Considering the Contextual Performance of Masculinity and Caring During Nursing Practice Education

1. Considering the Contextual Performance of Masculinity and Caring During Nursing Practice Education Peter Kellett MN RN Ryan Waldorf BN RN

2. Background • Nursing remains a profession largely comprised of women  Nursing is profoundly influenced by societal constructions and performances of femininity (an essentialized understanding of gender generally exists in society). • Patriarchal structures in society devalue caring work and associate it with the feminine (Poole & Issacs, 1997). (CNA, 2006) Vancouver Focus Group Participant I found that I had to. . .prove myself a lot more,…you get put in that group of all females, and it's just assumed that a woman is, is altruistic, that the woman is caring, compassionate. Whereas I felt that I had to be very, very careful … because I had to prove that I was all of those things, because it wasn't assumed that I was in nursing because I was caring, compassionate, with the woman it was assumed. Well, she's a woman, plus she's in nursing, you know, she must be caring.

3. Are Men Struggling in Nursing Education and Practice? • The proportion of men in nursing has not changed more than a percentage point in the last 2 decades, despite some evidence of increased enrollment of men in many nursing programs. • CNA/CASN have not been tracking attrition in Canadian nursing programs, including attrition by gender, so it is hard to get a clear picture. • Anecdotal evidence has suggested that attrition of men during nursing education programs may be much higher than that seen in women (Bartfay 2007; Brady & Sherrod 2003; Tosh-Kennedy, 2007; Villeneuve, 1994). • Within the NESA program, 2 years ago we had 60% attrition of men in the program between year 1 and year 2, which was significant since there were only 12 (~7%) that entered that class to begin with (Kellett, 2012). • One U.S. study during the period 1996-1999 reported an attrition rate of 7.5% among men nurses in the first 4 years following graduation as opposed to an attrition rate of 4.1% in the comparable cohort of women (Sochalski, 2002)

4. “In my experience as an educator over the past 8 years, it is rare that men make it through the program without at least one issue being raised related to their clinical practice” (Kellett, 2012) In a recent study by Gregory et al. (2009) examining nursing education and patient safety, men were disproportionally represented in the clinical learning contracts of one Canadian university nursing program (21.62%). A similar pattern has been noted in the Clinical Enhancement Plans (CEPs) in the 3rd and 4th year of the Nursing Education in Southwestern Alberta (NESA) program with men represented in 25% of CEPs in the past 2 years. Proportion of men across the program hovers around 5% . Edward Now, I would like men to think that nursing is quite welcoming to them, but … every time there’s a student issue, I say to the assistant, don’t tell me the gender, let me guess, this is a male student, isn’t it? How did you guess? I think if we looked at who’s getting into trouble in nursing, you’ll find, disproportionately, its men. Now why is that?

5. The Contextual Performance of Masculinity and Caring Caring as contextual (Harding, 2005) Evans (2002) – Men navigate contradictory and essentialized societal perspectives on men nurses Fisher (2009) – linked performance of gender to ability to engage in intimate care (“bodywork”) Contextual Performance of Masculinity and Caring Data collected from Halifax, Winnipeg and Vancouver (Kellett, 2010)

6. Women are Nurses • Suspicion of Homosexuality • Men’s Credibility as a Caregiver • Age of Client • Gender of Client • Influence of Other Audience Members • COP Differences • Women’s Ways of Knowing • Upbringing • Professional Socialization • Internalized Values (Kellett, 2010)

7. Strategies and Considerations for Clinical Educators • In the initial stages of clinical practice many men may feel uncomfortable in the role of caregiver • Physical touch is often considered outside the acceptable performance of masculinity • Men may have had limited opportunities to fulfill a caregiving role in the past • May worry that their touch will be sexualized (cautious caregiving) (Evans, 2001, 2002; Harding,2005; Harding et al., 2008; Kellett, 2010; Tillman, 2008) • May seem reluctant to engage with their clients • What may be considered avoidance or lack of initiative from one perspective can also be interpreted as fear and anxiety in the role of caregiver from another. • Take the time to talk to the student about the reasons for their actions/approach Vancouver Focus Group Participant When I see my students, the guys will always operate from like a three foot thing, … and the girls are like right in there, you know, to the point where the girls are stepping over that line way sooner than they should be. …But the guys take forever. Like, their first bed bath is really cool to watch that.

8. Research suggests that men in nursing may feel that they have to contain emotion and display a stoic presentation in emotionally charged or upsetting situations (Kellett, 2010; Milligan, 2001) May be more affected by a critical incident than they acknowledge May create a outward façade concealing internal distress as part of their performance of masculinity

9. In Kellett’s (2010) study, the men verbalized that they valued independence and autonomy, which is consistent with essentialized masculinities. Some men may feel that the demonstration of success requires them to look after their clients independently. Often reluctant to ask for help, which can be a patient safely issue (Gregory et al., 2009) because it fails to acknowledge the importance of working as a team, and the benefits of collective knowledge and experience. Sometimes labeled as arrogant, overconfident or as a “cowboy”! This outward confidence may not reflect the inward reality, which can be anxiety and turmoil. Talk to the student one on one to discover the reality, and to help them realize the way they may be perceived and the potential downsides of this practice. Richard “I was under the false assumption that I was assigned this assignment and if I didn't do each of the things that were involved in caring with those patients, that I wasn't doing my job, and that's not how it works, but that's how I thought it worked at the time. And it took, [a] conversation I had with the nurse educator, she said, well I can see that that's not what's really going on, and I said, I'm a lifelong loner, it's going to take me a little while to adjust. “

10. Some studies have suggested that men may use humor to diffuse uncomfortable situations, or as a strategy to establish rapport with male clients (Evans, 2001;Fisher, 2009; Harding, 2005; Kellett, 2010). When joking with men, it often takes on the character of “verbal sparring”, which may be interpreted as unprofessional or inconsistent with nursing caring performance norms. This can be considered to be part of the performance of caregiving as strength (Kellett, 2010). Occasionally these students may cross the line, but it is probably best to talk to them about how this may be perceived by others, while also recognizing that they are probably trying to overcome stereotypes of homosexuality or femininity commonly projected on men nurses in their performance of masculinity with these male clients. “you do treat the guys differently. I can certainly say things to another guy patient that I wouldn't say to some females. But we still use humor in their situation, just a different focus of it, or . . .emphasis, I guess. But humor is a really important factor of any kind of care, for taking care of them. “

11. As instructors, we need to avoid perpetuating the stereotype that men are questionable caregivers. • It should not be standard practice to require a chaperone, although if men are uncomfortable with the situation, it is reasonable for them to ask for support of a female instructor or colleague. • Men in Kellett’s (2010) study respected a woman’s right to refuse to have a man care for them, but expressed frustration when women colleagues/instructors made assumptions that a woman would be uncomfortable, or policed their access to women clients. e.g. asking a woman if they are OK having a male student (implies there is an issue). • Complex issue -because men may still want to reserve the right to trade off tasks or clients if they are concerned about the risk of false allegations of sexual misconduct. (e.g. female catheterization). Chris  ”Mostly I’m concerned about the patient being comfortable …it’s not a big deal to me, any aspect of care with a person, but … I tend to ask the patient if they’re comfortable with me doing it, and if they’re not, then I would request that the woman do that, and same with female catheterizations.”

12. In general, consider the fact that men may be having some unique challenges in their transition to the role of nurse and caregiver. If they are having performance issues, ask them about this, and incorporate the potential findings into remediation plans. Provide opportunities for mentorship. Does not necessarily have to be a man in nursing, just someone who is willing to listen and provide guidance related to navigating the world of nursing and caregiving. “I had actually one of the female nursing instructors pull me aside and said, I think you should go to lunch with some of the male nursing students in the years above me, and they kind of gave me the lay of the land. And I felt really lucky” Some men report feeling socially isolated (Anthony, 2004; Kellett, 2010) , so if possible place them in a clinical group or class with at least one other man. Boyd … he has to learn how to live in the world of nursing, because if he doesn't, then it can be a very alone world. You, I mean, ostracize isn't the right word, but you certainly, I mean. .. That's the word, isolated. You can be, you can be if you don't learn how to adapt, or if how to adjust so that you're accepted

13. QUESTIONS ?

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