nursing one man said, "I was a fireman and a part-time EMT [Emergency Medical Technician] and did not wish to grow old in a low paying, physically exhausting job" (p. 36), and another related that he wanted "to have a decent, reasonable scholarly trade earning a reasonable, liveable wage" (p. 36). This contradicts other authors (for example: Cyr, 1992; Holmes, 1987) who have contended that nursing is low-paid which makes it unattractive to men. It has been argued that the association of nursing and women's work, the centrality of being the breadwinner to manhood and a perception of nursing being a poorly paid profession has conspired to ensure that it has not been an attractive career choice for men. It does need to be noted that such research is not recent and there may well have been improvement in the earning power of nurses, as has been the case in New Zealand. In tandem with this discourse there has also been a theme in the nursing literature that has asserted nursing's link to women's work, which is undervalued, has lead to nursing also being undervalued and, hence, underpaid (Carter, 1994; Cummings, 1995; Hartnett & Bradley, 1986; Jacox, 1997; Williams, 1989, 1992).

Paradoxically, the breadwinner role also keeps some men in nursing. Apart from Bart, who saw nursing as a way to earn a living, no one in this study espoused financial security as a reason for becoming a nurse; however, several respondents' continued involvement in nursing is based on financial security needs. This can be inferred, in Warren's case, from his comment, "here I am at an age (i.e., middle-age) and I've got a job and it's too scary to leave." Edward became a nurse when he was single; however, some years later he decided against a career move into medicine, "I know I could have made it, but I would have worked pretty hard, and I thought [of] the cost to my kids".

While the "cost" that Edward alluded to may be financial, it may equally be emotional with respect to the decrease in time available together as a family if he were to undertake medical studies. Johnson, Goad and Canada (1984) cited a US report that highlights that after graduation 85% of men stay in nursing permanently, compared to about 35% of women. We can only speculate to the extent that these statistics reflect the pressure to be the main income earner as part of the male role and for women the pressure to take time out from their careers in order to be the primary caregiver to children.

Being Suited to an End or Personal Fulfilment?

This notion of expediency, or of being suited to the end in view, can also be seen as an underlying factor for those who chose nursing because of the opportunity to be of service to others. Nursing per se was a means to achieve their goal, be it Volunteer Service Abroad or working in third world countries: nursing was an avenue to personal fulfilment. These men, who viewed nursing as expediting their contribution to humanity, have remained in the profession whereas Bart, who viewed nursing purely as a "job", used the qualification to allow him the financial freedom to return to university and pursue other career options.

Given that many men come into the profession later in life it would be worth investigating whether or not the investment put into nursing education at a later stage in life is a factor for men remaining within the profession. No one in this study talked about this as an issue; however, Ellis et al. (2006) reported this finding in relation to men's experiences as nursing students. Both Ellis et al. and Boughn (2001) reported on the opportunities available in nursing as being important to men entering the profession.

The area in which this study differs from the findings reported in the overseas literature is the notion that nursing provides as avenue for personal fulfilment through caring for others. The international literature reports more on men's efforts as nurses to avoid 'caring' and strategies to mitigate threats to masculinity (for example: Abrahamsen, 2004; Evans, 1997; Kleinmann, 2004; Kvande, 2002; Williams, 1992). It is contended that the narratives provided by these men reflect Denzin's (1989) proposition that men and women giving meaning to their lives inform the narratives of biography. This meaning is not solely a private experience but can be a public performance in which experience is matched with culturally available narratives, scripts or transformational possibilities (Crawford, Nolan, & Brown, 1998).

Arguably, the thread that is common to the accounts of these men who have chosen nursing because of a search for meaning, personal fulfilment or a way of providing service to humanity is the value of caring.

Conclusion

The ideology of nursing as women's work is strong and for men to overcome such a powerful dogma, if they are to enter, and remain in the profession then they generally need to be invested with powerful motivation beyond merely seeing it as a suitable occupation. Five thematic groupings have been identified as significant in these men's decisions: formative experiences, the "Call", expediency, acquaintanceship with a nurse and personal fulfilment. These factors, however, do not necessarily operate in isolation and the reasons for becoming nurses are complex and multifactorial.

While the results reported here are generally congruent with the international literature on men's entry into nursing, this New Zealand study found that the transformational potential for personal fulfilment is more significant than is acknowledged elsewhere. It is an area that deserves more focus; rather than an emphasis on men's efforts to protect their masculinity as nurses it would provide richer understanding to investigate which are the significant factors which allow men to push against the 'male stream'.

While the se results cannot be generalised they do offer some insight into the decision-making process for men who are contemplating entry into nursing. They may provide useful insights for those who would wish to direct recruitment efforts directly at men.

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Thomas Harding, RN, PhD, Deputy Head, School of Nursing (NSW & ACT), Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
How can an inquirer persuade his
   or her audiences (including self)
   that the findings of an inquiry
   are worth paying attention to,
   worth taking account of? What
   arguments can be mounted, what
   criteria invoked, what questions
   asked, that would be persuasive
   on this issue? (p. 290)


I developed a very strong advocacy
   role when I was a kid and I used
   to advocate for my siblings and
   try to intervene when things were
   not fair ... So that's where my
   advocacy developed and then it
   was an outlet in nursing and I
   saw it as a natural thing when I
   went to work at the psychopaedic
   hospital.


I was caring for mainly autistic
   kids and there was one particular
   child that I was trying to get
   through to . one day I found this
   funny swing apparatus in one of
   the cupboards and I asked the
   staff what it was and they said,
   "Well, you can hang it up in the
   gymnasium and they can swing
   from it." So I strung it up and I
   pushed her and got the fright of
   my life because she just suddenly
   burst into this peal of clear laughter
   ... I got such a reward out of that I
   suddenly felt so joyful, you know,
   suddenly I had got the big payback
   for the care that I had given and
   so I thought I really want to learn
   about this I want to see if I can do
   this more often so I decided that I
   would do nursing.


I saw people who literally just left
   [in] one day. They took one look
   at what they were doing, turned
   a shade of green and headed for
   the door. And the other end of
   the scale, I think, is the person
   who came in with a kind of very
   ideal, soul-saving sort of notion,
   who would either leave or get
   that knocked out of them really
   quickly. A bit like people who tend
   to . all those professions really
   [like] social [work], probation,
   psychology come in with that
   idealism, soul-saving notion and
   pretty soon lose it or leave.


There was one ward over there
   where they would go in and hose
   people down from the rafters
   because that is where they had
   been climbing. The deteriorated
   people they would muck down at
   night like barnyard animals, give
   them a glass of cheap whiskey and
   send them off to sleep, and in the
   morning one of the patients would
   come along, rake out the straw like
   a barnyard and take it off to be
   composted down in the gardens.


It was a job available at the time,
   pretty much purely and simply.
   I had an aunt who worked at
   Community Hospital; she told me
   that it wasn't a bad job, that you
   made good wages there. I'd just
   flunked out of university, so [I]
   rolled up to the door and asked
   for a job.
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