"I don't know. It's so frustrating. There's only a one point difference between passing or failing this course. Yet when I look at the questions I got wrong, I don't think it shows my lack of knowledge, only that I think like a man, not like my nursing instructor."

So began a recent conversation with a current nursing student, a young man who's seeking to progress in an LPN-to-RN program. This successful LPN with 5 years experience, who's active in the Army National Guard, holds a 3.49 GPA in his nonnursing courses. Yet he's struggling with the transition to professional nursing practice. Unfortunately, his experience isn't atypical. Is it that men are less prepared to succeed in our nursing programs or is it that we don't effectively accommodate their learning styles and needs? Do we inadvertently create an environment that's biased against men? Do nursing instructors actually discriminate against men in their courses?

Examining gender bias

Studies that have explored men's experiences in nursing education programs demonstrate that gender bias and discrimination do occur.1 Recent research reports that the "barriers men face in nursing school are pervasive, consistent, and have changed little over time."2 Over 89% of the respondents from that study reported hearing anti-male remarks made by faculty in the classroom.3 Other studies have found that men experience the process of nursing education differently than women, are caught by surprise as they enter the "women's domain" of maternal-child nursing, and learn to express caring in a different manner than women.4-9

If gender bias is an unrecognized, unaddressed component of nursing education programs, the outcomes are clearly detrimental to our profession and limit our ability to recruit and retain a robust workforce. In the coverage of the current nursing shortage, the media have reported that men are more likely to leave nursing than their female counterparts. The 2000 National Sample Survey of Registered Nurses demonstrated that men leave nursing at a higher rate in the first 4 years of practice.10 It begs the question, is this higher rate of attrition related to alienation that men experience in their nursing education programs?

Unfortunately, in contemporary nursing literature, it's easy to find examples of gender bias and its impact on men who seek to pursue a nursing career.5,6,11,12 The outcomes of gender bias are harmful to the profession and create a cycle that perpetuates bias and limits the role of men in nursing. This cycle results in different learning experiences for men and women as nursing students, limits recruitment and retention of men, and perpetuates traditional male-female stereotypes that make the profession irrelevant to the diverse population that the profession claims to represent and serve.13-18

The Nightingale factor

In the 1830s, Theodore Fliedner established the first training school for deaconesses in Germany, which is where Florence Nightingale began her training in nursing.26 In the mid-1800s, Nightingale's accomplishments in the Crimean War, combined with her social prominence and political influence, coalesced with changing perceptions of gender roles in Victorian England to establish the foundation of the myth of the feminine nurse, in which it was "natural" for women to be nurses, and conversely, "unnatural" for men.

Well-educated, articulate, and influential, Nightingale advocated for nursing as an ideal occupation for gentlewomen and opposed men's involvement in nursing, even stating that their "horney hands" were detrimental to caring. She used nursing as a platform for emancipation from the limitations she faced as a single woman in Victorian England. In doing so, she sought to align nursing with women's sphere of influence, namely, motherhood and caring. By focusing on the natural characteristics of women, in which nursing was equated with caring and caring was an inborn trait fostered by mothering, nursing and femininity seemed an ideal fit. Men were excluded, as it was perceived that they didn't have the capacity for mothering or caring.1,27,28

The pervasiveness of viewing nursing as the ultimate feminine role can be traced to and throughout the twentieth century. In the 1940s, during a debate about expanding training and licensure to men who were already providing nursing care, a South African councilor was quoted as saying, "A man is a clumsy thing who does not know how to handle a sick person[horizontal ellipsis] Nursing is the proper profession for women. They are created for that purpose."29

Men were excluded from the training programs advocated by Nightingale. The nurse's role was viewed as subservient to the physician, who directed the care and ran the hospital. The training environment mimicked the cloistered atmosphere of a religious sisterhood and was designed to preserve virtue and protect young women from contamination from the outside. By the beginning of the twentieth century, there were only two training programs for men in the United States. These programs focused on clinical areas acceptable for male participation, such as psychiatry and urology. Men were often barred from training in obstetrics.

As nurses began to organize professionally, men, even those with training as nurses, were often excluded. In 1901, the Army Nurse Corps was founded and specifically excluded men from nursing roles in the military. It wasn't until after the Korean War that men were allowed to hold commissions and be nurses in the U.S. Army.

The changing tide

Despite the limited recognition given to their role and the overemphasis on women's contributions to nursing, historically men have participated in caregiving and have been described as nurses. (See "The history of men in nursing.") Since the mid-1950s, men have been commissioned as officers and nurses in all of the American military services. Although men represent less than 6% of the total nursing population, they comprise nearly 30% of military nurses. The proportion of men in first-responder roles and specialty practices such as emergency and critical care has grown at a faster rate then the total nursing population in recent years.30

The vision of the kindly, caring female evolved into the stereotype of "nurse" following the advent of organized nursing training. The image of the nurse became one of an individual who was "subordinate, nurturing, domestic, humble, and self-sacrificing."17 Consequently, men who are perceived as strong, aggressive, and dominant ceased to be seen as having a legitimate role in nursing. Research indicates that this perception has resulted in men being ostracized from nursing, and further proposes that the contributions of men to nursing have been "forgotten" as nursing evolved into a stereotyped female role.17

This collective memory loss of men's contributions to nursing has left men with little information about their historical roles as caregivers. Both men entering nursing programs and their predominately female instructors are likely to be unaware that men come to nursing with a legacy of caregiving.

This lack of knowledge may contribute to a sense that men are breaking new ground by choosing nursing as a career option in the twenty-first century. As men enter nursing programs, they may feel like pioneers starting a treacherous journey into a hostile and unwelcoming territory rather than following a well-blazed trail. Such negative perceptions limit nursing's ability to recruit from the nearly 50% of the population that isn't female.

The male experience

What happens when men enroll in a nursing education program? It's unlikely that they'll be greeted by blatant evidence of prejudice. In most instances, men are cordially and enthusiastically welcomed. However, a collision of cultures is brewing.

Men entering nursing programs tend to differ from their female counterparts. While their academic preparation is likely to be equivalent, they're typically older and have made a considered decision to enter nursing based on their knowledge of the working world and nursing acquaintances. They expect to care for others while using their knowledge and building their careers. They expect to be team players and may relate their previous life experiences to their expectations of the healthcare team. Instead, they find that not only does it take a different kind of effort to be part of a nursing team, but they've entered a female-dominated and cloistered environment.

Figure. Men are likely to describe nursing education as a way to break down barriers and to know what to do in a given situation.

As men and women enter nursing, their motivations are similar, yet divergent. Both enter nursing motivated by caring, service, and power. However, women's motives are more likely to be altruistic. Women describe themselves as wanting to make a difference for others and to empower others. They tend to seek the power to "be," while men seek the power to "do." Men describe the power of nursing as the knowledge they gain so that they can act.31-33

Men are likely to describe nursing education as a way to break down barriers and to know what to do in a given situation. Men's choice of nursing as a career is likely to be colored by practical considerations such as future salary, job security, and potential for promotion. Nursing is seen as a career that can provide for a family.34 Given this action orientation, is there any wonder that men are surprised when they enter a nursing program and find the initial focus is on therapeutic communication, listening, and reflecting?

Other challenges men face upon entering nursing school include:

* rigor of the academic and clinical load in nursing

* role strain related to no longer being the primary income provider

* unexpected feelings of isolation and loneliness while in the school setting.

Men are usually in the minority in nursing education programs. Due to their physical characteristics, they often feel that they stand out among their student peers.5 Men often report uncertainty about the expectations of their peers and instructors in the clinical setting. For example, should they volunteer to assist in heavy lifting or transporting patients at the risk of not fully focusing on their clinical assignment? When with peers, they find that they're often expected to be assertive and to take on leadership roles. Men report that they're likely to be more closely scrutinized than their female peers and often feel as if they're "under a microscope," whether in the classroom or clinical setting.

Modes of caring

Caring is the essential element of nursing. Yet, learning to demonstrate professional caring can be a trial for men who have been socialized to limit visible expressions of emotion and to use touch carefully for fear of implying sexual overtones. Unlike women, who are likely to display caring behaviors through touch and open expression of emotion, men must learn ways to demonstrate their caring.

One study of men in nursing programs found that as they progressed in their nursing education, their ability to express caring gradually evolved.8 Most of the men in this study felt that they demonstrated caring, but their caring actions were different from the ones employed by women. They were likely to describe their caring actions as "being connected" with their patients and recognized that they could be connected and attentive without employing the overt caring behaviors used by women. Yet, they feared their expressions of caring wouldn't be valued by their nursing instructors.8 Such fears aren't unsubstantiated.

Another study that explored nurses' caring behaviors found that the frequency of caring behaviors was similar among both genders.10 However, men in nursing and their patients were less likely to perceive the caring behaviors as having value than the female nurses and their patients.10

Certain clinical rotations are fraught with perceived hazards for men, especially those in the maternal-child setting, in which there's a high degree of intimacy inherent in nursing care. In addition, our societal norms expect that the maternal/female role is dominant in caring for children. Men report feeling hesitant and uncertain as they enter this rotation, and often take on an "extra-professional" demeanor to avoid being perceived from a sexual rather than a professional perspective by their patients.6

One reason men may feel uncomfortable in the maternal-child setting is that they're less likely to be assigned to female patients in other clinical settings. Without the opportunity to experience caring for a full range of patients, male students who don't interact with female patients in a variety of settings are more likely to feel unprepared and uncomfortable in any setting with female patients, including settings such as the emergency department or critical care units.35

Figure. Dialogue about differences in caring behaviors across genders is important.

Seeking guides and leaders

Just as men are likely to be the minority in their nursing education, it's also hard to find men available to be role models and mentors. While the percentage of men enrolled in nursing education programs is rising, the number of men who teach nursing remains low. The typical nursing faculty member is a white female in her late 40s to early 50s.

White, middle-aged women are likely to have a different worldview and perceptions than the few men who enter their programs. They're not likely to intuitively identify with the experiences of men. They likely were socialized to value feminine attributes of the nursing profession. While they probably won't consciously discriminate against men, they may inadvertently exhibit behaviors that perpetuate gender bias. Nursing faculty members set the climate for learning and should be active role models in accepting and welcoming men into the profession.

Subtle incidents of gender bias may significantly impact students' learning and success. To minimize gender bias, nursing faculty members need to become sensitized to the unique and different experiences of men in nursing programs. Educators need to value men's historical contributions to nursing and their legitimate roles as caregivers. Learning to care is an important component of nursing practice. Nursing faculty members, however, need to accept that genuine and effective caring may be displayed differently by students of different genders, ethnicities, and cultures.

While nursing programs are targeting men, little is changing within these programs to promote retention.36 Recent research has identified 33 barriers experienced by men in nursing education and found similarities in the rating of prevalence and importance of these barriers among men from varying geographical areas, academic backgrounds, and years postgraduation from nursing school.1These findings suggest that the environment in nursing education remains inhospitable to men.

Systemic change

Until the causes of gender bias and discrimination are adequately addressed in nursing programs, men will continue to experience nursing education as a foreign and unfamiliar world. This sense of alienation stems from the loss of men's contribution to nursing in our collective memory and from the differences that men experience in nursing programs. It's exacerbated by nursing's relatively recent feminized history. The alienation of men may be increased by unintended and unrecognized gender bias among nursing faculty, as well as a lack of role models and mentors as men progress through their nursing programs and enter practice.

Changing this situation will require addressing traditional nursing stereotypes, increasing nursing faculty's awareness of men's perceived experiences while learning nursing, and providing proactive solutions to address the alienation men experience in nursing education. Programs such as establishing mentors between new nursing students and practicing men in nursing may decrease the social isolation that men experience.

Dialogue about differences in caring behaviors across genders is important. Clinical experiences need to be structured to prepare men to comfortably provide care to women in both maternity and general care settings. Finally, it's time to rebuild stories about nursing's history with the inclusion of important roles men have undertaken as caregivers.

With the likelihood that the current nursing shortage will continue and worsen as the population of middle-aged nurses reach retirement, recruitment into the profession can't be limited to those who fit the traditional female stereotype. Nursing education programs need to implement actions that will promote recruitment and retention of men in nursing.

The history of men in nursing

Nursing continues to be a predominantly female profession, with men making up less than 6% of practicing nurses. The preliminary results of the 2004 National Sample Survey of Registered Nurses revealed that between 2000 and 2004, there was only a slight, insignificant increase from 5.4% in 2000 to 5.7% in 2004, despite campaigns to recruit men into nursing, such as Johnson & Johnson's "Dare to Care," Oregon's "Are You Man Enough to Be a Nurse?" and Oklahoma's Men in Nursing 2006 Calendar.19-22 Given the small numbers of men in the profession and the lack of role models for male nursing students, men who choose to enter nursing may well feel that they're the new pioneers, stepping off into a foreign and unexplored territory.

Yet, prior to the mid-1800s, men often served in nursing roles. The first known nursing school was founded in about 275 BC in India, where men served as surgeons' assistants and provided 24-hour care to the ill and injured in newly founded hospitals.13,23,24

Men have served in caring roles throughout the ages. In the Middle Ages, military nursing orders developed during the Crusades to care for knights and other pilgrims to the Holy Lands. The Hospital of St. John in Jerusalem was founded by the Knights Hospitallers, who nursed the sick and injured when they weren't in battle. One of the catalysts for the formation of crafts guilds was the need to provide care for elderly and injured workmen. Religious leaders formed orders and founded hospitals. In Grenada, Spain, Juan Ciudad founded the order of the Brothers of Mercy and opened a hospital. While in Germany, St. Camillus de Lellis established the Nursing Order of Ministers of the Sick.24

As hospitals supported by religious orders opened throughout Europe, care was often segregated by gender. Men provided care for male patients and were led by a male nursing director, often a member of the religious order. There was no formal training for nursing and care was based on tradition, folklore, and trial and error.

With the exception of the care provided in religious facilities, until the mid-nineteenth century nursing was considered low status work. Nurses came from three sources: women who were primarily home-based and cared for kin and neighbors; men and women who, as members of religious orders, had taken vows to care and serve; and rough, uneducated lay attendants who chose nursing as a last resort for their subsistence.25

References