Peter Kellett BN RN, MUN MN Student

1. The Contextual Performance of Masculinity and Caring Among Men Nurses: Implications for Nurse Educators Peter Kellett BN RN, MUN MN Student

2. Thesis Committee Dr.. Robert Meadus, Assistant Professor, Memorial University (Supervisor) Dr. Joan Evans, Associate Professor, Dalhousie University Dr. david Gregory, Professor, University of Lethbridge Contradictions and Tensions in the Lives of Men: Exploring Masculinities in the Numerically Female Dominated Professions of Nursing and Elementary School Teaching

3. All the world’s a stage, And the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts, His acts being seven ages (As You Like It., Act II, Scene VII, 139-143)

4. Past/ Traditional Perspectives • Biological Essentialism • Gender as Essentialist • Dichotomy • Sex Role • These perspectives still • quite pervasive • Current Perspectives • Socially Constructed • Historically Situated • Under Constant Revision • Multiple Masculinities • Hegemonic Masculinities • Gender as Social Performance • (Connell, 1995, 2001, 2005)

5. Caring in Men Nurses • Relatively little literature looking at men nurses’ perspectives on caring (Evans, 2001, 2002; Grady et al., 2008; Harding, 2005; Harding et al., 2008; Fisher, 2009; Ingle, 1988; Keogh & Gleeson, 2006; Milligan, 2001; O’Lynn, 2007b; Paterson et al., 1995,1996; ) • Several authors have suggested mens’ caring is different • Since multiple and contextual masculinities exist it would be problematic to suggest that there is one masculine perspective on caring, but there is some evidence to suggest that men nurses frequently understand and perform caring in a different way than their female colleagues (Harding; O’ Lynn, Paterson et al. )

6. Study Premise • Common understanding of caring within nursing is socially constructed by the membership of the profession ~ 94% women (CNA, 2009) • How has essentialized femininity influenced the concept of caring in nursing? • Nursing research to describe caring, primarily draws on the words, voices and perspectives of female participants, which could lead to the documentation of a feminized perspective on caring (Paley, 2001)

7. Purpose To explore men nurses perspectives on caring, while acknowledging the presence of multiple masculinities and femininities, and the potential contextual factors that influence men’s conceptualization of caring and reported caring behaviors . Research Question • How is men nurses’ caring conceptualized and expressed in their discourse?

8. Qualitative Research – Thematic Analysis • Masculinities are socially constructed and are subject to the contexts that influence their creation  no stable and consistent conceptualization of masculine caring making a positivist approach inappropriate. • Qualitative thematic analysis identified themes, potential interactions among themes and thematic patterns related to caring in the discourse of individual men and focus groups of men (Braun & Clark, 2006). Theoretical Framework Masculinity Theory (Coltrane, 1994; Connell, 1987, 1995, 2001; Connell & Messerschmidt, 2005)

9. Ethical Approval • Memorial University’s Human Investigation Committee (HIC) • University of Lethbridge’s Human Subject Research Committee (HSRC) • Original Study collected data with approval from Dalhousie University’s Social Sciences and Humanities Human Research Ethics Board and the University of Manitoba’s Education/Nursing Research Ethics Board

10. Participants • Person-centered interviews (Hollan, 2004) & purposive convenience sampling in original Study – Secondary data • 43 Individual interviews available – saturation after coding 21 interviews with men nurses across the country (Halifax (n=7), Winnipeg (n=7), Vancouver (n=7)) • Focus group at each site explored emerging themes from individual interviews

11. Age : Mean age 43.3 yrs , sd=7.37 • Years of Practice: Mean 16.9 yrs, sd =8.37 yrs • Education: 11 RN diploma, 5 BN/BscN, 3 Masters, 2 PhD • Marital Status: 10 married, 9 single, 2 unknown • Sexual Orientation: 5 gay, 15 straight, 1 unknown • Diverse Practice backgrounds • 15/21 – 71.4% stated they would choose nursing again

12. Contextual Elements Context Sub-themes Core “Overarching” Theme Performance Sub-themes Performance Elements “Strategies”

13. Female Nurse • Suspicion of Homosexuality • Men’s Credibility as a Caregiver • Age of Client • Gender of Client • Influence of Other Audience Members • COP Differences • Female Ways of Knowing • Upbringing • Professional Socialization • Internalized Values

14. 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

15. Cautious caregiving served as a strategy to address men’s concern that their nursing care, and particularly the intimate physical care they provide, will be misinterpreted as inappropriate or sexual misconduct. • Rooted in societal essentialized gender perspectives that situate men as unlikely providers of physical touch in a caring context, men acknowledged that their nursing care was frequently viewed with suspicion by clients and sometimes by colleagues. • The study participants therefore utilized cautious caregiving as a means to increase their acceptability as caregivers while also decreasing the risk that their care would be misinterpreted or lead to false allegations of misconduct. • Cautious caregiving was the most pervasive theme emerging from the analysis of the transcripts with 52 coded references drawn from 22 out of the possible 25 coded transcripts. • (Anthony, 2004; Evans, 2001, 2002; Fisher, 2009; Harding, 2005; Harding, et al., 2008; Inoue, et al., 2006; Keogh & Gleeson, 2006; Keogh & O'Lynn, 2007; O'Lynn, 2004, 2007a, 2007b; Paterson, et al., 1995; Paterson, et al., 1996; Pullen, et al., 2009; Tillman, 2008)

16. Vancouver Focus Group Participant When I started my career, this was big in the news, I don't even know if any of you will remember it, but the male nurse in Michigan who was … accused that he groped a woman when he was putting his hand up under her gown to put a lead on. And I went to work for the next couple of weeks very, very conscious, and I still am, very, very conscious of when I'm putting leads on and reaching up under her shirt.

17. Caregiving as strength acknowledges the role that greater physical size and strength has frequently played in men nurses’ practice. This common reality has manifested in the tendency for men to take on the roles of lifter, enforcer, and protector in the course of their caregiving. • Since men in nursing find themselves in a professional role that is associated with essentialized notions of femininity, many men embrace this physical role because it provides a familiar and comfortable means to contribute to the nursing team, while also enabling them to engage in an essentialized performance of masculinity that associates men’s caregiving role with that of physical protector. • Although men nurses often embraced the emphasis on their physical contribution to nursing care, this role was also frequently reinforced by female colleagues and by the health care system in general. • 49 text excerpts coded to this theme, representing 23 out of a possible 24 coded transcripts. • Previously described by (Anthony, 2004; Evans, 1997a, 2001, 2004a; Harding, 2005; Hart, 2005; Kelly, et al., 1996)

18. Vancouver Focus Group Participant But in the Emergency Department … when there was a violent or aggressive person or somebody who was maybe a little bit on the unsavoury or distasteful side, I would get them. Because, you know, I could deal with it better. I was almost used … in a role because our security … is often very inadequate, and I almost feel like sometimes I'm lumped in with nursing and security, like if there's a violent situation. And I had to call on my charge nurse one day and I'm like, how come whenever there is somebody in who's acting up you want me to go over and be involved in it.

19. 17 text excerpts coded to this theme from 11 of the 24 transcripts. • This theme not only refered to men nurses’ apparent affinity for technology, but also to the tendency for many of the participants to place greater emphasis on technical proficiency and the instrumental aspects of nursing tasks. • Some participants saw affinity to technology as an extension of mens’ societal gender role, or as a manifestation of men’s inborn qualities, thereby suggesting that these men held a more essentialized view of gender. • On interesting point is that the participants tended to associate the term “caring” with the affective or feminine approach and often presented technical/knowledge competence as a separate entity which men preferred to focus on. • Similar findings have been seen in the work of Ingle (1988) “the business of caring” , Inoue et al. (2006) “controlling feelings”, Milligan (2001) “managing emotions”

20. Jacob I find that the women tend to be much better at the empathic communication, … getting in there and making the patient comfortable. The men tend to be a little hard-assed about it, so I find that, although many of them are good clinicians; they know their stuff, they’re solid, you need to reinforce with them at times that, you know, touch your patient, talk to your patient. Don’t just look at the numbers, you know? Talk to your patient as a person; make them comfortable. You can have control of the situation, but make sure that they’re comfortable with it, you know? There’s that difference between the two. So I find that a lot of them relate to their patients very differently than female nurses do.

22. Blaine There are very few things that we trade off, cause generally, everyone’s pretty comfortable doing everything for everyone there, but we’re very sensitive … for instance, catheterization on a female. … I will always ask her first-hand, before I do it, do you want a woman to do this? So the approach that we use there, is really patient-focused. So the female nurses will [ask] do you want one of the guys to do your catheter? So it’s usually around those intimate kinds of things that are related to sexuality, the deep, dark secrets related to being a woman or a man or whatever it is, so we do trade those things off. You know, otherwise, we share the load equally. Winnipeg Focus Group Participant I mean, if you think for a second that the potential isn't there, that's when you're going to get into a problem. And it also depends, too, on the type of touch, and putting a hand on the shoulder, you know, putting your arm around somebody's shoulder if they're in a situation that they, they need it, it's a whole different ball game than going and, you know, lifting a gown up because you're looking at the dressing. Or, you know, there's, doing a catheterization. I mean, that's a whole different story, different kind of touching, that to me is, the touch from there is more professional touch … Cautious Touch Trading off Tasks (Anthony, 2004; Evans, 2001, 2002; Fisher, 2009; Harding, 2005; Harding, et al., 2008; Inoue, et al., 2006; Keogh & Gleeson, 2006; O'Lynn, 2007b; Paterson, et al., 1996; Pullen, et al., 2009; Tillman, 2008) (Evans, 2001, 2002; Fisher, 2009; Harding, 2005; Harding, et al., 2008; Inoue, et al., 2006)

23. Use of Female Chaperones John I would say it’s, for me anyway, much more concerning my female patients. Especially if they’re intoxicated with whatever, especially if they’ve been assaulted by a male, and especially if there’s some sort of mental issue there. …especially if it’s in a private situation, you know, like a closed door situation. …Yeah, I have somebody with me. A curtain there is fine, but a closed room, if I feel uncomfortable or if they make me feel that they’re uncomfortable, I get help. (Evans, 2001, 2002; Fisher, 2009; Harding, 2005; Harding, et al., 2008; Inoue, et al., 2006; Keogh & Gleeson, 2006; Pullen, et al., 2009)

24. Winnipeg Focus Group Participant That's one of the first things that'll come out, are you married.? So, if you're married, well, you're probably not gay. And if you're a female asking that question, so are you married, and the next question is, do you have kids? Because now, if you have kids and you're married, then that must mean that you know how to care. So, therefore, it's okay now for you to take care of a female. And those two it seems are just almost like a given. Identification of Marital Status (Evans, 2002; Fisher, 2009, Morin et al., 1999)

25. Boyd So, I went in and my instructor told me what we were going to do, but I was embarrassed for her. And so, the situation was absolutely horrible for that one day and I came out of there that day saying to myself, you know, if I don't get my act together and start thinking, this is what I have to do, this is my job, and I have to learn to deal with this kind of stuff. And so the next day I went in and essentially cracked a joke about the day before, and she laughed, I laughed, and everything was fine after that. Humor as a Tool to Establish a Relationship (Evans, 2001, 2002; Harding, 2005; Harding, et al., 2008; Inoue, et al., 2006)

26. Blaine So whether, yeah, I can be masculine, in, you know, putting my foot down with the behaviors of drug users when they’re using on the unit, when we have these psychotic episodes, so yup, I might act like a tough guy, I might run to the side of a younger female nurse you know, and play that role, and probably puff myself up and don’t even know it, you know, I’m sure I even lower my voice, you know, and even use different words, like tough guy words; yeah, I’m sure I do that. Tom I was kind of impressed, I remember with all the equipment and the technical stuff, so that's why I thought that I would like the ICU. … I'm sure you'd probably find that a greater number [men nurses] are in the ICU's, a dialysis-type unit, like any specialty that requires higher technical, and it's not to say that it's because I like or I dislike dealing with patients, but it's just that the technical stuff is there, and the machines and that doesn't fizz at all, the more the better, the more pumps around the better, the more equipment the better, it's got it all. Displaying Essentialist Masculine Cues Displaying an Affinity for Technology Talking about “blokey” things, playing the homophobe (Fisher, 2009) (Evans, 2001,2002; Harding, 2005)

27. Richard … there's areas where men feel more comfortable, I know there's like a higher percentage that work in psychiatry, and men seem to gravitate toward the more technical aspects of nursing, places where there's more machines, like the ICU's and more of the high prestige-type jobs, like down in the emergency room, or they'll do unusual things with their degrees like occupational health and safety for large companies, or, you know, aim at flight nursing or oil rigs, all sorts of things like that that may be a more traditionally-minded nurse wouldn't see as a practice setting. … I'd say with psychiatric nursing, because there's so many men there, they probably feel more comfortable in not being the only guy. And they're perceived I think in that setting as needed due to their strength. I've never been too sure about you know the validity of that kind of thing. Choice of Practice Setting (Brown et al., 2000; Egeland & Brown, 1989; Evans, 1997a, 2002; Fisher, 2009; Harding, 2005; Harding, et al., 2008; Williams, 2003)

28. Recommendations for Nursing Education • Address the effect of gender on the practice of both men an women – incorporate into nursing curricula and acknowledge in the evaluation of nursing performance • e.g. recognize the reasons for different expressions of caring/use of touch • Anecdotal evidence suggests high attrition rates for male nursing students; however, gender is frequently not tracked in nursing programs and is not reported in the CNA/CASN educational program survey. Is the attrition of men related to the performance of gender? • Programs or support measures to decrease attrition of men in nursing education and practice Efforts should focus on Equity rather than Equality Not suggesting special treatment, just a recognition that men may have some different challenges to overcome

29. Because of the socialization of men in accordance with essentialized masculinities they may be reluctant to ask for help (value independence, autonomy) • Some male students may feel that doing things on their own = success  some nurses may interpret this as arrogance or not being a team player • Patient safety implications (Gregory et al., 2009) • Because many men feel they have to contain emotion and display a stoic presentation, they may be more affected by stressful or emotional experiences than they seem • It should not be standard practice to require chaperones or to ask clients if they are OK with having a male student  reinforces the perspective that men are questionable caregivers • Men may initially find intimate care and particularly the use of touch in caring challenging – often not part of their past experience/socialization

30. Questions