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Male Nurses in Israel: Barriers, Motivation, and How They Are Perceived by Nursing Students
MALE NURSES IN ISRAEL: BARRIERS, MOTIVATION, AND HOW THEY ARE PERCEIVED BY NURSING STUDENTS LIAT ASHKENAZI, RN, MA*,†, ILANA LIVSHIZ-RIVEN, RN, PHD*,†, PNINA ROMEM, RN, PHD*, AND ORLI GRINSTEIN-COHEN, RN, PHD*,† The current worldwide nursing shortage remains a challenge for the nursing profession. Encouraging men to become nurses and, thereby, increasing the number of practitioners are crucial factors in facing this challenge. The historiography of nursing presents nursing as “women’s work,” based on the assumption that it is inherently appropriate for women only. Although men were employed as nurses even before nursing was recognized as a profession, male nurses were always a minority in the field. Over the years, the proportion of male nurses has increased, but they still comprise only 5 to 10% of the nursing workforce in the western world. This study examined men's motives for a career choice of nursing, how male nurses are perceived, and the barriers that they face. The study was conducted among 336 nursing students studying in a co-educational program in various academic tracks at a public, nonsectarian university in the south of Israel. Participants completed the following questionnaires in one study session: sociodemographic questionnaire; Attitudes Towards Men in Nursing Scale; motives for career choice questionnaire; and the questionnaire of the perceptions of the professional status of nursing. Study findings revealed that men tended to choose nursing because of financial constraints significantly more frequently than women (P=.001). Among the participants, there was no significant between-sex difference in the perception nursing as women's work (P=.002) or in perception of male nurses as homosexuals. Results of the study showed that the status of the nursing profession is considered low, and the low status deters men from choosing nursing as a career. The motivation for men's career choice must be understood, and men must be empowered to improve their work conditions and financial remuneration in order to recruit men to the field and to improve the perception of the profession and its public status. (Index words: Nursing; Gender bias; Attitude of male nurses; Perception of men in nursing; Male nursing) J Prof Nurs 0:1–8, 2016. © 2016 Elsevier Inc. All rights reserved.
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URSING AS A profession does not include enough men, despite it being originally considered a masculine career, even before it was recognized as a profession. History demonstrates that men had a dominant role in nursing, which has been documented in the a number of places, such as the monastic movement records
*Senior Teacher Nursing Department (Livshiz-Riven, Romem, Grinstein-Cohen), Recanati School for Health Professions, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel. †RN (Ashkenazi), Soroka University Medical Center, Beer Sheva, Israel. Address correspondence to Dr. Grinstein-Cohen: Recanati School for Health Professions, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel. E-mail: [email protected] (L. Ashkenazi), [email protected] (I. Livshiz-Riven), [email protected] (P. Romem), [email protected] (O. Grinstein-Cohen) 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (August), 2016: pp 1–7 © 2016 Elsevier Inc. All rights reserved.
from 1095 with the founding of St. Antonines to care for those with erysipelas and the mentally ill. Another example is the Knight Hospitallers of St. John of Jerusalem, 1200 (Mackintosh, 1997). There are many other examples of the major nursing role men had over the centuries, but these are a few. In the modern era, relatively few men choose nursing. The literature refers to approximately 5–10% male nurses in Canada and the United States of America (Meadus & Twomey, 2011), while other countries in the world range from 10% in the United Kingdom, 10.4% in Australia, 18% in Germany, 22.9% Portugal, 25% in the Philippines, and up to 29% in Iran (Bartfay, Bartfay, Clow, & Wu, 2010; Vaismoradi, Salsali, & Ahmadi, 2011; Wolfenden, 2011). Despite broad employment opportunities, men and women continue to reveal different preferences in career choices (Evans & Diekman, 2009). The historiography of nursing 1 http://dx.doi.org/10.1016/j.profnurs.2016.08.001
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presents the profession as feminine. In the 19th century, when Florence Nightingale established nursing as a profession, she promoted the idea that in order to be a “good nurse” one had to first be a “good woman.” She listed the essential qualities for both a woman and a nurse as nurturance, gentleness, empathy, compassion, tenderness, and unselfishness as opposed to male characteristics of belligerence, aggressiveness, and dominance (Brown, Nolan, & Crawford, 2000; Mackintosh, 1997). In fact, female nurses reflected the general social values of gender-based work, values inconsistent with the employment of men in nursing (Evans, 2004). Because the social structure of nursing was defined as feminine, it tended to deter men from entering the profession (Meadus, 2000). Some authors characterized male nurses as reducing their social status, in contrast to women who raised their status by choosing traditionally male professions, such as medicine or engineering (McMurry, 2011). Although in the last century there has been a significant change in the nature of caregiving professions, nursing continues to be considered a female profession (Twomey & Meadus, 2008). Although across time, the proportion of men who choose nursing has gradually risen, the percentage of male nurses in Israel, as in the rest of the western world, remains low, at 10.5% (Israel Ministry of Health, 2011). The premise of the gender approach is that most men's and women's work values are created early in life. These preliminary basic values can determine an adult's work experience and guide individuals when they choose a profession. Research has consistently found that women and men are drawn to develop careers in professions where their own gender dominates the workforce (Ji, Lapan, & Tate, 2004) and gender segregation of occupations is pervasive in the United States and elsewhere (Weisgram, Bigler, & Liben, 2010). Professions in which one gender represents less than 30% of those employed are called untraditional professions for that gender (Perrone, 2009). Men who choose predominantly female professions have a need to reinforce their masculinity because their career choice undermines it (Simpson, 2004). Cultural mores that strengthen “gender roles” are indirectly responsible for the lack of men in nursing (Kleinman, 2004). Men might refrain from choosing caregiving careers such as nursing because of the stereotypic connection of these professions to femininity (Loughrey, 2008). Society understands the integration of women in traditionally “male professions” but does not demonstrate that same understanding toward men who choose traditional women's work (Heppner & Heppner, 2009). Nursing is the health profession with the greatest disparity between men and women (Jeff, Oliffe, Phinney, & Garrett, 2009). The social perceptions and stereotypes of male nurses can be an effective barrier to men's entry into nursing practice and might affect their rate of attrition from nursing programs (McMillian, Morgan, & Ament, 2006). Studies have found that, in contrast to female nurses, male nurses tend to be apprehensive during the years of career development because of the gender expectations of the patients and the general public (Lane & Piercy, 2003; Yang, Gau, Shiau, Hu, & Shih, 2004). In a
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study performed among male psychiatric nurses in Great Britain, findings revealed that they felt a need to preserve their masculine identity. The investigators concluded that there was a need to build a gender identity for male nurses that can be regarded as “soft masculinity” and, thus, allow the nurse to maintain masculine qualities and while fulfilling social expectations for what is considered a feminine role (Holyoake, 2002). The minority status of men in traditionally women's professions actually has more advantages for men than drawbacks in terms of career development, unlike women's status in male-dominated professions (Kleinman, 2004). Some of the benefits are employment and advancement. According to social scientists, men strategically benefit from their gender and tend to achieve positions of power and authority within the predominantly female workforce (Simpson, 2004, 2005). The proportion of male nurses that fill senior positions exceeds with the proportion of men in nursing. This situation arose, apparently, because unlike women, men do not need to choose between their commitment to family life and child care and professional development (Yang et al., 2004). It is currently believed that the proportion of men in nursing will continue to rise because of the increasing complexity of medical technology and the rising reputation of the nursing profession. Increasing the proportion of male nurses is considered positive because it could help promote the status of the profession (Yu, 2008). The large gap between men and women in nursing is surprising in light of the decline in the gap between men and women in professions such as medicine and engineering (Davis & Bartfay, 2001). Studies that examined the reasons for this disparity found that gender barriers are stronger in nursing. In general, more men than women are deterred from choosing a profession seen as the territory of the opposite gender. Research demonstrates that men and women are drawn to start a career in the professions in which their gender is a majority in manpower (Ji et al., 2004). One of the barriers identified as discouraging men who have doubts about entering the nursing profession is the social stereotype of the gendered nature of nursing work that associates the characteristics of caring, compassion, nurturance, and empathy exclusively with women (Twomey & Meadus, 2008). One common stereotype of male nurses is that they are homosexuals (Hart, 2005; Jinks & Bradley, 2004; Meadus & Twomey, 2011). In addition, men are sometimes seen as having chosen nursing in default because they were not accepted to medical school (Hart, 2005; Zysberg & Berry, 2005). Another problem is that unlike the feminine touch, which is considered natural, men's touch raises suspicions that their motives are sexual and not professional, causing stress for the patient (Evans, 2002). An additional barrier for men, related to touch, is the preference of women patients to be treated by women when it concerns intimate care. In the Chur-Hansen study, women had a more pronounced preference for same-sex health care provider than men, particularly younger women. However with nonintimate care such as starting an infusion, there was no preference for same-sex health care provider (Chur-Hansen, 2002). But intimate physical touch is sometimes necessary in
ARTICLE IN PRESS order to provide appropriate nursing care. Paradoxically, intimate professional care by male physicians is socially acceptable, but this is not universally accepted when these services are provided by a man who is a nurse (Harding, North, & Perkins, 2008) The literature documents a lack of support and guidance for male nursing students (O'Lynn, 2004; Whittock & Leonard, 2003). The nursing curriculum has a gender bias and is stereotyped, in part, because most of the lecturers are women (Anthony, 2004; O'Lynn, 2004; Smith, 2006). The gender bias is also evident in learning materials directed to nurses and use the pronoun “she” or the words girl and sister to refer to the nurse (O'Lynn, 2004; Smith, 2006) and feminine images described in the classroom (Dyck, Oliffe, Phinney, & Garrett, 2009). Because the role of men in the history of nursing is not included in the nursing textbooks (O'Lynn, 2004; Smith, 2006), male nursing students also report a sense of social isolation and not belonging (O'Lynn, 2004; Stott, 2007; Whittock & Leonard, 2003) to the point that they reconsidered their career choice (Stott, 2007). Inoue, Chapman, and Wynaden (2006) concluded in their study that the nursing curriculum needs to be changed to empower career development for the male nurse. Nursing is an essential profession in the health care system; without it, the system cannot function properly. However, the complex skills required by nurses are not recognized by the general public or even by colleagues in closely related professions (Hasson, 2008). The nursing profession has a poor public image, and nurses are considered to be less competent than physicians, subordinate to them, and expected to carry out the doctor's orders. They are “physicians' handmaidens” and “physicians' assistants,” (Wang, Li, Hu, Chen, & Gao, 2011), despite the growing numbers of nurse practitioners who provide primary health care (Norwood, 2001). Despite the many advances in the nursing profession, nurses continue to face many image-related challenges that affect their status, power, and their ability to effect changes in health care (El-Halem, Hawashy, El-Dein, & Taha, 2011). What motivates men to choose nursing as a career? Ben Natan and Becker (2010) noted that career choice of both genders is an important milestone in life that reflects the individual's tendencies. In their study, they found a number of internal motives for choosing nursing: helping others, interest, appreciation and self-fulfillment, challenge and excitement, creativity and responsibility, social assistance, and professional status. The external motives they revealed were employment security, flexible hours, high salary, promotion and responsibility, comfortable work conditions, short training, and the ability to work and study at the same time. Similar motives were found in other studies: the desire to help others and to work with people (McCabe, Nowak, & Mullen, 2005; Rongstad, 2002); a secure profession in demand; a sense of doing something useful (Rongstad, 2002); interesting, challenging, and satisfying work (McCabe et al., 2005); salary and prestige; job security; and career development opportunities (Boughn, 2001; Twomey & Meadus, 2008) and options for mobility (Twomey & Meadus, 2008). In a
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study performed among registered nurses who work in general or psychiatric hospitals in Israel, Romem and Anson (2005) found significant gender differences in the internal motives for choosing nursing. Women reported helping others, interest in the field, and identification of appropriate personal characteristics. Both sexes reported job security, parental or spousal support, and early exposure to the profession as external motives. Zysberg and Berry (2005) found that women tended to underestimate the importance of economic needs for survival attached importance to other and were influenced by others who suggested that they were cut out to be nurses. Male motives: wages, job security, public image of the profession, and opportunities for professional advancement. Boughn (2001) noted that men attached greater importance to work conditions and salary, but both sexes attributed significance to the motive “helping others.” Thus, it is clear that gender differences and stereotypical views of the profession drive the choice of nursing as a career. But does the stereotype exist because too few men enter nursing, or is the stereotype a self-fulfilling prophecy that deters men from choosing nursing? Without understanding the direction of the connection between men and what influences their choice of nursing as a career, steps cannot be taken to increase male participation in the profession. Therefore, this study was undertaken in order to examine common perceptions about men who choose nursing as a profession and the motives behind their decision. Results of this study may be useful in promoting a change in perception of male nurses and stimulate improvement or correction of factors that hinder the men from choosing nursing. Such action could eventually lead to increasing number of male nurses and even help overcome the shortage of nurses.
Hypotheses of the Study 1. Nursing students in general consider nursing a
feminine profession. 2. Nursing students at all levels of study perceive
men in nursing as homosexuals and as having feminine or homosexual characteristics. 3. Male nursing students are more discouraged by the professional status of nursing than women are.
Materials and Methods The study was conducted at a university school of nursing in Israel. The university where the research was conducted is a nonsectarian, public university. The nursing students in the study were Israeli, Jews, Christian Arabs, and Bedouin. The study was cross-sectional and conducted in November 2011. The ethics committee of the faculty and the research committee of the school approved the study. It is important to explain that in Israel, nursing studies are structured as follow: 3-year program for registered nurse diploma and a 4-year program for bachelor of nursing (BN) degree and registered nurse (RN) diploma. A convenience sample of 290 students was recruited from all academic tracks within nursing (4-year BN, RN postlicensure to BN
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Table 1. Distribution of Study Population by Type of Academic Tracks and Participation Rate Response Study Academic track BN year 1 BN year 2 BN year 3 BN year 4 RN licensure to BN – year 1 RN to BN – Year 2 MN: Year 1 MN: Year 2 Total
No. of students
No. of respondents N (%)
71 51 55 37 31 30 47 44 366
64 44 28 25 29 28 39 33 290
(92%) (86%) (51%) (68%) (94%) (93%) (83%) (75%) (80%)
Men N (%)
Women N (%)
4 9 (20.5%) 3 (10.7%) 2 (8%) 1 (3.5%) 0 (0) 5 (12.9%) 3 (9.1%) 27 (9.3%)
60 35 (79.5%) 25 (89.3%) 23 (92%) 28 (96.5%) 28 (100%) 34 (87.1%) 30 (90.9%) 263 (90.7%)
Two hundred ninety students completed the questionnaire including 27 men and 263 women. The highest response rates were in class complementary degree first year. The response rate is among the lowest class of first degree third year of their studies.
program and MN – master's of nursing program), which included 80% of all students in the school. All students were eligible to participate; there were no exclusion criteria. Students had the right to refuse to participate in the study. The percentage may have resulted from a lack of responsiveness random class attendance at the end of completing the questionnaire. For full details, see Table 1.
Research Instruments Sociodemographic questionnaire developed by the researchers, including age, sex, and the income level of the participant's family. Attitudes Toward Men in Nursing Scale (Bartfay et al., 2010). The Attitudes Toward Men in Nursing Scale consists of Likert-type scale comprised of six questions where subjects can choose strongly disagree, disagree, neutral, agree, or strongly agree in response to the question. The questionnaire includes statements such as “I believe that nursing is not perceived as a very masculine or a ‘macho-type’ of career for males to pursue in our society.” The original questionnaire had a reliability Cronbach's alpha of .93. In this study, the questionnaire's reliability had a Cronbach's alpha of .66. Motives for career choice questionnaire: The questionnaire was developed by Romem and Anson in 1995. The questionnaire contains seven sections: profile sociodemographic, vocational training; motives for choosing the profession, roles, and jobs; overload and burnout; job autonomy; and job satisfaction. In this study, we used questions that examined motives for career choice. It consists of Likert-type scale comprised of 17 questions in which subjects can choose “to a large extent,” “moderate extent,” and “small extent” or “not at all” in response to the question. The questionnaire included statements such as “This is a profession that was my childhood dream” and “This is a profession that enables contact with people.” There is no reliability for this questionnaire. Questionnaire of the perceptions of the professional status of nursing: This questionnaire was developed by Ben Natan and Becker (2010) that consists of 75 statements and has a reliability Cronbach's alpha of .78. It was altered by the researcher of this article and
validated by content experts. The questionnaire consists of Likert-type scale comprised of four statements. One statement of Likert-type scale consisted of six grades ranging from low to much higher. Three other statements on the Likert-type scale had five grades ranging from very large extent, to a great extent, moderate extent, small extent, and not at all. The questionnaire included statements such as “The professional status of nursing was discouraging; however I ultimately choose the profession.” Before beginning the research described in this article, a small pilot study was done with 10 questionnaires (these were excluded from the final study). The purpose of the exploratory study was to obtain comments and criticism regarding the clarity of questions and test the limitations of the questionnaires. This exploratory study found the questions to be clear, and there was no need to amend them. Because the exploratory study was on a limited number of subjects, the Cronbach's alpha internal consistency test was not done on this questionnaire.
Study Procedures Participants were nursing students in the department of health science. The researcher who gave out the questionnaires was not their teacher. The students were approached during classes with mandatory attendance and were asked to complete an anonymous self-administered questionnaire that was collected within 20 minutes. Data Analysis. The data were coded, and statistical analyses were performed using Statistical Package for the Social Sciences (version?) and by carrying out t test and Fisher's Exact Test.
Results Hypothesis 1. Hypothesis that the nursing profession is perceived as a female character, tested by a new variable, we created “the nursing profession perceived as a feminine profession,” calculated as an average of 31–36 questions. To examine this hypothesis, it was necessary
ARTICLE IN PRESS to encode the answers to Question 35 so they match the direction of the other questions in a variable, thus the higher value of the profession was interpreted as more feminine. Examination of this hypothesis was performed using t test examiner bias sample values expected threshold value 2.5. The nursing profession was not perceived as characteristically feminine within the total sample. (t test (290) = −0.82, P N .05) (M = 2.48, SD = 0.51); thus, Hypothesis 1 was not confirmed. The more advanced the student was in his or her studies, the less the profession was considered feminine (P = .013). Thus, masters' degree students perceived nursing less as a field for women than BN students in their first and fourth year of study. Hypothesis 2. One hundred fifty-one (52.2%) of the participants did not agree with the statement that men in nursing are perceived as homosexuals and as having feminine characteristics. Among women, 48.9% did not agree with this claim versus 85.2% of the men. A significant difference was found between men's and women's opinions (P = .002); thus, Hypothesis 2 was rejected. Hypothesis 3. One hundred fifty-eight (55.5%) of the participants agreed to a great extent that the professional status of nursing dissuades men from choosing the profession. Forty-nine (17.1%) of the participants did not agree with that claim. Thus, Hypothesis 3 was confirmed.
Discussion This study examined the motives of male nursing students who chose the profession, the perceptions of their female classmates toward them, and selected perceived barriers of those who choose this field of practice. The goal was to understand the motivation behind the choice of this profession, and in so doing, the researchers wanted to determine what may improve male recruitment to nursing. There is virtually no disagreement with the statement that there is a serious nurse shortage worldwide. In order to overcome this shortage, an attempt should be made to boost the number of men in nursing, which is now 10% or less in all western countries (Meadus & Twomey, 2011; Trossman, 2003). This is not any easy task (Bartfay et al., 2010; Meadus & Twomey, 2007) owing to the feminine image of the profession (Meadus, 2000) and the stereotypes of male nurses, factors that interfere with recruitment of men and retaining them in the field across time (McMillian et al., 2006). Thus, despite the high unemployment rate in Europe, the proportion of men who choose nursing, a profession with guaranteed work, remains low (Meadus & Twomey, 2011). Jinks and Bradley (2004) found that between 1992 and 2002, there was an increase in the proportion of nursing students who agreed that male nurses are effeminate. This finding is similar to the finding of the current study that almost half the participants agreed with the statement than men who work as nurses are perceived as homosexuals or as having feminine characteristics. This assumption that male nurses are homosexuals is based on the patriarchal belief
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that nursing is a profession suitable exclusively for women (Meadus & Twomey, 2011). The stigma associated with homosexuality exposes male nurses to homophobia in the workplace and may deter their entry into the profession (Harding, 2007). The authors maintain that despite the fact that the results are limited, there is a great importance to enable men or find men male characteristics to enter the profession. The perception of male nurses as gay sometimes leads male nursing students to limit their connections with their female counterparts out of concern for being labeled effeminate, even to the point of hiding the fact that they are studying nursing (Wang et al., 2011). In a survey of male nurses, many stated that they felt the need to justify their career choice (Meadus & Twomey, 2011). The present study found that significantly more men had a negative attitude toward this view of male nurses as effeminate. Although the literature expresses the consensus that nursing is “women's work” since the time of Florence Nightingale (Lou, Yu, & Chen, 2010; McMillian et al., 2006; Meadus, 2000), findings from the present study show that the participants did not perceive nursing as characteristically feminine. This finding is supported by Jinks and Bradley (2004) who reported that, from 1992 to 2002, there was a decline in the number of nursing students who felt that nursing was a women's profession. The current study raises a question: How is it that nearly 50% of the participants reported that male nurses are homosexuals yet do not perceive the profession as feminine? The public image of nursing has undergone changes throughout the years, given the social environment. The stereotypical image of nursing world over is a major concern to senior nurses across the continents (Kalisch, Begeny, & Neumann, 2007; Takase, Maude, & Manias, 2006). Findings from the present study show that over 50% of the participants agreed that the professional status of nursing dissuades men from choosing the profession. This finding is supported by studies that found that the low public image of nursing deters men from choosing nursing as a profession (Kalisch et al., 2007; Wang et al., 2011). The inaccurate negative public image of nursing also causes the public to view the field as undesirable and, thus, harms recruitment of candidates in general and men in particular (Kalisch et al., 2007; Wang et al., 2011). Villeneuve (1994) noted that the low number of male nurses may reflect men's refusal to accept the perceived working conditions of the profession, suggesting that the job title and the associated images (not the practice of nursing) may deter men from joining the profession. Despite this, nursing functions are divided and based on gender, and men are directed to areas of specific specialties that are considered more male (Evans, 2004): such as the intensive care units and urgent care units. These areas are more intensive, demand more physical strength, and are considered to be highly regarded (Kleinman, 2004). The reasons that men choose untraditional professions such as nursing raise questions. In comparison to
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findings from studies regarding the motivation of men to become nurses, studies conducted in Israel among male teachers revealed that men were motivated to become teachers out of their desire to contribute to the individual and to society, out of their feeling of devotion toward children, and because of prior successful experiences in their work with them. In nursing, men are also motivated to join the profession out of a desire to help others, just as women are (Harding et al., 2008). The studies noted that women and men should work in fields that allow them to help others, allows them freedom to express themselves, and that supports their beliefs and ideologies. They further noted that salary would not be the main consideration when choosing a career (Avissar & Dvir, 2011).
Education Strategies Over the past two decades, there is more awareness of a need to change recruitment and education of male students to the nursing profession. Some strategies include study group formation to include first year students, mentors from previous years to guide and support the newer students, staff support, and guidance for the male students that will prepare them for the challenges specific to men in nursing (Brady & Sherrod, 2003; Smith, 2006). There is a need to promote a climate of acceptance of men in nursing in the schools of nursing and in the clinical environment in order to empower the career development of the male nurse (Inoue et al., 2006). There is also a need for a campaign to promote nursing as a profession open to both genders, regardless of race, religion, or sexual preference. The campaign should represent nursing as it truly is: a dynamic, challenging, intellectually stimulating, and rewarding profession. If the campaign is fought on several fronts and in many countries, the nursing profession could be perceived in a better light for new generations of nurses and in general.
Conclusions This study examined nursing students' perceptions of male nurses and their motives for nursing study and some selected barriers faced by men in nursing. The low public status of the profession and the barriers that prevent men from integrating in the field are interrelated. The image of nursing is gradually changing. However, the traditional iconic images of nursing continue to influence career choice (Rhodes, Morris, & Lazenby, 2011). Leaders in the nursing profession need to present nursing as offering opportunities for intellectual challenges, a platform for achieving goals, employment and financial security, and a chance for diversity and interaction in the workplace. Despite the proliferation of literature regarding nursing faculty shortage on a global scale (McDermid, Peters, Jackson, & Daly, 2012; Nardi & Gyurko, 2013), in Israel, no articles have yet been published on the subject, and it has not yet become an issue. On the contrary, the government has recently increased class size from 70 to 90 students. The number of nursing programs being offered in Israel has also increased. Those who educate
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nurses also need to reevaluate their strategies, to develop awareness of gender bias, and to provide a gender-neutral environment. Professional nursing associations and nursing schools have an important role in promoting a positive image of male nurses and for curbing the stereotype of nursing as a feminine profession. Men in nursing represent a strong and stable workforce. With today's increasing shortage of nurses, strategies for recruiting men to the field must be ongoing and innovative. The motivation for men's career choice must be understood and empowered to improve their work conditions and financial remuneration in order to recruit men to the field and to improve the perception of the profession and its public status.
Limitations of the Study and Implications for Future Research In this study, students from only one institution were surveyed, and the number of men in the study sample was small. Based on this fact, the authors would recommend further research in this area on a broader, international scale, across the spectrum of employment from both hospital and community settings, including various clinical fields. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References Anthony, A. S. (2004). Gender bias and discrimination in nursing education. Can we change it? Nurse Educator, 29, 121–125. Avissar, A., & Dvir, N. (2011). Men and women in education and computer studies: motivation, gender perception and family considerations (Pages 51, 140–169 (Hebrew)). Bartfay, W., Bartfay, E., Clow, K. A., & Wu, T. (2010). Attitudes and perception towards men in nursing education. The Internet Journal of Allied Health Sciences and Practice, 8, 1540–1580. Ben Natan, M., & Becker, F. (2010). Israelis' perceived motivation for choosing a nursing career. Nurse Education Today, 30, 308–313. Boughn, S. (2001). Why women and men choose nursing. Nursing and Health Care Perspectives, 22, 14–19. Brady, M. S., & Sherrod, D. R. (2003). Retaining men in nursing programs designed for women. Journal of Nursing Education, 42, 159–162. Brown, B., Nolan, P., & Crawford, P. (2000). Men in nursing: Ambivalence in care, gender and masculinity. International History of Nursing Journal, 5, 4–13. Chur-Hansen, A. (2002). Preferences for female and male nurses: The role of age, gender and previous experience – Year 2000 compared with 1984. Journal of Advanced Nursing, 37, 192–198. Davis, M. T., & Bartfay, W. J. (2001). Men in nursing: An untapped resource. The Canadian Nurse, 97, 14–18. Dyck, J. M., Oliffe, J., Phinney, A., & Garrett, B. (2009). Nursing instructors' and male nursing students' perceptions of undergraduate, classroom nursing education. Nurse Education Today, 29, 649–653. El-Halem, G. A., Hawashy, Z. E., El-Dein, G. A., & Taha, E. E. (2011). Undergraduate male nursing students' perception about
ARTICLE IN PRESS the image of the nursing profession. Journal of American Science, 7, 614–623. Evans, J. A. (2002). Cautious caregivers: Gender stereotypes and the sexualization of men nurses' touch. Journal of Advanced Nursing, 40, 441–448. Evans, J. (2004). Men nurses: A historical and feminist perspective. Journal of Advanced Nursing, 47, 321–328. Evans, C. D., & Diekman, A. B. (2009). On motivated role selection: Gender beliefs, distant goals and career interest. Psychology of Women Quarterly, 33, 235–249. Harding, T. (2007). The construction of men who are nurses as gay. Journal of Advanced Nursing, 60, 636–644. Harding, T., North, N., & Perkins, R. (2008). Sexualizing men's touch: Male nurses and the use of intimate touch in clinical practice. Research and Theory for Nursing Practice, 22, 88–102. Hart, K. A. (2005). What do men in nursing really think? Survey respondents speak out. Nursing, 35, 46–48. Hasson, S. (2008). Nursing in Israel – The current legal status, the preferred and the desired. Medicine and Law, 170–176 (Hebrew). Heppner, J. M., & Heppner, P. P. (2009). On men and work taking the road less traveled. Journal of Career Development, 36, 49–67. Holyoake, D. (2002). Male identity in mental health nursing. Nursing Standard, 16, 33–47. Inoue, M., Chapman, R., & Wynaden, D. (2006). Male nurses experiences of providing intimate care for women clients. Journal of Advanced Nursing, 55, 559–567. Israel Ministry of Health (2011). Manpower in health professions, 2010. 2011 Retrieved From: http://www.old. health.gov.il/download/docs/units/meida/manpower2010/7.pdf (Accessed 11.11.2013). Jeff, M., Oliffe, J., Phinney, A., & Garrett, B. (2009). Nursing instructors and male nursing students perceptions of undergraduate, classroom nursing education. Nurse Education Today, 29, 649–653. Ji, P., Lapan, R., & Tate, K. (2004). Vocational interests and career efficacy expectations in relation to occupational sextyping beliefs for eighth grade students. Journal of Career Development, 31, 143–154. Jinks, A. M., & Bradley, E. (2004). Angel, handmaiden, battleax or whore? A study which examines changes in newly recruited student nurses attitudes to gender and nursing stereotypes. Nurse Education Today, 24, 121–127. Kalisch, B. J., Begeny, S., & Neumann, S. (2007). The image of the nurse on the internet. Nursing Outlook, 55, 182–188. Kleinman, C. S. (2004). Understanding and capitalizing on men's advantages in nursing. Journal of Nursing Administration, 34, 78–82. Lane, N. & Piercy, N. F. (2003). The ethics of discrimination: Organizational mindsets and female employment disadvantage. Journal of Business Ethics, 44, 313–325. Lou, J-. H., Yu, H-. Y., & Chen, S-. H. (2010). Factors affecting the career development of male nurses: A structural equation model. Journal of Advanced Nursing, 66, 900–910. Loughrey, M. (2008). Just how male are male nurses? Journal of Clinical Nursing, 17, 1327–1334. MacKintosh, C. (1997). A historical study of men in nursing. Journal of Advanced Nursing, 26, 232–236. McCabe, R., Nowak, M., & Mullen, S. (2005). Nursing careers: What motivated nurses to choose their professions? Australian Bulletin of Labour, 31, 384–406. McDermid, F., Peters, K., Jackson, D., & Daly, J. (2012). Factors contributing to the shortage of nurse faculty: A review of the literature. Nurse Education Today, 32, 565–569.
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McMillian, J., Morgan, S. A., & Ament, P. (2006). Acceptance of male registered nurses by female registered nurses. Journal of Nursing Scholarship, 38, 100–106. McMurry, T. B. (2011). The image of male nurses and nursing leadership mobility. Nursing Forum, 46, 22–28. Meadus, R. J. (2000). Men in nursing: Barriers to recruitment. Nursing Forum, 35, 5–12. Meadus, R. J., & Twomey, J. C. (2007). Men in nursing: Making the right choice. The Canadian Nurse, 103, 13–16. Meadus, R. J., & Twomey, J. C. (2011). Men student nurses: The nursing education experience. Nursing Forum, 46, 269–279. Nardi, D. A., & Gyurko, C. C. (2013). The global nursing faculty shortage: status and solutions for change. Journal of Nursing Scholarship, 45, 317–326. Norwood, L. S. (2001). The invisibility of advanced practice nurses in popular magazines. Journal of the American Academy of Nurse Practitioners, 13, 129–133. O'Lynn, C. E. (2004). Gender based barriers for male students in nursing education program. Journal of Nursing Education, 43, 331–333. Perrone, K. M. (2009). Traditional and nontraditional work and family roles for women and men. Journal of Career Development, 36, 3–7. Rhodes, M. K., Morris, A. H., & Lazenby, R. B. (2011). Nursing at its best: Competent and caring. The Online Journal of Issues in Nursing, 16, 2. Romem, P., & Anson, O. (2005). Israeli men in nursing: Social and personal motives. Journal of Nursing Management, 13, 173–178. Rongstad, M. K. (2002). Recruitment to and motivation for nursing education and the nursing profession. Journal of Nursing Education, 41, 321–325. Simpson, R. (2004). Masculinity at work: The experiences of men in female dominated occupations. Work, Employment and Society, 18, 349–368. Simpson, R. (2005). Men in non-traditional occupations: Career entry, career orientation and experience of role strain. Gender, Work and Organization, 12, 363–380. Smith, J. S. (2006). Exploring the challenges for nontraditional male students transitioning into nursing program. Journal of Nursing Education, 45, 263–269. Stott, A. (2007). Exploring factors affecting attrition of male students from an undergraduate nursing course: A qualitative study. Nurse Education Today, 27, 325–332. Takase, M., Maude, P., & Manias, E. (2006). Impact of the perceived public image of nursing on nurses' work behavior. Journal of Advanced Nursing, 53, 333–343. Trossman, S. (2003). Caring Knows No Gender: Break the stereotype and boost the number of men in nursing. AJN The American Journal of Nursing, 103, 65–68. Twomey, J. C., & Meadus, R. J. (2008). Despite the barriers men nurses are satisfied with career choices. Canadian Journal of Career Development, 7, 30–34. Vaismoradi, M., Salsali, M., & Ahmadi, F. (2011). Perspectives of Iranian male nursing students regarding the role of nursing education in developing a professional identity: A content analysis study. Japan Journal of Nursing Science, 8, 174–183. Villeneuve, M. J. (1994). Recruiting and retaining men in nursing: A review of the literature. Journal of Professional Nursing, 10, 217–228. Wang, H., Li, X., Hu, X., Chen, H., & Gao, Y. (2011). Perceptions of nursing profession and learning experiences of male students in baccalaureate nursing program in Changsha, China. Nurse Education Today, 31, 36–42.
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Weisgram, E. S., Bigler, R. S., & Liben, L. S. (2010). Gender, values, and occupational interests among children, adolescents, and adults. Child Development, 81, 788–796. Whittock, M., & Leonard, L. (2003). Stepping outside the stereotype: A pilot study of the motivations and experiences of males in the nursing the profession. Journal of Nursing Management, 11, 242–249. Wolfenden, J. (2011). Men in nursing. Internet Journal of Allied Health Sciences and Practice, 9, 5.
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Yang, C-. I., Gau, M-. I., Shiau, S-. J., Hu, W-. H., & Shih, F-. J. (2004). Professional career development for male nurses. Journal of Advanced Nursing, 48, 642–650. Yu, X. (2008). Men in nursing origin, career path, and benefits to nursing as a profession. Home Health Care Management & Practice, 21, 72–73. Zysberg, L., & Berry, D. M. (2005). Gender and students' vocational choices in entering the field of nursing. Nursing Outlook, 53, 193–198.
N
URSING AS A profession does not include enough men, despite it being originally considered a masculine career, even before it was recognized as a profession. History demonstrates that men had a dominant role in nursing, which has been documented in the a number of places, such as the monastic movement records
*Senior Teacher Nursing Department (Livshiz-Riven, Romem, Grinstein-Cohen), Recanati School for Health Professions, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel. †RN (Ashkenazi), Soroka University Medical Center, Beer Sheva, Israel. Address correspondence to Dr. Grinstein-Cohen: Recanati School for Health Professions, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel. E-mail: [email protected] (L. Ashkenazi), [email protected] (I. Livshiz-Riven), [email protected] (P. Romem), [email protected] (O. Grinstein-Cohen) 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (August), 2016: pp 1–7 © 2016 Elsevier Inc. All rights reserved.
from 1095 with the founding of St. Antonines to care for those with erysipelas and the mentally ill. Another example is the Knight Hospitallers of St. John of Jerusalem, 1200 (Mackintosh, 1997). There are many other examples of the major nursing role men had over the centuries, but these are a few. In the modern era, relatively few men choose nursing. The literature refers to approximately 5–10% male nurses in Canada and the United States of America (Meadus & Twomey, 2011), while other countries in the world range from 10% in the United Kingdom, 10.4% in Australia, 18% in Germany, 22.9% Portugal, 25% in the Philippines, and up to 29% in Iran (Bartfay, Bartfay, Clow, & Wu, 2010; Vaismoradi, Salsali, & Ahmadi, 2011; Wolfenden, 2011). Despite broad employment opportunities, men and women continue to reveal different preferences in career choices (Evans & Diekman, 2009). The historiography of nursing 1 http://dx.doi.org/10.1016/j.profnurs.2016.08.001
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presents the profession as feminine. In the 19th century, when Florence Nightingale established nursing as a profession, she promoted the idea that in order to be a “good nurse” one had to first be a “good woman.” She listed the essential qualities for both a woman and a nurse as nurturance, gentleness, empathy, compassion, tenderness, and unselfishness as opposed to male characteristics of belligerence, aggressiveness, and dominance (Brown, Nolan, & Crawford, 2000; Mackintosh, 1997). In fact, female nurses reflected the general social values of gender-based work, values inconsistent with the employment of men in nursing (Evans, 2004). Because the social structure of nursing was defined as feminine, it tended to deter men from entering the profession (Meadus, 2000). Some authors characterized male nurses as reducing their social status, in contrast to women who raised their status by choosing traditionally male professions, such as medicine or engineering (McMurry, 2011). Although in the last century there has been a significant change in the nature of caregiving professions, nursing continues to be considered a female profession (Twomey & Meadus, 2008). Although across time, the proportion of men who choose nursing has gradually risen, the percentage of male nurses in Israel, as in the rest of the western world, remains low, at 10.5% (Israel Ministry of Health, 2011). The premise of the gender approach is that most men's and women's work values are created early in life. These preliminary basic values can determine an adult's work experience and guide individuals when they choose a profession. Research has consistently found that women and men are drawn to develop careers in professions where their own gender dominates the workforce (Ji, Lapan, & Tate, 2004) and gender segregation of occupations is pervasive in the United States and elsewhere (Weisgram, Bigler, & Liben, 2010). Professions in which one gender represents less than 30% of those employed are called untraditional professions for that gender (Perrone, 2009). Men who choose predominantly female professions have a need to reinforce their masculinity because their career choice undermines it (Simpson, 2004). Cultural mores that strengthen “gender roles” are indirectly responsible for the lack of men in nursing (Kleinman, 2004). Men might refrain from choosing caregiving careers such as nursing because of the stereotypic connection of these professions to femininity (Loughrey, 2008). Society understands the integration of women in traditionally “male professions” but does not demonstrate that same understanding toward men who choose traditional women's work (Heppner & Heppner, 2009). Nursing is the health profession with the greatest disparity between men and women (Jeff, Oliffe, Phinney, & Garrett, 2009). The social perceptions and stereotypes of male nurses can be an effective barrier to men's entry into nursing practice and might affect their rate of attrition from nursing programs (McMillian, Morgan, & Ament, 2006). Studies have found that, in contrast to female nurses, male nurses tend to be apprehensive during the years of career development because of the gender expectations of the patients and the general public (Lane & Piercy, 2003; Yang, Gau, Shiau, Hu, & Shih, 2004). In a
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study performed among male psychiatric nurses in Great Britain, findings revealed that they felt a need to preserve their masculine identity. The investigators concluded that there was a need to build a gender identity for male nurses that can be regarded as “soft masculinity” and, thus, allow the nurse to maintain masculine qualities and while fulfilling social expectations for what is considered a feminine role (Holyoake, 2002). The minority status of men in traditionally women's professions actually has more advantages for men than drawbacks in terms of career development, unlike women's status in male-dominated professions (Kleinman, 2004). Some of the benefits are employment and advancement. According to social scientists, men strategically benefit from their gender and tend to achieve positions of power and authority within the predominantly female workforce (Simpson, 2004, 2005). The proportion of male nurses that fill senior positions exceeds with the proportion of men in nursing. This situation arose, apparently, because unlike women, men do not need to choose between their commitment to family life and child care and professional development (Yang et al., 2004). It is currently believed that the proportion of men in nursing will continue to rise because of the increasing complexity of medical technology and the rising reputation of the nursing profession. Increasing the proportion of male nurses is considered positive because it could help promote the status of the profession (Yu, 2008). The large gap between men and women in nursing is surprising in light of the decline in the gap between men and women in professions such as medicine and engineering (Davis & Bartfay, 2001). Studies that examined the reasons for this disparity found that gender barriers are stronger in nursing. In general, more men than women are deterred from choosing a profession seen as the territory of the opposite gender. Research demonstrates that men and women are drawn to start a career in the professions in which their gender is a majority in manpower (Ji et al., 2004). One of the barriers identified as discouraging men who have doubts about entering the nursing profession is the social stereotype of the gendered nature of nursing work that associates the characteristics of caring, compassion, nurturance, and empathy exclusively with women (Twomey & Meadus, 2008). One common stereotype of male nurses is that they are homosexuals (Hart, 2005; Jinks & Bradley, 2004; Meadus & Twomey, 2011). In addition, men are sometimes seen as having chosen nursing in default because they were not accepted to medical school (Hart, 2005; Zysberg & Berry, 2005). Another problem is that unlike the feminine touch, which is considered natural, men's touch raises suspicions that their motives are sexual and not professional, causing stress for the patient (Evans, 2002). An additional barrier for men, related to touch, is the preference of women patients to be treated by women when it concerns intimate care. In the Chur-Hansen study, women had a more pronounced preference for same-sex health care provider than men, particularly younger women. However with nonintimate care such as starting an infusion, there was no preference for same-sex health care provider (Chur-Hansen, 2002). But intimate physical touch is sometimes necessary in
ARTICLE IN PRESS order to provide appropriate nursing care. Paradoxically, intimate professional care by male physicians is socially acceptable, but this is not universally accepted when these services are provided by a man who is a nurse (Harding, North, & Perkins, 2008) The literature documents a lack of support and guidance for male nursing students (O'Lynn, 2004; Whittock & Leonard, 2003). The nursing curriculum has a gender bias and is stereotyped, in part, because most of the lecturers are women (Anthony, 2004; O'Lynn, 2004; Smith, 2006). The gender bias is also evident in learning materials directed to nurses and use the pronoun “she” or the words girl and sister to refer to the nurse (O'Lynn, 2004; Smith, 2006) and feminine images described in the classroom (Dyck, Oliffe, Phinney, & Garrett, 2009). Because the role of men in the history of nursing is not included in the nursing textbooks (O'Lynn, 2004; Smith, 2006), male nursing students also report a sense of social isolation and not belonging (O'Lynn, 2004; Stott, 2007; Whittock & Leonard, 2003) to the point that they reconsidered their career choice (Stott, 2007). Inoue, Chapman, and Wynaden (2006) concluded in their study that the nursing curriculum needs to be changed to empower career development for the male nurse. Nursing is an essential profession in the health care system; without it, the system cannot function properly. However, the complex skills required by nurses are not recognized by the general public or even by colleagues in closely related professions (Hasson, 2008). The nursing profession has a poor public image, and nurses are considered to be less competent than physicians, subordinate to them, and expected to carry out the doctor's orders. They are “physicians' handmaidens” and “physicians' assistants,” (Wang, Li, Hu, Chen, & Gao, 2011), despite the growing numbers of nurse practitioners who provide primary health care (Norwood, 2001). Despite the many advances in the nursing profession, nurses continue to face many image-related challenges that affect their status, power, and their ability to effect changes in health care (El-Halem, Hawashy, El-Dein, & Taha, 2011). What motivates men to choose nursing as a career? Ben Natan and Becker (2010) noted that career choice of both genders is an important milestone in life that reflects the individual's tendencies. In their study, they found a number of internal motives for choosing nursing: helping others, interest, appreciation and self-fulfillment, challenge and excitement, creativity and responsibility, social assistance, and professional status. The external motives they revealed were employment security, flexible hours, high salary, promotion and responsibility, comfortable work conditions, short training, and the ability to work and study at the same time. Similar motives were found in other studies: the desire to help others and to work with people (McCabe, Nowak, & Mullen, 2005; Rongstad, 2002); a secure profession in demand; a sense of doing something useful (Rongstad, 2002); interesting, challenging, and satisfying work (McCabe et al., 2005); salary and prestige; job security; and career development opportunities (Boughn, 2001; Twomey & Meadus, 2008) and options for mobility (Twomey & Meadus, 2008). In a
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study performed among registered nurses who work in general or psychiatric hospitals in Israel, Romem and Anson (2005) found significant gender differences in the internal motives for choosing nursing. Women reported helping others, interest in the field, and identification of appropriate personal characteristics. Both sexes reported job security, parental or spousal support, and early exposure to the profession as external motives. Zysberg and Berry (2005) found that women tended to underestimate the importance of economic needs for survival attached importance to other and were influenced by others who suggested that they were cut out to be nurses. Male motives: wages, job security, public image of the profession, and opportunities for professional advancement. Boughn (2001) noted that men attached greater importance to work conditions and salary, but both sexes attributed significance to the motive “helping others.” Thus, it is clear that gender differences and stereotypical views of the profession drive the choice of nursing as a career. But does the stereotype exist because too few men enter nursing, or is the stereotype a self-fulfilling prophecy that deters men from choosing nursing? Without understanding the direction of the connection between men and what influences their choice of nursing as a career, steps cannot be taken to increase male participation in the profession. Therefore, this study was undertaken in order to examine common perceptions about men who choose nursing as a profession and the motives behind their decision. Results of this study may be useful in promoting a change in perception of male nurses and stimulate improvement or correction of factors that hinder the men from choosing nursing. Such action could eventually lead to increasing number of male nurses and even help overcome the shortage of nurses.
Hypotheses of the Study 1. Nursing students in general consider nursing a
feminine profession. 2. Nursing students at all levels of study perceive
men in nursing as homosexuals and as having feminine or homosexual characteristics. 3. Male nursing students are more discouraged by the professional status of nursing than women are.
Materials and Methods The study was conducted at a university school of nursing in Israel. The university where the research was conducted is a nonsectarian, public university. The nursing students in the study were Israeli, Jews, Christian Arabs, and Bedouin. The study was cross-sectional and conducted in November 2011. The ethics committee of the faculty and the research committee of the school approved the study. It is important to explain that in Israel, nursing studies are structured as follow: 3-year program for registered nurse diploma and a 4-year program for bachelor of nursing (BN) degree and registered nurse (RN) diploma. A convenience sample of 290 students was recruited from all academic tracks within nursing (4-year BN, RN postlicensure to BN
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Table 1. Distribution of Study Population by Type of Academic Tracks and Participation Rate Response Study Academic track BN year 1 BN year 2 BN year 3 BN year 4 RN licensure to BN – year 1 RN to BN – Year 2 MN: Year 1 MN: Year 2 Total
No. of students
No. of respondents N (%)
71 51 55 37 31 30 47 44 366
64 44 28 25 29 28 39 33 290
(92%) (86%) (51%) (68%) (94%) (93%) (83%) (75%) (80%)
Men N (%)
Women N (%)
4 9 (20.5%) 3 (10.7%) 2 (8%) 1 (3.5%) 0 (0) 5 (12.9%) 3 (9.1%) 27 (9.3%)
60 35 (79.5%) 25 (89.3%) 23 (92%) 28 (96.5%) 28 (100%) 34 (87.1%) 30 (90.9%) 263 (90.7%)
Two hundred ninety students completed the questionnaire including 27 men and 263 women. The highest response rates were in class complementary degree first year. The response rate is among the lowest class of first degree third year of their studies.
program and MN – master's of nursing program), which included 80% of all students in the school. All students were eligible to participate; there were no exclusion criteria. Students had the right to refuse to participate in the study. The percentage may have resulted from a lack of responsiveness random class attendance at the end of completing the questionnaire. For full details, see Table 1.
Research Instruments Sociodemographic questionnaire developed by the researchers, including age, sex, and the income level of the participant's family. Attitudes Toward Men in Nursing Scale (Bartfay et al., 2010). The Attitudes Toward Men in Nursing Scale consists of Likert-type scale comprised of six questions where subjects can choose strongly disagree, disagree, neutral, agree, or strongly agree in response to the question. The questionnaire includes statements such as “I believe that nursing is not perceived as a very masculine or a ‘macho-type’ of career for males to pursue in our society.” The original questionnaire had a reliability Cronbach's alpha of .93. In this study, the questionnaire's reliability had a Cronbach's alpha of .66. Motives for career choice questionnaire: The questionnaire was developed by Romem and Anson in 1995. The questionnaire contains seven sections: profile sociodemographic, vocational training; motives for choosing the profession, roles, and jobs; overload and burnout; job autonomy; and job satisfaction. In this study, we used questions that examined motives for career choice. It consists of Likert-type scale comprised of 17 questions in which subjects can choose “to a large extent,” “moderate extent,” and “small extent” or “not at all” in response to the question. The questionnaire included statements such as “This is a profession that was my childhood dream” and “This is a profession that enables contact with people.” There is no reliability for this questionnaire. Questionnaire of the perceptions of the professional status of nursing: This questionnaire was developed by Ben Natan and Becker (2010) that consists of 75 statements and has a reliability Cronbach's alpha of .78. It was altered by the researcher of this article and
validated by content experts. The questionnaire consists of Likert-type scale comprised of four statements. One statement of Likert-type scale consisted of six grades ranging from low to much higher. Three other statements on the Likert-type scale had five grades ranging from very large extent, to a great extent, moderate extent, small extent, and not at all. The questionnaire included statements such as “The professional status of nursing was discouraging; however I ultimately choose the profession.” Before beginning the research described in this article, a small pilot study was done with 10 questionnaires (these were excluded from the final study). The purpose of the exploratory study was to obtain comments and criticism regarding the clarity of questions and test the limitations of the questionnaires. This exploratory study found the questions to be clear, and there was no need to amend them. Because the exploratory study was on a limited number of subjects, the Cronbach's alpha internal consistency test was not done on this questionnaire.
Study Procedures Participants were nursing students in the department of health science. The researcher who gave out the questionnaires was not their teacher. The students were approached during classes with mandatory attendance and were asked to complete an anonymous self-administered questionnaire that was collected within 20 minutes. Data Analysis. The data were coded, and statistical analyses were performed using Statistical Package for the Social Sciences (version?) and by carrying out t test and Fisher's Exact Test.
Results Hypothesis 1. Hypothesis that the nursing profession is perceived as a female character, tested by a new variable, we created “the nursing profession perceived as a feminine profession,” calculated as an average of 31–36 questions. To examine this hypothesis, it was necessary
ARTICLE IN PRESS to encode the answers to Question 35 so they match the direction of the other questions in a variable, thus the higher value of the profession was interpreted as more feminine. Examination of this hypothesis was performed using t test examiner bias sample values expected threshold value 2.5. The nursing profession was not perceived as characteristically feminine within the total sample. (t test (290) = −0.82, P N .05) (M = 2.48, SD = 0.51); thus, Hypothesis 1 was not confirmed. The more advanced the student was in his or her studies, the less the profession was considered feminine (P = .013). Thus, masters' degree students perceived nursing less as a field for women than BN students in their first and fourth year of study. Hypothesis 2. One hundred fifty-one (52.2%) of the participants did not agree with the statement that men in nursing are perceived as homosexuals and as having feminine characteristics. Among women, 48.9% did not agree with this claim versus 85.2% of the men. A significant difference was found between men's and women's opinions (P = .002); thus, Hypothesis 2 was rejected. Hypothesis 3. One hundred fifty-eight (55.5%) of the participants agreed to a great extent that the professional status of nursing dissuades men from choosing the profession. Forty-nine (17.1%) of the participants did not agree with that claim. Thus, Hypothesis 3 was confirmed.
Discussion This study examined the motives of male nursing students who chose the profession, the perceptions of their female classmates toward them, and selected perceived barriers of those who choose this field of practice. The goal was to understand the motivation behind the choice of this profession, and in so doing, the researchers wanted to determine what may improve male recruitment to nursing. There is virtually no disagreement with the statement that there is a serious nurse shortage worldwide. In order to overcome this shortage, an attempt should be made to boost the number of men in nursing, which is now 10% or less in all western countries (Meadus & Twomey, 2011; Trossman, 2003). This is not any easy task (Bartfay et al., 2010; Meadus & Twomey, 2007) owing to the feminine image of the profession (Meadus, 2000) and the stereotypes of male nurses, factors that interfere with recruitment of men and retaining them in the field across time (McMillian et al., 2006). Thus, despite the high unemployment rate in Europe, the proportion of men who choose nursing, a profession with guaranteed work, remains low (Meadus & Twomey, 2011). Jinks and Bradley (2004) found that between 1992 and 2002, there was an increase in the proportion of nursing students who agreed that male nurses are effeminate. This finding is similar to the finding of the current study that almost half the participants agreed with the statement than men who work as nurses are perceived as homosexuals or as having feminine characteristics. This assumption that male nurses are homosexuals is based on the patriarchal belief
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that nursing is a profession suitable exclusively for women (Meadus & Twomey, 2011). The stigma associated with homosexuality exposes male nurses to homophobia in the workplace and may deter their entry into the profession (Harding, 2007). The authors maintain that despite the fact that the results are limited, there is a great importance to enable men or find men male characteristics to enter the profession. The perception of male nurses as gay sometimes leads male nursing students to limit their connections with their female counterparts out of concern for being labeled effeminate, even to the point of hiding the fact that they are studying nursing (Wang et al., 2011). In a survey of male nurses, many stated that they felt the need to justify their career choice (Meadus & Twomey, 2011). The present study found that significantly more men had a negative attitude toward this view of male nurses as effeminate. Although the literature expresses the consensus that nursing is “women's work” since the time of Florence Nightingale (Lou, Yu, & Chen, 2010; McMillian et al., 2006; Meadus, 2000), findings from the present study show that the participants did not perceive nursing as characteristically feminine. This finding is supported by Jinks and Bradley (2004) who reported that, from 1992 to 2002, there was a decline in the number of nursing students who felt that nursing was a women's profession. The current study raises a question: How is it that nearly 50% of the participants reported that male nurses are homosexuals yet do not perceive the profession as feminine? The public image of nursing has undergone changes throughout the years, given the social environment. The stereotypical image of nursing world over is a major concern to senior nurses across the continents (Kalisch, Begeny, & Neumann, 2007; Takase, Maude, & Manias, 2006). Findings from the present study show that over 50% of the participants agreed that the professional status of nursing dissuades men from choosing the profession. This finding is supported by studies that found that the low public image of nursing deters men from choosing nursing as a profession (Kalisch et al., 2007; Wang et al., 2011). The inaccurate negative public image of nursing also causes the public to view the field as undesirable and, thus, harms recruitment of candidates in general and men in particular (Kalisch et al., 2007; Wang et al., 2011). Villeneuve (1994) noted that the low number of male nurses may reflect men's refusal to accept the perceived working conditions of the profession, suggesting that the job title and the associated images (not the practice of nursing) may deter men from joining the profession. Despite this, nursing functions are divided and based on gender, and men are directed to areas of specific specialties that are considered more male (Evans, 2004): such as the intensive care units and urgent care units. These areas are more intensive, demand more physical strength, and are considered to be highly regarded (Kleinman, 2004). The reasons that men choose untraditional professions such as nursing raise questions. In comparison to
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findings from studies regarding the motivation of men to become nurses, studies conducted in Israel among male teachers revealed that men were motivated to become teachers out of their desire to contribute to the individual and to society, out of their feeling of devotion toward children, and because of prior successful experiences in their work with them. In nursing, men are also motivated to join the profession out of a desire to help others, just as women are (Harding et al., 2008). The studies noted that women and men should work in fields that allow them to help others, allows them freedom to express themselves, and that supports their beliefs and ideologies. They further noted that salary would not be the main consideration when choosing a career (Avissar & Dvir, 2011).
Education Strategies Over the past two decades, there is more awareness of a need to change recruitment and education of male students to the nursing profession. Some strategies include study group formation to include first year students, mentors from previous years to guide and support the newer students, staff support, and guidance for the male students that will prepare them for the challenges specific to men in nursing (Brady & Sherrod, 2003; Smith, 2006). There is a need to promote a climate of acceptance of men in nursing in the schools of nursing and in the clinical environment in order to empower the career development of the male nurse (Inoue et al., 2006). There is also a need for a campaign to promote nursing as a profession open to both genders, regardless of race, religion, or sexual preference. The campaign should represent nursing as it truly is: a dynamic, challenging, intellectually stimulating, and rewarding profession. If the campaign is fought on several fronts and in many countries, the nursing profession could be perceived in a better light for new generations of nurses and in general.
Conclusions This study examined nursing students' perceptions of male nurses and their motives for nursing study and some selected barriers faced by men in nursing. The low public status of the profession and the barriers that prevent men from integrating in the field are interrelated. The image of nursing is gradually changing. However, the traditional iconic images of nursing continue to influence career choice (Rhodes, Morris, & Lazenby, 2011). Leaders in the nursing profession need to present nursing as offering opportunities for intellectual challenges, a platform for achieving goals, employment and financial security, and a chance for diversity and interaction in the workplace. Despite the proliferation of literature regarding nursing faculty shortage on a global scale (McDermid, Peters, Jackson, & Daly, 2012; Nardi & Gyurko, 2013), in Israel, no articles have yet been published on the subject, and it has not yet become an issue. On the contrary, the government has recently increased class size from 70 to 90 students. The number of nursing programs being offered in Israel has also increased. Those who educate
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nurses also need to reevaluate their strategies, to develop awareness of gender bias, and to provide a gender-neutral environment. Professional nursing associations and nursing schools have an important role in promoting a positive image of male nurses and for curbing the stereotype of nursing as a feminine profession. Men in nursing represent a strong and stable workforce. With today's increasing shortage of nurses, strategies for recruiting men to the field must be ongoing and innovative. The motivation for men's career choice must be understood and empowered to improve their work conditions and financial remuneration in order to recruit men to the field and to improve the perception of the profession and its public status.
Limitations of the Study and Implications for Future Research In this study, students from only one institution were surveyed, and the number of men in the study sample was small. Based on this fact, the authors would recommend further research in this area on a broader, international scale, across the spectrum of employment from both hospital and community settings, including various clinical fields. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References Anthony, A. S. (2004). Gender bias and discrimination in nursing education. Can we change it? Nurse Educator, 29, 121–125. Avissar, A., & Dvir, N. (2011). Men and women in education and computer studies: motivation, gender perception and family considerations (Pages 51, 140–169 (Hebrew)). Bartfay, W., Bartfay, E., Clow, K. A., & Wu, T. (2010). Attitudes and perception towards men in nursing education. The Internet Journal of Allied Health Sciences and Practice, 8, 1540–1580. Ben Natan, M., & Becker, F. (2010). Israelis' perceived motivation for choosing a nursing career. Nurse Education Today, 30, 308–313. Boughn, S. (2001). Why women and men choose nursing. Nursing and Health Care Perspectives, 22, 14–19. Brady, M. S., & Sherrod, D. R. (2003). Retaining men in nursing programs designed for women. Journal of Nursing Education, 42, 159–162. Brown, B., Nolan, P., & Crawford, P. (2000). Men in nursing: Ambivalence in care, gender and masculinity. International History of Nursing Journal, 5, 4–13. Chur-Hansen, A. (2002). Preferences for female and male nurses: The role of age, gender and previous experience – Year 2000 compared with 1984. Journal of Advanced Nursing, 37, 192–198. Davis, M. T., & Bartfay, W. J. (2001). Men in nursing: An untapped resource. The Canadian Nurse, 97, 14–18. Dyck, J. M., Oliffe, J., Phinney, A., & Garrett, B. (2009). Nursing instructors' and male nursing students' perceptions of undergraduate, classroom nursing education. Nurse Education Today, 29, 649–653. El-Halem, G. A., Hawashy, Z. E., El-Dein, G. A., & Taha, E. E. (2011). Undergraduate male nursing students' perception about
ARTICLE IN PRESS the image of the nursing profession. Journal of American Science, 7, 614–623. Evans, J. A. (2002). Cautious caregivers: Gender stereotypes and the sexualization of men nurses' touch. Journal of Advanced Nursing, 40, 441–448. Evans, J. (2004). Men nurses: A historical and feminist perspective. Journal of Advanced Nursing, 47, 321–328. Evans, C. D., & Diekman, A. B. (2009). On motivated role selection: Gender beliefs, distant goals and career interest. Psychology of Women Quarterly, 33, 235–249. Harding, T. (2007). The construction of men who are nurses as gay. Journal of Advanced Nursing, 60, 636–644. Harding, T., North, N., & Perkins, R. (2008). Sexualizing men's touch: Male nurses and the use of intimate touch in clinical practice. Research and Theory for Nursing Practice, 22, 88–102. Hart, K. A. (2005). What do men in nursing really think? Survey respondents speak out. Nursing, 35, 46–48. Hasson, S. (2008). Nursing in Israel – The current legal status, the preferred and the desired. Medicine and Law, 170–176 (Hebrew). Heppner, J. M., & Heppner, P. P. (2009). On men and work taking the road less traveled. Journal of Career Development, 36, 49–67. Holyoake, D. (2002). Male identity in mental health nursing. Nursing Standard, 16, 33–47. Inoue, M., Chapman, R., & Wynaden, D. (2006). Male nurses experiences of providing intimate care for women clients. Journal of Advanced Nursing, 55, 559–567. Israel Ministry of Health (2011). Manpower in health professions, 2010. 2011 Retrieved From: http://www.old. health.gov.il/download/docs/units/meida/manpower2010/7.pdf (Accessed 11.11.2013). Jeff, M., Oliffe, J., Phinney, A., & Garrett, B. (2009). Nursing instructors and male nursing students perceptions of undergraduate, classroom nursing education. Nurse Education Today, 29, 649–653. Ji, P., Lapan, R., & Tate, K. (2004). Vocational interests and career efficacy expectations in relation to occupational sextyping beliefs for eighth grade students. Journal of Career Development, 31, 143–154. Jinks, A. M., & Bradley, E. (2004). Angel, handmaiden, battleax or whore? A study which examines changes in newly recruited student nurses attitudes to gender and nursing stereotypes. Nurse Education Today, 24, 121–127. Kalisch, B. J., Begeny, S., & Neumann, S. (2007). The image of the nurse on the internet. Nursing Outlook, 55, 182–188. Kleinman, C. S. (2004). Understanding and capitalizing on men's advantages in nursing. Journal of Nursing Administration, 34, 78–82. Lane, N. & Piercy, N. F. (2003). The ethics of discrimination: Organizational mindsets and female employment disadvantage. Journal of Business Ethics, 44, 313–325. Lou, J-. H., Yu, H-. Y., & Chen, S-. H. (2010). Factors affecting the career development of male nurses: A structural equation model. Journal of Advanced Nursing, 66, 900–910. Loughrey, M. (2008). Just how male are male nurses? Journal of Clinical Nursing, 17, 1327–1334. MacKintosh, C. (1997). A historical study of men in nursing. Journal of Advanced Nursing, 26, 232–236. McCabe, R., Nowak, M., & Mullen, S. (2005). Nursing careers: What motivated nurses to choose their professions? Australian Bulletin of Labour, 31, 384–406. McDermid, F., Peters, K., Jackson, D., & Daly, J. (2012). Factors contributing to the shortage of nurse faculty: A review of the literature. Nurse Education Today, 32, 565–569.
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McMillian, J., Morgan, S. A., & Ament, P. (2006). Acceptance of male registered nurses by female registered nurses. Journal of Nursing Scholarship, 38, 100–106. McMurry, T. B. (2011). The image of male nurses and nursing leadership mobility. Nursing Forum, 46, 22–28. Meadus, R. J. (2000). Men in nursing: Barriers to recruitment. Nursing Forum, 35, 5–12. Meadus, R. J., & Twomey, J. C. (2007). Men in nursing: Making the right choice. The Canadian Nurse, 103, 13–16. Meadus, R. J., & Twomey, J. C. (2011). Men student nurses: The nursing education experience. Nursing Forum, 46, 269–279. Nardi, D. A., & Gyurko, C. C. (2013). The global nursing faculty shortage: status and solutions for change. Journal of Nursing Scholarship, 45, 317–326. Norwood, L. S. (2001). The invisibility of advanced practice nurses in popular magazines. Journal of the American Academy of Nurse Practitioners, 13, 129–133. O'Lynn, C. E. (2004). Gender based barriers for male students in nursing education program. Journal of Nursing Education, 43, 331–333. Perrone, K. M. (2009). Traditional and nontraditional work and family roles for women and men. Journal of Career Development, 36, 3–7. Rhodes, M. K., Morris, A. H., & Lazenby, R. B. (2011). Nursing at its best: Competent and caring. The Online Journal of Issues in Nursing, 16, 2. Romem, P., & Anson, O. (2005). Israeli men in nursing: Social and personal motives. Journal of Nursing Management, 13, 173–178. Rongstad, M. K. (2002). Recruitment to and motivation for nursing education and the nursing profession. Journal of Nursing Education, 41, 321–325. Simpson, R. (2004). Masculinity at work: The experiences of men in female dominated occupations. Work, Employment and Society, 18, 349–368. Simpson, R. (2005). Men in non-traditional occupations: Career entry, career orientation and experience of role strain. Gender, Work and Organization, 12, 363–380. Smith, J. S. (2006). Exploring the challenges for nontraditional male students transitioning into nursing program. Journal of Nursing Education, 45, 263–269. Stott, A. (2007). Exploring factors affecting attrition of male students from an undergraduate nursing course: A qualitative study. Nurse Education Today, 27, 325–332. Takase, M., Maude, P., & Manias, E. (2006). Impact of the perceived public image of nursing on nurses' work behavior. Journal of Advanced Nursing, 53, 333–343. Trossman, S. (2003). Caring Knows No Gender: Break the stereotype and boost the number of men in nursing. AJN The American Journal of Nursing, 103, 65–68. Twomey, J. C., & Meadus, R. J. (2008). Despite the barriers men nurses are satisfied with career choices. Canadian Journal of Career Development, 7, 30–34. Vaismoradi, M., Salsali, M., & Ahmadi, F. (2011). Perspectives of Iranian male nursing students regarding the role of nursing education in developing a professional identity: A content analysis study. Japan Journal of Nursing Science, 8, 174–183. Villeneuve, M. J. (1994). Recruiting and retaining men in nursing: A review of the literature. Journal of Professional Nursing, 10, 217–228. Wang, H., Li, X., Hu, X., Chen, H., & Gao, Y. (2011). Perceptions of nursing profession and learning experiences of male students in baccalaureate nursing program in Changsha, China. Nurse Education Today, 31, 36–42.
8
ARTICLE IN PRESS
Weisgram, E. S., Bigler, R. S., & Liben, L. S. (2010). Gender, values, and occupational interests among children, adolescents, and adults. Child Development, 81, 788–796. Whittock, M., & Leonard, L. (2003). Stepping outside the stereotype: A pilot study of the motivations and experiences of males in the nursing the profession. Journal of Nursing Management, 11, 242–249. Wolfenden, J. (2011). Men in nursing. Internet Journal of Allied Health Sciences and Practice, 9, 5.
ASHKENAZI ET AL
Yang, C-. I., Gau, M-. I., Shiau, S-. J., Hu, W-. H., & Shih, F-. J. (2004). Professional career development for male nurses. Journal of Advanced Nursing, 48, 642–650. Yu, X. (2008). Men in nursing origin, career path, and benefits to nursing as a profession. Home Health Care Management & Practice, 21, 72–73. Zysberg, L., & Berry, D. M. (2005). Gender and students' vocational choices in entering the field of nursing. Nursing Outlook, 53, 193–198.