509833 research-article2013
JMHXXX10.1177/1557988313509833American Journal of Men’s HealthChan et al.
Article
Therapeutic Relationship Between Male Nursing Students and Female Patients
American Journal of Men’s Health 2014, Vol. 8(4) 300–309 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988313509833 jmh.sagepub.com
Zenobia C. Y. Chan PhD, RN1, Vera W. S. Chan MN, RN1, and Judy K. M. Tse MN, RN1
Abstract This article explores the therapeutic relationship between male nursing students and female patients, through the use of autobiography in a qualitative approach. For this study, 18 male nursing students enrolled in master’s and bachelor’s programs in Hong Kong were recruited. They were asked to make records in a diary and draw pictures of their therapeutic relationship with female patients from their clinical experiences and then participate in a focus group interview. Content analysis was carried out on the collected data. The essential factors influencing the development of a therapeutic relationship were found to be gender, symbolic meanings, and career features. Good experiences were also discussed. The results shed light on the experiences of male nursing students and how they make sense of their therapeutic relationship with female patients. Keywords gender difference, therapeutic relationship, nursing education
Introduction Nursing is a profession that is currently dominated by females (Best, 2003; Cancian & Oliker, 2000). Only a small percentage of males are involved in the industry. However, this was not always the case in the past. In the Middle Ages, it was common for male nurses to provide nursing care (Romem & Anson, 2005). The activities of Florence Nightingale revolutionized the role of nurses. She established nursing schools and claimed that only females who have a maternal instinct and caregiving attributes are eligible to be nurses (Cash, 1997). Since then, the nursing profession has come to be dominated by females. There are extensive studies on social perceptions of male nurses. People tend to believe that male nurses have different attributes than female nurses in terms of leadership qualities, masculinity, technical ability, sensitivity to the emotions of others, and the impact of their sexuality (Anthony, 2004; Ekstrom, 1999; Fisher, 2009; Hodes Research, 2005; Keogh & O’Lynn, 2007; Kleinman, 2004). Male nurses have been perceived as better at taking up leadership roles than female nurses. Since leadership has for centuries been regarded as a male’s inborn ability, this gender bias could be one of the reasons contributing to this perception in the field of nursing (Anthony, 2004; Kleinman, 2004). Apart from playing a leadership role, studies have revealed that female nurses
believe male nurses are perfect for tasks involving physical labor and dealing with aggressive and irritable patients (Hodes Research, 2005; Keogh & O’Lynn, 2007). Male nurses are also believed to be more suited to performing work requiring technical skills. Such a perception may be due to the gender-biased view that men are good at handling machines and possess better problem-solving skills (Kleinman, 2004). However, male nurses are thought to be less sensitive to other people’s emotions and less caring than female nurses (Ekstrom, 1999; Hodes Research, 2005). Last, the sexual orientation of male nurses has often been questioned by the public, and many male nurses are unfairly assumed to be homosexual and effeminate (Fisher, 2009; Hodes Research, 2005). In fact, no study has proven that sexual orientation affects nursing care performance. Although there have been many studies investigating the involvement of men in nursing, most have focused on the aspects of intimate care, gender differences, career, education, and the perceptions of male nurses (Bell-Scriber, 2008; Dittman, 2008; Fisher, 2009; Hodes Research, 2005; Hsu, Chen, Yu, & Lou, 2010; 1
The Hong Kong Polytechnic University, Kowloon, Hong Kong
Corresponding Author: Zenobia C. Y. Chan, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. Email: [email protected]
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Chan et al. Inoue, Chapman, & Wynaden, 2006; Keogh & O’Lynn, 2007; O’Lynn & Krautscheid, 2011; Wilbourn & Kee, 2010). There is a lack of research on the therapeutic relationship between male nurses and female patients from the perspective of male nurses and male nursing students. The voices of male nurses should be heard, as male nurses provide crucial manpower in the nursing industry, and men are as suited as females to being nurses.
Theoretical Background A therapeutic relationship can be defined as one that develops “when two (or more) people meet, and one has skills and expertise which the other wants to alleviate suffering or maintain the level of health. It is governed by legal, professional and ethical guidelines” (Fox, 2008, p. 16). The purpose of building up a therapeutic relationship is to fulfill nursing needs to the satisfaction of the patients (McQueen, 2000). A therapeutic relationship starts from the time of admission and ends at the point of discharge (Peplau, 1998). Previous studies have pointed out that a therapeutic relationship can have a profound influence on a patient—exceeding that of other therapy techniques (Antoniou & Blom, 2006; Johnson & Caldwell, 2011; Lambert & Barley, 2001). Numerous studies have also demonstrated that a therapeutic relationship can have a positive impact on patient treatment outcomes in terms of healing, restoration, and the delivery of tailor-made nursing care (Leininger, 2001; Wampold, 2001; Wright, 2010). The above-mentioned studies show that it is crucial for nurses and patients to develop a therapeutic relationship to optimize nursing care. Although male nurses have several superior attributes, numerous studies have demonstrated that the gender barrier between male nurses and female patients has a significant negative impact on the delivery of care by male nurses. This barrier is one that is erected by both parties (Inoue et al., 2006). Three major gender barriers have been identified: the type of nursing care, the presence of a chaperone, and the age of the patient and nurses (Keogh & O’Lynn, 2007). Providing nursing care such as taking vital signs and administering an intramuscular injection at the thigh is acceptable to both parties, whereas bathing female patients is not (Chur-Hansen, 2002; Inoue et al., 2006). The presence of a chaperone provides legal protection for male nurses and female patients. In such a case, informed consent should be obtained from the female patient on whether a chaperone is required before male nurses are permitted to deliver nursing care (Prideaux, 2010). Male nurses also reported that taking care of female patients, especially young ones, is very stressful (Chur-Hansen, 2002; Inoue et al., 2006). Male nurses and female patients feel embarrassed during the delivery of intimate nursing care (Keogh & Gleeson, 2006).
However, the gender barrier seems to be less of a problem in the case of doctors. The gender preference of patients with respect to the type of health care being delivered was explored in two studies (Delgado et al., 2011; Mavis, Vasilenko, Schnuth, Marshall, & Jeffs, 2005). The studies showed that a physician’s gender is more of an issue in intimate care, such as genital and obstetric-gynecological care. Patients were more likely to prefer physicians of the same gender as themselves. Although patients have a gender preference, Mavis et al. (2005) showed that a physician’s gender was in fact the least important characteristic to female patients when selecting a physician; rather, they viewed empathy and communication skills as the most important characteristics. Similar results were obtained in other studies that focused on the gender preference of patients with regard to obstetrician-gynecologists—that is, the majority of female patients were found to have no gender preference (Howell, Gardiner, & Concato, 2002; Johnson, Schnatz, Kelsey, & Ohannessian, 2005; Makam, Mallappa Saroja, & Edwards, 2010). Howell et al. (2002) and Makam et al. (2010) also revealed that patient satisfaction and patient preferences with respect to physicians were closely related to the knowledge, skill, and ability of the physician rather than to the physician’s gender. However, with respect to nurses, Howell et al. (2002) showed that there was a significant difference in the preferences of patients. In this case, a majority of patients preferred female nurses, as they felt more comfortable and less self-conscious in the presence of a female nurse. In a study conducted by Lodge, Mallett, Blake, and Fryatt (1997), gynecological patients also showed a significant preference for female nurses. Rather than indicating a lack of confidence in the ability of male nurses, this preference stemmed from the embarrassment patients felt about the idea of receiving intimate care from male nurses. In a study conducted by Fisher (2009), most of the male nurses reported that male patients rarely refused their care, whereas it was more common for female patients to do so. Other than the patients, some female nurses might also feel that it is inappropriate to have male nurses provide intimate care to female patients (Crossan & Mathew, 2013). The difference in gender preference difference could also be due to stereotyping, with the public identifying nursing as a feminine profession as well as thinking that intimacy and patient contact are more acceptable for females than males (Gray, 2010; Stott, 2007). According to prior studies, the gender barrier and stereotyping can make it difficult for male nurses to establish a therapeutic relationship with female patients. Thus, it is important to explore whether male nursing students nowadays are experiencing similar difficulties and, if so, to seek strategies for improving the situation.
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In fact, there have been very few studies exploring the therapeutic relationship between male nurses and female patients. One study pinpointed the major concerns that male nurses have when delivering intimate nursing care to female patients and their strategies for coping with the situation (Inoue et al., 2006). Unfortunately, there is a lack of studies on male nursing students in the area of therapeutic relationships. Thus, the specific aim of this study was to explore the therapeutic relationship between male nursing students and female patients in public and private hospitals. The objective was to identify the therapeutic relationship with female patients from the perspective of male nursing students, as well as to explore the factors that influence the development of such a relationship.
Method This study is part of a major research project titled “An Ethnographical Study on the Clinical and Academic Experiences of Chinese Male Nursing Students.” The results of another part of the project were published in the American Journal of Men’s Health. For this qualitative study, a narrative inquiry approach was adopted using autobiography, drawing, and focus group interviews. The approach allowed us to collect a great deal of open-ended and in-depth data from the participants and facilitated the exploring of experiences, hidden stories, and the perspective of male nursing students in their therapeutic relationship with female patients (Creswell, 2007; Morse, 1995).
Study Sample Snowball sampling was used in recruiting the participants. The participants were recruited from a university in Hong Kong that offers a registered nurse training program. This sampling approach relies on the social network of the participants, who share similar experiences and knowledge (Chambliss & Schutt, 2010; Howitt & Cramer, 2000). The targeted participants were male nursing students in the bachelor’s or master’s level of studies. The criteria for inclusion was that they should be fulltime male nursing students in the registered nurses training program at the bachelor’s or master’s level. Female nursing students were excluded from this study.
Data Collection This study was first approved by the university. Data was then collected in two stages. An information sheet and a consent form were provided and signed by all participants. They were informed that they had the right to withdraw at any time and were allowed to use a pseudonym to maintain their anonymity. Moreover, they were informed
Figure 1. Flow chart of the data collection process.
that if they had revealed any incidents that might contravene the code of practice (The Nursing Council of Hong Kong, 2002), confidentiality would be breached (Figure 1). Stage 1: Audio Form Diary. Autobiography is about the life experiences of the participants. In an autobiographic approach, participants are encouraged to record down their daily life experiences, emotions, and opinions in a diary (Harvey, 2011). This approach enhances our understanding of a person’s character and the underlying meaning of the participant’s life (Sargeant & Gross, 2011). As experiences in therapeutic relationships might vary from individual to individual, this method could be used to obtain a great deal of information, as it allows the participants to voice their thoughts freely. Stage 1 of this study lasted for 6 weeks. In this period, the participants were serving their clinical placement in hospitals. An audio recorder was given to each participant. The participants were required to voice their opinions and record events, following diary recording guidelines focusing on significant events relating to their therapeutic relationships with female patients during their placement, their own perceptions of this issue, and the date and time of each event. The participants kept the audio recorders for 6 weeks. The recorders were then returned to the research team. Stage 2: Step A, Drawing; Step B, Focus Group Interview. Drawing (Step A) is a commonly employed approach in nursing and psychological research. It is usually used in studies investigating sensitive events for adults, such as the menopausal journey, past abuse, and traumatic events in life (Guenette & Marshall, 2009; Guez, Lev-Wiesel, Valetsky, Sztul, & Pener, 2010; Morgan, McInerney, Rumbold, & Liamputtong, 2009). It is believed that drawing can demonstrate the participants’ creativity and facilitate the discussion of sensitive issues. In our study, the drawing session lasted for 30 minutes. The participants were invited to individually draw a picture on an A4-sized sheet of paper about their therapeutic relationships with female patients in a clinical setting, according to instructions.
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Chan et al. A focus group interview (Step B) was conducted after the drawing session. This approach is commonly used in nursing research to obtain the perceptions and thoughts of participants through a discussion (Gerrish & Lacey, 2006; Twinn, 1998). Interview guidelines with open-ended questions and guided statements were established. The participants were asked to discuss the meaning of their drawings and what inspired their drawing, so as to help us further understand their work. The participants were separated into two groups, with 8 to 10 participants per group. Each interview lasted for about an hour and was audio-taped. Moreover, field notes were taken by three researchers.
Data Analysis The audio-taped diaries were summarized, and the interview records were manually transcribed. This study adopted Guillemin’s (2004) approach in analyzing the drawings. The participants’ description of each drawing was extracted from the interview transcripts to avoid misinterpreting the drawings. In this study, a modified form of Chenail’s (2012a, 2012b) and Waltz, Strickland, and Lenz’s (2010) model on the procedures for conducting a content analysis was adopted. After obtaining the diary summaries and the interview transcripts, the researchers individually studied the information to familiarize themselves with the content. Each researcher identified specific drawings and defined the meaningful units. The researchers went through the process of categorization and coding individually. To ensure conciseness, during the peer meetings the researchers went back and forth between the data and the classification system. The researchers then got together to compare the analysis and revise the categories. Any discrepancies were solved by consensus or directed to the supervisor. The categories were finalized until saturation was achieved. Themes were defined at the end of the data analysis.
Results A total of 18 male nursing students participated in this study. Ten of them were master’s students, whereas the remaining participants were pursuing a bachelor’s degree. They ranged in age from 22 to 30 years, with an average age of 25. Eight participants were recruited to record a diary, and 18 participants joined the drawing session and focus group interview. This study revealed the development of therapeutic relationships between the male nursing students and the female patients in a Chinese society. A total of three themes were identified: (a) gender and therapeutic relationships, (b) symbolic meanings and therapeutic relationships,
and (c) career features and therapeutic relationships. With regard to the coding system, P represents participants, gender is coded as Male (M), and academic level is coded as undergraduate (U) and master’s (M). For example, P-10MU stands for Participant 10, a male undergraduate.
Theme 1: Gender and Therapeutic Relationships This theme discusses how gender difference affects the therapeutic relationships between male nursing students and female patients. Two subthemes were identified: the presence of a chaperon and internal perception. When the male nursing students were asked to draw the therapeutic relationship between themselves and the female patients, some of them expressed the view that the presence of a chaperon is essential. The male nursing students felt that a chaperon played an important role in protecting the legal rights of both parties when male nursing students were required to provide nursing care to female patients. However, they stated that they wondered “whether the chaperon is really available.” On the other hand, the majority of male nursing students had developed different internal perceptions when building a therapeutic relationship with female patients. Some felt a sense of embarrassment and guilt when taking care of female patients. The following two quotes represented a general sentiment among those students who felt embarrassed. P-2MU stated, “When I face female patients, I feel very embarrassed. If I take a proactive role in providing nursing care to the female patient, will she suspect my motives?” Another participant, P-6MM, claimed that “I feel so guilty when I observe the delivery of a baby. I need to observe this procedure secretly. It really feels so bad” (Figure 2). Two male nursing students, P-4MU and P-2MM, said that they “would provide the same nursing care to the patients, no matter whether they are male or female.” The following quote was one of the most representative, “As a professional nurse, we would provide the same quality of nursing care to all patients” (P-5MU, P-6Mu, and P-1MM). The focus was only on the task, not on the gender of the patients. Although the male nursing students had the ability to provide nursing care to both male and female patients, most stressed that they were vigilant when dealing with female patients. They tended to “keep their distance” and “avoid contact” with the female patients. In the ward, they were always taught to pay extra attention and had been warned by other nursing staff, “Hey, you have to pay attention as she is a female patient. If she sues you, you
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Figure 2. Many eyes (left); a big eye (middle); embarrassment (right).
will be in trouble!” (P-8MM). Some male nursing students explained that they had to prevent false accusations of sexual harassment from being made, even though there was no policy of prohibiting male nurses from taking care of female patients. To avoid threats to their future career and professional registration, male nursing students tended to escape from the job of providing nursing care to female patients. When the male nursing students were asked to imagine the scenario of providing care to female patients, they usually assumed that the female patients must have negative feelings. They believed that females would “feel uncomfortable,” “refuse the procedure,” and would “not choose male nurses if they had a choice.”
Theme 2: Symbolic Meanings and Therapeutic Relationships This theme discusses how symbolic meaning affects the development of a therapeutic relationship. Symbolic meaning is a kind of symbolic interactionism in which “people’s behaviors in interactions with others in social settings are governed by their conception of themselves” (Turner, 2013, p. 331). This theme has two subthemes: social context and obstacles. Regarding social context, the development of therapeutic relationships between the male nursing students and the female patients was influenced by Chinese culture and the media. Both the male nursing students and the female patients were deeply affected by previous news reports of sexual harassment in hospitals. All the male nursing students stated that after hearing such news, they became much more vigilant when providing care to female patients. The following quote represented their concerns “This kind of news reminds you to be careful and not to get too close to female patients” (P-6MU, P-3MM, and P-7MM). Under the influence of Chinese culture, both male nursing students and female patients had a strong sense of the traditional
concept that “men and women should maintain a proper distance from each other” (P-3MU). The male nursing students became vigilant because they needed to prevent the accusation of sexual harassment from being raised. All these fears were obstacles to the building of a therapeutic relationship between the male nursing students and the female patients. Regarding obstacles to the forming of therapeutic relationships, some male nursing students drew a wall or curtain when asked to describe the therapeutic relationship between them and their female patients. Figure 3 depicts the barriers between the male nursing students and the female patients. They explained that the wall and the curtain were erected by “embarrassment,” different internal perceptions as mentioned before, “limited types of procedures,” “Chinese culture,” and the “media.” Furthermore, as P-9MM commented, “The wall will become thicker and thicker in the foreseeable future.”
Theme 3: Career Features and Therapeutic Relationships This theme identifies the relationship between the development of a therapeutic relationship and the characteristics of a nursing career. Three subthemes can be identified: the type of procedure, the age of the female patients, and good experiences. With regard to the first subtheme (type of procedure), most of the male nursing students stated that their success in building a therapeutic relationship with female patients depends on the type of nursing care that needs to be given. They considered whether the procedures involved in providing care were “invasive” or involved “the need for physical contact.” They agreed that the “invasive” procedures and the procedures “involving physical contact” included bathing and any procedures that involved sensitive areas, namely, the breasts, abdomen, back, and pubic area. They usually
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Figure 3. Wall as barrier (left); curtain as barrier (right).
avoid providing those procedures because they all agreed that all these procedures would make both parties feel uncomfortable. On the other hand, the male nursing students agreed that measuring temperature, charting inputs/ outputs, and communicating verbally were acceptable. When they could provide nursing care to the female patients comfortably without any concerns, it was easier to build a therapeutic relationship. During the focus group interview, the male nursing students highlighted the point that they felt embarrassed when taking care of female patients, but the level of their embarrassment depended on the age of the female patients. They usually felt more comfortable delivering nursing care to older female patients because they believed that older female patients were “less conscious” and “open-minded.” Therefore, it was easier for the older female patients to accept the nursing care provided by the male nurses. Some male nursing students had good experiences when building a therapeutic relationship with female patients. Figure 4 is an illustration of such an experience. Several male nursing students had good experiences in the obstetric unit. For example, P-10MM explained, “In the picture, both the female patient and I wear a smiling face. I feel so great and happy because the mother said that I am welcome to perform the prenatal assessment and observe the breastfeeding procedure.” P-4MM added, “The mother invited me to conduct the abdominal examination in order to assess the fetal presentation. This experience makes me feel happy.”
Discussion Previous studies had not concentrated on the therapeutic relationship of male nurses or students with female patients
Figure 4. Prenatal assessment given by a male nursing student.
but only noted the existence and benefits of such a relationship. This study reveals how male nursing students in Hong Kong perceive their relationship with female patients and provides insights on the factors influencing the development of therapeutic relationships. The results indicate that the most influential factors in the development of a therapeutic relationship are the media, cultural background, and the age of the patient. Everyone makes mistakes, and there are some cases of misconduct or sexual harassment by male nurses. Although such cases are not common, as the media has magnified such misconduct, the community keeps an eye
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on any male nurse with a female patient as if the male nurse is certain to engage in misconduct. As time passes, female patients may prefer female nurses to male nurses. Consequently, due to public opinion, male nurses are conscious that their actions could be misunderstood and have tried to avoid being alone with female patients. Male nursing students have also reported that they have sometimes been treated as though they had approached female patients on purpose. Similar to other studies, male nurses were not welcomed for the task of caring for female patients (Keogh & Gleeson, 2006). Such mistrust from females and the public would prevent a therapeutic relationship from developing between male nurses and female patients. Beals (2002) indicated that a therapeutic relationship is greatly influenced by cultural background. Because of the influence of traditional Chinese culture, the male nursing students might feel embarrassed about taking care of females, thus prohibiting the development of a good therapeutic relationship. The participants expressed this belief by drawing a wall or a cross or a curtain between themselves and the patients. When caring for such patients, nurses might have to perform a variety of tasks, ranging from obtaining medical histories verbally to administering injections of medication or cleaning and dressing wounds (Chur-Hansen, 2002; Inoue et al., 2006). The participants stated that they are allowed to perform tasks that do not require them to physically touch the patients and that permit them to keep their distance from the patients. However, tasks that require the touching of body parts are banned, and the care they are able to deliver to female patients would therefore not be sufficiently holistic to allow a therapeutic relationship to be established. Sometimes, the embarrassment might be due to the age of the female patients. Studies have suggested that male nursing students feel less embarrassed about taking care of older female patients (Chur-Hansen, 2002; Inoue et al., 2006). This article also provided evidence that male nursing students feel more comfortable caring for older female patients than younger ones. Older patients were thought to be more open-minded about the idea of receiving care from male nurses and less suspicious about the motives of the male students in providing nursing care to them. The participants’ fear of taking care of young females prevented a therapeutic relationship from developing between such patients and male nurses. Although there is no law or policy stating that male nurses are not allowed to take care of female patients when they are alone, usually a chaperon is present when males provide nursing care in Hong Kong. Previous studies from overseas have mentioned the importance of a chaperon (Prideaux, 2010). Having a chaperon present not only protects the patients from inappropriate behavior
but also protects male nurses who are only concerned about providing care. When male students provide nursing care, most are not concerned about whether they are caring for a male or a female but only about delivering the best care possible (Keogh & O’Lynn, 2007). However, due to gender bias, some female patients might feel uncomfortable about receiving care from male nurses; thus, the presence of a chaperon has become necessary in clinical settings. Yet, due to the shortage of manpower, it is not always possible to have another nurse present as a chaperon. Male nursing students themselves would not try to deliver nursing care alone, as they worry about being misunderstood. As mentioned, trust is a major criterion for developing good therapeutic relationships (Horberg, Brunt, & Axelsson, 2004; Videbeck, 2011). Good relationships were reported by the participants, who suggested that communication to seek approval from patients is required for good relationships to develop. Communication is one of the most important components in any relationship, and especially in therapeutic relationships (Clarkson, 2003, O’Connell, 2008). The participants stated that with sufficient communication they would be less embarrassed and more confident about providing care to female patients. Seeking the approval of female patients is always considered necessary before male nurses perform care. Seeking permission from female patients prevents misunderstandings and allows a relationship of trust to develop. The therapeutic relationships that the male nursing students had formed seem to have influenced their perceptions and actions. Those participants who reported having good therapeutic relationships during their clinical placement were later identified to be more competent in caring for female patients. Therefore, it can be concluded that the male nursing students’ competence and satisfaction with their career is linked to the development of good therapeutic relationships with female patients.
Recommendations and Implications There are several limitations in this study. First, because it is a qualitative study, the result from a sample may not be generalizable to the population as a whole (Tse & Chan, 2011). Only one local nursing training school was included in this study for investigation; therefore, it would be beneficial to include all nursing training institutes in Hong Kong or even students in other countries to obtain a more comprehensive view. Second, the number of years of clinical experience possessed by the participants could have influenced the results that were obtained. Although the participants were drawn from both the master’s and bachelor’s programs for registered nurses, due to their course schedules the students have limited time
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Chan et al. for a clinical practicum every year. The variety of wards in which they can serve is also limited, due to the limited number of vacancies that are available. If the participants could be chosen from among male nurses with extensive working experience, more detailed insights could be obtained, which could enhance the credibility of the data. Third, data were only collected in one timeline. A longitudinal study should be carried out every year throughout the length of the program to identify any changes that might occur in the therapeutic relationships between the male nursing students and the female patients. In considering therapeutic relationships, it is preferable to consider both nurses and patients, instead of just one party. The development of therapeutic relationships requires cooperation between nurses and patients during the period of care. Further investigating therapeutic relationships from the perspectives of both male nurses and female patients could yield more comprehensive results, and comparing the results from different parties would further improve the value of the study. The drawings of the male nursing students reflected the real situations that they faced and their therapeutic relationship with female patients. Most of the participants depicted situations that they had come across or what they thought would happen. Drawing allowed the participants to freely express their creativity and opinions and to demonstrate how they perceived the relationships between themselves and the female patients. A good therapeutic relationship is conducive to a successful recovery, both physical and psychological. Thus, it is necessary to reveal how therapeutic relationships develop (Mottram, 2008; Videbeck, 2011). Although men are still in the minority in the nursing industry, their opinions or experiences should not be neglected. It is very important to express the perspectives of male nurses and seek improvements. Lent, Brown, and Hackett (1994) identified self-efficacy as having a great impact on job performance. By understanding therapeutic relationships from the perspective of male nursing students, it is possible to shed light on how job satisfaction relates to the self-efficacy of such students (Wyatt & Harrison, 2010). Not surprisingly, gender is the most significance issue in the development of therapeutic relationships. Influenced by social norms, male nursing students were kept away from female patients and were only allowed to perform a limited number of nursing procedures. However, if more males are to enter this female-dominated industry, it is necessary to hear their voices on the care of female patients. It is very important to see how male nursing students perceive themselves in this industry. Such perceptions could be affected by social norms or educational programs. It is suggested that nurse training programs do not
favor females and that males can also be competent nurses (Kleinman, 2004). This study is also intended to provide suggestions for current nurse training programs. Male nursing students might be at a greater disadvantage than female students by their limited clinical exposure, especially in specialties such as obstetrics–gynecology (Anthony, 2004; Keogh & O’Lynn, 2007). Although some places such as emergency departments or intensive care units favor male nurses (Nilsson & Larsson, 2005), male nurses should have the right to choose where to work, and suggestions from male nursing students on this issue should be solicited.
Conclusions Nurses play a critical role in the health care system. The percentage of male nurses is still low in Hong Kong. This study can provide a platform for male nursing students to express their perceptions of therapeutic relationships with female patients. The findings demonstrate that the forming of a therapeutic relationship between a male nursing student and a female patient is influenced by the presence of a chaperon, social context, and the type of procedure involved. The attitudes of female patients are also critical in the development of such relationships. If male nursing students are welcome to provide nursing care, a sense of mutual trust can be fostered. As this research is participant-driven, it gives a new angle for understanding the position of male nursing students. It is believed that the suggestions made here can help to improve current nurse training programs. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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JMHXXX10.1177/1557988313509833American Journal of Men’s HealthChan et al.
Article
Therapeutic Relationship Between Male Nursing Students and Female Patients
American Journal of Men’s Health 2014, Vol. 8(4) 300–309 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988313509833 jmh.sagepub.com
Zenobia C. Y. Chan PhD, RN1, Vera W. S. Chan MN, RN1, and Judy K. M. Tse MN, RN1
Abstract This article explores the therapeutic relationship between male nursing students and female patients, through the use of autobiography in a qualitative approach. For this study, 18 male nursing students enrolled in master’s and bachelor’s programs in Hong Kong were recruited. They were asked to make records in a diary and draw pictures of their therapeutic relationship with female patients from their clinical experiences and then participate in a focus group interview. Content analysis was carried out on the collected data. The essential factors influencing the development of a therapeutic relationship were found to be gender, symbolic meanings, and career features. Good experiences were also discussed. The results shed light on the experiences of male nursing students and how they make sense of their therapeutic relationship with female patients. Keywords gender difference, therapeutic relationship, nursing education
Introduction Nursing is a profession that is currently dominated by females (Best, 2003; Cancian & Oliker, 2000). Only a small percentage of males are involved in the industry. However, this was not always the case in the past. In the Middle Ages, it was common for male nurses to provide nursing care (Romem & Anson, 2005). The activities of Florence Nightingale revolutionized the role of nurses. She established nursing schools and claimed that only females who have a maternal instinct and caregiving attributes are eligible to be nurses (Cash, 1997). Since then, the nursing profession has come to be dominated by females. There are extensive studies on social perceptions of male nurses. People tend to believe that male nurses have different attributes than female nurses in terms of leadership qualities, masculinity, technical ability, sensitivity to the emotions of others, and the impact of their sexuality (Anthony, 2004; Ekstrom, 1999; Fisher, 2009; Hodes Research, 2005; Keogh & O’Lynn, 2007; Kleinman, 2004). Male nurses have been perceived as better at taking up leadership roles than female nurses. Since leadership has for centuries been regarded as a male’s inborn ability, this gender bias could be one of the reasons contributing to this perception in the field of nursing (Anthony, 2004; Kleinman, 2004). Apart from playing a leadership role, studies have revealed that female nurses
believe male nurses are perfect for tasks involving physical labor and dealing with aggressive and irritable patients (Hodes Research, 2005; Keogh & O’Lynn, 2007). Male nurses are also believed to be more suited to performing work requiring technical skills. Such a perception may be due to the gender-biased view that men are good at handling machines and possess better problem-solving skills (Kleinman, 2004). However, male nurses are thought to be less sensitive to other people’s emotions and less caring than female nurses (Ekstrom, 1999; Hodes Research, 2005). Last, the sexual orientation of male nurses has often been questioned by the public, and many male nurses are unfairly assumed to be homosexual and effeminate (Fisher, 2009; Hodes Research, 2005). In fact, no study has proven that sexual orientation affects nursing care performance. Although there have been many studies investigating the involvement of men in nursing, most have focused on the aspects of intimate care, gender differences, career, education, and the perceptions of male nurses (Bell-Scriber, 2008; Dittman, 2008; Fisher, 2009; Hodes Research, 2005; Hsu, Chen, Yu, & Lou, 2010; 1
The Hong Kong Polytechnic University, Kowloon, Hong Kong
Corresponding Author: Zenobia C. Y. Chan, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. Email: [email protected]
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Chan et al. Inoue, Chapman, & Wynaden, 2006; Keogh & O’Lynn, 2007; O’Lynn & Krautscheid, 2011; Wilbourn & Kee, 2010). There is a lack of research on the therapeutic relationship between male nurses and female patients from the perspective of male nurses and male nursing students. The voices of male nurses should be heard, as male nurses provide crucial manpower in the nursing industry, and men are as suited as females to being nurses.
Theoretical Background A therapeutic relationship can be defined as one that develops “when two (or more) people meet, and one has skills and expertise which the other wants to alleviate suffering or maintain the level of health. It is governed by legal, professional and ethical guidelines” (Fox, 2008, p. 16). The purpose of building up a therapeutic relationship is to fulfill nursing needs to the satisfaction of the patients (McQueen, 2000). A therapeutic relationship starts from the time of admission and ends at the point of discharge (Peplau, 1998). Previous studies have pointed out that a therapeutic relationship can have a profound influence on a patient—exceeding that of other therapy techniques (Antoniou & Blom, 2006; Johnson & Caldwell, 2011; Lambert & Barley, 2001). Numerous studies have also demonstrated that a therapeutic relationship can have a positive impact on patient treatment outcomes in terms of healing, restoration, and the delivery of tailor-made nursing care (Leininger, 2001; Wampold, 2001; Wright, 2010). The above-mentioned studies show that it is crucial for nurses and patients to develop a therapeutic relationship to optimize nursing care. Although male nurses have several superior attributes, numerous studies have demonstrated that the gender barrier between male nurses and female patients has a significant negative impact on the delivery of care by male nurses. This barrier is one that is erected by both parties (Inoue et al., 2006). Three major gender barriers have been identified: the type of nursing care, the presence of a chaperone, and the age of the patient and nurses (Keogh & O’Lynn, 2007). Providing nursing care such as taking vital signs and administering an intramuscular injection at the thigh is acceptable to both parties, whereas bathing female patients is not (Chur-Hansen, 2002; Inoue et al., 2006). The presence of a chaperone provides legal protection for male nurses and female patients. In such a case, informed consent should be obtained from the female patient on whether a chaperone is required before male nurses are permitted to deliver nursing care (Prideaux, 2010). Male nurses also reported that taking care of female patients, especially young ones, is very stressful (Chur-Hansen, 2002; Inoue et al., 2006). Male nurses and female patients feel embarrassed during the delivery of intimate nursing care (Keogh & Gleeson, 2006).
However, the gender barrier seems to be less of a problem in the case of doctors. The gender preference of patients with respect to the type of health care being delivered was explored in two studies (Delgado et al., 2011; Mavis, Vasilenko, Schnuth, Marshall, & Jeffs, 2005). The studies showed that a physician’s gender is more of an issue in intimate care, such as genital and obstetric-gynecological care. Patients were more likely to prefer physicians of the same gender as themselves. Although patients have a gender preference, Mavis et al. (2005) showed that a physician’s gender was in fact the least important characteristic to female patients when selecting a physician; rather, they viewed empathy and communication skills as the most important characteristics. Similar results were obtained in other studies that focused on the gender preference of patients with regard to obstetrician-gynecologists—that is, the majority of female patients were found to have no gender preference (Howell, Gardiner, & Concato, 2002; Johnson, Schnatz, Kelsey, & Ohannessian, 2005; Makam, Mallappa Saroja, & Edwards, 2010). Howell et al. (2002) and Makam et al. (2010) also revealed that patient satisfaction and patient preferences with respect to physicians were closely related to the knowledge, skill, and ability of the physician rather than to the physician’s gender. However, with respect to nurses, Howell et al. (2002) showed that there was a significant difference in the preferences of patients. In this case, a majority of patients preferred female nurses, as they felt more comfortable and less self-conscious in the presence of a female nurse. In a study conducted by Lodge, Mallett, Blake, and Fryatt (1997), gynecological patients also showed a significant preference for female nurses. Rather than indicating a lack of confidence in the ability of male nurses, this preference stemmed from the embarrassment patients felt about the idea of receiving intimate care from male nurses. In a study conducted by Fisher (2009), most of the male nurses reported that male patients rarely refused their care, whereas it was more common for female patients to do so. Other than the patients, some female nurses might also feel that it is inappropriate to have male nurses provide intimate care to female patients (Crossan & Mathew, 2013). The difference in gender preference difference could also be due to stereotyping, with the public identifying nursing as a feminine profession as well as thinking that intimacy and patient contact are more acceptable for females than males (Gray, 2010; Stott, 2007). According to prior studies, the gender barrier and stereotyping can make it difficult for male nurses to establish a therapeutic relationship with female patients. Thus, it is important to explore whether male nursing students nowadays are experiencing similar difficulties and, if so, to seek strategies for improving the situation.
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In fact, there have been very few studies exploring the therapeutic relationship between male nurses and female patients. One study pinpointed the major concerns that male nurses have when delivering intimate nursing care to female patients and their strategies for coping with the situation (Inoue et al., 2006). Unfortunately, there is a lack of studies on male nursing students in the area of therapeutic relationships. Thus, the specific aim of this study was to explore the therapeutic relationship between male nursing students and female patients in public and private hospitals. The objective was to identify the therapeutic relationship with female patients from the perspective of male nursing students, as well as to explore the factors that influence the development of such a relationship.
Method This study is part of a major research project titled “An Ethnographical Study on the Clinical and Academic Experiences of Chinese Male Nursing Students.” The results of another part of the project were published in the American Journal of Men’s Health. For this qualitative study, a narrative inquiry approach was adopted using autobiography, drawing, and focus group interviews. The approach allowed us to collect a great deal of open-ended and in-depth data from the participants and facilitated the exploring of experiences, hidden stories, and the perspective of male nursing students in their therapeutic relationship with female patients (Creswell, 2007; Morse, 1995).
Study Sample Snowball sampling was used in recruiting the participants. The participants were recruited from a university in Hong Kong that offers a registered nurse training program. This sampling approach relies on the social network of the participants, who share similar experiences and knowledge (Chambliss & Schutt, 2010; Howitt & Cramer, 2000). The targeted participants were male nursing students in the bachelor’s or master’s level of studies. The criteria for inclusion was that they should be fulltime male nursing students in the registered nurses training program at the bachelor’s or master’s level. Female nursing students were excluded from this study.
Data Collection This study was first approved by the university. Data was then collected in two stages. An information sheet and a consent form were provided and signed by all participants. They were informed that they had the right to withdraw at any time and were allowed to use a pseudonym to maintain their anonymity. Moreover, they were informed
Figure 1. Flow chart of the data collection process.
that if they had revealed any incidents that might contravene the code of practice (The Nursing Council of Hong Kong, 2002), confidentiality would be breached (Figure 1). Stage 1: Audio Form Diary. Autobiography is about the life experiences of the participants. In an autobiographic approach, participants are encouraged to record down their daily life experiences, emotions, and opinions in a diary (Harvey, 2011). This approach enhances our understanding of a person’s character and the underlying meaning of the participant’s life (Sargeant & Gross, 2011). As experiences in therapeutic relationships might vary from individual to individual, this method could be used to obtain a great deal of information, as it allows the participants to voice their thoughts freely. Stage 1 of this study lasted for 6 weeks. In this period, the participants were serving their clinical placement in hospitals. An audio recorder was given to each participant. The participants were required to voice their opinions and record events, following diary recording guidelines focusing on significant events relating to their therapeutic relationships with female patients during their placement, their own perceptions of this issue, and the date and time of each event. The participants kept the audio recorders for 6 weeks. The recorders were then returned to the research team. Stage 2: Step A, Drawing; Step B, Focus Group Interview. Drawing (Step A) is a commonly employed approach in nursing and psychological research. It is usually used in studies investigating sensitive events for adults, such as the menopausal journey, past abuse, and traumatic events in life (Guenette & Marshall, 2009; Guez, Lev-Wiesel, Valetsky, Sztul, & Pener, 2010; Morgan, McInerney, Rumbold, & Liamputtong, 2009). It is believed that drawing can demonstrate the participants’ creativity and facilitate the discussion of sensitive issues. In our study, the drawing session lasted for 30 minutes. The participants were invited to individually draw a picture on an A4-sized sheet of paper about their therapeutic relationships with female patients in a clinical setting, according to instructions.
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Chan et al. A focus group interview (Step B) was conducted after the drawing session. This approach is commonly used in nursing research to obtain the perceptions and thoughts of participants through a discussion (Gerrish & Lacey, 2006; Twinn, 1998). Interview guidelines with open-ended questions and guided statements were established. The participants were asked to discuss the meaning of their drawings and what inspired their drawing, so as to help us further understand their work. The participants were separated into two groups, with 8 to 10 participants per group. Each interview lasted for about an hour and was audio-taped. Moreover, field notes were taken by three researchers.
Data Analysis The audio-taped diaries were summarized, and the interview records were manually transcribed. This study adopted Guillemin’s (2004) approach in analyzing the drawings. The participants’ description of each drawing was extracted from the interview transcripts to avoid misinterpreting the drawings. In this study, a modified form of Chenail’s (2012a, 2012b) and Waltz, Strickland, and Lenz’s (2010) model on the procedures for conducting a content analysis was adopted. After obtaining the diary summaries and the interview transcripts, the researchers individually studied the information to familiarize themselves with the content. Each researcher identified specific drawings and defined the meaningful units. The researchers went through the process of categorization and coding individually. To ensure conciseness, during the peer meetings the researchers went back and forth between the data and the classification system. The researchers then got together to compare the analysis and revise the categories. Any discrepancies were solved by consensus or directed to the supervisor. The categories were finalized until saturation was achieved. Themes were defined at the end of the data analysis.
Results A total of 18 male nursing students participated in this study. Ten of them were master’s students, whereas the remaining participants were pursuing a bachelor’s degree. They ranged in age from 22 to 30 years, with an average age of 25. Eight participants were recruited to record a diary, and 18 participants joined the drawing session and focus group interview. This study revealed the development of therapeutic relationships between the male nursing students and the female patients in a Chinese society. A total of three themes were identified: (a) gender and therapeutic relationships, (b) symbolic meanings and therapeutic relationships,
and (c) career features and therapeutic relationships. With regard to the coding system, P represents participants, gender is coded as Male (M), and academic level is coded as undergraduate (U) and master’s (M). For example, P-10MU stands for Participant 10, a male undergraduate.
Theme 1: Gender and Therapeutic Relationships This theme discusses how gender difference affects the therapeutic relationships between male nursing students and female patients. Two subthemes were identified: the presence of a chaperon and internal perception. When the male nursing students were asked to draw the therapeutic relationship between themselves and the female patients, some of them expressed the view that the presence of a chaperon is essential. The male nursing students felt that a chaperon played an important role in protecting the legal rights of both parties when male nursing students were required to provide nursing care to female patients. However, they stated that they wondered “whether the chaperon is really available.” On the other hand, the majority of male nursing students had developed different internal perceptions when building a therapeutic relationship with female patients. Some felt a sense of embarrassment and guilt when taking care of female patients. The following two quotes represented a general sentiment among those students who felt embarrassed. P-2MU stated, “When I face female patients, I feel very embarrassed. If I take a proactive role in providing nursing care to the female patient, will she suspect my motives?” Another participant, P-6MM, claimed that “I feel so guilty when I observe the delivery of a baby. I need to observe this procedure secretly. It really feels so bad” (Figure 2). Two male nursing students, P-4MU and P-2MM, said that they “would provide the same nursing care to the patients, no matter whether they are male or female.” The following quote was one of the most representative, “As a professional nurse, we would provide the same quality of nursing care to all patients” (P-5MU, P-6Mu, and P-1MM). The focus was only on the task, not on the gender of the patients. Although the male nursing students had the ability to provide nursing care to both male and female patients, most stressed that they were vigilant when dealing with female patients. They tended to “keep their distance” and “avoid contact” with the female patients. In the ward, they were always taught to pay extra attention and had been warned by other nursing staff, “Hey, you have to pay attention as she is a female patient. If she sues you, you
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Figure 2. Many eyes (left); a big eye (middle); embarrassment (right).
will be in trouble!” (P-8MM). Some male nursing students explained that they had to prevent false accusations of sexual harassment from being made, even though there was no policy of prohibiting male nurses from taking care of female patients. To avoid threats to their future career and professional registration, male nursing students tended to escape from the job of providing nursing care to female patients. When the male nursing students were asked to imagine the scenario of providing care to female patients, they usually assumed that the female patients must have negative feelings. They believed that females would “feel uncomfortable,” “refuse the procedure,” and would “not choose male nurses if they had a choice.”
Theme 2: Symbolic Meanings and Therapeutic Relationships This theme discusses how symbolic meaning affects the development of a therapeutic relationship. Symbolic meaning is a kind of symbolic interactionism in which “people’s behaviors in interactions with others in social settings are governed by their conception of themselves” (Turner, 2013, p. 331). This theme has two subthemes: social context and obstacles. Regarding social context, the development of therapeutic relationships between the male nursing students and the female patients was influenced by Chinese culture and the media. Both the male nursing students and the female patients were deeply affected by previous news reports of sexual harassment in hospitals. All the male nursing students stated that after hearing such news, they became much more vigilant when providing care to female patients. The following quote represented their concerns “This kind of news reminds you to be careful and not to get too close to female patients” (P-6MU, P-3MM, and P-7MM). Under the influence of Chinese culture, both male nursing students and female patients had a strong sense of the traditional
concept that “men and women should maintain a proper distance from each other” (P-3MU). The male nursing students became vigilant because they needed to prevent the accusation of sexual harassment from being raised. All these fears were obstacles to the building of a therapeutic relationship between the male nursing students and the female patients. Regarding obstacles to the forming of therapeutic relationships, some male nursing students drew a wall or curtain when asked to describe the therapeutic relationship between them and their female patients. Figure 3 depicts the barriers between the male nursing students and the female patients. They explained that the wall and the curtain were erected by “embarrassment,” different internal perceptions as mentioned before, “limited types of procedures,” “Chinese culture,” and the “media.” Furthermore, as P-9MM commented, “The wall will become thicker and thicker in the foreseeable future.”
Theme 3: Career Features and Therapeutic Relationships This theme identifies the relationship between the development of a therapeutic relationship and the characteristics of a nursing career. Three subthemes can be identified: the type of procedure, the age of the female patients, and good experiences. With regard to the first subtheme (type of procedure), most of the male nursing students stated that their success in building a therapeutic relationship with female patients depends on the type of nursing care that needs to be given. They considered whether the procedures involved in providing care were “invasive” or involved “the need for physical contact.” They agreed that the “invasive” procedures and the procedures “involving physical contact” included bathing and any procedures that involved sensitive areas, namely, the breasts, abdomen, back, and pubic area. They usually
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Figure 3. Wall as barrier (left); curtain as barrier (right).
avoid providing those procedures because they all agreed that all these procedures would make both parties feel uncomfortable. On the other hand, the male nursing students agreed that measuring temperature, charting inputs/ outputs, and communicating verbally were acceptable. When they could provide nursing care to the female patients comfortably without any concerns, it was easier to build a therapeutic relationship. During the focus group interview, the male nursing students highlighted the point that they felt embarrassed when taking care of female patients, but the level of their embarrassment depended on the age of the female patients. They usually felt more comfortable delivering nursing care to older female patients because they believed that older female patients were “less conscious” and “open-minded.” Therefore, it was easier for the older female patients to accept the nursing care provided by the male nurses. Some male nursing students had good experiences when building a therapeutic relationship with female patients. Figure 4 is an illustration of such an experience. Several male nursing students had good experiences in the obstetric unit. For example, P-10MM explained, “In the picture, both the female patient and I wear a smiling face. I feel so great and happy because the mother said that I am welcome to perform the prenatal assessment and observe the breastfeeding procedure.” P-4MM added, “The mother invited me to conduct the abdominal examination in order to assess the fetal presentation. This experience makes me feel happy.”
Discussion Previous studies had not concentrated on the therapeutic relationship of male nurses or students with female patients
Figure 4. Prenatal assessment given by a male nursing student.
but only noted the existence and benefits of such a relationship. This study reveals how male nursing students in Hong Kong perceive their relationship with female patients and provides insights on the factors influencing the development of therapeutic relationships. The results indicate that the most influential factors in the development of a therapeutic relationship are the media, cultural background, and the age of the patient. Everyone makes mistakes, and there are some cases of misconduct or sexual harassment by male nurses. Although such cases are not common, as the media has magnified such misconduct, the community keeps an eye
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on any male nurse with a female patient as if the male nurse is certain to engage in misconduct. As time passes, female patients may prefer female nurses to male nurses. Consequently, due to public opinion, male nurses are conscious that their actions could be misunderstood and have tried to avoid being alone with female patients. Male nursing students have also reported that they have sometimes been treated as though they had approached female patients on purpose. Similar to other studies, male nurses were not welcomed for the task of caring for female patients (Keogh & Gleeson, 2006). Such mistrust from females and the public would prevent a therapeutic relationship from developing between male nurses and female patients. Beals (2002) indicated that a therapeutic relationship is greatly influenced by cultural background. Because of the influence of traditional Chinese culture, the male nursing students might feel embarrassed about taking care of females, thus prohibiting the development of a good therapeutic relationship. The participants expressed this belief by drawing a wall or a cross or a curtain between themselves and the patients. When caring for such patients, nurses might have to perform a variety of tasks, ranging from obtaining medical histories verbally to administering injections of medication or cleaning and dressing wounds (Chur-Hansen, 2002; Inoue et al., 2006). The participants stated that they are allowed to perform tasks that do not require them to physically touch the patients and that permit them to keep their distance from the patients. However, tasks that require the touching of body parts are banned, and the care they are able to deliver to female patients would therefore not be sufficiently holistic to allow a therapeutic relationship to be established. Sometimes, the embarrassment might be due to the age of the female patients. Studies have suggested that male nursing students feel less embarrassed about taking care of older female patients (Chur-Hansen, 2002; Inoue et al., 2006). This article also provided evidence that male nursing students feel more comfortable caring for older female patients than younger ones. Older patients were thought to be more open-minded about the idea of receiving care from male nurses and less suspicious about the motives of the male students in providing nursing care to them. The participants’ fear of taking care of young females prevented a therapeutic relationship from developing between such patients and male nurses. Although there is no law or policy stating that male nurses are not allowed to take care of female patients when they are alone, usually a chaperon is present when males provide nursing care in Hong Kong. Previous studies from overseas have mentioned the importance of a chaperon (Prideaux, 2010). Having a chaperon present not only protects the patients from inappropriate behavior
but also protects male nurses who are only concerned about providing care. When male students provide nursing care, most are not concerned about whether they are caring for a male or a female but only about delivering the best care possible (Keogh & O’Lynn, 2007). However, due to gender bias, some female patients might feel uncomfortable about receiving care from male nurses; thus, the presence of a chaperon has become necessary in clinical settings. Yet, due to the shortage of manpower, it is not always possible to have another nurse present as a chaperon. Male nursing students themselves would not try to deliver nursing care alone, as they worry about being misunderstood. As mentioned, trust is a major criterion for developing good therapeutic relationships (Horberg, Brunt, & Axelsson, 2004; Videbeck, 2011). Good relationships were reported by the participants, who suggested that communication to seek approval from patients is required for good relationships to develop. Communication is one of the most important components in any relationship, and especially in therapeutic relationships (Clarkson, 2003, O’Connell, 2008). The participants stated that with sufficient communication they would be less embarrassed and more confident about providing care to female patients. Seeking the approval of female patients is always considered necessary before male nurses perform care. Seeking permission from female patients prevents misunderstandings and allows a relationship of trust to develop. The therapeutic relationships that the male nursing students had formed seem to have influenced their perceptions and actions. Those participants who reported having good therapeutic relationships during their clinical placement were later identified to be more competent in caring for female patients. Therefore, it can be concluded that the male nursing students’ competence and satisfaction with their career is linked to the development of good therapeutic relationships with female patients.
Recommendations and Implications There are several limitations in this study. First, because it is a qualitative study, the result from a sample may not be generalizable to the population as a whole (Tse & Chan, 2011). Only one local nursing training school was included in this study for investigation; therefore, it would be beneficial to include all nursing training institutes in Hong Kong or even students in other countries to obtain a more comprehensive view. Second, the number of years of clinical experience possessed by the participants could have influenced the results that were obtained. Although the participants were drawn from both the master’s and bachelor’s programs for registered nurses, due to their course schedules the students have limited time
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Chan et al. for a clinical practicum every year. The variety of wards in which they can serve is also limited, due to the limited number of vacancies that are available. If the participants could be chosen from among male nurses with extensive working experience, more detailed insights could be obtained, which could enhance the credibility of the data. Third, data were only collected in one timeline. A longitudinal study should be carried out every year throughout the length of the program to identify any changes that might occur in the therapeutic relationships between the male nursing students and the female patients. In considering therapeutic relationships, it is preferable to consider both nurses and patients, instead of just one party. The development of therapeutic relationships requires cooperation between nurses and patients during the period of care. Further investigating therapeutic relationships from the perspectives of both male nurses and female patients could yield more comprehensive results, and comparing the results from different parties would further improve the value of the study. The drawings of the male nursing students reflected the real situations that they faced and their therapeutic relationship with female patients. Most of the participants depicted situations that they had come across or what they thought would happen. Drawing allowed the participants to freely express their creativity and opinions and to demonstrate how they perceived the relationships between themselves and the female patients. A good therapeutic relationship is conducive to a successful recovery, both physical and psychological. Thus, it is necessary to reveal how therapeutic relationships develop (Mottram, 2008; Videbeck, 2011). Although men are still in the minority in the nursing industry, their opinions or experiences should not be neglected. It is very important to express the perspectives of male nurses and seek improvements. Lent, Brown, and Hackett (1994) identified self-efficacy as having a great impact on job performance. By understanding therapeutic relationships from the perspective of male nursing students, it is possible to shed light on how job satisfaction relates to the self-efficacy of such students (Wyatt & Harrison, 2010). Not surprisingly, gender is the most significance issue in the development of therapeutic relationships. Influenced by social norms, male nursing students were kept away from female patients and were only allowed to perform a limited number of nursing procedures. However, if more males are to enter this female-dominated industry, it is necessary to hear their voices on the care of female patients. It is very important to see how male nursing students perceive themselves in this industry. Such perceptions could be affected by social norms or educational programs. It is suggested that nurse training programs do not
favor females and that males can also be competent nurses (Kleinman, 2004). This study is also intended to provide suggestions for current nurse training programs. Male nursing students might be at a greater disadvantage than female students by their limited clinical exposure, especially in specialties such as obstetrics–gynecology (Anthony, 2004; Keogh & O’Lynn, 2007). Although some places such as emergency departments or intensive care units favor male nurses (Nilsson & Larsson, 2005), male nurses should have the right to choose where to work, and suggestions from male nursing students on this issue should be solicited.
Conclusions Nurses play a critical role in the health care system. The percentage of male nurses is still low in Hong Kong. This study can provide a platform for male nursing students to express their perceptions of therapeutic relationships with female patients. The findings demonstrate that the forming of a therapeutic relationship between a male nursing student and a female patient is influenced by the presence of a chaperon, social context, and the type of procedure involved. The attitudes of female patients are also critical in the development of such relationships. If male nursing students are welcome to provide nursing care, a sense of mutual trust can be fostered. As this research is participant-driven, it gives a new angle for understanding the position of male nursing students. It is believed that the suggestions made here can help to improve current nurse training programs. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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