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Men studying to be nurses : an exploration of the lived experience of men in undergraduate nursing education Hakami, Rana 2020

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Men Studying to be Nurses:  An Exploration of the Lived Experience of Men in Undergraduate Nursing Education by Rana Hakami B. Sc. The University of British Columbia, 2004M.A. New York University, 2007A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES Counselling PsychologyTHE UNIVERSITY OF BRITISH COLUMBIA VancouverApril 2020 © Rana Hakami, 2020 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled: Men Studying to be Nurses: An Exploration of the Lived Experience of Men in Undergraduate Nursing Education submitted by Rana Hakami in partial fulfillment of the requirements for the degree of Master of Arts in Counselling Psychology Examining Committee: Richard Young, Ed.D., R.Psych. Supervisor  William Borgen, Ph.D., R.Psych. Supervisory Committee Member John Oliffe, Ph.D., R.N.  Supervisory Committee Member iii Abstract Nursing is as a gendered profession dominated by women. Studies have focused on understanding how men function as nurses, and how nursing education can increase gender diversity in the profession. These studies often imply differences between men and women, or sometimes a lack of inclusivity in nursing. Gender may not predict academic success or distress in nursing students; yet students report experiencing nursing education diversely because of their gendered experiences. Gender framework analysis has been used in literature to consider the role of gender in professional identity development for nurses. In these studies, gender is socially constructed or socialized through role-modeling. Based on this assumption, it is possible that undergraduate students who are not yet immersed in the professional culture may experience nursing differently than practicing nurses. Using a qualitative design, men engaged in entry-to-practice Bachelor of Science in Nursing degree programs participated in semi-structured individual interviews sharing their lived experiences of studying to become nurses. The goal was to use interpretive phenomenological methodology and analysis to give voice to the experience of men studying nursing. The study found the following: participants chose nursing to align their purpose with their personal values; despite being in the minority they had found their professional home in nursing; they made meaning of their experience by processing the incidents where they witnessed or experienced historic gender biased assumptions, and they felt supported in their journey - even though they still desired access to missing resources. In the end, they did not perceive that their gender was a significant part of their experience, but their educational journey was influenced by their gender due to the presence of gender systems.  iv Lay Summary Even though nursing is a profession numerically dominated by women worldwide, each year more and more men enroll in postsecondary educational programs to become registered nurses. This study explored the experience of a group of men from a variety of institutions in British Columbia who were engaged in one of these undergraduate degree programs. The purpose of the study was to understand these men’s experiences with the hope of understanding how gender could influence vocational training. Ultimately, the men who participated in the study identified that learning to become a nurse is less about what culture thinks someone should become based on their perceived or identified gender, and more about how someone wants to contribute as member of society – regardless of gender, sex, or sexual or emotional orientation. Potential applications and areas for future research include nursing education, guidance and career counselling, or gender studies.  v Preface This thesis is the original, unpublished, independent work of the author, Rana Hakami.  Rana Hakami collected all data, conducted all analyses, and wrote the manuscript. Dr. Richard Young acted as research supervisor and principal investigator. He provided guidance and feedback throughout the design, analysis, and writing of this research project. Dr. William Borgen and Dr. John Oliffe participated as members of the supervisory committee and approved the proposal and final oral defense of this research project. This research was conducted with the approval of the University of British Columbia (UBC) Office of Research Ethics (ORS), Behavioural Research Ethics Board (BREB). The number of the certificate obtained for this research is: H18-0357.  vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ................................................................................................................................ iv Preface ............................................................................................................................................ v Table of Contents .......................................................................................................................... vi List of Tables .................................................................................................................................. x Acknowledgements ....................................................................................................................... xi Dedication ..................................................................................................................................... xii Introduction ................................................................................................................................... 1 Historical Perspectives: Men’s Involvement in Nursing. ........................................................ 3 Choosing Nursing as a Career and the Experience of Men in Nursing ................................... 4 Sex, Gender, and Socially Constructed Gender Roles. ............................................................ 7 Experiencing the Socialization of Gender Roles as Nursing Students .................................... 8 Research Question ................................................................................................................. 11 Purpose ................................................................................................................................... 11 Literature Review ........................................................................................................................ 13 What is Significant in Students’ Experiences of Studying Nursing? .................................... 14 Factors in the Clinical Placement that Promote Success ................................................... 14 Positive Relationships with Instructors and Peers Promotes Success ............................... 15 Unclear if Gender Effects Academic Performance ........................................................... 15 What is Significant about the Gender Ideologies in the Profession of Nursing? ................... 16 Doing and Undoing Gender as a Theoretical Framework ................................................. 17 Gender Ideologies Prevalent in Nursing and Work Life Satisfaction ............................... 18 vii Social Role Theory and Ambivalent Sexism ..................................................................... 19 What is the Lived Experience of Men Studying to become Nurses? .................................... 21 Students’ Experience of Being Recruited into Nursing .................................................... 21 Students’ Experiences of Clinical Placements .................................................................. 23 Students’ Experiences through a Gender Analysis Framework ........................................ 23 Limitations of Past Literature ................................................................................................ 25 Method .......................................................................................................................................... 26 Interpretative Phenomenological Analysis ............................................................................ 26 Research Design ..................................................................................................................... 27 Participants. ............................................................................................................................ 27 Participant Recruitment ..................................................................................................... 29 Participant Demographics ................................................................................................. 29 Data Collection and Overview of Activities .......................................................................... 30 Data Analysis ......................................................................................................................... 31 IPA Approach .................................................................................................................... 31 Situating the Researcher in the Study ................................................................................ 32 Trustworthiness of Study Findings ........................................................................................ 34 Gender Related Biases and Assumptions. ......................................................................... 35 Measures of Validity, Credibility and Rigour ................................................................... 36 Member Checks and Reflexivity ....................................................................................... 38 Final Presentation of Data as Validity Measure ................................................................ 39 Ethical Considerations ........................................................................................................... 40 Data Management. ............................................................................................................. 40 viii Findings ........................................................................................................................................ 41 A Note on Themes Presented within the Common Lived Experience .................................. 41 A Note on Presentation of Analyzed Data ............................................................................. 42 Overview of Findings ............................................................................................................ 42 Aligning Purpose with Personal Values ................................................................................ 43 Changing Course ............................................................................................................... 44 Mastering the Application of Science ............................................................................... 46 Focusing on Building Relationships .................................................................................. 47 Feeling at Home in the Profession ......................................................................................... 48 Defining a Good Nurse. ..................................................................................................... 49 Being Accepted as a Nurse. ............................................................................................... 52 Acceptance is Mostly Universal. ....................................................................................... 52 Processing Effects of Historic Assumptions .......................................................................... 53 Experiencing and Processing Assumptions from General Public. .................................... 55 Experiencing and Processing Assumptions from Educators. ............................................ 57 Reframing to Dismantle Assumptions. .............................................................................. 60 Feeling Supported in their Journey ........................................................................................ 62 Environmental or Relational Resources. ........................................................................... 62 Personal Resources and Helpful Attributes. ...................................................................... 65 Wishing for Missing Resources ............................................................................................. 68 Conclusion ............................................................................................................................. 70 Discussion ..................................................................................................................................... 71 Study Goals and Deliverables ................................................................................................ 72 ix Relevance of Findings to Previous Research ......................................................................... 74 Addressing the Gap by Focusing on Undergraduates ....................................................... 74 Adding Recency and Confirming Past Findings ............................................................... 76 Continuing the Conversation on Gender Norms in Nursing Education ............................ 78 Continuing the Dialogue on Gender Ideologies and the World of Work .......................... 80 Potential Avenues for Application ......................................................................................... 82 A Place for Dialogue and Learning ................................................................................... 82 An Opportunity for Evidence Informed Student Support ................................................. 83 Limitations of the Current Study ........................................................................................... 84 Directions for Future Research .............................................................................................. 86 Conclusion ............................................................................................................................. 87 References .................................................................................................................................... 88 Appendices ................................................................................................................................. 103 Appendix A Vancouver Regional District BSN Programs ............................................. 103 Appendix B: Research Study Recruitment Poster ........................................................... 105 Appendix C Research Participant Consent Form ............................................................ 106 Appendix D Participant Screening Phone Interview Protocol ........................................ 112 Appendix E Semi-Structured Interview Protocol ............................................................ 114 x List of Tables Table 1 0HDVXUHVWR,QFUHDVH9DOLGLW\,PSOHPHQWHGLQ&XUUHQW6WXG\.............................................. 36 Table 2 *UHDWHU9DQFRXYHU5HJLRQDO'LVWULFW*95'%613URJUDms........................................... 103 xi Acknowledgements I wish to begin by acknowledging that the land on which the majority of my academic and professional training and development has occurred is the traditional, ancestral, and unceded territory of the xwməθkwəy̓əm (Musqueam) People. As a guest on this land, I will be forever grateful for the teachings I have received while I have had the privilege of learning and working here. I also offer my sincere gratitude to the Elders that have shared their wisdom with me, my colleagues, and my fellow students.  I also wish to offer my enduring gratitude to the faculty, staff and my fellow students at UBC, who have inspired me to strive for excellence and authenticity. Specifically, I wish to thank my peers in the Counselling Psychology program, and every nursing student who has inspired me by allowing me to be a part of their educational journey.  I am deeply appreciative for the supervision provided by Dr. R. Young, whose patience, wisdom, and thoughtful questions taught me to aspire for clarity and depth in my pursuit of knowledge. I wish to thank Dr. J. L. Oliffe for his early acceptance and continued support of this research project. Finally, I wish to thank Dr. W. Borgen for joining the supervisory team.  Special thanks are owed to my friends and family who have been there for me with meals, words of encouragement, and never-ending faith in my success. Finally, I owe particular thanks to my amazing parents, who have supported me throughout my many years of education - morally, emotionally, and financially.  xii Dedication   I dedicate this thesis to my loved ones who cannot not be here to celebrate the end with me. My grandmothers and great grandmother, true matriarchs and exceptional leaders. My wonderful grandfather, who taught me that strength and courage are genderblind.  My uncle who instilled in me a love of science and inquiry.  Dr. Jennifer Kryworuchko – a dear friend who had faith in me, even when I did not.     1 Introduction Nursing is a regulated profession and clinical field of practice that has traditionally been viewed as both female-typed and dominated by women. The workforce – which is represented by Registered Nurses (RNs), Nurse Practitioners (NPs), Psychiatric Nurses (RPNs), and Licensed Practical Nurses (LPNs), is predominantly comprised of women. Reported numbers of women RNs range from 89.24% in the United Kingdom (UK) to 91.4% in the United States of America (USA) (Fielden & Burke, 2014) and 91.7% in Canada (Canadian Institute for Health Information [CIHI], 2019). Despite the worldwide shortage of nurses, and recruitment attempts to attract men into the profession, research still reports a sentiment that nursing is an uncomfortable place for men (McLaughlin, et al., 2010). Florence Nightingale is credited with the creation of the organizing principles of the profession at a time of heightened Victorian ideology (Anthony, 2004). Therefore, there is also a significance of notable female historic role models that embody feminine gender norms in the history of nursing (Hoeve, et al., 2013). In addition, the concept of providing care is feminized, gendering the foundation of nursing education and practice theory (Jordal & Heggen, 2015). Based on these trends, researchers had predicted that men would continue to be the minority in this profession for years to come (Dyck, et al., 2009).  Despite the predictions in past research literature, each year more men in Canada continue to want to become nurses – as reflected in the overall reported increase of 7.4% in the number of men in the regulated nursing workforce (RNs, NPs, LPNs, and RPNs) in the last five years - specifically with a 1.9% increase in the number men who practiced as RNs from 2010 – 2019 (CIHI, 2019). Cottingham (2019) confirms that the role of men in nursing has been of interest to researchers from nursing scholarship, sociology, and gender studies; however, he   2 argues that this interest has incorrectly appropriated “disenfranchisement of men in nursing” and ignored the inherent privilege held by the men practicing as nurses (p. 197).  Restrictive gender norms and systems have been shown to have adverse effects for all health care providers, and in turn impact health outcomes for all regardless of gender (Hay, et al., 2019). The experience of men studying to become nurses is important to understand not because they are in any way shape or form marginalized in the profession, but for a myriad of other essential reasons. First and foremost, continuing to understand the recent experience of men studying nursing furthers the conversation on complex gender systems and dynamics in the profession (Evans, 1997). This exploration also allows researchers and educators to understand more about the workforce in general, and how men choosing a field of study where they are the minority could experience challenging norms of traditionally restrictive gender norms (Shen-Miller & Smiler, 2015). Therefore, understanding more about the gendered experience of students studying nursing has the potential to create the opportunity for providing the information needed to learn more about the experience of men studying a vocation that has been documented to have been dominated by restrictive gender norms in the past.  Following a brief overview of historical perspectives in nursing, and a survey of the literature on motivational factors and key experience requirements that have led students to choose to study nursing, this study establishes the rationale for why it is important to use interpretive phenomenological inquiry to explore this phenomenon. The task at hand is to understand the lived experience of being a man who is also studying to become a nurse. Historically, it has been reported that men who choose professions that match societal gender norms can experience benefits resulting from existing masculine ideology (Cheng, 1999; Paechter, 2006; Shippers, 2007). On the other hand, it has also been documented that men who   3 choose traditionally female typed professions could potentially experience marginalization due to gender role strain and going against the normalized gender socialization that occurs in society (Levant & Richmond, 2014; Levant 2011).  Therefore, much like most conversations on the role of gender norms in society, this one is also complex. Most of the currently available literature on the experience of men studying to become nurses is either not recent, includes men and women in study populations due to a scarcity of men students available, or combines the experience of graduate students (who are already intrenched in the profession and practicing as registered nurses during their graduate studies) with the experience of undergraduate students learning to become registered nurses.  This study aspires to add recent voices of men studying to become registered nurses to the current conversation on the gendered experiences of nursing as vocation. The goal of the study is to add to the continued understanding about this complex issue with the hope that furthering this conversation in the literature may have knowledge translation potential for the understanding gender socialization and dynamics in scholarship of nursing, career counselling and student support.  Historical Perspectives: Men’s Involvement in Nursing.  Why is important for this study to explore historical perspectives on the role of men in the profession of nursing? Because Florence Nightingale is essentially credited with pioneering and separating nursing from the medical profession in developing the image of the modern nurse (Hoeve, et al. 2013). However, Evans (2004a) documented the involvement of men in nursing as early as the fourth or fifth century – through the Order of St. John of Jerusalem. Also, the Alexian Brothers - a religious order of craftsmen who tended to the sick - established the first psychiatric Schools of Nursing in the USA in the 20th century. Evans reported that after the   4 modernization of nursing during the times of Victorian family ideology, medicine divided into the current patriarchal socialization of men as physicians and women as nurses. In her feminist review, Evans concluded that the minimization of the role of men in nursing may have contributed to the institutionalization of patriarchal practices in medicine that negatively impacted both men and women.  Over forty years ago, a quantitative study was published focusing on the occupational values and aspirations of male nursing students (Auster, 1978). Auster postulated that as a result of decrease in sex stereotyping and decrease in discrimination over time, the society of the future could reflect an occupational structure that “reflects the true potential of both sexes” (p. 231). Twenty years after Auster’s study, another team of researchers identified the following in a qualitative study: society saw nursing as feminine, men participating in their study reported experiencing self-doubt and isolation, and high school counsellors at the time were not prepared to introduce nursing as a career to men (Kelly, et al., 1996). These early studies in the exploration of men studying to be nurses identified nursing as a profession marketed to women more than men. However, both sets of researchers demonstrated hope the future would rectify this trend.  Choosing Nursing as a Career and the Experience of Men in Nursing  Despite the predominance of women in nursing, both historically and numerically, men are still choosing to be nurses. What motivational factors influence nursing as a career choice for individuals, and is there diversity in motivational factors for men and women? Twenty-five years ago, a doctoral dissertation in psychology exploring the factors related to career choice in male and female dominated professions, found that while participants tended to choose a profession with similar interpersonal attributes to their own self-image, choosing a profession aligned with   5 their self-image did not predict higher self-esteem or confidence as vocational theory had predicted (McLean, 1989). Also, as part of a larger longitudinal study, researchers found that students chose nursing because they wanted to be nurses regardless of their gender or sex (Wilkes, et al., 2015). A systematic review of qualitative studies on motivational factors influencing men to choose nursing as a career (spanning from 1970 to 2013) identified similar findings (Yi & Keogh, 2016). Additionally, Simpson (2005) found that men who choose nursing could be categorized into one of three types: seekers (those who chose nursing specifically), finders (those who came upon nursing as a result of investigating general career decisions), and settlers (who often chose nursing after dissatisfaction with a traditionally masculine typed career).  In a review of nursing education and practice literature, Kouta and Katie (2011) found significant evidence of gender discrimination in nursing education and practice. In another government funded study, men in nursing were identified as an underrepresented population that required special attention (Pringle, et al., 2004). O’Lynn (2004) conducted a study sampling 200 practicing male nurses and concluded that barriers men face in nursing were reported to be “pervasive, consistent, and have changed little over time” (p. 229). Scholars also identified that other components of a student’s identity in addition to their identified gender - or the type of program students chose to engage in - may have created more complex situations and barriers (Conner, et al., 2016; Smith, 2006). Participants in these studies reported a lack of male facilities, lack of male faculty, and lack of male perspectives in textbooks as part of their experience (Smith, 2006). One qualitative study found participants enjoyed being nurses, but they reported that they did not enjoy nursing school (Ellis, et al., 2006). Therefore, it would seem that men   6 choose to study nursing despite the reported barriers and perceived discomfort they may encounter.  In a quantitative study, researchers found that men were more likely to leave nursing programs than women, and even completers of all genders felt nursing was a more appropriate career choice for women (McLaughlin, et al., 2010). Another qualitative study found that participants reported contradictions between their masculine gender identity and their choice to practice as a nurse (O’Connor, 2015). Additionally, a mixed methods study demonstrated that men practicing as nurses tended to horizontally segregate into areas of practice that they themselves perceived as more masculine (Snyder & Green, 2008). The potential for men to feel uncomfortable in nursing is reported to be more exacerbated in countries and cultures that are traditionally ruled by patriarchal laws, customs, and practices – such as Iran, Jordan, Turkey, or traditionally Chinese customs in Hong Kong (Al-Zein & Alkhawaldeh, 2015; Chan, et al., 2014; Karabacak, et al., 2012; Valizadeh, et al., 2014;). These cited studies emphasized how individuals’ self-image of their gender - and how their identified gender related to their occupational choice – were often experienced through the lens of social and cultural norms.  In addition to barriers men face when choosing nursing, nursing students in general are reported to face a series of unique and common stressors during their undergraduate education. Studies have found that nursing students in general reported high levels of stress and anxiety leading to feelings of inadequacy and rejection in nursing school (Reeve, et al., 2014). Additional studies have identified the following: nursing students faced greater sources of stress than average undergraduate students, they faced specific sources of stress related to clinical education, and each student had varied coping mechanisms which hindered or bolstered their success in studying to be nurses (Boulton & O’Connell, 2017; Deasy, et al., 2014; Pulido-Martos, et al.,   7 2012; Prijmachuk & Richards, 2007;). In the above studies gender was not reported to be a specific predictor of stress in nursing school. However, the aforementioned research did not investigate the role of gender or gender norms in the perception of stress or coping mechanisms available to participants, and the researchers often cited the rationale for this limitation to be the scarcity of men nursing students as volunteer participants. Sex, Gender, and Socially Constructed Gender Roles.  In addition to understanding the historical perspective of the involvement of men in the profession, and the reasons why men choose to study nursing or become nurses, it is also foundationally important to this inquiry to understand how gender is defined and conceptualized in both society and research literature. Trait type and sex type models of gender are criticized in the literature because they are rooted in biological essentialism – which is the notion that behaviour and characteristics of an individual are the product of the individual’s genes as opposed to their environment, social learning, or circumstance (Bem, 1994; Winter, 2015). Other conceptualizations of gender systems recognize gender as a socially constructed product of the following two functions within each individual: the automatic sex categorization of self and other, and a complicated series of interactions coordinated based on societal rules derived from dominant sex stereotypes (Ridgeway & Correll, 2004; West & Zimmerman, 1987).  Even with socially constructed conceptualizations of the gender system, a divide is still created between man versus woman (Connell, 1995). This leads to the concept of hegemonic masculinity– a way of being for men that allows their dominance over women, and other men. This concept of hegemonic masculinity can replicate itself when gender norms are unchallenged (Connell & Messerschmidt, 2005). In this type of masculine ideology populations of able-bodied, white, heterosexual, middle to upper class Christian men create the basis for a normative   8 approach that leads to socialization and role modeling of the masculine ideal (Levant, 2011). However, this type of traditional masculine ideology is contradictory to what most men and boys actually do in practice (Cheng, 1999). Refining masculinities to better resemble the diverse realities of men’s practices has led gender relations scholars to embrace that masculinities vary depending on culture, ethnicity, class or sexual orientation (Shippers, 2007). Also, conventional and binary understandings of gender roles are reported to create problematic representations that cannot encapsulate the diversity within and between populations of men and women (Johnson & Repta, 2014).  Experiencing the Socialization of Gender Roles as Nursing Students  To truly learn how to understand the effects of gender in the experiences of the individual, after identifying how gender is conceptualized, it is important to explore how the socialization of gender creates societal expectations for men and women. Gender roles are defined as the rules or standards that dictate the behaviour of women and men, and individuals are reported to internalize these roles based on the societal messages they receive about the correct gender for their perceived body (Johnson & Repta, 2014). Researchers have documented a positive relationship between subscription to masculine ideology and increased mental health problems for men (Wong, et al., 2017). Another group found that men in female typed professions who subscribed to masculine ideology faced greater societal stress than men in male typed professions (Korek, et al., 2014). Specifically, in nursing and primary education, Evans and Frank (2003) found that the contradictions men feel towards dominant masculinities may have led some men to experience tensions when reflecting on their gender and their chosen profession.    9 Evans (2002, 2004) found that this tension may be specifically associated with societal interpretations of qualities of men’s bodies (such as strength) and the sexualization of men’s touch as it relates to the nursing profession. This stress can be conceptualized by the socialization paradigm of gender role strain paradigm (GRSP), which stipulates the following: gender ideologies identify beliefs that prescribe appropriate roles for men and women, these role norms are inconsistent with reality because many individuals violate them in practice, and violating them can lead to negative psychological consequences for these individuals (Levant & Richmond, 2014; Levant 2011). Nursing students who identify as men have been reported to experience the complex gender dynamics institutionalized within the profession. In a mixed-method cross-national study set in the UK and Australia, a team of researchers discovered that belongingness was demonstrated to be a prerequisite to clinical learning for all nurses (Levett-Jones & Lathlean, 2008). Further studies based on this finding have demonstrated that minority women students have higher attrition rates in nursing than Caucasian women (Sedgewick, et al., 2014). In another study exploring belongingness in clinical practice, while there was no significant variation reported for belongingness between men and women, researchers found that men self-reported significantly lower levels of efficacy which the researchers interpreted as suggesting that “men experience marginalization and discrimination” (Sedgewick & Kellett, 2015, p. 121). Therefore, this literature suggests that it could be possible for students who identify as men to feel marginalized studying nursing, just as it could be possible for men practicing as nurses to experience gender role strain from their chosen profession. However, this could also be an example of the type of study Cottingham (2019) critiqued for appropriating marginalization for men in nursing while ignoring the inherent privilege of the participants.    10 While unrelated to nursing, another study of fifteen male university students in Canada found that masculine ideals and cultural constructs influenced participants experienced and expressed depression (Oliffe, et al., 2010). As stated in earlier studies, studying to be a nurse is reported as being stressful for all students; however, these conclusion were based on studies with limited numbers of men as participants – and as previously identified, studies that did not explore the role of gender in experiencing or management of stress. If studying nursing is stressful for all students, and men experience stress and depression uniquely due to cultural constructs prevalent in society about masculinities; then one example of an area where men could have diverse experiences from their peers based on their identified gender could be how they experience the stress prevalent in studying nursing.  The issue of how stress in nursing school may be experienced by men studying nursing is only one minor example of why it becomes imperative to further the conversation on gender roles in registered nurse training programs and understand the current lived experience of this population of students. The goal of this current study’s inquiry was not solely to further understanding of the gendered experience of studying nursing to support men who want to be nurses as individuals in career transition, as students, or even as future nursing professionals. By learning more about the gendered experience of a group of men who are experiencing being the minority for likely the first time in their lives, this inquiry also hoped to deepen understanding with regards to how gender roles and socialization of gender effect the lived experience of students as they engaged in vocational training within health systems steeped in tradition, history, and complex gender dynamics.    11 Research Question  This study continued examining the phenomenon of studying nursing for men. To address the current gaps in recent literature, this study refined the population studied to undergraduate students, and focused on gathering data when students are actively engaged with their first educational journey on the road to becoming a registered nurse. This study addressed the following question: For men studying nursing, what is the lived experience of studying to become a registered nurse?  Purpose Exploring the experiences of men studying nursing allowed the researchers to generate insight and continue the conversation on gender relations within nursing as a profession and add the voice of recent men undergraduate students to this conversation. However, it is important to not generalize findings from the lived experience of one group of students who identify as men to all men studying nursing. Masculinities, the performances of gender, gender relations, and the gendered division of work in nursing are complex (Evans 1997; Evans & Frank, 2003; Evans 2004a; Kellett, Gregory, & Evans, 2014). The additional insight gained from this study could allow scholars to further understand the potential effects of traditional restrictive gender norms and systems on the participants’’ experience– especially those involved in the training and education of health care professionals (Hay, et al., 2019; Kellett, et al., 2014). Also, this insight could allow mental health professionals to understand the possible impacts of gender related work and vocational training obstacles to work life satisfaction (Rochlen, et al., 2009).  In the end, it is just as true today as it was fifteen years ago – gender bias in education could impede recruitment into the profession of nursing, and gender bias can be unknowingly perpetuated (Anthony, 2004). When gender biases and norms impact health systems, they could   12 compromise the wellbeing of both health care providers as well as the health of communities (Hay, et al., 2019). Therefore, furthering understanding on the gendered experience of one group of health care providers in training has the potential to improve the future experiences of their peers – and in the long run, the wellbeing of the community at large.     13 Literature Review A review of the scholarly literature on the experience of men studying nursing was conducted. To ensure depth and breadth of inquiry, the literature review also included topics related to gender roles and systems in nursing and nursing education. The population relevant to this study was undergraduate men nursing students, and the geographic focus of the study was undergraduate programs producing future registered nurses (RNs) in western Canada. Nursing is a regulated profession globally and in British Columbia (BC) (British Columbia College of Nursing Professionals [BCCNP], 2018). Nursing education programs are normally reviewed and accredited by national professional associations worldwide to promote excellence in education (Canadian Association of Schools of Nursing [CASN], 2018). To contextualize the experience of studying to be a nurse, the following review draws heavily from nursing education scholarship to identify salient experiences related to studying to become a nurse. The literature also focuses on studies using phenomenological inquiry to explore the lived experience of students or adults learning a new profession or skill.  Finally, due to the institutionalized gender systems in nursing, this review also includes literature that explores how identified gender may have an effect on the lived experience of men studying nursing. From here on in, to ensure the study does not conflate the conceptualization of sex and gender in a way that replicates problematic categorizations that rely on biological essentialism, the author focuses on identified gender, and writes about ‘men studying nursing’, or ‘men nursing students.’ At times, it was not possible to identify participants of previous studies by their identified gender instead of their perceived biological sex because the researchers of the study being reviewed only reported participant demographics by identifying the participants’ sex   14 as their gender. In those cases, author is required to rely on the categorizations as identified by the study being reviewed.  What is Significant in Students’ Experiences of Studying Nursing?  Since Holland (1999) reported that the journey from student to practicing nurse is an ill-defined one, many researchers have attempted to identify what aspects of the journey are significant to learners. Most prominent in the literature is the work of a team led by Levett-Jones and Lathlean that identified belongingness in clinical practice settings to be a prerequisite for ascent to competence as a nurse (Levett-Jones & Lathlean 2008; 2009b; Levett-Jones, et al., 2009). In addition to the importance of belongingness, the following factors in the upcoming section have been demonstrated to have a relationship with academic performance of students in nursing programs.  Factors in the Clinical Placement that Promote Success  In additional to the research on professional belongingness in clinical practice sites reviewed above, other factures present in clinical settings promote the success of nursing students. Suikkala and Leino-Kilpi (2005) found that when a student experienced a positive relationship with a patient in clinical practice, the impact was demonstrated to be mutually beneficial for both student and patient. Other common-sense factors that were reported to positively influence the journey from student to practicing nurse in the clinical practice site are as follows: the presence of mutual respect and regard for others (Chesser-Smyth, 2005), and adequate attendance in prescribed educational activities during the program (McCarey, et al., 2007).    15 Positive Relationships with Instructors and Peers Promotes Success  Nursing students report feeling empowered when they perceive the following to be present: being valued as a team member and being valued as a person (Bradbury-Jones, et al., 2011). Furthermore, faculty empathy appears to have a direct positive relationship with students’ professional development (Mikkonen, et al., 2015). In addition, a study found that when students perceived that faculty showed compassion, they were able to perform better academically (Torregosa, et al., 2016). Finally, a large national study in the USA found that students who experienced decreased satisfaction with peer support were less likely to graduate, and that men participating in the study reported higher satisfaction with peer support than women participants (Abshire, et al., 2018). This study is significant among the literature reviewed because a critical mass (39%) of the total data were students who identified as men, and the availability of enough men among the participant pool made it possible for the researchers in this study to report a finding related to the relationship between gender and studying nursing.  Unclear if Gender Effects Academic Performance  In an integrative review of qualitative and quantitative studies spanning from 1999 – 2011 investigating factors related to attrition in nursing programs, researchers found the following factors that have been reported to influence academic performance and attrition in undergraduate nursing students: demographics, academic factors, cognitive factors, and personality/behavioural factors (Pitt, et al., 2012). While the aforementioned review did not conclude that gender was a significant factor correlated with academic performance, three studies from the UK included in this review had identified gender as being a predictor of attrition. Ofori and Charlton (2002) identified support seeking behaviour as a significant predictor in their path model designed to describe what psychological processes underly nursing   16 students’ academic performance. Due to the small number of participants who identified as men (17 out of 315 total participants), a shortfall of this 2002 study is the fact that the researchers were not able to delve deeper into the relationship between gender and support seeking due to lack of gender diversity in participants.  In the studies reviewed related to significant experiences for students studying to become nurses, none of the quantitative of mixed method studies identified gender as a predictor of performance in the experience of studying nursing. However, despite this, some researchers did question in the discussion of their findings if the identified gender of the participants had an effect on their experience of studying nursing (Chesser-Smyth, 2005; Ofori & Charlton, 2002). Therefore, gender does not appear to be a predictor of academic success for those who are studying to become nurses. However, the students’ identified gender, could have subtle effects on how the students experience the various aspects of their nursing program. This has not often been a focus of investigation in past studies, likely due to the historic and continued low enrolment of men in entry-to-practice nursing programs.  What is Significant about the Gender Ideologies in the Profession of Nursing?  As outlined in the Introduction, because of the institutionalized gender roles prevalent in society, gender relations and gendered division of labour in nursing practice and education are documented to be salient and complex (Evans 1997; Evans 2004a; Evans & Frank, 2003; Kellett, et al., 2014). Despite the documented negative personal and societal implications of a system that categorizes individuals as men or women (Levant 2011; Levant & Richmond, 2014); gender, as a system of categorization, is postulated to be so ubiquitous that it is sometimes the background identity to all other roles the individual has (Ridgeway & Correll, 2004).    17 As identified previously, research has reported that at least in North America, men enter nursing for similar reasons as women do – to help others and be of service to society (Dyck, et al., 2009). However, images of nursing that men brought with themselves to their new role had a significant impact on their choice to remain engaged in the profession (Spouse, 2000). The gender or perceived sex of nurse who identifies as a woman is not normally discussed; however, the perceived sex of a man who practices as an RN is explicitly stated in society’s label of ‘male nurse’ (McLaughlin, et al., 2010). Several studies have attempted to quantify the degree of masculinity and femininity in nurses or nursing students using the Bem Sex-Role Inventory (BSRI) (Al-Zein & Alkhawaldeh, 2015; Fisher, 2011; Thompson, et al., 2011; Loughrey, 2008). However, these studies are problematic as they continue to propagate hegemonic masculinities and masculine ideology in nursing by correlating success as a nurse to biological sex characteristics of males and females.  Doing and Undoing Gender as a Theoretical Framework During a foundational study that contributed to the theoretical framework of viewing gender as a social construct, West and Zimmerman (1987) were able to define gender as an “achieved status,” something men and women created, or performed, through “psychological, social, and cultural means” - as opposed to a fixed inherent part of their identity based on their biological sex (p. 125). In response to the research that used West and Zimmerman’s framework to demonstrate performing, or doing, gender; Deutsch (2007) created a theoretical framework for how to conceptualize undoing gender – or actively resisting perpetuating the hegemonic structures of the gender system. Deutsch’s change in focus postulated that it was important to study - through their interactions - how people both conformed to and resisted traditional gender norms. Juxtaposed to studies that bolstered problematic gender ideologies inherent in a binary   18 sex categorization of nurses, many other studies explore how men participate in nursing despite the existence of institutionalized sexism in the profession.  A qualitative study from New Zealand found that there was a significant potential for personal fulfillment that motivated men to join the woman-dominated profession of nursing (Harding, 2009). Meadus and Twomey (2011) found that it was not men’s gender that made nursing a difficult career choice for them, but the gender biases the participants in their study faced in nursing education and practice areas that created challenges for them. This finding is echoed from a different perspective in the ethnographic interpretive study of undergraduate nursing students’ perception of undergraduate nursing classroom education (Dyck, et al., 2009). The researchers from this study recommended that nursing instructors re-evaluate how they view gender in their educational practices, avoid stereotypes and parodies of traditional masculinities, and reject the assumption that all men in nursing are homogeneous. Another study used Deutsch’s (2007) theoretical framework of doing and undoing gender to find that men in female typed professions of nursing and elementary education do gender by conforming to masculinity, while simultaneously appropriating femininity so that their hegemonic masculine identity is both subverted and maintained (Pullen & Simpson, 2009).  Gender Ideologies Prevalent in Nursing and Work Life Satisfaction Understanding how gender ideologies and masculinities are defined highlights why barriers could exist for men working as nurses, and how those barriers could lead to stress. However, when examining how men in nursing function in their work and life roles, researchers found that some men in nursing reported less gender role conflict and greater satisfaction with work and life than the normative sample of men included as control (Rochlen, et al., 2009). These men were reported to have a strong supportive network, assessed their professional skills   19 positively, and perceived fewer barriers related to their gender. Rochlen and colleagues’ study confirmed the existence of gender related barriers for some men in nursing; however, it also highlighted that the perceived strain from those barriers could be alleviated when men identify supports and coping strategies.  While the negative consequences of hegemonic masculinities on society and the individual have been well researched, another approach is to view masculinities through the positive psychology positive masculinity (PPPM) paradigm – which is a strength-based approach that focuses on positive aspects of male development (McDermott, et al., 2018). McDermott and colleagues concluded that while there is no solid definition for positive masculinity, it is important to capture men’s subscription to beliefs and behaviours that promote healthy positive experiences for men. Rochlen and colleagues’ (2007) study can also be viewed as supporting evidence that focusing on positive masculinities development provided the men in the study with resources, they needed to sustainably address the gender role strain that they may have experienced.  Social Role Theory and Ambivalent Sexism  West and Zimmerman (1987) concluded that gender was ubiquitous to social relations and institutions, and this ubiquity reinforced the reproduction of gender hierarchies in society making everyone complicit in maintaining the gender order (Johnston & Repta, 2014). This institutionalized gender order is reported to give men more power, access, and money than women in nearly every society in the world, which often leads to sexism and patriarchy.  An alternative perspective to understanding how men and women perform their gender identities is to examine the dynamics of the gender system that may lead to an unequal distribution of power created in gender systems in the first place. Ambivalent Sexism created a   20 theory of sexism that showed two positively correlated components of sexism:  hostile sexism (classic prejudice exhibited towards women based on hostility towards their biological sex or gender identity) and benevolent sexism (which is the series of seemingly positive attitudes towards stereotypically feminine qualities that make women subservient and dependent on men) (Glick & Fiske, 1996). In this theory, these components of sexism combined to create ambivalence towards women that propagated the hegemonic masculinities present in gender systems and created inequity in gendered social interactions. Understanding sexism is relevant to this study because research has reported that individuals embody stereotypical gender roles irrespective of their identified gender based on societal messages received about the correct gender assigned to their perceived body (Johnson & Repta, 2014). Therefore, it could be possible that men studying nursing may still experience sexism based on societal messages they have received about the correct gender role societal norms dictate they should be occupying.  Using Glick and Fiske’s Ambivalent Sexism Inventory (ASI) (1996), a team of researchers examined the attitudes of students towards nursing as a profession, and appropriateness of the role of nurse for men and women (Clow, et al., 2014). The researchers found the following: greater exposure to men in nursing increased positive attitudes towards nursing from participants, the stereotypes that men and women held regarding male nurses differed based on the individual’s context, and participants from diverse contexts reacted diversely to men in the nursing role. Participants with benevolent sexism towards women tended to idealize female nurses – which tended to maintain the gender imbalance in nursing. The researchers concluded that ambivalent sexism increased negative perceptions of non-traditional gender roles for both men and women. In a follow up study, they concluded that emphasizing   21 traditional masculinity of men in nursing led to increases in role incongruity perceived and increased negative perceptions of men in the nursing role (Clow, et al., 2015). In conclusion, these studies echo this foundational principle predominant in the literature – the experience of nursing is not difficult for men because of their identified gender. However, men practicing nursing can experience psychological and societal stress when they encounter the following: a lack of support from partners and family, the inability to personally evaluate their own skills and abilities highly, or the perception of greater gender bias in the workplace (Rochlen, et al., 2009). If these factors lead to the experience of psychological and societal stress for men practicing as nurses, it is important to explore the impact of these factors on men studying to be nurses.  What is the Lived Experience of Men Studying to become Nurses?   Much of the literature on the experience of men studying nursing is generated by nursing research and teaching scholarship. This is a prolific area of research; however, many of the qualitative studies available state that their primary purpose is to evaluate student experiences, educational curriculum, and learning activities to increase recruitment and retention of men into the profession. In addition to the quantitative studies already discussed that related to the various components of the Ascent to Competence Framework (Levett‐Jones & Lathlean, 2009b) in nursing education, the studies below focus on the students’ experiences of the educational programs.  Students’ Experience of Being Recruited into Nursing  Whitlock and Leonard (2003) conducted a pilot study using qualitative methodology, semi-structured interviews, and systematic data analysis to understand the motivation of men entering nursing. The researchers expressly stated the ultimate aim of their study was to increase   22 the recruitment of men into the profession in the UK. While the results of their pilot study added to the understanding of the experience of men studying nursing, the researchers focused their analysis and discussion on how to impact recruitment efforts through marketing strategies. In another study nursing educators conducted interviews with undergraduate students, and after qualitative descriptive analysis of the transcripts found the following themes in the participants’ experience of being a nursing student: feeling overworked, feeling unprepared, working to meet conflicting demands, and seeking support and respect from faculty (Magnussen & Amundson, 2003). Again, the discussion of the results primarily focused on how these findings can be applied by educators to evaluate and enhance nursing education. Additionally, Wilson (2005) conducted a study to understand the lived experience of male undergraduate students in Australia, using phenomenological methodology as outlined by Field and Morse (1985). Wilson reported that the participants accepted nursing as an acceptable profession for men; however, he concluded that changes were required in nursing education for men to flourish in the profession.  Next, a team of researchers conducted a qualitative descriptive study specifically with undergraduates in an accelerated nursing degree program to understand the following: why men enter nursing, what challenges they face, and what supports their needs (Conner, et al., 2016). The researchers concluded that the accelerated program appealed to the men participating in the study as this was predominantly a second career training choice for them. This conclusion continues to highlight that while the initial study helped further the understanding of the lived experience of the students, the focus of analysis and discussion of the results centred on the evaluation of the type of educational program the participants were enrolled in.    23 Students’ Experiences of Clinical Placements Students’ experience of clinical placements while studying nursing is another area that has received considerable attention in the literature. As previously cited, Chesser-Smyth (2005) conducted a study using descriptive phenomenology of the lived experience of undergraduates’ first clinical placement experience in Ireland. The researcher found that mutual respect and regard in clinical placements had a positive effect on the experience of the students, and the acquisition of knowledge by the participants led to the participants reporting a higher sense of confidence in themselves. Also, a team of researchers in Iran conducted a qualitative study using interpretive phenomenology to explore the lived experience of Iranian nursing students in their clinical placements (Peyrovi, et al., 2005). After analyzing the themes that they were able to isolate in their results, the researchers concluded that students were paying attention to their knowledge acquisition and practice of caring. The researchers also speculated that students’ self-awareness could have the potential to benefit their future success. Again, while this study added to the understanding of the lived experience of men study nursing, the discussion of the findings was focused on program evaluation. A further study interviewed first year nursing students about their experiences with empowerment during their clinical learning experience using interpretive phenomenology and found that students reported feeling empowered when they were valued as learners, team members, and people (Bradbury-Jones, et al., 2011). This study stayed true to the core principle of interpretive phenomenology and closely examined the lived experience of the participants.   Students’ Experiences through a Gender Analysis Framework A third area that has received considerable attention in the literature is understanding the students’ experience of nursing through a gender analysis framework. This work began in 1997   24 with Evans’s exploration of gender segregation in the profession and the hidden advantage for men prevalent in nursing and continued with a national qualitative study that explored the tensions and contradictions present in the female dominated profession of nursing (Evans & Frank, 2003). Tillman’s (2006) doctoral dissertation used phenomenological inquiry to help understand the meaning of masculinity for male undergraduate nursing students. He found that while participants rejected hegemonic masculinities, they recognized the benefits they received from patriarchal systems in existence, and that nursing education influenced their meaning of masculinities. This echoed the findings of the interpretive ethnographic study of male students’ classroom experiences that found the following themes: male students reported relying on roles and behaviours associated with traditional masculinities, they reported being accommodated but not integrated into their learning experiences, and they reported experiencing incongruity between their educational preferences as men and the predominant techniques available in nursing education (Dyck, et al., 2009).  In conclusion, while there is wealth of research available on the lived experience of men studying nursing, most of that research has been conducted by nurses and nursing educators with two primary objectives. The first objective of these researchers appears to have been assessing the recruitment and retention of men into nursing as a profession. Their second objective appears to have been evaluating the fit and suitability of nursing educational programs and learning activities for the men participating in them. While this research provides a strong foundation for further exploration, most of it is has not been conducted recently. Of the qualitative studies exploring the lived experience of men studying nursing in this review, only a small handful were published in the last five years. Also, in the discussion of the findings related to the lived experience of men studying nursing, there appears to be an imbalance with respect to focusing on   25 the students’ personal and career development as nurses vs. program evaluation of entry-to-practice nursing programs.  Limitations of Past Literature  To summarize the concepts reviewed above, because of the gender system prevalent in society, gender is a ubiquitous system of categorization present in most aspects of human interaction and everyday life - despite the potentially negative impacts of a binary gender system that imposes hegemonic masculine ideologies on the individual and society as a whole. Nursing, as a profession that is numerically dominated by women internationally, is often perceived as a female typed profession. Therefore, both men and women practicing as registered nurses appear to engage in elaborate and complex practices in order to ‘do’ and ‘undo’ societally expected gender norms of masculinity and femininity as they engage in nursing care. Students who are studying to be nurses not only face similar challenges when navigating the gender ideologies present in nursing as a profession, but they also face other unique challenges related to their ascent to competence as a nurse in training.  Currently the literature on the experience of men engaged in nursing implies that men may have a unique lived experience as they study nursing. The available body of literature provides a strong foundation for understanding this experience; however, most of the literature reviewed was not recently conducted. Also, there is appears to be a gap in literature for interpretive phenomenological studies exploring the lived experience of men studying nursing at the undergraduate (entry to practice) level. Therefore, while there is already a wealth of studies that explore this phenomenon, the existing body of available literature could benefit from a current study that is conducted only with men nursing students – to capture the lived experience of men studying nursing prior to graduation from their bachelor’s programs.    26 Method This study continues in the tradition of past literature to explore the lived experience of men studying nursing, with the goal of deepening understanding with regards to the students’ gendered experience. The study addresses the following research question:  1) For men studying nursing, what is the lived experience of studying to become a registered nurse?  This study follows a qualitative research design and interpretive phenomenological approach. Interpretative phenomenological analysis (IPA) (Smith & Osborne, 2003) examines in detail both the individual lived experience and how individuals make sense of that experience (Eatough & Smith, 2017). IPA as a method allows for the exploration of the subtly complex experience of men studying to become nurses, and guides the researcher to understand the rich experience of these men as they make meaning of their experience studying a vocation where they may, for the first time in their lives, not be the dominant gender present. Volunteer undergraduate students in entry to practice registered nurse bachelor’s programs were invited to participate in semi-structured interviews with the researcher. The researcher then used IPA as the methodological approach to thematically analyze the interview transcripts to isolate the core common lived experience of the participants. Findings were shared with participants through member checks, to ensure the final report was an accurate and representative presentation of how the participants made meaning of their experience becoming nurses.  Interpretative Phenomenological Analysis  Interpretive phenomenological analysis (IPA) explores details of how research participants make sense of their own personal and social worlds, with the researcher and the participants as active members in this exploration (Smith & Osborn, 2003). IPA has roots in the   27 Heideggerian hermeneutic phenomenology, which allows for the exploration of meaning within everyday experiences (Reiners, 2012). IPA assumes there is a link between what people say about an experience and how they make meaning of that experience (through their emotions and cognitions). In pioneering this method, Smith and Osborn (2003) also assumed that there is a link between what research participants share about how they make meaning of their lived experience and how the researcher chooses to interpret the participants’ accounts.  Research Design  As demonstrated by the literature review, the use of qualitative research design to explore the lived experience of men practicing as nurses is a well-established approach (Bradbury-Jones, et al., 2010; Chesser-Smyth, 2005; Conner, et al. 2016; Kellett, 2010; Meadus & Twomey 2011; Magnussen & Amundsen, 2003; Peyrovi, et al., 2005; Schmidt, 2016; Tillman, 2006). In addition, qualitative methodology is routinely used to understand the lived experiences of students experiencing a common phenomenon (Liu & Winder, 2014; Pollock & Biles 2016; Salas, et al., 2014). In fact, Guignon (2012) saw the act of becoming a human between birth and death as a bracketed event or phenomenon that is able to be explored using hermeneutic phenomenology. The research design for this study follows in the traditions established by previous literature. However, the subtle departures from existing studies allowed the researcher to address the existing gap in literature and provide findings from a recent phenomenological inquiry that focused only on men in entry to practice undergraduate education for registered nurses in training.  Participants.  Participants were men actively enrolled as full-time students in an undergraduate Bachelor of Science in Nursing (BSN or BScN) Program. Smith and Osborn (2003) state that   28 there is no defined best practice sample size for IPA; however, five to six participants are often sufficient to both reach saturation of meaning and identify a common core experience (Smith, et al., 2009). Published studies using IPA as a method to explore students’ lived experience have ranged from five participants (Liu & Winder, 2014; Peyrovi, et al., 2005) to 17 participants (Salas, et al., 2014). For this study, nine participants who met the inclusion criteria were recruited on a first come first served basis.  All full-time undergraduate students who identified as men, were enrolled in a Bachelor of Science in Nursing (BSN or BScN) program in an accredited post-secondary institution approved by the British Columbia College of Nursing Professionals (BCCNP) in the lower mainland of British Columbia, and who had completed a minimum of one clinical placement or practice learning course at the time of the study were eligible for this study. BSN programs are the gold standard for streamlined and focused paths of entry-to-practice as a Registered Nurse (RN) (CASN, 2018). Also, institutions must be approved by the BCCNP for students graduating from the program to be eligible for licensure to practice as a registered nurse (BCCNP, 2018).  Appendix A summarizes the institutions in the Lower Mainland of British Columbia that offer BSN or BScN Programs, as well as identifying the initial clinical practice placement course within each program (at the time of data collection). The geographic region was limited to the Lower Mainland for convenience sampling and ease of data collection. Eligible institutions for inclusion in this study were as follows: British Columbia Institute of Technology (BCIT), Douglas College (DC), Langara College, Kwantlen Polytechnic University (KPU), Trinity Western University (TWU), University of the Fraser Valley (UFV), and Vancouver Community College (VCC).  The University of British Columbia’s Vancouver campus was eligible based on   29 program offered and geographic location; however, it was excluded to avoid conflict of interest for researcher and author.  Participant Recruitment  IPA requires the recruitment of a small number of participants from a homogenous sample pool to allow the researcher to explore the rich and thick lived experience of the participants (Alase, 2017). Purposive criterion sampling strategy was used to recruit participants. Appendix B is the Research Study Recruitment Poster, and Appendix C is the Research Participant Consent Form. Together both Appendix B and C created the study advertisement. The study advertisement was directly circulated to students via faculty and staff in the various eligible BSN or BScN programs (as outlined in Appendix A). The study advertisement was also circulated through social media by the researcher. Interested participants contacted the researcher via phone or email. The researcher conducted a brief phone interview with volunteers to assess fit with inclusion criteria (see Appendix D for protocol).  Participant Demographics  At the time of their interviews, of the nine participants five were in the final year of their BSN or BScN program, while the rest had reached the halfway point of the respective programs. All participants identified as Canadian, one identified as second generation Canadian, and two identified as Canadians of Asian descent. Ages ranged from 22 to 39 years of age (Mean = 29). In terms of educational background or vocational training, seven of the nine participants had completed at least one additional bachelor’s degree or vocational training program prior to their engagement with this nursing bachelor’s degree. All participants identified as male, five of the participants identified as heterosexual, two of the participants identified as gay, one participant identified as questioning, and one participant did not identify their sexual or emotional   30 orientation. Four of the participants lived with their long-term domestic partner, two were married and lived with their spouse, and the rest were single or did not specify their relationship status.   Data Collection and Overview of Activities Eligible participants set a mutually beneficial date, time, and location for their face-to-face semi-structured open-ended interview with the researcher. To maximize ease of access, interviews were conducted in private meeting rooms in educational institutions, libraries, and community centres normally situated in the city or municipality of the participant’s choice. The researcher reviewed Informed Consent Forms (Appendix C) with the participants twice: once during the initial phone interview, and again before the start of the face-to-face semi structured interview. Informed consent was obtained from participants prior to the start of the interview.  Interviews were audio recorded and transcribed and ranged from 61 to 110 minutes, with a mean interview length of 81 minutes. These semi-structured interviews were guided by the protocol in Appendix E; however, each participant was provided with the freedom to share their significant experiences as they saw fit. Observations were recorded by the researcher, which included the participants’ accounts, as well as the researcher’s own reflections on these accounts. When appropriate, the researcher followed up with open-ended and probing questions to better understand the participants’ cognitions, feelings, or relationship to the story as a way to gather rich information about the participants lived experience (Creswell, 2007). During the interview, participants were provided with the opportunity to complete a short anonymous survey included with the Informed Consent Form (Appendix C) to provide optional demographic data to assist the researcher with placing the participating students within the larger general pool of students studying nursing. Audio-recorded interviews were transcribed verbatim, using listening of the   31 recordings by the researcher. Following analysis of the interviews, thematic findings and the final product of researcher’s analysis were forwarded to participants to allow for member checks and feedback as a validity measure.  Data Analysis Interpretive phenomenology is defined as a cyclical and iterative engagement with the text provided from participant interview transcripts to identify, interpret, and explore patterns that arise with respect to how participants make meaning of their individual lived experience (Smythe, et al., 2008). These patterns help researchers explore what is collectively shared amongst those who experience the same phenomenon (Van Manen, 2016).  IPA Approach  IPA methodology allows for guided structure to support the iterative process of the exploration of meaning making by those experiencing the same phenomenon (Smith & Osborn, 2003). The researcher chose to complete the verbatim interview transcripts herself, to create a foundation for deep engagement with the text of each interview. Each transcript from each individual participant was read several times, analyzed for literal meaning and themes, and then re-reviewed both for interpretations and deeper meanings within itself, and for the emergence of patterns of themes and categories between interviews. During these readings the researcher identified themes and subthemes informed by the literal meaning of the participants’ lived experience, and the researcher’s interpretations of these accounts. Then all the emergent themes were combined into one master list, and transcripts of all the interviews are cross referenced to explore which themes appeared in which texts as a common thread. After the themes and subordinate themes for all participants were reviewed, analyzed, and cross referenced, a final statement was crafted outlining the meanings embedded in the participants’ collective   32 experience. In IPA, the participants are active co-creators of this analysis and narrative account. Therefore, participants were provided with the opportunity to read the final product of researcher’s analysis and provide feedback from their perspective on what was produced.  Situating the Researcher in the Study  Because IPA is both an investigation of how participants make meaning of their lived experience, and how the researcher interprets what is shared from their lived experience, it is important to situate the researcher within the context of the study – both in the research design, and during the process of obtaining consent from the volunteer participants (Eatough & Smith, 2017). While reviewing the Research Participant Consent Form (Appendix C) with the participants, the researcher outlined how she situated herself within the study as a researcher, counsellor in training, and student affairs administrator in Nursing education. Participants had opportunity to review the consent form as part of the research advertisement before contacting the researcher to volunteer, ask questions about the study, and learn about the researcher’s connection to the study, during both the preliminary phone interview and the face-to-face interview for the study. Here I will situate myself within the research design from the scholarly perspective.  For successful phenomenological inquiry, the researcher must have access to the culture and the community being explored. In addition to studying Counselling Psychology as a graduate student, I have also been providing academic and student support services at UBC Vancouver’s School of Nursing for eight years. Through this professional affiliation, I have obtained access to the community and culture of nursing education. Therefore, I am connected to this community as an administrator and facilitator of educational experiences for others. It is primarily through my professional role that I have come to identify the importance of continuing to add recent student   33 voices to be the body of literature surrounding best practices in the arena of guidance and counselling of adults perusing education to aid with career development or career transitions. However, I am not a practicing nurse or a nursing educator which benefited this study in two significant ways. First, it provided the participants with additional layer of anonymity to share their experiences without any connection to academic or practice-based evaluation of their competencies as a nursing student or nurse in training. Second, my academic and professional interest as a graduate student in counselling psychology allowed me to stay true to one of the main aims of IPA, which is identified as drawing attention to how “felt meaning” is communicated to others through analysis of lived experience (Eatough & Smith, 201, p. 11).  As a Student Affairs professional, I care deeply about the experience of students participating in nursing degree programs, which allowed me to commit to the close examination and interpretation of the lived experience of research participants (Smith, et al., 2009). However, throughout the process of research design, data collection, and analysis I was mindful that over the last 8 years of facilitating nursing educational programs and student support services to, I may have adopted preconceived notions about nursing and nursing education. For example, I may have been anecdotally already been aware of, or perhaps personally encountered or witnessed, some of the patterns and themes identified in the literature review about the experience of students studying nursing. However, it was important that I remember this study was not about my experience of men studying nursing as an outside observer and facilitator. It was crucial to be mindful that what I was asking for was access into the participants’ world through their stories and their reflections on their experience. Qualitative studies using IPA need to be participant-oriented in nature (Alase, 2017); therefore, as a researcher I needed to be   34 mindful that I was making sense of the participants’ accounts, as they made sense of their lived experience of nursing education.  To ensure this mindfulness, I engaged in active and reflexive journaling about these preconceived notions – from research design, to interviewing participants, data analysis, and writing of the final report - to help decrease the risk of bias. I also regularly sought reflexive consults with my faculty supervisors and academic peers in both counselling and nursing education.  Trustworthiness of Study Findings  It is well documented that establishing rigour is the researcher’s responsibility (Creswell, et al., 2007; Hays, et al., 2014). Phenomenology requires authenticity, reflexivity, and genuineness (Creswell, et al., 2007). To ensure trustworthiness and rigour, as the researcher I engaged in a practice of reflexivity throughout the research process – from proposal to final product. This included journaling and reflexivity during research design, data collection, and data analysis; reflexive reading of journal articles; meetings with my research supervisor to discuss my reflections; and keeping a journal of notes to minimize bias, increase transparency, and add to the validity and rigour of the study.  The first step in minimizing bias was identifying the biases that may have already existed. As a researcher and author, I had to be aware of three sources of potential bias. The first source of bias is often common in IPA studies, because the researcher is often both a human experiencing a phenomenon being explored, and the unbiased researcher observing how others experience that phenomenon that is the subject of the study (Alase, 2017). Second, there could be potential bias related to my dual role as a researcher of the student experience and a provider of   35 services to students (Noon, 2018). Finally, there could be potential bias related to how gender and sex is conceptualized in this study (Johnson & Repta, 2014).  The first source of potential bias was minimal in the context of this study – I am the researcher observing the lived experience of the participants; however, I am neither a nurse in training nor a man. However, as discussed early the second source of bias has greater potential in my specific context and circumstance. While situating myself as the researcher in the study, I identified the biases and assumptions that may have come from my connection to nursing education, and how these biases may have impacted my role as a researcher. By eliminating UBC Vancouver’s BSN Program, I ensured that there is no prior association between the research participants and myself. Participants were also informed during the process of obtaining informed consent (Appendix C) that there are no current or future academic consequences should they choose to participate or withdraw from the study at any point.  Finally, there is always potential for inherent bias related how gender and sex are conceptualized in research studies (Johnson & Repta, 2014). The upcoming section outlines the biases related to the conceptualization of gender and sex in research in general, as well as in this particular study.   Gender Related Biases and Assumptions.  There are two main sources of bias related to gender and sex. First and foremost, research is a socially constructed enterprise, and thus gendered in practice (Johnson & Repta, 2014). Not only does gender conceptualization have implications for all aspects of research design, but also research questions and methodologies are influenced by “processes and research institutions imbued with gender bias” (Johnson & Repta, 2014, p. 19). Second, according to their theory of gender systems, Ridgeway and Correll (2004) identified all mixed sex interactions as interactions where gender is effectively salient, and it could influence bias in the evaluation of self and   36 others. As I identify as a cis-gendered heterosexual woman, my gender identity makes interviewing men an example of the type of interaction where gender is effectively salient. However, the principal investigator and supervisor of this study identifies as a man, did not participate in conducting the interviews, and participated in the reflexive second read of the anonymized transcripts and thematic analysis to add to the trustworthiness and rigour of the findings. In addition to my supervisor who identifies as a man, I was able to participate in reflexive consults with nurses, counsellors, and scholars in nursing and counselling psychology throughout the study to examine personal and societal biases with regard to gender and gender roles in the professional avenues of career development and education.  Measures of Validity, Credibility and Rigour  Table 1 demonstrates identified measures for increasing the credibility of qualitative research (Shenton, 2004), and how those measures were incorporated into this study. Table 1 Measures to Increase Validity Implemented in Current Study  Measure to Increase Validity (Shenton, 2004)   Implementation Strategy in Current Study  Using methods previously well established, and familiarity with available literature to assess congruence of findings with past studies  Extensive literature review conducted to identify existing studies & methodological practices relevant to the lived experience of men practicing as nurses, nursing students' lived experience, and phenomenology in vocational and academic training of adult learners.   Early familiarity with the culture of the organizations being studied   Academic & professional qualifications of graduate student researcher and author (graduate prepared Student Affairs professional with 15 years of professional experience supporting students in post-secondary, and 8 years of professional experience supporting nursing education).                                                                                                           Faculty specializing in Nursing Education, Vocational Training, and Career Counselling on supervisory committee.     37  Participant triangulation to allow for verification of individual experiences against each other    As identified in the participant demographics, participants represented a wide range of the total pool of people experiencing this phenomenon. While all the participants shared their gender identity and were enrolled in the same type of current degree program, that is where the similarities end. Their ages spanned a 17-year range, and they represented a diversity of educational backgrounds, career and personal developmental life stages, relationship statuses, and sexual and emotional orientations.    Site triangulation to allow for minimizing the impact of local factors from one particular institution on the study    The study intentionally recruited participants from seven different institutions – with different levels of classification as institutions of higher education (college vs. university), different types of BSN or BScN programs (accelerated, advanced standing, direct entry from high school, and bridging programs), and a diversity of institutional, faculty, and educational cultures. This reduced the impact of any student experiences that may have been localized to a single program or curriculum.    Anonymity and safety to ensure participant honesty  Assuring participants of the safety and low risk nature of the study during the process of obtaining informed consent (Appendix C) and outlining for participants the use of established data management practices allowed for the anonymity and confidentiality required to increase honesty of participants.    Iterative questioning and probing to create the possibility of thick description in data analysis and reach saturation  Eligible volunteer participants set mutually beneficial date, time, and location of interviews. The researcher travelled to the preferred municipality or city of the participants to increase of access to the study.                                                            Interviews with participants ranged from 61 - 110 minutes (Mean = 82 minutes, 45 seconds) which allowed for iterative questions and probing for participants, and this allowed for thick description of phenomenon (studying nursing).   Member checks with research participants prior to finalizing the research product  An anonymized summary of each interview, as well as a summary of the core shared experience themes as identified by all participants, was shared with each participant individually. Once participant feedback was incorporated into core experience summary, and the individual themes identified within that summary were refined based on participant feedback, each participant had an opportunity to review the anonymized quotations from their personal interview before finalization of the report to facilitate their co-creation of the study report. Once participant feedback was incorporated, a copy of the final research report was shared with participants for second round of feedback. 78% of participants actively engaged with member checks and provided feedback to the author.    38 Member Checks and Reflexivity  In qualitative studies, member checking – or providing participants with an opportunity to provide feedback on the final research report – is a commonly used reliable way to increase trustworthiness and rigour of phenomenological inquiries (Alase, 2017; Creswell, et al 2007; Shenton, 2004). This practice is also known as participant or respondent validation (Birt, et al. 2016). However, as with any research tool, it is important for the researcher to know what the potential risks of member checks may be – especially with a small sample of an easily identifiable group of participants. While Hallett (2013) agrees that member checks are vitality important to establishing credibility and trustworthiness in the study findings, he identifies that one of the risks of triangulation – either participant triangulation or site triangulation – could be the loss of privacy and violation of participant confidentiality through member checks done right. During this study, the researcher was mindful of this throughout the process of study design, participant recruitment, and building rapport and relationships with participants to obtain informed consent and conduct the study interview. As identified in Table 1, participants were provided with not one, but four, opportunities to engage with the data analysis by reviewing the core summary experience, providing feedback on the themes identified from the analyzed data, and reviewing quotations from their personal interview prior to finalization of the report. The fourth and final opportunity for engagement was receiving the final study report prior to the final defense. The researcher and author encouraged them to voluntarily engage in this process to ensure the study authentically represents and lived experience and captures their voices. Seven of the nine total participants actively engaged with member checks throughout the data analysis process. These participants provided feedback to the author that allowed for validation of the core experience summary, refinement of themes and structure, confirmation of accuracy of   39 interpretation based on how quotations were represented. Overall, they identified that the core experience and themes resonated with their lived experience, and a few were pleasantly surprised to have their lived experience normalized through the common lived experience of their peers.  In addition to member checks with the participants of the study, as an added reflexivity measure, the author consulted with two men practicing as registered nurses and nurse educators from her personal and professional networks. Care was taken to protect the anonymity of the participants in these consults, and these men were not connected to the participants, participants’ institutions, or the study. The anonymized overall core experience summary and themes (without any participant quotations or identifying information) was reviewed with these colleagues to explore if these findings resonated with their experience of men nursing students today. Both of these nurses provided feedback that not only did this description of the lived experience of men studying nursing resonate with how they experienced students in the practice and learning environments, but also that many of the themes identified resonated with their own experience of their undergraduate education as they were becoming nurses.  Final Presentation of Data as Validity Measure  Inviting feedback and consulting with research supervisors, as well as inviting scrutiny from peers and academics are additional measures that add to the rigour and validity of qualitative research (Shenton, 2004; Creswell, et al., 2007). During research design, the study proposal was vetted and approved by the research supervisory team prior to finalization of research question and methodology. This included an oral defense of the study proposal prior to submission for Ethics Approval from the Behavrioural Ethics Review Board (BREB). The final presentation of the findings culminated in an oral defense, and the submission of this master’s thesis to the Faculty of Graduate and Postdoctoral Studies at UBC. Upon completion of the   40 study, the researchers explored the opportunity to invite further academic scrutiny by investigating dissemination of the presentation of the final report at professional conferences or publication in peer reviewed and professional journals.  Ethical Considerations Research ethics approval was obtained prior to the start of data collection from all relevant institutional bodies, including the home institution of the researchers and any of the institutions where students were eligible to participate as volunteers. The home institution of the researchers was eliminated as an eligible site for data collection to eliminate conflict of interest. As outlined in Appendix C, informed consent was obtained from all participants. During this process potential risks and benefits were thoroughly reviewed with participants. As the participants were sharing accounts of educational experiences, ethics review boards identified the study had minimal risk. However, a list of institutional and community resources was provided to each participant at the end of the interview to mitigate even the minimal potential for risk associated with the study. Participants were assigned anonymized participant IDs and pseudonyms, all identifying information was removed from data in final report to protect the confidentiality of participants.  Data Management.  All participant consent forms, digital recordings of interviews, and files related to data collection or analysis were stored on encrypted and password protected devices locked in a secure location in compliance with regional and institutional data security regulations. All participants were assigned participant IDs that were kept in a separate secure location. Participants were informed on data security measures, as well as measures in place to protect their privacy.   41 Findings The main purpose of this study was to explore the lived experience of men studying to be registered nurses as they engage in Bachelor of Science in Nursing degree programs. The goals of this exploration were as follows: to add the voices of recent prelicensure undergraduate students to the current research literature, to further the understanding of undergraduate students’ experience of gender relations and traditionally restrictive gender norms as they study to become registered nurses. In order to realize these goals, the study attempted to answer the following research question: For men studying nursing, what is the lived experience of studying to become a registered nurse?  A Note on Themes Presented within the Common Lived Experience    To address the research question for the study, and ensure that participants are encouraged to share their full and rich lived experience of studying to become a registered nurse, the question used in the semi-structured individual interviews, as outlined in Appendix E, was as follows: What is your experience of studying to be a nurse? However, the study inclusion and exclusion criteria (as outlined in the methods chapter) narrowed the pool of potential eligible participants only to those who identified as men. Upon first review of the analyzed data, it may appear that only some of the themes and patterns that emerged were explicitly related to the participants’ identified gender. However, within society’s current gender systems, gender norms are ubiquitous. Therefore, even the parts of the lived experience of participants that appear to be unrelated to their identified gender are still a component of their gendered experience as men studying to become nurses.    42 A Note on Presentation of Analyzed Data  The findings of analyzed data, which included an individual interview with each participant, are presented in this chapter. As previously identified, anonymous quotations from participant interviews were identified by assigned participant pseudonyms, and they were used to develop the rich description of the phenomenon and increase trustworthiness of findings. However, where identifying information within the quotations is required to demonstrate how participants made meaning of their experience, participant pseudonyms are withheld to maintain confidentiality of participant identities. Overview of Findings Overall, from the perspective of the men interviewed, studying to become a nurse aligned their personal values with their vocational choice. By choosing to study nursing the participants gained direct access to the practical application of scientific knowledge and health care expertise in an impactful person-centered manner. From the participants’ perspective, becoming a nurse combined their interest in scientific application of knowledge with their desire for a professional role that provided financial stability and recognized them for making a difference. They appreciated that nursing recognized the importance of strong relational practice as a cornerstone of the profession. They also valued the chance to be recognized and celebrated for their practical application of health science knowledge. With professional access to this avenue of health care practice, they felt there was a potential for vocational fulfillment. The experience of becoming a nurse also aided the participants’ ability to develop and refine their relational practice skills as it related to their life, their career, and the practice arena. These men made meaning of their experience by reflecting on the relationships they had with their peers, their instructors, and their patients.    43 The following five themes emerged from the data analysis of the lived experience of participants:  1) aligning purpose with personal values, 2) feeling at home in the profession, 3) processing the effects of historic assumptions, 4) feeling supported in their journey, and 5) wishing for missing experiences. The first theme of aligning purpose with personal values was the most salient in participants’ reflections. This theme included the following subthemes: changing course, mastering the application of science, and focusing on building relationships. The second theme of feeling at home in the profession was subdivided into the following three subthemes: defining ‘a good nurse,’ being accepted as a nurse, and learning that acceptance is mostly universal. The second theme of processing effects of historic assumptions was subdivided as follows: experiencing assumptions from the general public, experiencing assumptions from educators, and reframing to dismantle assumptions. Finally, the fourth theme of feeling supported in their journey was subdivided as follows: relational sources of support and supportive personal attributes.  In conclusion, by studying nursing the participants aligned their personal and professional values by embracing the role of becoming a nurse. Each theme represents a focal point for the participants’ common lived experience and assists in understanding and providing order to how they made meaning of their experience of completing an undergraduate Bachelor of Science in Nursing degree and becoming a registered nurse.  Aligning Purpose with Personal Values  For the men interviewed, studying nursing meant engaging in purposeful career training in order to align their vocation with their personal and professional values.     44 Based on the analysis of interview data and participant feedback post-analysis, this was the most salient finding that identified how the participants made meaning of their experience. As demonstrated by this participant’s account of how he chose nursing as a vocation, becoming a registered nurse was seen by the participants as a career that was worth the risks and challenges associated with the profession.  I was like man that would be a very fulfilling career, but I have this awesome job that would be very tough to walk away from. But then I consulted my [partner] and thought, let’s give it a shot! I had a great job… I could support my family for the rest of my life… it was entertaining… but it [wasn’t] fulfilling. And so that’s the main [reason], that’s why I’m in nursing. To try and get a fulfilling job. (Jack)  Changing Course As identified in the overview of the participant demographics, study participants included both men who had chosen to study nursing directly after high school, and men who had chosen to complete a Bachelor of Science in Nursing after completing previous degrees or vocational training. Regardless of prior educational or vocational background, going back to school to become a nurse was a deliberate change in profession or shift in academic training.  Sometimes, the decision to change course was precipitated by the participant experiencing dissatisfaction with a series of previous vocational choices.  I guess I had a couple of kicks at the can before I ended up here… Before this I had several sort of a false start careers. After high school I worked… Then I went back to school and got my degree… Unfortunately, I found myself in a large amount of debt… So, [I worked]… I guess the ‘how I got into nursing’ is that I paid off my student loans, but I found myself very unhappy, and wanting more meaning. (Tom)   45 Alternatively, another participant chose to change careers not only because of the absence of fulfillment, but also because they experienced the presence of negative personal consequences from their current job.  I did another undergraduate degree beforehand. Completely unrelated. I started working in that field, and then after a while… I started getting bored and depressed, and stuff like that. So I started researching other career paths. (Charles)  At times, the choice to become a nurse centered on participants being drawn to clinical practice and not being drawn to other more traditional avenues. One participant chose nursing because it allowed provision of health care services in this specific clinical capacity.  After university I realized I didn’t want to pursue a career in medicine, it wasn’t really quite right for me. I decided upon more of an administrative role. And from there, I went from working mostly in… administrative roles to wanting to do a little bit more of a clinical aspect still. So that’s what drew me back to nursing on top of the [health care] work environment. (Tim) Whereas another participant became a health care provider in a serendipitous way and was drawn to becoming a registered nurse through happenstance.  Once I started nursing, I started seeing… what the lifestyle I was living did to you and your body, and your family… Nursing just gave me a new perspective on life and how fragile people are. Before it was all about how tough you were, … now to me toughness is just a word, and we’re all fragile beings. (Fred)  Even for the participants who engaged with BSN programs directly after high school, they deliberately chose to complete this specific degree - their decision was usually as a result of a lack of fit between what they wanted to do professionally and their initial program of study.   46 Basically, I was in college for [major]… I realized after the first semester not for me… After studying some biology, and talking to academic advisors, they recommended nursing, and then I researched the career. I’d never really thought about it before. Researched the career, watched some videos about what nursing entails, etc… and decided, yup. (Jaime)  Sometimes the shift in program of study occurred swiftly, during their university career – as in the above example. At other times, the shift in academic interests and goals started earlier and took place more gradually – as it did in the participant example below.  This is all started when I was [young]. I was like, maybe I’ll go to med school. And then I volunteered more in health care and realized that doctors don’t actually spend a lot of time with their patients. Sometimes they don’t get to build the connections that people actually working bedside get to. (Andy)  Mastering the Application of Science  Regardless of why they chose to become nurses, the men were proud that they now had direct access to expertise and practical application of scientific knowledge in an impactful person-centered way. One participant identified that his engagement with health science application, and nursing’s connection between service delivery and application of science was his source of pride, and one of his main reasons for satisfaction with his chosen profession.  I have a previous degree... I wanted to put that to work in my career. I discovered very quickly I didn’t like being a lab tech. I stumbled on nursing after successive years of just trying out various employment. It was an effort to put my science background to work, but also work directly with people – which were my most fulfilling jobs to date. And that’s how I came across nursing as a profession. Using my science background   47 and engaging with the medical sciences is a big part of my satisfaction from nursing. (Rob)  Another participant spoke jovially beaming with pride as he recalled an anecdote about one of his most memorable patient interactions as a student nurse - one where he was able to successfully carry out complex nursing skills that required the application of scientific knowledge in a high-stake environment.   This one’s probably not the one you were looking for, like the big emotional thing. One time, a doctor asked me to hang an IV for an acute case, and [the patient] was super tachycardic too, and I was just like holy moly… Super sick person, super high alert med, first med, and our instructor had a reputation for being hard core, so I was like, alright. I was kind of freaking out on the inside… I was like, holy moly – I’m actually doing this. Went well though! [Andy] Focusing on Building Relationships  In addition to an affinity for the application of scientific knowledge involved in providing nursing care, the men in this study also held a deep-seated personal value for relationship building and relational practice. Nursing provided them with the opportunity to be both recognized and celebrated for their commitment to excellent relational practice. With these relationships… it just feels like there’s more of an importance to it? When something goes wrong in hospital, and it doesn’t have to be something medically wrong, it’s just a relationship that goes south – and a patient experience has some sort of a negative interaction, it’s horrible for them… When you’re doing well with those patients… it really feels like you’ve saved suffering. (Rob)  Also, by studying nursing the men developed and refined their relational practice skills.   48  I found being in nursing I can communicate better… I feel like I’m able to listen more to people… I could see and read them a bit more… and in that sense, looking at non-verbal cues, similar to verbal cues. From there acknowledging their feelings, and from there compare their mood and affect, and try to piece that together with the context they’re going through. (Pat)  From the participants’ perspective, studying nursing connected them to a well-respected professional role that combined relational practice, teamwork, and the evidence informed application of scientific knowledge in a meaningful and fulfilling practice arena within health care.  Feeling at Home in the Profession  Despite the scarcity of men in nursing, the participants experienced feeling at home in the profession, which provided them with a source of pride and personal accomplishment. This experience of pride and accomplishment in finding their professional fit in nursing appeared to be linked both to the men’s mastery of scientific disciplinary skills needed for exceptional nursing practice, and acceptance of their mastery of required nursing skills by others. From the participants’ perspective, they felt that at this moment in time in our society, it is normal, and in certain cases appreciated, to have men practicing as nurses. I think it was a great experience in peds [pediatrics] – and in OB [obstetrics]. I think a lot of the fathers for example were happy to have another guy around. Not to say they have to feed off of male energy – that sounds a bit odd. But a lot of the times they feel like, ‘oh, I can talk to [you] about um… about my fears and my concerns.’ And sometimes they just needed somebody to talk about things that aren’t about the kid. Sometimes the parents need taking care of too. (Tim)   49 Sometimes, connecting with patients because they were men – not in spite of their gender - confirmed the value they can bring to the role, even in a practice setting where they may normally feel out of place.  There was this one family…  the baby actually couldn’t breathe, so it went straight to NICU [Neo-natal Intensive Care Unit]. And the dad and me just went and hung out in the NICU for a few hours together, and I just supported him… I got to feel the sense of uncertainty from the dad but be able to comfort him, in a way. It felt nice to be in that position and be able to help. So that was really one of the times that I felt as a student nurse, I was able to actually help… (Jaime)  Defining a Good Nurse. First and foremost, the men interviewed experienced a sense of professional belonging that stemmed from a common belief that providing quality nursing care had no association to gender identity, gender expression, sex assigned at birth, or sexual or emotional orientation of the nurse providing the care.  I know people see male nurses and female nurses differently, but to me the way that people have always accepted me is all depending on my approach. If I look busy, rushed, people don’t treat me as good. But if I look like I’m going to spend time with them, or [appear] more caring, people are much more accepting. (Fred)  All the participants believed their gender was not significant or salient in how they provided nursing care. However, they also recognized that their presenting gender could be salient in interactions with patients, and they were pleasantly surprised when it was not as prominent of an issue as they predicted.    50 I was really worried about providing things like peri care – like you know changing people, washing people with catheters, that sort of stuff – for women. Because I felt I really didn’t want to make anybody feel uncomfortable… It’s not as uncomfortable as that may sound, in a medical setting – if you’re professional. So, I was just surprised. It was surprising to me that people accepted care, and are thankful for receiving the care, and there wasn’t as much awkwardness. (Tom)  In addition to acknowledging that their gender was seen by others as a salient presenting aspect of their identity, the participants also recognized that traditional gender roles and historic assumptions related to nursing may have led others to make assumptions about their sexual and emotional orientation.   It’s none of their business, so if that’s what they want to believe… It doesn’t matter to me. If they think I’m gay, they think I’m gay… It has nothing to do with my nursing! Denying you’re gay is a weird thing – it’s almost like you’re ashamed of that, which is not right… Ya… so I usually don’t address [it]. (Anonymous Participant)  The participants were also pleasantly surprised that acceptance of men as providers of nursing care by patients was often true across most modern of cultures, as well as among children, youth, and most adults.  As they made meaning of their experience by reflecting on their educational journey, the participants identified people who were exceptional practicing nurses without focusing on the gender of the nurse as the salient presenting characteristic in their descriptions. Sometimes the identified exemplary nursing role models were the nurses they were shadowing in practice.   Another great part of nursing school is sort of checking in with the facts of reality – in some ways. And in that [specific patient’s] case, I feel it was very well handled by the   51 nurse [I was shadowing]. And so I looked at the nurse, and the way she handled that, and it was like the best – like that’s the nurse I want to be! (Tom)  While other times the role model nurses were their clinical instructors.  With mental health [nursing] the skills are not hard skills (like IV’s and injections). It’s all like soft skills, communication. That takes years and years to build up, and it’s apparent through my instructor who I admire. She was like the pinnacle of mental health nursing. It really made me appreciate her ability to talk to others and understand them. That’s like end goals there if I ever want to go into mental health, being able to dive into someone’s like personality, their context, their lives. (Pat)  However, in addition to identifying exceptional role models, the participants also singled out antimodels, nurses who did not embody their ideals for nursing. In these cases, like the one below, the participants were motivated to not emulate these examples.  You see nurses on the ward who’ve just kind of… dropped that out of the profession. They’ll get everything done, their patients will get discharged, they’ll be… more or less healthy, but…. You haven’t really made an impact on someone’s life there? If you put some thought into [the patient’s specific circumstance], then you have – hopefully – made a tangible difference in that person’s life. Even if it was just a positive experience in health care setting… I think because I’ve thought about it, I’ve chosen to incorporate it into my profession, but some people just don’t. (Rob)  From the perspective of the participants of this study, they felt that great nursing is more about how you nurse, and less about who you are.    52 Being Accepted as a Nurse.  For the most part, participants were pleasantly surprised, and they were happy to receive positive reactions when they shared their choice to become nurses with others.  My friends were all super supportive, they were like, ‘ya! that sounds like you’d be good at it! It’s nice that you’re planning something that you’re passionate for!’ I don’t think people treat it positively or negatively - maybe slightly positively? Just like in a way that you know, you met a firefighter you’d be like oh cool that you’re doing good work… But then it’s just going to the background, not the foreground or anything. (Charles)  Acceptance is Mostly Universal.  Prior to starting their journey, the participants had either heard stories or received advice that they were going to be facing challenges, or they experienced bringing with them their own anticipated ideas of potential difficulties. However, after choosing nursing and engaging with the profession, they were comforted to see the anticipated challenges were absent most of the time.  I think initially I thought that there was going to be some negative feedback. But all I know- it’s been actually surprisingly positive. Both from co-workers, from patients, from family members, friends have all been pretty positive. So, I’m happy. (Tim)  Participants also reported being pleasantly surprised at being accepted, and even valued, by patients from more traditional cultures of origin.  A lot of the Asian populations had no problem with the guys … Sometimes there would be like a c-section I could go observe, or a woman labouring. Lots of woman let me watch the birth, and they were fine with that, which was great. (Jaime)   53 From the participants’ experience, this general acceptance of men as nurses may be a result of the evolution of society’s cultural climate over time. Alternatively, some identified this acceptance as being linked to the status of their chosen profession in North America – a place that values and respects nursing as a vital profession in the healthcare eco-system and strives for gender equity despite the strong influence of traditional binary gender systems.  I think education now-a-days is set up in a way that you’re able to succeed regardless of gender. We’re not being asked to disregard gender; we’re being asked to celebrate it. So I think that’s kind of an important thing to realize that… it’s not that we’re trying to take it [gender] away from the conversation, it’s that we’re trying to say… how can we incorporate each one of those [characteristics] into the opposite gender so that we can all work better as a team? (Tim)  Processing Effects of Historic Assumptions  As previously identified, the participants felt their identified gender and the minority status of their gender in nursing were mostly insignificant in their overall lived experience of studying to become nurses. However, they did unanimously acknowledge that today’s level of acceptance towards men in nursing did not always exist. Processing the effects of historic assumptions about gender roles in nursing was perceived to be infrequent by the participants. However, this was still a significant issue the participants reflected on and identified as having had to navigate as part of their experience of studying nursing.  Like maybe it was something 20 years ago, or maybe 15 years ago. Like the ‘men in nursing may be effeminate’ thing, or some question mark gender roles or something like that. But I don’t experience that anymore, nor would I. (Jack)   54 In fact, the participants felt that experiencing the effects of historic and traditional assumptions about gender roles in nursing was so rare, that some participants had never experienced any differences between their experience and the experiences of their women peers.  So far, I don’t notice anything different between myself and my female peers in terms of interacting with patients. I think because patients are very receptive to student nurses. (Pat)  The men interviewed reported that while it was rare to witness or experience, historic and traditional societal assumptions regarding gender roles had at times led to participants experiencing or witnessing inaccurate assumptions made about how and why men engaged with nursing as a profession. These antiquated assumptions were reported to be infrequent, yet present in the following types of interactions: between patients or the general public and nurses or nursing students, among nurses, between nurses and nursing students, between clinical instructors or faculty and students, and embedded in the nursing educational experiences made available to the participants of the study. To provide context to the previous statement it may help to quantify what infrequent but significant means in relation to the data analysis of this study. Each participant interview was over an hour long, and over half of each interview centered around the participants sharing examples related to how they processed experiencing or witnessing inaccurate assumptions about men’s role in nursing – either in general or their own personal choice. However, in the sharing of these accounts, it was also important for the participants to identify these as infrequent and not the majority of their experience.  To protect the anonymity and confidentiality of the participants it is not possible to share an example for each case, as the examples from the interviews contain many unique identifiers that could betray participant anonymity. However, two broad experiences did emerge for the   55 participants: making meaning of assumptions arising from the general public or making meaning of assumptions made by educators associated with the participants’ programs and clinical sites.   Experiencing and Processing Assumptions from General Public. When the inaccurate stereotypical assumptions originated from patients in clinical nursing settings, the participants’ personal support network, or the general public; participants’ negative emotional experiences ranged from disappointment in themselves or others, to feelings of invalidation or despondency from a lack of recognition of the legitimacy in their career choice to become a nurse. Examples of the interactions between the participants and the general public that highlighted old ways of perceiving the role of men in nursing included the following: innocent and honest mistakes about the participant’s role, or jokes targeted towards other men who were registered nurses practicing in clinical settings with the participants – as highlighted in the example below.  I did have a male nurse which I was following around, and a patient who was kind of making fun of him. I thought, ‘oh interesting, you’re making fun of the actual nurse, but not the student nurse.’ (Pat)  Another example of an interaction that resulted from an outdated and inaccurate assumption was when a nurse in clinical site made an assumption about one of the participant’s physical abilities.  I think one of the nurses went up to me, and was like, Oh, you look strong. Open this package up for me. I’m like, sure! Which is kinda really amusing to me. (Pat)  On a more impactful level, another participant noted the internal conflict that sometimes comes with being refused by patients - as a student or a man. On one hand, the participant recognized that patients have a choice, and the right to refuse care for any reason. On the other hand, the participants always hope for acceptance from patients.    56 I think probably more often you would get turned down for being a student. Uh… rather than your gender. And it does happen – like both scenarios do happen. I guess it’s less than I’d think, but more than I’d hope…? But ultimately at the end of the day it’s their choice, and you kind of have to step away. It’s difficult because you feel it is kind of a commentary on your competence, but [you understand] you’re a student nurse, and at the end of the day… patients come first. (Tim)  Participants acknowledged that in these cases, the rejection sometimes led to disappointment in self because it felt like a judgement on the participant’s ability to master the required skills of providing nursing care.  Finally, another more frequent historical and inaccurate assumption made by patients, members of the general public, or friends and family was the assumption that nursing is a means to an end of becoming a physician for the participants. Sometimes as outlined in the example below, participants’ reactions to this were mild and inconsequential to how they made meaning of their experience.  Once in a while like the very old patients (80 – 90) they’ll come and say, ‘oh are you my doctor?’ and I’m like ‘no, I’m the nurse’ and they’re like, ‘oh, okay.’ And that’s pretty much it. (Andy)  However, this same assumption from patients did at times cause discomfort in the participants who did not want to accept the insinuation that the end goal of eventually becoming a physician was a better or higher status position than the end goal of being a nurse.  I feel like that’s kind of a recurring theme where a patient will try to be really nice to me and they’ll be like ‘Oh you’re really good at nursing, you should go be a doctor later!’…  I think that the only thing that kind of irks me is when they presume that I’m   57 not doing what I want, I’m leaving something on the table, or I can upgrade and do something more important or better. And I’m not sure girls experience the same thing… (Charles) In some cases, as in the following example, the frustration was so significant that the participants felt that the patient’s assumptions felt invalidating.  The other reaction is ‘that’s great how long will it take you to be a doctor?’… Which I’ve never really understood. Because in my mind they’ve always been very separate professions, and there’s been no expectation that one would lead to another… I have very clear reasons of having chased this profession. And I get very concrete solid benefits out of it myself. To have someone not really recognize any of that and literally not see this time of my life which is leading to a finite goal that I’m putting tons of effort into – to then be like ‘oh, ya but then when’s the next thing? When you going to move past this end goal to the actual real profession?’ It’s a bit invalidating. (Rob) Ultimately, participants were uncomfortable with the insinuation that the end goal of eventually becoming a physician was a better or higher status position than the end goal of being a nurse. Excluding the specific assumption that becoming a physician was more appropriate for men than becoming a nurse was, generally participants were either not effected by, or often quite forgiving, when they experienced inaccurate assumptions stemming from historical gender roles in nursing and health care made by patients or the general public. Experiencing and Processing Assumptions from Educators. However, when these inaccurate historic and stereotypical assumptions appeared to affect the participants’ educational experience, their assessment as students, or the provision of patient care, it led to a variety of negative experiences for the men who participated in the study. As in   58 the previous discussion, sometimes the experience resulted only in mild annoyance; however, the participants still felt capable of addressing those responsible for making the inaccurate assumption.  One time I had an instructor… We noticed she would be so nit-picky with whatever the guys did, and the exact same thing would happen with a girl and [that student] would be okay. So we approached her [the instructor] about it. (Jaime)  At other times, participants were confused and disappointment by the experience of witnessing or experiencing their educator making inaccurate assumptions stemming from historic gender stereotypes. However, they were still hopeful there was more to the educator’s story that they were not privy too as students – as identified in the example below.  [There was] one instructor [who explicitly included] guys in her clinical groups ‘to avoid conflict’… It was that whole stretch where it’s a very female centric work force. And there’s that perception that perhaps men are not as meticulous…or don’t have the same type of instincts? And I think most of my colleagues and most of my classmates would challenge that notion. Um… but the fact that the instructor brought it up was kind of a weird moment… I don’t know what past experience she may have had. I would hope it didn’t have anything to do with gender, might have been just that group of people. (Tim)  The most difficult experience for the participants was when an educator’s assumptions impacted how their learning was assessed and evaluated, which had real consequences on their chance for success – both in the program and their future career.  I was surprised [to receive feedback] I had been very dismissive of [my instructor] in front of the class, by… uh… chuckling nervously, or whatever. She felt disrespected…   59 [The instructor and I] had a little bit of a discussion about that, about participating in class, and uh… going forward our relationship was good. Honestly, it was her perception of who I was (to a certain extent) that made her think that that’s what I was trying to express. Because I’m confident. Because I’m large. And because I have a certain way of carrying myself… I can’t really count for other people’s assumptions. I can… touch base with them and make sure I’m conducting myself in such a way that I minimize those assumptions from getting in the way. [This incident] really affected me, because I was like, ‘wow! That’s totally not the person I want to be.’ And it [being perceived that way] really hurt my feelings, and it really made me upset. (Tom)  From the participants’ perspectives, even similar learning opportunities in similar clinical settings were experienced differently, depending on whether or not their educators appeared to entertain stereotypical and inaccurate assumptions with regards to gender roles and provision of care. One participant was able to thrive in a setting where normally nurses who are men are even more marginalized due to the nature of the patient population and presenting concerns. He shares this example about teaching a health skill to a new mom.  [The patient] was young. She was younger than I was. And I remember her and her boyfriend, who was probably more shocked than she was… So just fostering that relationship between the boyfriend who wasn’t super thrilled that there was a guy teaching this. We ended up getting along in the end, but it was definitely… it was difficult. And trying to include him in the whole process too, also having somebody watch me, grading me on the whole situation…But I had a really great instructor, um… and she was super passionate, and actually had extra training in breastfeeding. So I was able to help out with a lot of techniques that she had taught us. (Fred)    60 However, another participant was puzzled, and had difficulty coming to terms with the incongruence between their personal experience of the situation and the instructor’s assessment of their experience.   [My clinical instructor] totally misinterpreted my impression of the situation. Like on a couple of occasions she brought up that she was so sorry, and she could feel my disappointment when someone didn’t want me [to be their nurse], but it only happened one time. I didn’t care, but for her it was a big deal… Kind of creating this situation that wasn’t there – in my experience, in my interpretation. Maybe she saw something I didn’t see, and I’m open to that. But I definitely didn’t see or experience that. (Jack)  In the end, all participants reiterated repeatedly during their interviews that they were very satisfied with their choice to study to become nurses, and they repeated they rarely witnessed or experienced educators treating them in a way that underscored inaccurate historic societal assumptions that are still active today about gender roles and provision of health care. However, each of the participants also had a handful of stories that had stayed with them enough to share during their interview, and these stories negatively impacted their lived experience of studying to become a nurse.  Reframing to Dismantle Assumptions. In addition to processing the experiencing of rare - but significant - instances where historic and inaccurate assumptions about the role of men in nursing that were still alive in today’s otherwise modern and progressive society; all the participants decided to engage in reframing the interactions to dismantle these inaccurate assumptions gently and safely – when they were able to establish trust, time allowed for the hard conversation required, and the context of the situation called for it.    61 I still think it’s a bit of an invalidating statement, this idea that nursing is a caring profession, and only maternal caring people can do it. It’s invalidating to my own experience, but it’s also just insulting to the women in the profession… Caring is definitely a fundamental aspect of nursing, but anyone can care. Anyone – everyone cares about humanity, so I don’t really see the association? And when I see my friend who’s [an acute care] nurse run a code there’s nothing maternal about that, she’s taking on a very strong leadership role. Any conversation that approaches those sorts of divides I always try and actively dismantle, for both sides. I just find it a bit dumb. (Rob)  The most common effective strategy for reframing these assumptions identified by the participants was focusing on the scientific and professional aspects of medicine and delivering quality care. This strategy was effective with patients, as well as close members of the participant’s networks and educators alike. Like [my relative], he is a man’s man, and he was probably one of the worst as far as pushback and the explicitly saying ‘why would you go into a woman’s job’… But our culture outside of nursing school really presents nursing like Florence Nightingale holding someone’s hand at the bedside. And [society doesn’t] talk about the brave moments, or the technical knowhow that you have to have, and the biomedical model that you’re using. I’ve just been telling him what I’m actually doing, and sort of deliberately reframing things to make him understand what nurses actually do? I think that sort of changed his perception of what nurses do, maybe a little bit. Now he’s like, ‘oh it seems like you really found something that’s good for you, and it’s really meaningful. I’m glad that you’re doing this work.’ (Tom)   62 From the participants’ perspective, the goal of reframing these interactions to dismantle the assumptions was not purely to create ease and comfort for themselves, but to also begin to remove the inaccurate gender role stereotyping that was harming both men and women in nursing.  Feeling Supported in their Journey  Another emerging commonality of the participants’ lived experience was their inventory of resources that supported their journeys. These supportive resources were common among participants regardless of the diversity present in the age, culture of origin, relationship status, level of prior education, or developmental stage in life or career of the participants interviewed.  Environmental or Relational Resources. First and foremost, the participants identified that their primary source of support and resilience was having a strong support network consisting of family, friends, and peers. This was the most significant resource for the participants, and this support network was often tied to the reason why they had chosen to become nurses.  I married into a family that loved school… So I told them I was interested in nursing. The fulfilling [career] is good, and my family loves it because it is stable… If not for them, I wouldn’t have chosen [to go back to school]. (Jack)  The participants wanted to care for this support network and valued the long-term possibility of contributing positively to the individuals within their support network.  Another one of the reasons I was thinking about nursing is because of my parents… So the fact that nursing provides you with a pension, that’ll mean that I’ll have some extra money to put aside for them and help take care of them as well. (Charles)   63 Next was a supportive educational environment – within their programs of study and their clinical sites – that consisted of genuine respect and supportive relationships with instructors, role models in practice sites, and collaboration among allied health professionals in clinical sites. This supportive educational environment started with the presence of supportive faculty.  I found that even though I’m super stressed, the nursing program is really supportive. Like very supportive. I could easily approach any of my instructors, tell them my situation, and they’re so receptive towards it, and they are there to support me after. (Pat)  In addition to educators, the participants cherished the community support they received from their peers.  Nursing School? Everybody’s very nice, everybody’s very supportive. It’s a very like team sport I would say. Everybody’s got each other’s backs… Like we have one [classmate] who just made a schedule on excel and shared it with us so we can do things in on time. Or there’s [other classmate] for example this semester who put together notes for this course, so another person did it for like another course, so it’s like very… people take up roles a lot. It’s like one big community I would say. It’s pretty nice. (Charles) Last but certainly not least, all the participants spoke with the same level of admiration for the ideal clinical learning environment, as exemplified by this participant’s account. It’s a very big learning unit – there’s students from all over, all different institutions, precepting… and nurses there are really good at fostering a learning environment – very supportive. And I thought that was amazing, so I was really happy with that. I was   64 really happy that. I thought they fostered a good working environment – they were really nice to us. (Andy) However, it is important to acknowledge that educational environments were evaluated on a case by case basis by the participants – not every learning opportunity or clinical placement in a program was experienced similarly. If the elements of genuine respect, supportive relationships, and role modelling of collaboration were present, then this type of an environment was a source of support. However, as discussed in the previous theme, if the environment was impacted by pedagogy that stemmed from inaccurate and historic assumptions about traditional gender roles and nursing, then on those occasions the environment became a challenge or obstacle for the participant to endure.  Finally, the presence of role models and mentors made a difference to the lived experience of the participants. All the participants acknowledged, and were grateful, that they were surrounded by a plethora of exceptional women mentors and role models in the profession. However, they also identified that it was particularly helpful to have men who could act as mentors and role models – both in academia and in the practice arena. As in the next example shared, it was sometimes the presence of men in the profession that encouraged them to think about nursing as a viable professional role for a man.  Years ago I’d met some male nurses, the stigma was taken down about male nursing at that time. So I was very open to it… I didn’t necessarily buy into the stereotypical male nurse [is] effeminate thing. Didn’t buy into that, it was just kind of a mystery to me. But then meeting male nurses, and hearing about how the career is not only fulfilling, but they find a lot of freedom. So it was very appealing to me when I met those guys. There was no stigma, and no… there was nothing that held me back. (Jack)   65 Whereas for other participants, it was encountering men as role models while they were in training that helped them feel at home in the profession.  I had a few shifts in [emergency]…There was a lot of male nurses there. And I could just totally be myself. Actually, I worked with more male nurses than female nurses in emerge – just where I was anyways – I was triaging and stuff… I didn’t never… feel like I had to act any different in [emergency]. That’s probably the reason that I felt a lot more comfortable, and the fact that there were a lot more male nurses (Jaime) The comfort in nurses who were men as role models was identified by the participants to be because these men had successfully walked the path the participants were walking today, and this aided the participants in feeling hopeful about their own future.   Personal Resources and Helpful Attributes.   In terms of personal resources, the participants felt supported in their experience when they were able to draw on the following personal resources: sense of confidence, learning to identify gatekeepers, personal awareness of privilege, consciously checking in with their definitions of masculinities, and an openness to being in the minority. In terms of confidence as a resource, many of the participants identified their personal healthy sense of confidence – both in their own knowledge and skills as a student, and the value they brought to the profession of nursing – as a significant resource assisting them with their journeys to become nurses.  I’ve got a lot of experience; I’ve always been very confident. Even though I wasn’t reading too much about extensive pathophysiology, I’ve always been very interested in what I’ve done so I’ve read about new techniques… So there’s always tons of stuff. So I’ve always felt very confident, my marks are really good, and I enjoy the material. (Fred)    66 However, it is important to note that participants did not attribute their personal confidence to their gender. Participants identified self-confidence as desirable trait in all nursing students.  All the guys in it [the program] are generally assertive and confident .... And you can see that with the girls too. If they’re not very assertive, or not very confident they’ll get picked on. And the assertive confident girls – like they just rock it, perfect. No problems! They’re awesome. (Andy)  The participants felt reassured when they were able to learn how to identify who the gatekeepers were in any of the educational settings, as this was crucial to their survival in their journey to become a nurse.  Like if you know nurses you know the number one thing in nursing school is how you get along with your clinical instructor. Also, every nursing student needs to watch out for the gatekeepers. There [are] certain people, certain health care professionals, that say that they feel like they’ll be the ones to decide if you have what it takes. And if they think you don’t, they’ll go tell your clinical instructor, and they’ll tell why. (Jack)  Next, participants were mindful that despite their chosen profession and their personal dismal of societally expected gender norms associated with their identified gender, they were not immune to the social preconditioning present in society. I’m not immune to the social conditioning… I try and look at most things in my life objectively, but the image of what a nurse is, or what a doctor is, if I were to just think of that it would probably look the same as any other person in society who maybe didn’t spend quite as much time being more introspective about the thing. (Rob)  Additionally, the participants also acknowledged their awareness of the societal privilege that comes with identifying as a man.    67 Always stops me when I’m reading it… every single time, because I’m the nurse, so I’m putting myself in the nurse’s place and all of sudden it says ‘she’ [and] it sort of breaks that flow? And then I’m like, ‘oh, this must be what it’s like for my sisters when it would say he in stories or whatever…’ That’s an experience that’s new to me as well? It was interesting because it was the first time that I was ever subjected to it. That was the first time where I’ve ever been subjected to a situation where my gender was not the assumed gender? I think that that’s actually been the majority of my experiences when it comes to being male in nursing school. I mean I think that I’m sort of insulated to a certain degree from being harmed by that because I’m privileged in so many other ways. (Tom) However, participants also experienced frustration and anger when they confronted the fact that due to the historic and traditional gender norms in society and health care, many of their women role models, colleagues, peers, and instructors have not had the same access to privileges they have access to. This was particularly salient for the participants who identified as heterosexual cis-gendered men. Like I don’t feel threatened … My female friends share really inappropriate situations [they experience]. Like one of my friends was even groped already. Like I don’t face that - that’s the male experience of nursing. I don’t get half that stuff, not even a quarter (that I hear my female friends report to me). Which makes me pretty frustrated. (Anonymous Participant)  The participants also experienced that it was not possible to dismantle the historic assumptions prevalent in nursing without engaging in self-reflection and acknowledging their personal cultural context.   68 You have to – to a certain extent - examine your own relationship with those things [gender roles]. Because to say that like, ‘maternal care and stuff like that is purely a construct, and you can just choose to get rid of it’ is also not true because we are very much cultural beings, grew up with culture, and everyone lives and breathes their social reality. So you do have to spend some time to examine it, strip it down, and get to the core to really make that a true statement. (Rob) Finally, the last personal attribute identified as helpful by all the men interviewed in this study was being enthusiastically open and willing to socialize, communicate, and work in societal and professional spheres where they might at times be conspicuous because they were in the minority.  It’s refreshing. I think it’s a different point of view. Yes, you are exposed to your classmates [who] are female, and again of course the researchers, and the papers you read, are more female centric. That has actually opened my eyes to more things… And understanding the lenses that somebody has come from I think it’s a positive thing. (Tim)  Wishing for Missing Resources  During the iterative interviews, to help understand their experience of studying nursing, the participants were asked by the researcher if there were resources and supports that would have aided their experience positively, or things they wish they had experienced. The final theme in the lived experience of the men interviewed was the commonality in the things they found had been either missing from their experience, or difficult to access.  First and foremost, participants identified that lack of collaboration among nurses and allied healthcare professionals in the field made them feel challenged.    69 Almost every clinical, you’ll get like a talk – like kind of a group talk – from a nurse on the floor. Like they’ll point out, ‘Oh! I see that there are some guys here. We think that’s great, we need more men… but…’ and that’s when that [assumption] will come – [the nurse] worrying you might not have the caring nature, and might not be able to connect… so they’ll say things like that…… I know this is difficult for some of the guys. However, I’ve decided it’s my job to succeed no matter what. (Jack) All participants identified the ideal learning environment to be one that role modeled the inter- and intra-professional elements of providing care that was being taught in their theoretical learning of nursing foundations. Next, the participants experienced having a difficult time finding access to formal and informal mentorship opportunities prior to the completion of the program. The participants had a desire for this to be more readily available - both in their programs of study and in the clinical setting.  I actually honestly feel that if people could spend a day-in-the-life in certain nursing situations, more men might consider nursing as a possibility. People who like me like to work with people, but are also really interested in science and technology and working in teams… Even in some of [the] advertisements I’ve seen for the nursing school, the [lack of emphasis on science and technology] I feel could possibly act as a barrier…Not a barrier… but I guess a barrier in the sense that I had to do some deep digging before I decided to break free to apply. A resource? I cringe to say a few more male mentors. Just so there are [examples]… Just like normalizing it – just people being like ‘I made a career of this’. (Tom)  Finally, and most closely linked to their gendered experience of nursing, the participants experienced difficulty in finding a place to openly and safely process how to navigate identifying   70 as a man and learning to become a nurse– without fear of judgment or evaluation (academically, societally, or personally).  For example, we have classes that have to do with social justice. They’ll openly talk about a stereotype or a construct. And you just have to stay silent. It’s hard to have an opinion… I've seen people have opinions, and sometimes questioning what’s taught gets the radar put on you, and your ideas get taken – what you've said is out of context. (Jack) As discussed earlier in Reframing to Dismantle Assumptions, the participants wondered if this processing could contribute to the dismantling of historic assumptions about men in nursing – not simply for themselves, but for all those with diverse gender identifications who would come after them.  There are movements, and we should mention that [nursing theory] is founded by feminist thoughts [schools of thought] that are kind of leading to the theories we’re discussing, but I don’t equate feminism with being targeted for females. Both genders can appreciate feminism as we can be appreciating any other school of thought. (Tim) Conclusion  The overall statement that tied together the lived experience of the participants of this study was that learning to become a registered nurse was not related to a person’s visible identify. It was related to how a nurse in training applied the scientific knowledge they mastered, and how they practiced the technical skills they learned while building relationships with colleagues, patients, and the community. While gender was not perceived to be a significant by the participants, due to the gendered systems in society it was a salient aspect of how they processed their experience of identifying as men and studying to become nurses.    71 Discussion This study set out with the following purpose: to understand the lived experience of men studying to become registered nurses as they engaged in Bachelor of Science in Nursing degree programs. The goals of this exploration were two-fold:  • First Goal: To add the voices of recent and prelicensure undergraduate students to the current research literature surrounding the experience of men studying to become registered nurses.  • Second Goal: To contribute to furthering the understanding of gender relations and restrictive gender norms present in nursing and nursing education specifically, and vocational training overall.  Nine eligible participants volunteered for the study, and individual semi-structured interviews were conducted with each volunteer. Data from the individual interviews was thematically analyzed using IPA methodology. The following five themes emerged from the lived experience of the participants:  1) Participants chose nursing to align their purpose with their personal values. This included changing course professionally or academically, mastering the clinical application of health sciences, and honing their relational practice skills.  2) Participants felt that despite their numerical minority status in the profession, they had found their professional home in nursing. Finding this fit for participants began with defining - for themselves, and others - what it meant to be a good nurse. Then the participants found acceptance of themselves as nurses from the external world, and they were pleasantly surprised to realize that this acceptance is mostly universal.    72 3) Participants made meaning of their experience of identifying as men and studying to become registered nurses by processing incidents where they experienced or witnessed historic assumptions that were made about men in nursing. For participants, this included processing the effects of these experiences and reflecting on how these experiences felt. The effects on the participants were varied depending on who they perceived was making the assumption (general public versus the educational program). The participants also found that they were personally committed to dismantling these assumptions when possible. 4) Participants felt supported in their experience of this phenomenon by a series of personal and relational resources. Relational, and sometimes environmental, resources included support from their personal networks, a supportive educational environment, a collaborative clinical learning space, and the presence of other men who practiced as registered nurses - acting as mentors and role models. Personal resources included self-confidence, acknowledgment of the gender norms and hierarchy present in health systems, reflexivity about their own privilege as men in these systems, and an openness to occupy the role of nurse while being in the numeric minority.  5) Finally, participants also wished for better access to supportive experiences – ones they found were sometimes lacking, or hard to find. These included the following: having access to collaborative interprofessional learning environments within nursing; finding a safe space to navigate gender norms and the gendered experience in nursing; and greater access to more men who are practicing nurses to act as mentors and role models.  Study Goals and Deliverables  The first goal of the study was achieved primarily through the research design, and implementation of the strategic inclusion and exclusion criteria for the study. Three specific   73 measures allowed the researchers to meet this first goal: limiting the pool of eligible participants to undergraduate students who identify as men, requesting that participants are registered and continuing in Bachelor of Science in Nursing (BSN or BScN) degree programs, and completing data collection from participants prior to their program completion. Because of these specific measures, all five themes that emerged from the analyzed data reflected, and focused on, contributing the experience of recent prelicensure undergraduate men studying to become registered nurses to the existing body of knowledge.  Because studying gender relations and gender systems is complex, the second goal of the study required a more nuanced approach. To ensure that the participants were able to freely and honestly share their account of their lived experience, they were purposefully not asked the following question in the study interview: what is your experience of being a man and studying to be a nurse? Instead they were asked this specific question: what is your experience of studying nursing? Yet, to ensure the study focused on the experience of men, the study inclusion criteria limited eligible participants to students who identified as men. This was done to minimize guiding the participants, and it allowed them to decide what parts of their experience they wished to focus on.  An interesting observation for the researcher was the fact that at the beginning of every interview, the participants were curious as to what they could possibly contribute to a study of this nature, as they had not perceived their experience to be particularly unique. However, when the researcher inquired why they had volunteered for the study if they felt that way, they reported being curious about the experience of their peers, and how that may compare to their own experience. Once the interviews began, the participants had no trouble sharing their experience at length. Most of what they shared either related to them identifying as a man in a system   74 numerically dominated by women, or it reflected their gendered experience within their educational journey. For both the researcher and participants, the overarching insight that emerged was the fact that while the participants’ gender did not seem to them to be a significant part of their journey; upon reflecting on their lived experience, they were all able to identify and resonate with themes that emerged from their experience within a gendered context. Therefore, the second goal of the study was achieved through the analysis of the rich and complex description of the participants’ experience and situating their experience within the existing body of knowledge related to this phenomenon. This chapter focused on the discussion of the analyzed data, and potential applications for knowledge translation in this field.  Relevance of Findings to Previous Research  The findings of this study confirm much of what is already known about the experience of men within the profession of nursing – either as practicing nurses or as nurses in training. Specifically, the study was able to add recent findings to this already robust body of literature; and focus the findings by limiting the pool of participants to undergraduate students only. By limiting the eligibility criteria to men, but having an open interview question to ensure participants chose the focus of their interview; the study was able to minimize the bias within its research design, and further the conversation in the literature around the role of traditional gender norms in health systems as it relates to nursing education specifically; and more generally, as it relates to vocational choice and training for men within professions traditionally dominated by women.  Addressing the Gap by Focusing on Undergraduates  Previous qualitative studies identified in the literature review had limited their purposive sampling to a single institution or academic training centre (Bradbury-Jones, et al., 2010;   75 Chesser-Smyth, 2005; Conner, et al. 2016; Magnussen & Amundsen, 2003; Peyrovi, et al., 2005; Schmidt, 2016; Tillman, 2006). Due to the historic and continued low enrolment of men in nursing programs, this often limited the number of men available to volunteer for these studies. To address the low availability of men nursing students as participants, some researchers chose to expand their eligible pool of participants to include graduate and undergraduate students (Kellett, 2010; Peyrovi, 2005). However, all graduate nursing students have already become practicing nurses prior to graduate school. Which means they are closer to nurses in continuing education programs than they are to student nurses in undergraduate programs. Other researchers took a different approach, and they expanded the geographic region of their study’s eligible sample pool of participants (Kellett, 2010; Meadus & Twomey, 2011). One study previously reviewed had limited their purposive sampling to one cohort of students in one academic institution, which led to only one male participant out of a total of 52 eligible participants in the pool (Chesser-Smyth, et al., 2005). This led to some studies, such as Ofori and Charlton (2002), explicitly identifying in their limitations that they were not able to delve deeper into the effect of gender on their research questions. This current study was able to follow in the tradition of these researchers yet address some of the limitations identified in these previous studies. This study strategically expanded the eligible sampling population by including seven institutions that were reviewed and accredited by the same professional and regulatory bodies. This specific measure ensured that all seven programs contributing potential participants were training students to become registered nurses with the same scope of practice during their degree programs. This meant that participants were in fact experiencing the same phenomenon, even though their degree programs were located at different institutions. This study also expanded the pool of eligible participants to include any   76 student currently enrolled and continuing in a Bachelor of Science in Nursing degree program, as long as they had completed at least one clinical practice placement course. The two strategies combined were successful in securing nine participants who were all in the process of completing their entry to RN practice degrees at the time of data collection. This allowed the researchers of this study to reach saturation with confidence as they analyzed the available data, even though they had focused the pool of participants.  Adding Recency and Confirming Past Findings  With the exception of a limited number of studies reviewed that were conducted in the last four years (Abshire, et al., 2018; Conner, et al., 2016; Eatough & Smith, 2017; Torregosa, et al., 2016; Yi & Keogh, 2016), most studies reviewed had explored the experience of men studying nursing at least 10 to 15 years ago. In the last decade, much has changed in the world and the profession of nursing– including, but not limited to, a 1.9% steady increase in Canada, alone, of men practicing as registered nurses (RNs) (CIHI, 2019). This study allowed its researchers to add recent findings to this body of literature. What is notable in terms of this contribution is the fact that this study confirmed and validated previous findings - adding trustworthiness and rigour to both this study, and the findings available in the current body of literature.  The first theme that emerged from the analysis of the interview data, aligning purpose with personal values – validated the previous finding that men, like women, seek out nursing as a profession to be of service to society (Dyck, et al., 2009). Also, in exploring the participants’ stories, it became clear that their motivations to choose nursing could still be easily grouped into the categories of seekers, finders, and settlers (Simpson, 2005). Additionally, the subtheme of changing course that was identified within the overall theme of aligning purpose with personal   77 values demonstrated that the participants of this study, much like those in Smith’s 2006 study, chose nursing despite the challenges presented in popular culture, society, or popular perceptions of the program. However, unlike previous studies reviewed (Al-Zein & Alkhawaldeh, 2015; Chan, et al., 2014; Karabacak, et al., 2012; Valizadeh, et al., 2014;), within the Canadian context of these participants, culture of origin did not appear to present a challenge in terms of finding acceptance for the participants as men and as nurses – not from their families nor from the public at large. In this study, this was specifically identified by the subtheme of acceptance is mostly universal within the broader theme of finding their home in the profession.  The fourth theme of this study where participants identified relational and personal supports was also able to confirm past findings. For the participants of this study, presence of supportive and empathetic clinical instructors, faculty, peers, and practice partners helped them feel supported in their journeys towards becoming registered nurses. This finding confirmed studies that had previously identified the importance of relationships between faculty, peers, and the student in nursing programs (Bradbury-Jones, 2011; Mikkonen, et al, 2015; Torregosa, 2016; Abshire, et al., 2018). In fact, in addition to identifying supportive clinical sites as an important relational resource within their experience, the participants of this study also wished for increased access to collaborative interprofessional clinical learning environments. This was identified in the fifth and final theme of wishing for missing resources. This theme, and these findings, were in line with the Ascent to Competence Framework (Lathlean & Levett-Jones, 2008); which validated the notion that for the participants of this study, a feeling of belonging in clinical practice was a necessary and  desired component of their experience of becoming nurses.  While a significant amount of time has passed, and much has changed in the world and the profession of nursing, the basic foundations of the experience of becoming a nurse are still   78 holding steady. While the journey itself is still complex; studies like this one help address Holland’s (1999) recommendation to continue exploration into this field of research. It is important to note that while findings from qualitative studies cannot be generalized, studies like this one continue to add to the conversation attempting to understand the lived experience of men studying to become nurses. A specific avenue within this area of investigation that is particularly relevant to this current study is the conversation on gender norms – both from a nursing education perspective, and a vocational training or career counselling perspective.  Continuing the Conversation on Gender Norms in Nursing Education  As identified in the literature review, at least two studies from over a decade ago identified that gender bias and stereotypes of traditional gender roles had negative consequences on student learning in nursing education (Anthony, 2004; Dyck, et al. 2009). Both of these studies identified strategies for educators to re-evaluate how they view and present gender in their teaching. Unfortunately, the current study demonstrated that some of these identified gender biases were still prevalent, and they continued to have an effect on the experience of this study’s participants.  This finding was evident in three of the themes that emerged from the data analysis. First, the presence of challenging gender bias became evident when the second theme of processing the effect of historic assumptions was juxtaposed to the third theme that outlined sources of support in the participants’ journeys. In the theme feeling supported in their journey, participants had identified supportive educators as a relational resource that helped them feel supported.  However, when these same educators made assumptions about the participants that stemmed from traditional and outdated gender norms, the participants reported feeling the most discouraged or confused. Next, the negative effects of gender bias on the participants’   79 experiences was demonstrated when the first theme of aligning purpose with personal values was juxtaposed to the fourth and fifth themes of feeling supported in their journey and wishing for missing resources. Just as Harding (2009) had indicated, the participants of the current study found significant personal fulfilment in choosing nursing because it aligned their purpose of delivering exceptional health care with their personal value of being of service through relationship building. Additionally, as evident in the theme of feeling supported in their journey; participants identified two personal attributes that supported their journey. These included both the ability to reflect on the hierarchies present within the gender system, and the ability to acknowledge their own privilege as men within that system. However, in the final theme of wishing for missing resources, the participants of this study yearned for a safe place within their educational journey to collectively navigate these reflections and experiences. Not having easy access to this space did not stop the participants from continuing on with their journey to become nurses; however, it did leave them wondering if having this resource would have supported them. This yearning is validated by Meadus and Twomey’s (2011) study that found that one of the challenges men in nursing faced was the gender bias they were confronted with within their educational programs. Finally, a desire for mentorship from men by the participants is validated by the Positive Psychology Positive Masculinities (PPPM) study, that identified the need for identification of behaviours that promote heathy positive experiences for men (McDermott, et al., 2018).  In the end, a conversation that began over 20 years ago with Evans’s (1997) inquiry into gender segregation in nursing continued with this study. As Evans outlined in her feminist review, the role of men in nursing, gender dynamics in the profession, and perception of gender norms in nursing are complex; partly due to the history of nursing, and partly due to the   80 complexity of gender systems in society (Evans, 2004a). However, researchers, including Evans (2004a) and Anthony (2004), have also identified that understanding the gender dynamics within nursing educational programs, and challenging traditional teaching strategies in nursing, both have the potential to remove bias and create more equitable experiences. The recommendation of these early researchers is supported by recent research led by the Steering Committee of The Lancet Series on “Gender Equality, Norms, and Health” that identified restrictive gender norms in health systems led to health inequities, and the committee “proposed action to systemically identify and address restrictive gender norms within health systems” (Hay, et al., 2019, p. 2535). Based on the fifth and final theme identified by the participants of the current study, and the participants’ expressed desire for an easily accessible safe space for dialogue on gender norms in nursing, as the author of this study I did become curious. I wondered if having access to such a space would in a miniscule part have helped the participants contribute to the mandate of creating health equity through dismantling of restrictive gender norms?  Continuing the Dialogue on Gender Ideologies and the World of Work In addition to adding to the literature exploring the experience of students training to become nurses, and the role of men professionally engaging with nursing as a vocation, the current study is also able to contribute recent findings to the vast body of literature that is focused on gender ideologies within the world of work. However, it is important to take a step back from this area and reiterate that conventional binary gender roles of man versus woman, masculine versus feminine, or male-type versus female-typed cannot encapsulate the diversity within populations of men and women (Johnson & Repta, 2014). Focusing on this rhetoric only replicates the problematic gender norms within society. This reminder of the inadequacy of the gender binary to represent people accurately is echoed in the second theme of feeling at home in   81 the profession, and specifically the subtheme of defining a good nurse. In this study, the participants identified being reassured by a core unifying principle of their common lived experience – the belief that being a ‘good nurse’ has no correlation to the sex, gender identity, sexual or emotional orientation, or presenting masculinities or femininities of the person providing nursing care.  Also, this study confirmed the finding that when men are open to distancing themselves from traditional masculine ideologies, they were able to experience less gender role strain when engaging professionally in a role that is traditionally female typed (Levant, 2011; Levant & Richmond 2014). This is relevant in the theme of feeling supported in their journey. Participants of the current study identified the following three personal attributes as supporting them in their experience: acknowledgement of the hierarchy created through patriarchal systems created as a result of traditional masculine ideologies, recognition of their own privilege as men within these systems, and an openness to function within systems where they will most likely be in the minority. Another way to view these helpful personal attributes could be to state that these participants found comfort and support in distancing themselves from the traditional masculine ideologies that create gender role strain (Levant, 2011; Levant & Richmond, 2014). The participants also identified strong support networks as part of their relational resources supporting them in their journey, and this echoes the finding that men engaged in traditional female-type professions with strong personal supports have higher satisfaction and lower stress than even counterparts in normative samples used as controls (Rochlen, et al., 2009). The researchers mentioned in this section have at times postulated that if beliefs defined by socialized gender ideologies were dismantled, then it may be possible to create a reality where being in violation of gender norms no longer has any consequence on individuals who choose to do that.   82 Bringing together the findings from the current study with the studies discussed here, a hypothetical question that comes to the forefront is this: would having a safe space to navigate issues related to gender roles, nursing, and training to become a nurse create this possibility for these men?  Potential Avenues for Application  It is difficult to identify viable applications resulting from a qualitative study where the purpose is to understand the lived experience of a very specific group of participants. Qualitative studies, especially qualitative studies using interpretive phenomenological analysis, do not have findings that can be generalized because their findings represent the lived experience of only the participant group. However, they do create a springboard for future research related to the phenomenon in question, or population being studied. Assuming it was possible to conduct sufficient additional research to investigate the generalizability of any of the findings from this study; there are a few possibilities for application and knowledge translation.  A Place for Dialogue and Learning  As already identified in the fifth and final theme, wishing for missing resources, the following three applications may be helpful in supporting the experience of men studying nursing: access to safe and open dialogue about gender, access to collaborative clinical learning environments, and access to experienced men practicing as registered nurses who can act as role models and mentors. Based on these findings, it may be possible to research the development of a program that combines all three to a single resource. This resource or program could begin with the idea of a safe space within nursing educational programs for all students, not just men, to discuss and navigate privilege, the gendered aspect of nursing care, and how restrictive gender norms or socialized definitions of masculinities and femininities effect their experience of   83 learning to become nurses. It would be important to pay attention to how either nursing educators or experienced practicing nurses could be incorporated within this space and program delivery, to ensure the students have access to role models and mentors to explore these experiences with. However, it would be important that these educators or practicing nurses do not come to this space with the goal of academically assessing or evaluating the students during these conversations to ensure safety and openness of dialogue. This is what would make this resource different from the support of peer groups, which provides a place to safely and openly vent about frustrations or celebrate perceived successes. Finally, it would be important to ensure the role models and mentors represent a diversity of genders, sexual and emotional orientations, cultures of origin, and personal backgrounds. This would hopefully allow every student to find someone whose story resonates with their own. Then like the participants in this study wished, they would be able to say, ‘this person has been where I am now, and they made it, which means I can too.’  An Opportunity for Evidence Informed Student Support  As identified throughout the literature review, one of the common applications for previous research on the experience of men studying nursing has been to understand how to recruit more men into the profession – to both increase the representation of men within the total number of practicing nurses, and to meet the anticipated shortages in the nursing workforce. The fourth theme of the findings of this study, feeling supported in their journey, identified relational resources and personal attributes that helped the participants feel supported. If additional investigations confirmed that these findings were generalizable to all men studying nursing, or even all students studying nursing, then institutions could support prospective applicants and new students understand what resources they need to develop before they embark on their journey to become nurses. Decreasing the effects of marginalization, and creating environments   84 where students feel they matter is a foundational cornerstone of all academic programs’ recruitment and student support strategies (Schlossberg, 1989). Therefore, programs could use strategies that support favoring mattering over marginalization, coupled with the potentially generalizable findings from this study, to help new students feel like they matter by helping them develop the resources they need to feel supported in their journey. This may lead to the increase in the number of men, and students from other minority groups in nursing – not because they were recruited, but because they found their way to nursing by aligning their purpose with their personal values.  Ultimately both of these applications would require extensive research before they can be implemented. First researchers would have to explore and validate if any of these findings are generalizable to other students studying to become nurses. Through this additional research, the findings would be refined, and any programs or strategies would be more closely aligned to the refined and clarified versions of the findings in the future studies. Next, stakeholders would need to be consulted at each stage of implementation. Ultimately, the potential for application and knowledge translation is still quite distant; however, all programs have to start somewhere.  Limitations of the Current Study  The current study purposefully focused on men undergraduate students training to become registered nurses by completing Bachelor of Science in Nursing degree programs. This was done primarily to limit the scope of the project to create a sustainable mandate for a master’s level graduating thesis, and to allow for a focused contribution to the current body of literature. While practical and pragmatic, this focus does create significant limitations for this study. This section reviews the limitations of the current study, and the following section on future research possibilities attempts to address how those limitations could be addressed in the future.    85 As identified in the methods chapter, this focus does exclude all those in the gender identity spectrum who do not identify as men – this includes women, people who identify as trans, non-binary, or gender queer, plus any other gender identities not listed here. One of the conclusions from the study was that gender was not perceived to be a significant part of the experience of the men participating in this study, yet their experience of studying to become nurses was affected by their gender, and the dominant gender system within nursing and nursing education. If that is the case, then how is the experience of other students affected by restrictive gender norms and systems within nursing education? This study does not address this question. Additionally, limiting eligible participants to those registered in bachelor’s programs training to become registered nurses excludes all other students training to engage as other roles with nursing in other scopes of practice. This includes those studying to become licensed practical nurses (LPNs) and psychiatric nurses (RPNs). Also, limiting eligible participants to undergraduate students did allow for a focused addition to the body of literature that addressed a gap; however, it actively excluded all graduate students studying to become Nurse Practitioners (NPs). If the gendered context of nursing practice within medicine and health care delivery has a complex history, what this study does not address is what effects gender has on the experience of other nursing roles within the profession.   Finally, if the study had a goal of contributing to the current literature related to vocational training and career counselling for individuals choosing to engage professionally in a role that appears to be incongruent with socialized gender norms related to their identified gender, then this study only covers one group of potential people (men), and one professional role (nursing). There are many other professional roles that are socialized to be sex-typed within   86 the binary gender system, and this study does not address the lived experience of any of the other individuals that would engage in any one of those roles.  Directions for Future Research  It is the already stated identified curiosities and hypothetical questions that open up the possibilities for future research branching off from the current study. First and foremost, there is a mandate to dismantle the problematic conceptualizations of gender, and the binary gender system within research design in health research (Johnson & Repta, 2014). Also, there is a need to find diverse approaches to exploring the influence of gender (both masculinities and femininities) on experiences related to health and health care delivery (Bottorff, et al., 2014). Therefore, it would be important to explore the potential of replicating this study with students with diverse gender identities. For example, using the same geographic region and list of eligible undergraduate programs, it would be important to conduct separate studies to ask the following groups of students what their experience of studying nursing has been: women, students who identify as non-binary, trans students, or student who identify as gender queer. Using interpretive phenomenology to explore the lived experience of each of these groups of undergraduate students representing a greater diversity within the gender identity spectrum could provide researchers with rich data to further understand the influence of gender on the experience of becoming a nurse.  Alternatively, one of the stipulations of this study was to focus on the experience of undergraduate students before they graduate as registered nurses. A question that arises from this is this: does the experience of developing as a registered nurse differ from the experience of learning to become a nurse after graduation and in new graduate training programs? Another way of asking the same question would be as follows: does the experience of being a nurse change   87 and evolve overtime? Or is a person’s experience of becoming a nurse static after completion of their formal academic training? Conducting a grounded theory study with the same participants three to five years after graduation would allow researchers to understand how learning to become a nurse continues to develop after graduation from entry to practice degree programs.  Finally, as addressed in the section outlining the limitations of the current study, what this study is not able to do is address the lived experience of people from anywhere along the gender identity spectrum who choose to engage professionally with a role that is not traditionally socialized to be associated with their personal gender identity or perceived gender or sex. Therefore, the current study’s research design could be adapted to answer the following question: what is your experience of training to become your chosen professional role? To accommodate a greater diversity of participants for this future study, researchers could potentially open up the eligible pool of participants to any student registered in a professional degree or vocational certificate program that finds they are in the minority based on how they identify their gender, and how society’s gender norms relate to their chosen profession.  Conclusion  The history of the involvement of men in the provision of nursing care dates back to the fourth century (Evans 1997). Existing literature focusing on the experience of men in nursing has been of ongoing interest to scholars in a variety of academic disciplines (Cottingham, 2019). This study was able to contribute to this robust body of literature, by adding the recent voices of undergraduate students. With additional research, the findings of this study could potentially be used for knowledge translation in nursing education, or student support services within postsecondary education. Finally, this study could serve as a springboard for future research into the influence of gender on vocational training and career counselling initiative.    88 References Abshire, D. A., Graves, J. M., Roberts, M. L., Katz, J., Barbosa-Leiker, C., & Corbett, C. F. (2018). Student support in accelerated nursing programs: Gender-based perspectives and impact on academic outcomes. 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Contemporary Nurse, 52(1), 95-105. doi: 10.1080/10376178.2016.1192952     103 Appendices  Appendix A  Vancouver Regional District BSN Programs  A survey of post-secondary institutions in the Greater Vancouver Regional District (GVRD) was conducted to determine which colleges and universities offer a bachelor’s degree for entry to practice as a registered nurse (Bachelor of Science in Nursing (BSN)). The University of British Columbia’s Vancouver Campus was eliminated as a potential venue for recruiting participants due to conflict of interest with the researcher’s professional role at that institution. Below is a summary of eligible institutions, the types of programs offered, the first clinical practice course in each of the programs, and when those courses are normally scheduled to occur. The purpose of this table was to assist with data collection parameters and screening for inclusion / exclusion criteria. Please note this table does not include curriculum changes implemented after time of data collection for this study.  Table 2  List of Greater Vancouver Regional District (GVRD) BSN Programs Institution Program First Practice Course(s) Date Range Program Website Link Course Descriptions British Columbia Institute of Technology (BCIT)  Bachelor of Science in Nursing (BScN), 3-year, 2 intakes - August & January  NURS 1030 (Jan 2018 Intake & Prior)  September - December     January - April  https://www.bcit.ca/study/programs/8875bsn#details https://www.bcit.ca/study/programs/8875bsn#courses Douglas College (DC)  Bachelor of Science in Nursing (3-year program) with Fall or Winter intake NURS 2113 – Beginning Client Care  September – December (Fall Intake) or January – April (Winter Intake)  https://www.douglascollege.ca/programs-courses/catalogue/programs/BSNURS https://www.douglascollege.ca/programs-courses/catalogue/courses/NURS/NURS2113 Kwantlen Polytechnic University (KPU)  Bachelor of Science in Nursing (BSN), 4-year program  NRSG 2145 - Nursing Practice 1  September - December http://www.kpu.ca/calendar/2017-18/health/nursing/nursing-deg.html http://www.kpu.ca/calendar/2017-18/courses/nrsg/index.html#nrsg2145      104 Table2 (Continued) List of GVRD BSN Programs (Continued…)  Langara College  Bachelor of Science in Nursing (BSN), 3-year program, 2 intakes September & January  NURS 1160 & NURS 1163  September - December        January - April   https://langara.ca/programs-and-courses/programs/nursing/program-curriculum.html https://langara.ca/programs-and-courses/programs/nursing/program-curriculum.html Trinity Western University (TWU)  Bachelor of Science in Nursing (BScN) – 4-year program, rolling admission  NURS 113  September - December         https://www.twu.ca/sites/default/files/2019-20-nursing-major.pdf https://www.twu.ca/sites/default/files/2019-2020_academic_calendar_2.pdf Vancouver Community College (VCC)  Bachelor of Science in Nursing (BSN), 36-month program for year 1 entry, and 2 years advanced entry for practical nurses  NURS 1164 - Nursing Clinical Practice 1 (Year 1 Entry)                  NURS 3164 Clinical Mental Health Nursing (Advanced Entry)  September - December (NURS 11640                                     January - April (NURS 3164)  http://www.vcc.ca/media/vancouver-community-college/content-assets/documents/programs/program-one-pagers/198_HeSc_Nursing_BScN_Advanced_OnePager_20170816.pdf   http://www.vcc.ca/media/vancouver-community-college/content-assets/documents/programs/program-one-pagers/220_HeSc_Nursing_BScN_Year1Entry_OnePager__20170816.pdf http://www.vcc.ca/programscourses/courses/clinical-mental-health-nurs-3164/        http://www.vcc.ca/programscourses/courses/nursing-clinical-practice-1-nurs-1164/ -University of the Fraser Valley (UFV)  Bachelor of Science in Nursing (BSN), Two Options: 4-year program (September + January Start), 3-year program (September start)  NURS 106 - Nursing Practice  September - December https://www.ufv.ca/calendar/current/ProgramsF-L/HEALTH_NURS.htm https://www.ufv.ca/calendar/current/CourseDescriptions/NURS.htm    105 Appendix B: Research Study Recruitment Poster Men Studying to be Nurses: An Exploration of the Experiences of Men in Undergraduate Nursing Education Do you identify as a man? Are you currently enrolled in a full time Bachelor of Science in Nursing Program at a post-secondary institution in the Lower Mainland? We want to hear from you! We are currently looking for volunteers to participate in a study exploring the individual lived experiences of men studying nursing in their first entry to practice degree. If interested and eligible, you will be asked to participate in an interview that will take approximately 90 to 120 minutes, and you will be given an opportunity to discuss your experiences and reflections on your current educational journey and future chosen profession.  The principal investigator is Dr. Richard Young, a professor in the Faculty of Education with the Department of Educational and Counselling Psychology, and Special Education.   Conducting the research is Rana Hakami, a student in the Master of Arts in Counselling Psychology program.  In appreciation for your time you will receive a $15 (fifteen Canadian dollar) stipend. For   more information about the study, or to volunteer for the study, please contact: Rana Hakami  at  604-209-6750oremail: rana.hakami@alumni.ubc.ca H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  106 Appendix C   Research Participant Consent Form Title of study: Men Studying to be Nurses: An Exploration of the Experiences of Men in Undergraduate Nursing Education  Principal Investigator Dr. Richard Young, Ed.D., Professor, UBC Counselling Psychology Registered Psychologist 604–822–6380 richard.young@ubc.ca  Student Investigator Rana Hakami, M.A., B.Sc. MA student, Counselling Psychology 604-209-6750  rana.hakami@alumni.ubc.ca Introduction: Thank you for choosing to participate in this study. This work is affiliated with UBC course CNPS 599 and is a requirement in partial fulfillment for the student investigator’s Master of Arts (M.A.) in Counselling Psychology degree requirements. Please note that we are seeking persons who identify as men and are registered full time in a Bachelor of Science in nursing program at a post-secondary institution in the Greater Vancouver Regional District and have completed at minimum one clinical practice course. Taking part in this study is voluntary and you may withdraw from the study at any time. Your academic standing as a student will not be affected whether you choose to participate or not, and your participation will not be reported to your home educational institution. The study is described below. This description tells you about the risks, inconvenience, or discomforts which you might experience. Participating in the study might not benefit you, but things learned might benefit others. You should discuss any questions you have about this study with Ms. Hakami, the student investigator.  Purpose: The purpose of this research is to explore the individual lived experiences of men studying to be nurses as they engage in their first entry to practice nursing degree. These experiences are any which the H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  107 student studying to be a nurse has found significant in their journey to becoming a nurse, and which may or may not have been impacted in some way by their self-identified gender as a man.  You are being invited to participate in this research because you have identified yourself as a man studying to be a nurse while registered in a Bachelor of Science in nursing degree program.  Study Procedures: This study will involve two interviews with Rana Hakami, the master’s student for this study. If you are interested in this study, you will be asked to participate in a phone interview to assess your fit as a participant with the research study’s inclusion criteria. Following confirmation of eligibility, you will be asked to participate in a face-to-face interview with the student investigator at a time, date and location that is mutually beneficial for both parties. The interview will begin with the discussion of this consent form and its signing. Following this you will be asked to share your individual account of how, when and why you chose to study nursing. Following this, you will be asked to participate in an open-ended interview to gather detailed insight into your individual experience of studying to be a nurse by answering a series of open-ended questions related to your experiences. Following this, you will be asked to provide your personal reflections on how you envision yourself engaging with nursing as a profession upon graduation.  After completing the interview, you will be asked to provide your feedback about the process. In total, this process will take about 90-120 minutes, or 1.5 to 2 hours. Following the interview, Ms. Hakami will analyze your interview, and those of the other participants, for the themes that arise related to this research study. Once themes have been identified, you will be contacted again by Ms. Hakami through email with a copy of the themes drawn from your interview. She will ask if you find yourself in agreement with her interpretation. Any disagreement will be discussed and included in the analysis process. H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  108 Study Results The results of this study will be reported in a graduate thesis and may also be published in journal articles and books and presented in poster sessions at professional conferences. While safeguards will be in place to protect your identity, you should know that researchers are sometimes required to make their data available at time of publication. Should this be a requirement of publication, your personal identity will be protected and the data that is shared will be de-identified. Once data is made publicly available, you will not be able to withdraw your data from the study. You will be provided with an electronic copy of the graduate thesis to your email address. Potential Risks of the Study Some participants may feel discomfort related to disclosing aspects of their experience as students who are men studying to be nurses. We do not believe that any part of this interview process will cause you harm or be bad for you. We do understand that discussing personal history and experiences in gendered environments may be upsetting. Please let Ms. Hakami know if you have any concerns. Should you require additional support, at the end of the interview Ms. Hakami can provide you with names and contact information for counseling/support services in your area.  Potential Benefits of the Study You may be helped in this study through your participation in the interview. You may find that discussing your experiences as a man studying to be a nurse and reflecting on the effect of your gender on your current educational journey helps you in some way. This may include, but is not limited to, helping with your perspective and outlook on engagement with your chosen profession. Alternatively, your participation in this research may benefit nursing education, and other men studying to be nurses by contributing to the knowledge of gender issues in this profession. No benefits can be guaranteed. Confidentiality H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  109 Your confidentiality will be respected. No information that discloses your identity will be released unless you give your consent or required by law. While you are required to be actively engaged in a full-time Bachelor of Science in nursing program to be eligible for study participation, your participation will not be shared with your home institution. The researchers will have safeguards in place to protect each participant’s identity. However, due to the small sample size and unique population being studied your confidentiality cannot be fully guaranteed. All physical and digital documents will be stored in a secure locked office, and all devices (computers, laptops, USB drives, and digital storage solutions) will be both password protected and encrypted to comply with regional and institutional policies and laws. This includes audio recordings. These files can only be accessed by Ms. Hakami and Dr. Young. Participants will not be identified by their real names in any reports of the completed study. Dr. Young as Principal Investigator is responsible for the data in this study, and the data related to this study will be retained securely for a minimum of five years after publication in compliance with institutional policy.   At any point in the study, if you reveal that there has been an incident that involves abuse and/or neglect of a child, an elderly person, or any other person who belongs to a vulnerable population (or that there is a risk of such occurring), please be advised that the researcher must, by law, report this information to the appropriate authorities. If you disclose intent to harm yourself or others, the researcher will be required by law to report this information to the appropriate authorities as well. Payment Each participant will receive a $15 CA (Canadian Dollars) stipend for their participation. Contact for Complaints If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  110 Office of Research Ethics at 604-822-8598 or if by long distance email RSIL@ors.ubc.ca or call toll free 1-877-822-8598.Participant Consent and Signature Page Taking part in this study is entirely up to you. You have the right to refuse to participate in this study. If you decide to take part, you may choose to pull out of the study at any time without giving a reason and without negative consequences. • Your signature below indicates that you have received a copy of this consent form for your ownrecords and that you consent to participate in this study.• The demographic data you provide after your signature is optional and will be used to help theresearcher situate you in the general population of students studying to be a nurse.Participant Signature                                         Date (dd/mm/yyyy)   ______________________________________________________________________________ Printed Name of the Participant signing above _______________________________________________________________________________H18-0357 Version 3 Date: 01/31/2019 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education THE UNIVERSITY OF BRITISH COLUMBIA  111 Participant Demographic Information (Optional): • Complete the following self-report questionnaire and return to the researcher at the end of yourinterview.• Your demographic information will not be linked to your interview responses to protect youranonymity during the study.• The demographic information is collected to help the researcher situate the participants in the studywithin the general population of students studying nursing.1. How do you currently describe your gender identity? Please specify: ____________________  I prefer not to answer 2. What is your age in years? Please specify: ____________________  I prefer not to answer 3. Which categories best describes your educational experience prior to your current program ofstudy?  High school diploma or equivalent   Vocational training  Some college  Bachelor’s degree  Some post-bachelor’s courses  Graduate degree  Other __________________  I prefer not to answer112 Appendix D  Participant Screening Phone Interview Protocol The following interview protocol outlines how those interested in participating in the study will be screened to ensure fit with inclusion exclusion criteria, to set up phone interview. Text in italics include additional instructions for researcher conducting the interview based on volunteer response.  Introduction from researcher to volunteer: Thank you for your interest in this research study. The following questions will help me determine if you fit the inclusion / exclusion criteria for our study.  1. How did you learn about the study? (Open Ended)2. Have you had an opportunity to review the study recruitment poster? Ifparticipant says no, review information verbally on the phone. 3. How do you currently identify yourself in terms of your gender identity? (Openended question).  4. Are you currently enrolled in a Bachelor of Science in Nursing Program in theGreater Vancouver Regional District / Lower Mainland? If yes, which school and program? (Open ended response, check answer against options in Appendix A.)   5. Have you completed at least one clinical practice course within your bachelor’sprogram? (Y/N). If yes, please specify which course and the completion date. (Open ended question, answers will be compared to the list of courses in Appendix A for assessment of fit with inclusion criteria).  6. As stated in the recruitment poster, all participant identities will remainconfidential and anonymous. However, we require contact information to arrange the interview. Please provide your first and last name, phone number and email to arrange a time for the in-113 person interview. I will also provide you with an electronic copy of the consent form for you to complete and bring to the in-person interview. (Collect information for follow up).  7. Do you have any questions about the study or your participation? (Open Ended)8. We should set aside two hours for administrative tasks and the interviewcombined, and at the end of the interview you will be provided with a $15 stipend as an honorarium. When is the most convenient time for you to participate in the interview? (Set date and time)  9. At the interview we may ask you to provide us with demographic information(such as data age, gender, past education experience) to help the researcher understand how you fit with the general population of students studying to be a nurse. Do we have your permission to collect this information? (Y/N). Closing from researcher to eligible volunteer: Thank you for your interest in our study. We will contact you via email confirming your interview time, date and location, and a PDF copy of the research participant consent forms for you to complete prior to arrival. If you have any questions, please do not hesitate to contact me at rana.hakami@alumni.ubc.ca or 604-209-6750.  Closing from researcher to ineligible volunteer: Thank you for your interest in our study. Unfortunately, you do not meet our study participant inclusion criteria based on [state reason].  114 Appendix E  Semi-Structured Interview Protocol The following interview protocol outlines initial questions prompts that will guide the discussion with each participant during each face-to-face interview. After welcoming each participant, reviewing study information, and documenting participant consent, the researcher will begin recording the interview. The researcher will ask the participant to introduce themselves and their program of study. After the initial introduction, one of the question prompts below will be used to guide the interview:  • What is your experience of studying to be a nurse?o Prompt (if needed): Start from the beginning (when you decided to study nursing)and share the significant events you have experienced until today.o Prompt (if needed): Reflect on your experiences with your peers, your faculty,and patients in your specific course work and clinical or laboratory practicesettings, and share the significant relationships, interactions, or moments that youhave experienced until today.As the participant begins to tell their story, the researcher will ask additional open-ended questions to learn more about how the participant has made meaning regarding their individual experience. It is important to note that each participant will be free to share their own accounts and experiences in a manner that is acceptable to them, and these initial prompt questions serve simply as a guide for the researcher to begin the conversation. At the end of the interview the researcher will thank the participant for their contribution and provide a timeline and estimate for when the participant will be contacted to have an opportunity to review the results of the study and provide feedback on the data analysis and discussion.   

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