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Nursing instructors' and male nursing students' perceptions of undergraduate, classroom nursing education… Dyck, Jeffery Mark 2007

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NURSING INSTRUCTORS' AND MALE NURSING STUDENTS' PERCEPTIONS OF UNDERGRADUATE, CLASSROOM NURSING EDUCATION: AN INTERPRETIVE ETHNOGRAPHIC STUDY by J E F F E R Y M A R K D Y C K B.A., The University of British Columbia, 1994 B.S.N., The University of British Columbia, 2003 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES THE UNIVERSITY OF BRITISH COLUMBIA August 2007 © Jeffery Mark Dyck, 2007 11 Abstract In Canadian schools of nursing, men constitute around 9% of the student cohort. Among the men who attend schools of nursing, rates of attrition are far higher than those of female students. There is little research that addresses the character and quality of male nursing students' educational experiences, nursing instructors' understandings of gender in the context of nursing education and the relationship between gender and the culture of the nursing classroom. This multi-site qualitative study utilized an interpretive ethnographic methodology and was conducted at two large, undergraduate schools of nursing in Western Canada. Data collection consisted of participant observation of 15 classroom teaching sessions (24 hours) followed by semi-structured interviews of between 60 and 90 minutes duration with 6 male, upper level nursing students who were participants in the classes and 6 female nursing instructors who taught the classes. Major themes that resulted from data analysis addressed the role of men in the nursing classroom and the culture of nursing education. The role of men in the nursing classroom was characterized by the theme of playing a different role: relying on traditional masculinities. Men's behaviours aligned closely with traditional masculinities and involved components of leadership, assertiveness, comic relief and risk-taking. The theme of masculinities in a feminine place addressed the sexualized and sometimes stereotyped identity of male nursing students, as well as the fact that they see themselves as being accommodated rather than integrated in the classroom setting. The theme of incongruence between masculinities and femininities involved the disconnect that men perceived between male and female priorities and learning styles, as well as the risks that men face in the maternity clinical rotation and around the use of touch in the clinical setting. Ill These findings suggest that nursing instructors need to consider gender when planning and carrying out their teaching, avoid parody or stereotypes of masculinities, and avoid assumptions that male students are homogeneous. These actions could help lower the attrition rate of male nursing students and offset the nursing shortage. Further research that is longitudinal and which includes data from female students would help enrich these findings. iv Table of Contents Abstract i i Table of Contents iv List of Tables vi i Acknowledgements v i i i Dedication ix Chapter 1 Introduction 1 Background 1 Problems 2 Purpose and Significance 3 The Current Conceptualization of Gender 3 Research Questions 4 Summary • 4 Chapter Two Literature Review 5 Overview of the Literature Review 5 Context 5 Calls to arms 5 The history of men in nursing 6 Theoretical underpirinings: Gender and nursing 7 Empirical Evidence 8 The experiences of men in nursing practice 8 Sex role strain and status contradiction 8 Stereotypes 9 Advantages for male nurses 10 Caring 12 Men in nursing education 12 Motivations for entering nursing 12 The salience of obstetrical clinical rotation 13 Nursing education as a gendered place 15 Problems and challenges 15 Teaching and learning 18 Shortcomings in the State of Knowledge; Justifications for this Study 19 Chapter 3 Research Methodology 22 Interpretive Ethnography .22 Sample 23 Settings 26 Recruitment 26 Data Collection 27 Data Analysis 28 Rigor 30 Ethical Considerations 30 Summary 31 Chapter Four Research Findings 32 Adjusted Research Questions 32 Overview 34 Playing a Different Role: Relying on Traditional Masculinities 34 Stepping out 35 Stepping up 38 Stepping in 40 The Culture of Nursing Education: Masculinities in a Feminine Place 44 A sexualized identity 44 Stereotypes and parodies of masculinities 46 The gay stereotype 49 Accommodation rather than integration 51 Assumptions of familiarity with the feminine 53 The Culture of Nursing Education: Incongruence between Masculinities and Femininities 54 Overfeeling and underdoing 54 Different risks: The potential for rejection in the maternity rotation 59 Disparate caring and touch 62 Chapter 5 Discussion 66 Overall Picture of the Findings 66 Relationship to Research Questions 67 Relationship to the Literature 70 Limitations 72 Implications and Recommendations 74 Recommendations for Future Research 77 Conclusion 78 References 80 Appendix A : Behavioural Ethics Approval Certificates 87 Appendix B: Flyer 89 vi Appendix C: Letter of contact (instructors) 90 Appendix D: Letter of contact (students) 92 Appendix E: Information letter for all students 94 Appendix F: Consent form (instructors) 96 Appendix G: Consent form (students) 99 Appendix H: Participant observation guide 102 Appendix I: Interview guide (instructors) 104 Appendix J: Interview guide (students) 105 vii List of Tables Table 1 Characteristics of Educator Participants 25 Table 2 Characteristics of Student Participants 2 5 Acknowledgements I am indebted to Dr . A l i s o n Phinney and D r . John Oliffe for their patience, encouragement and thoughtful insight throughout the thesis process, as wel l as to the Katherine M c M i l l a n Director's Discretionary Fund for providing funding that helped make this research possible. Dedication This thesis is dedicated to my longsuffering wife and daughter. Never again may you have hear "I can't [insert social or family obligation]—I have to work on my thesis." 1 Chapter 1 Introduction Background Registered nurses (RNs) represent the single largest group of health care providers in Canada, with 268,376 RNs practicing in 2005 (Canadian Nurses Association, 2005). Nursing also represents one of the professional occupations with the widest numerical disparity between men and women, with men constituting 5.6% of the registered nurses in Canada (Canadian Institute for Health Information, 2005). In light of the changes to other previously-disproportionate gender splits in professional occupations such as medicine and engineering, the persistence of this disparate ratio between genders is exceptional (Davis & Bartfay, 2001; MacPhail, 1996; Meadus, 2000; O'Lynn, 2004; Sullivan, 2000; Villeneuve, 1994). From within the profession itself, gender diversity has been identified as an inherently worthy goal, in that there is a moral obligation for nurses to reflect the populations with whom they work (American Association of Schools of Nursing, 2001; Auster, 1979; Brady & Sherrod, 2003; Meadus; Sims & Baldwin, 1995; Sullivan, 2000). The differences between the number of men and women in institutions that educate future RNs are also significant. In Canadian schools of nursing, the most recent available statistics indicate that men constitute around 9% of the student cohort (Statistics Canada, 2000). These low male enrolment rates in undergraduate programs of nursing exist in the context of a protracted and worsening global shortage of registered nurses (Canadian Nurses Association, 2005; International Council of Nurses, 2004). Given this pervasive and high-stakes shortage of front-line nurses, faculties of nursing education can ill-afford to continue to predominantly draw 2 applicants from half of the population. As O'Lynn (2004) perceptively notes, i f men entered nursing at the same rates as did women, there could possibly be no nursing shortage. In spite of this, past and present enrolment patterns indicate an untapped pool of caring and competent recruits for nursing (Anders, 1993; Cummings, 1995; Davis & Bartfay, 2001; O'Lynn). There are therefore not only moral reasons but also demographic and labour supply considerations to the number of men in nursing education. Problems Among the cohort of men who attend schools of nursing, rates of attrition (failure to graduate) are far higher than those of female students (Blankenship, 1991; Brady & Sherrod, 2003; O'Lynn, 2004; Poliafico, 1998; Sprouse, 1996; Stott, 2003; Villeneuve, 1994). While statistical data on attrition rates are difficult to extrapolate, it has been estimated that up to half of the men who enrol in undergraduate nursing education drop out or fail before graduating (Sprouse, as cited in Poliafico; Villeneuve). The small number of studies that have examined the educational experiences of male nursing students suggest that they tend to have an experience which they perceive to be quite different from that of their female counterparts (Anthony, 2004; Auster, 1979; Kelly, Shoemaker, & Steele, 1996; O'Lynn, 2004; Paterson et al., 1996). However, the precise character of these differences is not consistently articulated in the literature: some studies have identified negative aspects of men's experiences, such as isolation, stereotyping and higher performance expectations (Cummings, 1995; Kelly, Shoemaker, & Steele, 1996; Paterson et al.; Stott, 2003). Conversely, a significant body of research exists that details the positive discrimination or advantages conferred on men in nursing by virtue of being small in number (Evans, 1997; Johnson, 1989; Snavely & Fairhurst, 1984; Williams, 1995). It remains to be seen whether this 3 espoused hidden advantage or patriarchal dividend exists in the classroom from the students' or teachers' perspectives. It is also unclear in the literature whether male nursing students consider themselves to be a minority group per se, with accompanying homogeneity and marginalization that are typically associated with other minority groups. Finally, the majority of research on men's educational experiences in nursing has been situated in the clinical context. Given that classroom learning constitutes a significant number, or even majority, of contact hours in most undergraduate nursing curricula, it was prudent to investigate that particular learning environment. Purpose and Significance There is a lack of clarity and understanding around the character and quality of male nursing students' subjective educational experiences. A reasonable response to this phenomenon was to seek a deeper understanding of how male nursing students perceive their classroom experiences and to describe these in detail. A valuable, and necessary, counterpart to these data was to determine i f and/or how nursing instructors think about, plan for and address these issues related to gender in their classrooms. The findings from this research can be used to inform the practice of nursing educators, with the ultimate goal of improving the quality of classroom nursing education. The Current Conceptualization of Gender Gender can be defined as "that complex of social meanings that is attached to biological sex" (Kimmel & Messner, as quoted in Evans, 2002, p. 442). In the past, the concept of gender has been often been conflated with the idea of sex: as a binary of male and female, with membership in each mutually-exclusive category signified solely by anatomy (Moynihan, 1998). It is now 4 accepted that this essentialist conceptualization is simplistic at best, stereotypical and inaccurate at worst. Gender is now conceptualized as encompassing multiple masculinities and femininities, indicating that there are numerous and widely varying ways of men and women enacting their sex in their daily lives (Kimmel & Messner, as cited in Evans). The nursing classroom, like all institutions, is a social construction that provides a setting for this enacting of one's sex. From within this theoretical framework, this study wil l be used to explore and describe students' and teachers' perceived salience of the relationship between gender and the culture of the nursing classroom. Research Questions The research questions that guided this study were: 1. How does gender inform and influence the culture of the nursing classroom? 2. How do male undergraduate nursing students perceive and interpret their experiences in the nursing classroom? 3. How do classroom nursing educators think about, plan for and address the fact that men constitute a small number of nursing students? Summary The educational experiences of male nursing students are poorly understood in the literature, and the way that nursing educators think about the gender split in their classroom has been inadequately researched. Male students are far more likely than their female counterparts to fail to complete their educational programs and graduate successfully. The purpose of this study was to understand the classroom experiences of both male nursing students and the women who teach them. 5 Chapter Two Literature Review The literature on male nurses in general, and male nursing students in particular, has grown in recent years, though a survey of this body of knowledge shows it to be sparse, superficial and often out of date. Many of the studies that have been published date from the 1970s, an era that is generally thought to mark the beginning of social examination of traditional gender roles. Since that point, the literature has grown incrementally, in spite of the significant changes society has seen with regard to previous assumptions about gender and its impact on society and the workplace. Overview of the Literature Review This literature review will attempt to explore the state of knowledge regarding the experiences of male nursing students. It will begin with an examination of the broader context of the body of knowledge, with reference to the many 'calls to arms' that profession has recently sounded, to the history of men in nursing, and to the gender-related theory that underlies the issues of men in nursing and nursing education. The empirical evidence of the literature will then be presented, firstly with reference to men in the nursing profession, and then secondly, and more specifically, to men in nursing education. Finally, I will present a synthesis of the current state of knowledge and identify some of the deficits that this study aimed to address. Context Calls to arms A great deal of the literature on men in nursing is better characterized as editorializing rather than empirical data, including many 'calls to arms' for the profession to foster gender diversity in 6 the workplace and, to a lesser extent, schools of nursing (American Association of Colleges of Nursing, 2001; Anders, 1993; Poliafico, 1998; Sullivan, 2000). These articles tend to lament the historically low numbers of men in nursing and serve as a rallying cry for the profession to acknowledge and act upon the potential contribution of increasing the number of males who study and practice nursing. The rationales for increasing the number of men in nursing vary. Some authors cite a moral and ethical obligation on the part of the profession to reflect, as much as is possible, the demographics of the populations that nurses serve (American Association of Colleges of Nursing; Auster, 1979; Brady & Sherrod, 2003; Meadus, 2000; Sims & Baldwin, 1995; Sullivan, 2000). Others adopt a more pragmatic perspective, noting that in the present global shortage of nurses it is counterproductive to continue to largely exclude or ignore roughly half of the prospective pool of future nurses (O'Lynn, 2004). While this message is indeed valid, it lends little to gaining an understanding of why exactly this situation was the case in the past and why it has persisted into the twenty-first century. The problematic nature of the status quo is certainly worth stating, but history has proven it to be remarkably resilient in the absence of an understanding of what factors underlie this phenomenon. The history of men in nursing There is a sizable body of literature that addresses the history of men in nursing, with a consensus that men have made longstanding and significant contributions to the nursing profession. In order to make this point, such research necessarily makes reference to the organization of health care prior to the European Middle Ages, when providing direct health care to persons beyond one's family was almost exclusively the domain of men (Anthony, 2004; Cyr, 1992). Many commentators make the point that men have played a central role in nursing since the 4th or 5th centuries, and that it is only since the mid-19th century that men have largely been ignored and variously excluded from nursing practice. In light of this long-term perspective on 7 gender and nursing, the femininization of nursing since the 1850s is the historical exception rather than the rule (Anthony; Cyr; Davis & Bartfay, 2001; Evans, 2004b; Mackintosh, 1997). From this broad historical perspective, it is evident that the involvement of men in what is now characterized as nursing is not a modem anachronism, but rather a modest reassertion of the important and long-established role of men in the provision of care. Like the rallying cries for an increase in the numbers of men in the profession, this historically-focused literature emphasizes that there should be more men in nursing because it is far from unprecedented, and that a more gender-equitable organization of care is in the best interests of patients. Theoretical underpinnings: Gender and nursing A n important body of knowledge that underlies this study has demonstrated that the profession of nursing is rooted in the feminine domain (Cummings, 1995; Evans, 2004b; O'Lynn, 2004; Villeneuve, 1994). Underlying this fact is the concept of gender, a socially constructed, and most often unconscious and unexamined idea in which notions of masculinity and femininity are created (Cummings). There is a strong and relatively long-standing association of nursing with femininity, a fact which is central to any examination of men in nursing or of men in nursing education. In light of this, several researchers have examined the role of gender in nursing both in the past and in the present, an arena in which the work of Joan Evans stands out. Evans has explored the deep association between nursing and femininities, as well as the ways in which the gender-based division of labour in larger society is reflected in the norms and organization of hospitals, health care and nursing culture (Evans, 1997; 2002; 2003; 2004a; 2004b). She and others note that it is no coincidence that at the same time as most nurses have been women, nursing practice has come to be associated with traditionally feminine traits such as caring, nurturing and healing (Cummings; Evans, 2004b). 8 In his seminal study on recruiting and retaining men in nursing, Villeneuve notes that both the language (referring to the feminine origins of the verb nurse) and the recent history of nursing have sexualized nursing practice, and sexualized it firmly in the domain of the feminine. In entering such a profession, men make a decision to bear an "enormous stigma" (Chodorow, as cited in Whittock & Leonard, 2003, p. 244). As Meadus (2000) notes, nursing is considered as an extension of the natural role of women in society, and those men who choose to enter nursing are "occupationally atypical" (Lemkau, as cited in Villeneuve, p. 219) and fundamentally different from other men. Nor is the gendered nature of the nursing profession restricted to practice contexts. Some researchers have made the point that the culture of nursing education and the institutions that provide it are also gendered and likewise rooted in femininities (Kermode, 2006; O'Lynn, 2004). Empirical Evidence The experiences of men in nursing practice Sex role strain and status contradiction There is a significant body of knowledge that addresses the question of whether male nurses experience the psychological construct of sex role strain in their clinical practice. Sex role strain is a phenomenon that emerges when an individual perceives a disconnect between conflicting role expectations that are rooted in social norms (Baker, 2001; Egeland & Brown, 1988). The concept was initially conceived by Goode in 1960 as "the difficulty one experiences in meeting one's perceived role obligations" (Goode, as cited in Baker, 2001, p. 378). Within role strain theory, the nature of this difficulty can take different forms. As such, there are four different facets of role strain: (a) overload, which exists when the sheer number of roles, rather than their conflicting nature, presents a challenge; (b) conflict, where different roles are perceived as being mutually exclusive; (c) incongruity, in which an individual's role obligations fit poorly with his 9 or her attitudes, skills or values; and (d) ambiguity, where there is a lack of clarity or understanding of exactly what a role entails (Sherrod, 1991). In the case of male nursing students, Sherrod found statistically significant, though not high, role strain existed in each domain—other than role strain overload—and that levels in these three domains were significantly higher than those of their female student counterparts. Other studies have concurred that both male nursing students (Baker; Stott, 2003) and male nurses (Egeland & Brown) are subject to significant, though not severe, levels of role strain. As Stott (2003) notes, there is no consensus in the current literature as to the degree of role strain that male nurses experience. Stereotypes One consequence faced by men who enter a profession that is associated with femininity is that of stereotyping. In spite of the broad social changes in gender roles that have occurred, several studies spanning several decades and covering numerous practice and educational contexts have firmly established that for male nurses, antiquated and inaccurate stereotypes have been and remain a pervasive and unwelcome reality (Auster, 1979; Baker, 2001; Cummings, 1995; Cyr, 1992; Egeland & Brown, 1988; Ellis, Meeker, & Hyde, 2006; Okrainec, 1993b; Rochelle, 2002; Schoenmaker & Radosevich, 1976; Sherrod, 1991; Stott, in press; Wilson, 2005). Male nurses and male nursing students encounter stereotypes from both within and without the profession, with friends, family, the media, coworkers and educators, often making the presumption that they are performing women's work (Evans, 1997; Villeneuve, 1994). There is a broad social consensus that to enter the field of nursing one must possess attributes such as empathy, nurturing and service—all of which are associated with the feminine (Williams, 1995). One manifestation of this perceived difference exists in the persistent stereotype of the gay male nurse (Cummings; Evans, 2002; Evans, 2003; Evans, 2004b, Kelly, Schoemaker, & Steele, 1996; Meadus, 2000; Poliafico, 1998; Wilson, 2005). This inaccurate conflation of sexual orientation 10 and career choice has been noted to be one of the most prevalent and persistent stereotypes of men in nursing. There is an implicit judgment in this stereotype that because a man has chosen a profession that is associated with the feminine and is predominantly performed by women, his masculinity, and therefore sexual identity, must be anomalous, or at least suspect (Williams, 1995). Numerous studies spanning a broad range of times and places have confirmed the near-ubiquitous presence of this stereotype and the detrimental role that it has played in the experience of both gay and straight nurses alike, as well as on efforts to recruit greater number of men into the profession (Kelly, Schoemaker, & Steele; Meadus; Poliafico; Williams, 1995). In the specific case of male nursing students, the gay stereotype is equally pervasive; in virtually all of the studies into the experiences of male nursing students that presently exist, this stereotype has been noted (Anthony, 2004; Boughn, 1994; Kelly, Shoemaker, & Steele; Williams; Wilson). While thegay stereotype appears to be the most prevalent, there are other preconceptions that male nurses have been reported to encounter. Cyr found that among his study participants, male nurses cited the preconception that they were unable to become physicians, thus entering nursing as a 'Plan B,' as well as the fact that their female nursing colleagues see them as brawn rather than brain: that is, physically strong and useful rather than valued for intelligence or caring (1992). Advantages for male nurses While much of the literature characterizes the experience of male nurses and male nursing students as exclusively negative, there is research suggesting that there can be substantial benefits to being a member of a small minority group, such as that of a male in nursing or in nursing education. Substantial evidence exists that men in nursing may both enjoy and benefit from their belonging to a visible and numerically small group (Cummings, 1995; Evans, 2003; Evans, 2004b; Johnson, 1989; Snavely & Fairhurst, 1984; Stott, 2003; Williams, 1995). 11 The character and degree of this advantage has been conceptualized in a variety of ways. Evans in particular (1997, 2004b) has elucidated the potential positives available to men in nursing practice. She notes that society ascribes value and high position to all that is male and masculine, regardless of whether a situational numerical minority exists. As such, the culturally inherent value of what it is that men do often supersedes the socially-ascribed low status of nursing (Evans, 2004b). A n indicator of this tendency is the disproportionately high representation of men in nursing leadership positions. Evans notes that this phenomenon is less marked in Canada when compared with other English-speaking countries, but she and others point out that the proportion of male nurses who hold positions in management and administration exceeds the proportion of female nurses (Cummings; Williams, 1995). Evans states that men in nursing enjoy a situational dominance which makes it difficult to characterize male nurses as truly disadvantaged in their low numbers (Evans, 1997). Williams (1995) came to similar conclusions when examining the profession from the perspective of a sociologist rather than a nurse, characterizing men in nursing as possessing a hidden advantage. Other authors have similarly contended that male students, not unlike their colleagues who have already graduated, are generally better treated by their instructors and receive more attention than their female counterparts (Cummings, 1995; Evans, 2003; Evans, 2004b; Johnson, 1989; Snavely & Fairhurst, 1984; Stott, 2003; Williams). Snavely and Fairhurst (1984) found over two decades ago that male students did not encounter the dynamics of tokenism in their nursing education, unlike many other minority groups. Tokenism is the phenomenon characterized by Kanter proposing that numerical under-representation leads to greater performance pressure, social isolation and role entrapment. In the case of male nursing students, tokenism was not found in their experience, and in fact they perceived a higher rather than lower status by virtue of their small numbers. As Stott (2003) 12 notes, "far from being disadvantaged, sexism from within nursing tends to favour male students" (P- 94). Caring Several scholars have addressed the way in which male nurses learn to care and exhibit their care to clients. Men have been found to be equally caring as their female counterparts, but with differences in the way that they develop particular care-giving styles, and in how they demonstrate this in the clinical arena, especially with regard to the cautious use of therapeutic touching (Evans, 2002; Hilton, 2002; Meadus, 2000; Stott, 2003; Villeneuve, 1994). As with so many other aspects of men in nursing, the significance of gender is inextricable from an examination of whether, or how, men demonstrate care in their interactions with patients. The very fact that this is a subject for study is likely a reflection of the socially-entrenched idea that caring is a feminine trait. Research has not supported this assumption, however, indicating that men not only have a strong desire to provide empathic and genuine care when working with patients, but are able to do so successfully (Grant, 2004; MacDougall, 1997; Meadus; Paterson et al., Whittock & Leonard, 2003). This is not to say that men and women think about and act out their caring in exactly the same ways. Paterson et al. found that there are significant differences in the way that men think about, and learn to demonstrate, caring (1996). This is a phenomenon that is often displayed in the ways that men touch their patients. As a reflection of the potential of being perceived as a sexually motivated, men learn to be much more judicious and conservative in their use of touch in their patient interactions (Evans). Men in nursing education Motivations for entering nursing There is a significant body of research that explores men's motivations for entering the nursing profession, given that doing so is a countercultural or counter-gender role action in light of the 13 strong association between nursing and femininity in western cultures (Brady & Sherrod, 2003; Davis & Bartfay, 2001; Evans, 2003; Evans 2004b; Villeneuve, 1994). The collective results from this research suggest that men enter nursing for much the same reasons as women: because they like people, they want to help others, and they believe the work wil l be interesting and secure (Anders, 1993; Bush, 1976; Cyr, 1992; Kelly, Shoemaker, & Steele, 1996; Meadus, 2000; Okrainec, 1994; Soerlie, Talseth, & Norberg, 1997). Beyond these altruistic motives, there are also more practical reasons for men to enter nursing. Recent work by Meadus and Twomey (2007) notes the expectation of a good salary, job security and strong career opportunities. Wilson (2005) has found that men entering nursing cited the importance of job stability, a perceived good personality fit and expected job satisfaction in choosing to enter the profession. The salience of obstetrical clinical rotation Among men who enter nursing, the obstetrical clinical rotation has been shown to be a powerful and significant experience (Okrainec, 1993a; Okrainec, 1993b; Patterson & Morin, 2002; Sherrod; 1991; Streubert & O'Toole, 1991; Trachtenberg, 2000). It is in this venue that stereotypes about the nursing profession, ideas around men in nursing, cultural notions of the birthing experience and cultural ideals about men's roles in birthing appear to collide. There is agreement that the obstetrical clinical rotation is a source of confused and often contradictory expectations for male nursing students, and that they often encounter discrimination from patients, staff nurses and clinical instructors. Patterson and Morin found in a phenomenological study that male nursing students often faced their obstetrical rotation with fear and apprehension, in which they felt like outside visitors entering into an exclusively female domain. Trachtenberg revealed similar feelings, but also found that the fact that male students feel singled out by virtue of their gender in obstetrical clinical placements was not a unanimously negative aspect. Rather, participants characterized it as a phenomenon that had both positive and negative aspects. The 14 negative aspects included such feelings as exclusion and apartness, but they also noted that it was sometimes an advantage to be a member of a minority and to receive more attention from both staff and instructors by virtue of their gender. To summarize, the existing knowledge around men in nursing and in nursing education consists of a modest body of work around men in nursing practice, a smaller amount of research regarding men in nursing education, and nothing examining the classroom context. While some studies addressing the experiences of male nurses make mention of male nursing students or include a component thereof, only around 14 articles were located that dealt exclusively or extensively with the particular experiences of men in nursing education. O f these, there are comparatively few that take data analysis deeper than simply summarizing the findings and discussing; few studies attempt to take the analysis further to understand the complexity of male students' experiences in a gender disproportionate environment. While many of the themes and issues revealed parallel the experiences and thoughts of male nurses, they are certainly not shown to be synonymous. There are aspects that vary significantly from those of men in practice. One of the central issues that the literature reveals is that men live an experience of nursing education that is very different from the majority female student cohort (Anthony, 2004; Ellis, Meeker, & Hyde, 2006; Kelly, Shoemaker, & Steele, 1996; Okrainec, 1994; Paterson et al., 1996; Schoenmaker & Radosevich, 1976; Wilson, 2005). These differences are multidimensional and varied, and include both perceived benefits and disadvantages. The literature suggests that the impressions and experiences of men in nursing are certainly not homogeneous. Nonetheless, commonalities can be identified across the body of knowledge that can be characterized around the themes of nursing education as a gendered place; problems and challenges; perceived advantages; and teaching and learning. 15 Nursing education as a gendered place The theoretical literature on nursing suggested that the profession of nursing is a profoundly gendered institution. It should come as no surprise, then, that one of the predominant themes in the literature on male nursing students is that schools of nursing are also gendered, and similarly rooted in femininities (Anthony, 2004; Ellis, Meeker, & Hyde, 2006; Kelly, Shoemaker, & Steele, 1996; Mcintosh, 2002; Okrainec, 1994; Paterson et al., 1996; Schoenmaker & Radosevich, 1976; Wilson, 2005). Students participating in these studies identified that the environment, norms, culture and practice of education in schools of nursing are profoundly rooted in the modern, feminine history of the profession. The disparate numerical ratio between men and women in nursing education is reflected in the culture of the schools themselves, a phenomenon that is not limited to one particular venue, but rather transcends clinical, classroom or extracurricular situations. Without exception, male nursing students indicate clearly that their education is occurring in a context that is not simply made up of more women than men, but that the very nature and culture of the educational environments are inextricable from femininities. This finding is often stated explicitly in the findings and discussion of studies, though occasionally it is presented as a theoretical assumption implicit in the methodology and research questions. A n example of the latter is the 1996 study by Kelly, Shoemaker and Steele in which the prominent findings of male students' isolation from female colleagues and instructors and the prevalence of stereotypes suggested a larger gendered setting that is apart from the men. Problems and challenges The literature cites numerous specific challenges that men ascribe to their educational experiences. Many of these closely echo the findings around men in nursing practice. Like their practicing colleagues, male nursing students attest to the ubiquity and inaccuracy of stereotypes (Kelly, Shoemaker, & Steele, 1996; Paterson et al., 1996; Schoenmaker & Radosevich, 1976; 16 Wilson, 2005). The most common of these, as in the case of male nurses, was the gay stereotype, whereby students felt suspected in their sexual orientation by either direct or indirect comments, originating from friends, family and even from fellow students. One of the responses that this commonly invokes is the pressure to assert the fact that one is heterosexual (Kelly, Shoemaker, & Steele). The perceived incongruity between nursing and masculinities is itself a problem and challenge that male nursing students experience. A common manifestation of this is self-doubt around the validity and wisdom of their career choice (Kelly, Shoemaker, & Steele, 1996; Stott, in press). This represents little change from findings of a generation earlier, when Schoenmaker and Radosevich (1976) found that one-third of male nursing students were reluctant to tell family and friends about their career choice. Another common finding is the presence of isolation on the part of male nursing students. As a consequence of the association of nursing education with femininities, many male students claim to feel isolated and distanced from the norms and central culture of their schools of nursing (Anthony, 2004; Kermode, 2006; O'Lynn, 2004). Numerous and varied aspects of nursing education contribute to this feeling. O'Lynn (2004) noted in his recent study that over 80% of male participants cited the lack of any male mentorship programs, the absence of any mention of men's contributions to nursing and the ubiquitous use of "she' and "her" in classes and textbooks as aspects of nursing education that made them ultimately feel isolated and excluded. These findings echo those of Kelly, Shoemaker and Steele (1996) and Stott (in press) who all found that isolation and loneliness characterized the experiences of men in their study, a fact that the studies' participants attributed to being male in nursing education. 17 A final major, negative aspect to men's experiences in nursing education—and one that is frequently related to the feelings of isolation—is the lack of males in leadership in nursing education. Specifically, men lament that fact that there are so few men both on faculty at schools of nursing and in practice during their clinical placements (Brady & Sherrod, 2003; Ellis, Meeker, & Hyde, 2006; O'Lynn, 2004). Male nursing students feel that simply having more men in teaching positions would make them feel less excluded and less of an anomaly in the profession. The most commonly cited rationale for this impression is that men feel they lack role models. The fact that so few men teach in nursing contributes to their feeling of being isolated outsiders who lack a point of reference to an authority figure that they can relate to from a gender perspective (Brady; Ellis, Meeker, & Hyde; OLynn). There are evidently numerous challenges and unwelcome aspects to men's experiences in nursing education. However, the literature does not suggest that nursing education is all bad for men. There are aspects to their experience that they enjoy and those to which they ascribe an advantage to their gender, most often around receiving greater attention from their instructors and colleagues and in anticipation of an easy climb up the career ladder following graduation (Ellis, Meeker, & Hyde, 2006). In light of the challenges and frustrations that men associate with nursing education, it would be easy to presume that they profoundly dislike their learning experiences. Interestingly, that is not the case, and several studies attest to the fact that, overall, men are satisfied with the quality and character of their education in spite of challenges (Kelly, Shoemaker, & Steele; Okrainec, 1990, 1994). Older studies have also found that men do not feel like tokens in nursing education (Snavely & Fairhurst, 1984) and that they do not experience significant levels of role strain (Okrainec, 1987). 18 Teaching and learning Men's impressions of teaching and learning in nursing education are also complex and even contradictory. As previously noted, men want more of their instructors to be men. A perceived advantage that they ascribe to this is would be the increased prevalence of men's learning styles in the delivery of material. While in the field of education there is no consensus on the relationship between learning styles and gender, the literature on men in nursing education reveals that men do indeed believe that the delivery of learning materials almost exclusively reflects female learning styles (Anthony, 2004; Kermode, 2006; O'Lynn, 2004). In a recent study, male student interviewees also identified significant and frustrating differences between the communication styles of men and women, going so far as to characterize nursing education as set up by women, for women and geared towards women's understanding (Ellis, Meeker, & Hyde, 2006). Men also believe that they often face different performance expectations in nursing education. In clinical settings, this often takes the form of increased physical expectations, such as transferring and lifting, but in classroom education men often feel pressure from instructors to be more assertive than female students and to assume a leadership role (Anthony, 2004; O'Lynn, 2004). Another expectation that men perceive is the need to prove their worth of being in the profession, which is manifested in increased performance expectations both in clinical and in the classroom (Cummings, 1995; Kelly, Shoemaker, & Steele, 1996; Paterson et al.). This is a difficult challenge for men, especially as they also cite the presumption that they are too assertive and academically competitive (Wilson, 2005). A consequence of this 'lose-lose' situation for men is that they may feel that their instructors see them as an often unwanted, educational variable that must be dealt with, and a threat to female authority in the nursing classroom (Brady & Sherrod, 2003; Kermode, 2005; Schoenmaker & Radosevich, 1976). In teaching situations, there is also a 19 stated tendency on the part of educators to isolate male students both in the class and in clinical, often ensuring that small numbers of men are spread around with never more than one man in a clinical group or small working group (Stott, in press). This contributes to the feelings of isolation and exclusion that men in several studies have noted (Anthony; O'Lynn; Stott). Finally, men also reveal specific preferences in their teaching and learning with one of the common threads being a preference for kinaesthetic and technical subjects and course materials and a lack of interest in the psychosocial and affective components (Auster, 1979, Schoenmaker & Radosevich, 1976; Stott, in press). They also desire classroom examples, materials and anecdotes to be gender-inclusive, and not always generalizable to the female (Kermode, 2005; O'Lynn, 2004). It is clear from the literature that nursing education is a gendered institution and one that presents a variety of challenges and frustrations for men; frustrations and challenges that are ultimately exacerbated by the fact that men feel their female instructors neither recognize nor acknowledge this fact (O'Lynn, 2004). Shortcomings in the State of Knowledge; Justifications for this Study It is clear that while a growing body of knowledge around the experiences of men in nursing education does exist, there are significant and numerous shortcomings and gaps that indicate a need for further research. In spite of some insightful studies that have been published within the last several years, the fact remains that much of the literature on men in nursing and nursing education is more than ten years old. Social and cultural norms are capable of rapid change, and it would be inaccurate to assume that a situation that is rooted in gender and change would remain static. As such, it is necessary to supplement much of this earlier research. 20 There are also methodological shortcomings in much of the literature. Among the researchers who have studied the experiences of men in nursing education, most have utilized survey-based quantitative studies and few have adopted a phenomenological, qualitative perspective. Many of the earlier studies are also characterized by a lack of stated consideration for issues of scientific rigor and a tendency to simply summarize findings, rather than analyze for deeper and more complex meaning. In light of the importance of the individualized and subjective meaning that the complexity of the phenomena in question involves, a reasonable response is to enrich survey data with an interpretive, phenomenological approach (Denzin & Lincoln, 2000; Morse & Field, 1995). It is also clear from a review of the literature that there is an emphasis on the psychological manifestations of being a man in nursing education. The most obvious example of this is the significant body of knowledge around the psychological construct of role strain. While a psychological approach is certainly valid, there is less research into the sociological complexity of the culture of nursing education, a situation that a phenomenological analysis such is better able to address. In addition, there is virtually no existing research into the perspectives that nursing educators have on gender and the nursing classroom, or indeed any literature that specifically addresses the nursing classroom, deficits which this study is able to make an initial attempt to resolve. Finally, the small size of the body of literature is in itself a deficiency. One manifestation of this small body of knowledge is the frequent cyclical referencing within the existing literature, where statements are cited from one study to another as with the implication of fact, but without apparent origin in rigorous research. In spite of being a small proportion of nursing students, men in nursing education constitute tens of thousands of individuals, and in order to better understand 21 their experiences and the character of their educational environments, it is necessary to supplement this modest body of literature with further examination. 22 Chapter 3 Research Methodology Let that which shows itself be seen from itself in the very way in which it shows itself from itself. (Heidegger, as cited in Polifroni & Welch, 1999, p. 294) As the preceding discussions regarding the background, research problem and existing literature suggest, the current understanding of the experiences of male nursing students and the corresponding response of nursing educators is clearly in its formative stages. As such, a qualitative methodology is appropriate. In the formative stages of understanding a phenomenon, a qualitative approach, emphasizing the emic perspective and with data collection in a naturalistic context, is an appropriate methodology (Morse & Field, 1995). Qualitative research seeks to answer questions around the way that social experiences are created and given meaning (Denzin & Lincoln, 2000). In essence, this encapsulates the goal of this study: to understand the way that the social and relational experience of male nursing students and female nursing instructors in the culture of nursing education are created, understood and interpreted by each. Interpretive Ethnography Within the domain of qualitative design there exist multiple specific research methodologies. The design that was chosen for this study was interpretive ethnography in the tradition of Benner (1994, 2001), Geertz (1973); and Malone (1998, 2000). Interpretive ethnography is a research method in which the insights gained from individuals' personal, subjective narrative accounts are utilized so that the taken-for-granted understandings and background meanings that shape human conduct can be uncovered (Malone, 1998). It is a means of ascertaining the beliefs, values and experiences of individuals (Morse & Field, 1995) and involves the gathering of data from 23 embodied member participants, primarily through participant observation and interviews (Benner, 1994; Malone, 1998). Interpretive ethnography is most often undertaken within the context of a culture. Significantly, the nursing classroom has been conceptualized as constituting a culture, with accompanying norms, values, power structures and role expectations (Macintosh, 2002; Sims & Baldwin, 1995). Interpretive ethnography should not be confused with classical ethnography, in reference to the positivist efforts of twentieth-century anthropologists to capture the salient traits and truths of an ethnic group. Rather, interpretive ethnography acknowledges that multiple truths and multiple realities exist for different informants, and it does not seek or espouse a single truth waiting to be discovered by a researcher. Interpretive ethnography is rooted in the ontology of Martin Heidegger, which presumes humans to be self-defining, embodied, temporal beings for whom things have significance and value (Leonard, 1994). This worldview presumes that understanding human beings necessitates interpretation, and this interpretive exercise is called hermeneutics—the description and study of meaningful human phenomena in a detailed, systematic and careful way (Heidegger, as cited in Polifroni & Welch, 1999; Leonard; Packer, 1985). In its essence, it is a particular kind of intellectual effort that is best described, and indeed defined, as thick description (Ryle, as cited in Geertz, 1973). Sample In order to gain understanding of the culture of nursing education from both a teaching perspective and a learning perspective, this study necessitated the recruitment of both nursing instructors and nursing students. As 97% of nursing instructors in Canada are women (Canadian Institute for Health Research, 2005), only female educators were recruited for the study. I sought to include instructors from a variety of ages, amounts of classroom teaching experience and 24 education levels in order to maximize the breadth of potential insights, experiences and narratives. Underlying this decision was the assumption that perceptions of classroom education are highly individual, and may well vary according to such parameters. Thus, inclusion criteria for instructor participants were: female sex; and currently or recently teaching a third-or fourth year, classroom-based course in an undergraduate nursing program at one of the two sites where ethics approval had been obtained. I had hoped to enlist participants from a variety of cultural backgrounds, but was unable to do so; each of the six instructors was from a Caucasian-Canadian background. Given the focus on the particular experiences and understanding of male nursing students, only male students were invited to participate. Male nursing students who were at a third- or fourth-year level in their nursing education were sought, as undergraduate students at this point in their learning would presumably have a larger body of educational experience from which to draw insights and narratives. As such, inclusion criteria for student participants were: male sex; and current enrolment in the third or fourth year of the undergraduate nursing program at one of the two sites where ethics approval had been obtained. Like the instructor participants, the students who ultimately agreed to participate were culturally homogeneous as Caucasian-Canadians. A total of six nursing students and six nursing instructors were interviewed for the study. The instructors ranged in age from 28 to 59 with an average age of 47 years. Their number of years as nursing educators had a similarly wide span, ranging from a low of 3.5 years to a high of 26 years, with an average of 16 years' teaching experience. The instructors' own level of education varied between masters degrees and doctoral degrees. Each instructor's highest attained degree was in nursing. These parameters for each of the educators who participated in the study are summarized in Table 1. 25 Table 1: Characteristics of Educator Participants Educator number Age Years of teaching experience Level of education 1 39 6 years Masters degree 2 46 16 years Masters degree 3 59 16 years Doctoral degree 4 28 3.5 years Masters degree 5 58 31 years Masters degree 6 51 26 years Doctoral degree The six student participants were also relatively heterogeneous. They ranged in age from 22 to 44 with an average of 30 years. A l l had completed some post-secondary education prior to entering nursing education (averaging 3 years), as is the norm among contemporary nursing students. This pre-existing educational experience proved to be a useful counterpoint in their understanding of the culture of nursing classrooms. Table 2: Characteristics of Student Participants Student number Age Educational year Prior years of non-nursing post-secondary education 2 3 4 5 6 32 44 22 23 26 31 3 years 2.5 years 2.5 years 5 years 2 years 2 years 26 Settings The study was conducted within two large schools of nursing in urban settings of British Columbia. A l l of the interviews and classroom observations were conducted in the context of Bachelor of Science in Nursing programs. Recruitment The study consisted of two phases: firstly, participant observation of classroom teaching sessions; and secondly, semi-structured interviews with the instructor of the teaching class and one or two of the male students in the class. In the ethnographic tradition, it is important to observe phenomena in the context in which they occur (Morse & Field, 1995). As the context of the study was the nursing classroom, it would likely have been insufficient or even inaccurate to draw conclusions with regard to the research questions without the researcher personally observing interaction in this environment. Following ethics approval from the respective institutional ethics review board at the two schools of nursing, an effort was made to recruit instructors of third- or fourth-year nursing courses that were conducted in a classroom environment. Thus, clinical-based and lab-based courses were excluded, as were courses offered by other disciplines within the institution. I posted flyers (Appendix B) throughout the nursing departments at the two sites as well as delivering letters of invitation (Appendix C) to instructors whose teaching assignments met the study's criteria of level and delivery method. In total, four instructors at site A and two instructors at site B responded and met with me to discuss the proposed research, with each agreeing to have me observe their classroom teaching sessions on three separate, future dates during the academic term, pending the approval of the students in the classes. 27 In order to obtain consent for my proposed observations from all students in the class, both male and female, each instructor participant granted me a block of time at the beginning of a class to explain my research, field questions and distribute a letter of explanation to each student (Appendix E). Any student who was not comfortable with my observing the class in the future was informed that he or she could communicate this with me, the course instructor, or a member of my thesis committee in person, by phone or by email. Research ethics boards at both sites approved a passive consent process, in which the absence of any student dissent was taken as approval to proceed with classroom observations on three future dates. No student in any of the proposed observation classes dissented. At this introductory and explanatory class I also presented letters of invitation to all the male members of the class in an effort to recruit my student interviewees (Appendix D). Sampling of both instructors and students was therefore conducted on a convenience basis. Data Collection After a one-week window allowing for students to respond who did not wish for me to observe their class, a series of three classroom observations was scheduled with the instructor and the students then made aware of these three dates. The classroom observation sessions numbered 15 in total (three observations of five instructors), as one instructor I interviewed did not teach an appropriate class during the term in question. The observations ranged from 60 to 90 minutes in duration, and utilized the participant observation guide (Appendix H) developed for the study. Following each observation, I completed reflective field notes. A wide range of subject matters and course objectives were represented among the fifteen classes observed. The classes ranged in size from totals of 23 students to 56 students present, with the number of men enrolled ranging from two to nine. In each of the classes where participant observation was agreed to by the instructor and proposed to the class there was at least one male student who made contact 28 expressing an interest in being interviewed. In one class there were two men who agreed to participate. Thus, the total number of students interviewed in the course of the study was six. After the completion of all three classroom observations, interviews were scheduled with both the instructor and the student(s) who had previously agreed to grant an interview. The interviews of each course's instructor and student(s) were conducted separately, with no preference given to whose interview was conducted first. The interviews were semi-structured and, after written consent was obtained (Appendices F and G), were conducted according to the instructor interview and student interview templates developed for the study (Appendices I and J). Narratives of actual experiences were elicited as often as possible, as these are important sources of meaning in the interpretive tradition (Benner, 1994; Polkinghorne, 1988). Interviews were conducted at locations convenient to the participants and varied from 60 to 90 minutes in duration. Each participant was interviewed one time. The interviews were digitally recorded and I wrote field notes reflecting on my own impressions of the interview immediately after the interview. These field notes provided an important reflective component of the research process, allowing me to propose initial observations and interpretations of the content and process of the interview. These field notes from both the interviews and the observations became a third source of data from which to draw conclusions, in addition to the observation instrument and interview transcripts themselves. Data Analysis In accordance with a systematic, hermeneutic approach, the goal of data analysis was to uncover namrally-occurring concerns and meanings of the participants, with the goal of accurately presenting their voices (Benner, 1994; Geertz, 1973). As noted above, analysis began immediately following each observation session and interview with the writing of field notes. 29 Both during and after each event, the study's research questions provided a guiding lens for preliminary analysis. Following each interview, the digital audio file was sent electronically to an experienced transcriptionist, who in turn provided a word-processed transcript of the interview. The transcripts contained not only the word content of the conversation but also non-lexical components such as "mmm mmm" (signifying agreement) and pauses and hesitations. The transcripts were initially read and reread in order to gain familiarity and clarity on the content, concerns and meanings revealed by participants, and impressions and questions were written in the margin of each transcript. At this early stage, no effort was made to identify commonalities or points of comparison between different participants, but rather to understand and appreciate each data source in and of itself. Following this preliminary analysis I examined the transcripts for themes with the aim to gain a broad comprehension of the data on an intraparticipant level (Morse & Field, 1995). The twelve interview transcripts were examined in two groups: the student interviews forming one block of data and the instructor interviews another. A n alternative approach to this would have been to consider each student-instructor pairing as a unit of analysis. However, preliminary analysis suggested far more points of similarity between the six students as a unit and the six instructors as a unit, with regard to both content and relevance to the research questions. At this point, an understanding of the phenomena underlying the data in terms of the data itself was sought through the identification of themes. Potential themes were identified and excerpts from the transcripts relating to these themes were selected and sorted by cutting and pasting electronically. As a reflective activity, I journaled about each emerging theme. Through this process, the validity of preliminary themes were either confirmed or disproved, and an understanding of the phenomena underlying the data in the terms of the data itself was attained. 30 Rigor At all stages of the research, scientific rigor was fostered. The goal of this research, and indeed of all qualitative research, was not to draw conclusions that are reproducible into contexts and among individuals beyond the participants of the study (Morse & Field, 1995). Rather, the goal was to implement measures that would ensure that the analysis and research methods were conducted with care and thoroughness, with the ultimate goal that the findings be trustworthy. Such efforts included the use of multiple data sources; multiple data collection strategies; recording and transcription of interviews; the writing of field notes following participant observation and interviews; simultaneous data collection and analysis; the maintenance of an audit trail throughout the process; and regular debriefing, reflection, and solicitation of input from committee members (Malone, 1998, 2000; Morse & Field). These efforts to foster rigor also aided in reflexivity, given that the student researcher is a male R N with an accompanying body of experiences, assumptions and potential biases around undergraduate nursing education. Ethical Considerations As in any research involving human subjects, it was paramount to take measures to ensure that the study was conducted in accordance with accepted ethical norms with regard to respect for persons. At numerous points in the conceptualization and execution of the study, ethical considerations were addressed. Ethics approval from behavioural ethics review boards (Appendix A) was obtained both for the research proposal and instruments themselves, and also for conducting the observations and interviews within the two schools of nursing. During the recruitment phase of the study, I explained verbally and in the form of a letter the background, purposes, methods,and confidentiality safeguards of the study to all potential study participants. While nursing instructors were approached in person, I maintained a passive rather 31 than active role i n recruiting male nursing students i n order that perceived coercion be avoided. D u r i n g the explanation o f the study to the potential observations classes, verbal assent was requested from all students, and observation would not have taken place i f any student i n the class d i d not agree to it. Written consent was obtained from al l the nursing instructors and student interviewees. Coded identification numbers were used to label the data collected and project computer files were password protected. N o identifying information regarding participants was used i n communications between mysel f and the thesis committee. This measure was implemented to ensure that committee members were not aware o f the identities o f particular nursing educators, given the small size o f the nursing education community i n the lower mainland. Transcripts, field notes and observation documents were kept i n a locked filing cabinet, separately from participants' signed consent forms. Summary This chapter has explained the rationale for choosing a qualitative methodology and, specifically, an interpretive ethnographic approach within that research tradition. The actual steps that were undertaken i n carrying out the study were elucidated, as were the process o f deriving conclusions from the raw data and the efforts made to ensure the study was conducted i n a scientifically rigorous and ethically sound manner. 32 Chapter Four Research Findings As noted, the research questions guiding this study focused specifically on the classroom context, as did the initial interview guides that helped structure interviews, the participant observation instrument developed for the study, and indeed the participant observation itself. It became clear, however, that this narrow and finite focus was not an accurate reflection of what participants wanted to communicate and what they believed to be significant in their lives. Early in the data collection and analysis, it became apparent that issues of gender were part of a richer body of experiences that occurred not only in the classroom, but also addressed clinical experiences, the public image of nursing, and the nature and culture of both nursing generally and nursing education specifically. This broader scope was most notable among the student participants, where a significant proportion of narratives represented experiences in the clinical domain, impressions and salient exchanges around nursing education in general, and their feelings around nursing and their place in the profession. To a lesser extent, this was also the case among the instructor participants, with many of their narratives also situated in settings outside the classroom and related to experiences with students in clinical settings or outside of direct teaching contexts. Adjusted Research Questions As a consequence, it was necessary to adjust the research questions as the study progressed in order to broaden the scope of the study to include clinical and laboratory experiences, including some that occurred outside the official curricula, with the ultimate goal of better reflecting the 33 lived reality of participants. The final wording of the overarching research questions that provided this study was: 1. How does gender inform and influence the culture of nursing and nursing education? (previously How does gender inform and influence the culture of the nursing classroom?). The following two research questions were used to address the overarching research question and guide the specific interview questions and participant observations: 1. How do male undergraduate nursing students perceive and interpret their experiences in nursing education? (previously How do male undergraduate nursing students perceive and interpret their experiences in the nursing classroom?). 2. How do classroom nursing educators describe teaching men nursing students? (previously How do classroom nursing educators think about, plan for and address the fact that men constitute a small number of nursing students). These adjustments allowed for an examination of nursing education that spoke clearly to the classroom context, but did not exclude other domains or experiences. Ultimately, the analysis framework centred on the experiences of the student participants. The nursing instructors' interview data were included and analysed as a third method of data collection (in addition to student interviews and participant observations) that would inform a response to the overarching research question whilst explicitly addressing research question two. The study findings that follow describe the prominent themes derived from an analysis of the student interview data, triangulated with the participant observation data, field notes and instructor interview data. 34 Overview The men interviewed for this study provided invaluable insights into their experiences in nursing education. As might be expected, experiences were diverse. While the specifics of each man's thoughts, narratives and opinions spanned a wide range of topics, three salient themes were derived from the analysis, each of which was evident in and across the participant interviews. The first of these addresses men's roles and their reliance on traditional masculinities in the classroom, actions that were characterized as stepping out, stepping up and stepping in. The second theme of masculinities in a feminine place encompasses the sexualized and stereotyped identity of men in nursing education, and the sub-themes of accommodation, not integration and assumptions offamiliarity with the feminine. The third theme of incongruence between masculinities and femininities addresses the culture of nursing education and draws on classroom, clinical and lab experiences. Playing a Different Role: Relying on Traditional Masculinities In terms of the roles taken up by men in the classroom and in the broader culture of nursing, the study participants were clearly influenced by traditional masculinities. The roles included leadership (which is not, it should be noted, synonymous with power), assertiveness and visibility. The terms stepping out, stepping up, and stepping in capture some of the major nuances of this theme. The term stepping out refers to a willingness to be visible, overt and plain to the view of both instructors and colleagues. This includes the willingness to speak and present oneself to a group, class, or instructor and a consequent rejection of stoicism, as well as putting a figurative stamp on the dynamic and direction of a teaching session. The idea of stepping up encompasses taking risk and taking onus, putting oneself'out there' with the risk of failure, accepting a challenge to perform, and taking some responsibility for the direction and character 35 of a teaching session. Finally, the idea of stepping in connotes intervening, mediating or providing an alternative viewpoint in the context of an argument or conflict. Each of these characteristics was demonstrated in the course of teaching sessions that I observed and was attested to in interviews with both students and teachers. Stepping out Although the number of men in the classes I observed varied from a low of 4% (one male in a class of 25) to a high of 19% (nine males in a class of 47), one of the consistent occurrences was the fact that, proportionally, the men asked more questions and made more statements than their female colleagues. While accounting for individual differences in participation levels among the men I interviewed, as well as those that I did not, this phenomenon was still notable. For example, in a class on the techniques of urinary catheterization that was composed of eight men and 45 women, approximately two-thirds of the questions and comments on the subject matter during the teaching session came from the men. This fact was recognized by the students themselves. For example, Alex 1 noted: So you have definitely way more [questions] per ratio. I always ask questions and [other male student] always asks questions and [another male student] always asks questions. Just that you have three out of four or two out of four in either context who are always asking questions compared to the others and there's definitely a significant difference. Likewise, Chris explained that he and the class as a whole noted how he was identified as being one of the most outspoken students: "And the other students have recognized that. Actually 1 A l l participants' responses have been given a pseudonym to protect confidentiality. 36 before that, [name] asked a question 'who are the most outspoken people in the group?' and I was the first name that was thrown out there." Not only was this phenomenon evident in larger class discussions, but also in group work. For example, when male students were working in small groups, they were almost always the one chosen by their colleagues to act as spokesperson. Interestingly, the male students during their interviews largely denied that they tend to take on an increased leadership role in their education, but it was evident in the group work that I witnessed, and occasionally alluded to in stories the men told. For example, Paul related how in his small, seminar-format class, the only two students who repeated the rotating role of chairperson over the course of the semester were himself and the other male member of the class. It would be inaccurate to construe from the data that the most vocal members of any class are always men, or that each and every man in a nursing class is a vocal and unabashed contributor to discussion and asker of questions. What was apparent, however, was that the quantity of questions and statements made by men over the course of the classes I observed consistently exceeded their numerical proportion of the students in the class. This increased level of participation and assertiveness was also one of the prominent themes in my discussions with the instructors. Without exception, they related examples of times when the men in a particular class were notable for their willingness to offer answers and suggestions, and to play a central role in discussion and problem-solving. Sandra characterized the participation level of male students over her many years of teaching: I'm just trying to think i f I've ever had a guy in a classroom that didn't ask questions . . . there's always women in the class that don't ask questions in front of the whole class, but then there's a lot of them so maybe that's just a 37 proportionate thing. Even i f it is proportionate and I have three guys in this class they all ask questions, all three of them, now one of them maybe not quite as much or as often as the other two but they, all three of them do and they're not afraid to, in front of the whole class to stick their hands up. Another aspect of stepping out was the repeated observation across all settings that men were the near-exclusive source of jokes during classroom and small group interactions. While only one interviewee made mention of this, it is telling that in over the course of the 15 classes observed, every joke originated, without exception, with a male student. Tom was the only informant to make explicit reference to the tendency of men in the classroom to play the role of jokester, or as he characterized it, "comic relief: I think too almost like I don't know i f this is true or not but an impression I get too is a lot of guys are sort of like on for comic relief in the class by some of our responses or I think the class is much more apt to laugh at something [name] says or [name] says or just even presentations when they, you know, do physical comedy. Well 1 mean let's say for [name's] group, I mean he made everyone laugh just sort of between scenes, when they were changing by just taking the mike and just, you know, making rock and roll base sounds when they were changing scenes or, or, I mean I know I ended up making people laugh just sort of in this video, you know. Just as not every man in nursing education is vocal and extroverted, it would be wrong to presume that every man in nursing education adopts a comical or humour-based persona in the classroom. It was nonetheless notable how the men in this study adopted such a distinct identity, and how similar traits were not taken up by any of the female students in the observed classes. 38 Stepping up A second facet of the different role that male students play in nursing classrooms is that of stepping up. As noted previously, this denotes a willingness to meet a challenge and to take a risk. In the classroom context, this frequently manifested as a man's willingness to challenge a professor, to provide a counterpoint to a discussion or to otherwise play an iconoclastic role— something that in any public environment always constitutes a risk, and is an integral performance component of traditional masculinities. Numerous examples of this were observed, and both students and teachers mentioned it in their interviews. In one teaching session, the instructor began the class by asking the students how they felt about the unique format of a recently submitted assignment. Several female students expressed mild satisfaction with the logistics of completing the assignment. After these voices of approval, however, a male student whom 1 later interviewed stated "I hated it!" In another class, Andrew put up his hand to challenge the instructor on the accuracy of the tracheotomy-cleaning technique that was presented and, in the subsequent interview, he explained how he addressed a potential disconnect between what the instructor taught about a particular diagnosis and what actually happens in contemporary clinical practice: I brought that up in the classroom my instructor said, 'No, that's not what they do' and I said, 'Yes, they do' and she was going to be right and I was going to be wrong and we argued back and forth and I brought in a paper to prove that's what happened and she just said thanks and continued on like nothing happened. Andrew later explained his rationale for being willing to take the risk of making himself vulnerable and not opting for a more passive and acquiescent approach: "I want to learn stuff, I don't care what I look like I just want to get it done and know the information so I have no problem asking questions." 39 While the men acknowledged this role that they sometimes played and, like Andrew, stated that they were quite willing to do so, some went further to express their frustration with the fact that their female colleagues were reluctant to disagree or express dissent. In his interview, Chris talked about a class discussion where he sensed his classmates' reluctance to dissent: "There was not a whole lot going on and like no one was disagreeing with anything else that anybody said. [Disagreeing] was something that I would do from time to time." As Chris suggests, there was also occasional frustration with the perceived homogeneity of the contributions and comments that female students would make. In Tom's synopses of a particular classroom discussion he suggested, " A l l the girls in the class could talk about the same thing and say the same thing in totally different ways . . . they each had to say something but it was pretty much the same thing that was recycled." In contrast, Tom talked about the counterpoint contributions that he and his male colleagues regularly provided: I think i f anything some of the guys will say something that doesn't go with the flow. It's more of an exception, so I think guys wil l speak more by exception than by just sort of contributing by saying sort of a different twist on the same thing. Even more frankly, Tom questioned whether "maybe girls are just better at beating around the bush." He later explained what he believed to underlie this phenomenon: "I really don't have any problems expressing my feelings and I think that shows in class when I say what's on my mind, and also in my questioning." As Tom states, there is a willingness on the part of male students to take the risk to express their thoughts, despite the fact that they may run contrary to the majority opinion and/or the opinion or expectations of the instructor. This phenomenon was also noticed and mentioned by the nursing instructors, several of whom had examples of instances when they had been challenged by male students, even going so far as 40 to identify this as a general trait of male nursing students, what Arlene called the "challenging viewpoint." A n example that Allison cited from recent experience was the way in which one of the male students was well known for "bringing up the differences in practice on the units where they're working. [He] wi l l constantly bring up differences on his unit compared to the other. Almost every week there's something he wants to ask about." Arlene, and others, spoke highly of this characteristic and the contribution that it made to the quantity and depth of classroom discussion. However, the instructors made it clear that they appreciated this only within certain limits, and when they perceived that a male student was overdoing this, their frustration was evident. Arlene stated that "over the years I've heard faculty talk about male students as i f like they're pushing us too hard, you know, or that they find them more challenging, and they say that it's not a good thing." In the case of Allison's student who often brought up the differences between units, she spoke of how he was sometimes a source of stimulation and discussion, but sometimes a source of irritation and antagonism in the class. Stepping in In addition to stepping out and stepping up, men also talked about stepping in, or intervening in a situation that they felt needed modification. This differed from asking questions or challenging an instructor, but rather took the form of men asserting themselves in order to facilitate a solution to a learning problem or perceived interpersonal rift. This phenomenon was exemplified by Chris in how he addressed what he felt was a harsh criticism of a female classmate's presentation by other colleagues: I felt I needed to step in there and give her a pat on the shoulder because overall the presentation was really good, I-mean she didn't fill up fifty minutes with nothing and she looked hurt so maybe people are going through other things outside of school that maybe would impact, you know, and she's from [another school of nursing] so they're around all these students and don't know anybody, 41 they don't know how to accept this so, yeah, I mean, I did it on purpose, I felt the need to step in there. Chris felt that an intervention was necessary in this situation, and he did not wait for someone else to step in, but rather took on the responsibility himself to address the situation. Another side of this was demonstrated by Andrew when he explained how he felt a sense of responsibility for ensuring that justice prevails in the class: There's people now that leave that class in tears and they don't want to go back because they don't push, they don't stick up for themselves and I often feel like I should try to say something when I think female students are being treated unfairly. Andrew followed this up by relating examples of times when he did indeed say something to the instructor to advocate for or protect his female classmates, something that none of the men spoke of doing in defence of a male colleague. It seems clear from this analysis that, in certain situations, the men adopted roles that closely aligned with the elements of traditional masculinities such as risk-taking behaviour, assertiveness and leadership that have been previously identified by nursing scholars (Evans, 2003; Villeneuve, 1994). There are indicators in the data that speak to the factors that underlie this freedom and willingness to be assertive and occasionally iconoclastic. One such explanation is the notion that by virtue of simply entering the profession of nursing with its widely known gender disproportion, men are already committing a decisive and challenging act (Evans; Wilson, 2005). Several of the men position themselves as a pioneer or a forerunner by virtue of their career choice, and from this starting point, being a leader or devil's advocate in the classroom setting was a likely extension of this behaviour. As Alex expressed it, "Even before I 42 was a nurse I was someone who challenged stuff." He later elaborated on the relationship between the type of men that enter nursing, the act of entering nursing as a man, and the role that men play in nursing school: I think it comes down to again the type of guys that come into this, because there are going to be people who are challenged and working against something, so I think it's part of the general structure of the people who would do this going into things . . . You go into the motivations and why someone would come into something like this that's against social norms or the status of a guy, then are you are going to have characteristics that might be, you know, groundbreaking in a leadership kind of style. I mean me being a guy especially now 1 know it's eight and ninety-one or something like that. Coming into this I feel like a forerunner for sure, I feel like a, you know, a leader in this sort of thing. Alex elaborated on this sentiment later in his interview: I feel like in a way just like women going into traditionally male dominated work places and shaking up the structure of male dominated work places, men going into female dominated work places is going to do the exact same thing. Other men echoed these thoughts, confirming that for them the very act of choosing as a male to enter a profession that comprises 91% women is a "challenging" and "groundbreaking" act. Given this point of reference, it is hardly surprising that many male students carry forward an approach of not fading into the background, acquiescing and going with the flow of the class. A significant proportion of the men in this study attested to the fact that they sometimes, in Alex's words, "shake things up" in the class. Nursing instructors proposed similar explanations. Arlene talked at length about the fact that entering nursing for women was often "expected, or easy," but for men it was a very definite and unique choice. This concurs with the findings of nursing researchers who have identified how men who enter nursing are "occupationally atypical" 43 (Lernkau, as cited in Villeneuve, 1994, p. 219) and how it is a countercultural act for men to choose the profession (Whittock & Leonard, 2003). The expectations of traditional masculinities and men's apparent reliance on them very likely create a synergy with these phenomena of stepping out, stepping up and stepping in. Not only are men committing a challenging act by applying to nursing school, but the roles and expectations of traditional masculinities prescribe a challenging, assertive and leadership role to men, a fact that may well heighten the tendency for male students to put a decisive stamp on the character of teaching sessions and group work. The emotional expression of women is also expected, and the defence and honouring of it (as noted in the idea of stepping in) is an expected response to this. One thing is clear from this theme—that many men feel sufficiently safe in the classroom environment that they can exhibit, either consciously or unconsciously, masculinities that are in a minority in nursing education. Any real or imagined risk of sanction does not apparently override the desire or need to perform and interact in traditionally masculine ways. While these phenomena were consistently apparent in interviews and observations, the literature does not address the particular roles that men play in the nursing classroom. Evans (2003) has previously identified the ways in which men manage their masculinity in nursing; however, the way that men rely on, or perform masculinities in the nursing classroom is poorly understood. The fact that this appears to be previously undocumented is a curious fact, given that the differences in participation levels between male and female students that exists, not just in these data but also in conversations with nursing educators. 44 The Culture of Nursing Education: Masculinities in a Feminine Place What does the fact that men often adopt distinct roles in their nursing education say about their gender identities and, more broadly, the culture of nursing education? Several of the narratives that male students shared suggest that the men in nursing classes ascribe to themselves a distinctly different identity from that of their female colleagues. From the data, the salient aspects of this identity include the fact that they are sexualized; that they feel stereotyped and sometimes parodied in their masculinity; and that they are outsiders who are accommodated but not necessarily integrated. These sub-themes suggest that the culture of nursing education is closely associated with femininities and that men's identities and masculinities exist and operate within a gendered culture. A sexualized identity "If you were a single guy, it would be a gold mine." (Paul) None of the questions I posed to the men during interviews addressed this issue of sexuality. In spite of this, several men made mention of actual or potential romantic relationships, of sexual tension and innuendo between themselves and their female counterparts, and of the sexualisation of the place that they occupy and of their identity in nursing education. The domain of heterosexuality is a thread that underlies many of the narratives these men shared, and many of the salient comments they made about being a man in nursing education. These often had a tone of levity and humour about them, but the near ubiquity of these comments belies their off-the-cuff tone. A n example of the sexually relevant tone of talking about nursing education is provided by Chris when he talks about one of his male nursing student colleagues entering the classroom for the 45 first time: " M y friend [name] goes to [another nursing school]. He walked in, he would walk into the room and he's a tall, good-looking blonde guy and his sister equated it to a woman walking onto a construction site". While the comment in question originated with a woman who was not a nursing student, by appealing to a stereotypical sexually-charged scenario of an attractive woman being leered at by construction workers, a potent image is created of the potentially sexual nature of a man surrounded by a large number of women in a domain characterized by and dominated by women. Several of the men alluded to the fact that this was a positive situation and one that made them feel not victimized, but privileged to be in an opportune place for establishing new relationships: I mean there's not all that many single women in the program, so it ain't that, but it gives you a little bit of peacocking chance, and that way maybe like in conversations, group discussions, 1 engage like crazy because I'm showing women what I think about, and i f they like it they're going to like me. This "peacocking" paid off for some of the men, in that they were able to establish romantic relationships with their female classmates. In Alex's case, this had a pleasing outcome: "I had three girlfriends in my class, but one was before nursing [laughter]. I'm not with that class where I had those girlfriends, so now I can start from scratch." Similarly, Chris dated female classmates in the past, though he believed that in doing so he somehow affected the larger group dynamics: "I did date a girl in the first semester from our class. I don't know how that's impacted the dynamic. I feel it has." The possibility of this dynamic is not lost on those who are outside the profession as well, as Nate spoke of: "I have this friend who when I told him I was going into nursing he's like, 'You're so lucky; you're going to be going to class with a whole bunch of women.'" 46 These men spoke spontaneously of the sexual reality of their nursing education and it was identified not only by men who were single and hoping not to be, but also by the two men who were in stable relationships and who stated they were not looking to establish new relationships. This was an unexpected finding in the data, and one which nursing instructors did not make mention of in their interviews. The sole place that this finding is echoed in the nursing literature was in the work of Evans (2002). This overt heterosexual dynamic could be construed as a postured reaction to the stereotype of the gay male nurse, a stereotype which figures prominently both in the literature and in other narratives that the men participants shared (Meadus, 2000; Wilson, 2005). It appears that the number and degree of sex-related comments and anecdotes were not simply a response to and reflection of the demographics of nursing, but a statement of its nature and culture. Heterosexual posturing on the part of men certainly exists within the domain of traditional masculinities, whereby masculinity and heterosexuality are commonly conflated and privileged, and homosexuality is subordinated. The history of nursing as a matriarchal profession rooted in nurturing and female notions of caring may require that men adopt one of two positions: either not being sexually relevant to the female majority (and possibly being or suspected of being homosexual); or, a position of acknowledging and exhibiting heterosexuality, such as the data suggested in the current study. While a small number of male nursing students were interviewed, it is interesting that none of the six men appeared to adopt the former approach of portraying a non-masculinities posture in their interactions and narratives. This would likely not have been a theme i f the culture of nursing education were a gender-neutral or gender-equal domain. Stereotypes and parodies of masculinities The gendered nature of men's identities in the nursing classroom was also evident in the stereotypes and parodied interactions that the participants related, especially in response to 47 classroom interactions that I observed. While the men did not attest to generally or frequently feeling stereotyped in the classroom context, they were acutely aware of times when masculinities were in fact stereotyped. One particular classroom event, and the responses of the male students, exemplified this tendency. In this classroom teaching session, the instructor showed a comical video clip of a new father donning a biohazard suit and respirator to change his new infant's diaper. Both men who were present in the class when the clip was shown mentioned it in their interviews, expressing frustration around the stereotyped parody of fatherhood that it conveyed. In another class, a video clip was shown of a family therapy session which addressed a teenage daughter's drug use. The instructor asked what the father's response to the issue might be given that he was apt to be more task-oriented and less emotional. In their subsequent interviews, both of the men who were present in this class expressed frustration at what they perceived as stereotypes of men in general and their typical behaviour. A third interaction that I witnessed and which the male interviewees noted involved another send-up or parody of male behaviour in the form of a cartoon that preceded a class addressing the issue of power. In each of the three panels of the cartoon, a perturbed wife was standing in her kitchen in a housecoat late at night as her husband walked in. The first panel, captioned "late," shows the wife holding a small rolling pin; the second panel, captioned "drunk," sees the wife holding a large rolling pin; the third panel, captioned "lipstick," depicts the wife holding a gun. In their interviews, the male students from these classes told me that they found these class components questionable in terms of the messages they communicated about men, gender roles and who can be the object of a public joke. It was surprising to observe these parodied characterizations of gender in an era of political correctness and anti-discrimination. Moreover, dominant discourses of nurses needing to respect individuality and diversity were, at least in part, disrupted by such practices. Educators tend to 48 model this philosophy by not offending groups on the basis of their personal or group characteristics or membership. The instructor who presented these class components stated when I interviewed her that she often chooses such statements, videos clips and cartoons in an ironic vein, and with the goal of catalyzing a discussion that challenges the status quo and the social messages that underlie them. Contrary to her hopes, the class as a whole and the men that I interviewed seemed to interpret these as humour, and they failed to generate discussion that questioned the messages. As such, in the opinion of the men, they ended up reinforcing rather than disrupting stereotypes. While isolated to one instructor and one class, it was telling how resonant these kinds of gender-rooted statements and jokes were with the men. In the six male student interviews there was a clear consensus that they are treated fairly and thoughtfully by their instructors but, in spite of this, they were aware of statements or materials that they perceived to suggest a stereotypical masculine identity for themselves or for other men. It is difficult to reconcile these two positions, but part of the identity of male nursing students could possibly be construed as being accepted but vulnerable to parody and stereotyping in the classroom. The students I interviewed questioned whether classroom components that played on stereotypical femininities would be utilized in a nursing classroom, and whether stereotypes or parodies of women would be 'fair game' in the culture of nursing classrooms, or in the culture of classrooms from other disciplines. It could be interpreted from such interactions that masculinities are the 'other' within the culture of nursing classrooms and that masculinities are considered to be a counterpoint or contrast to norms, baseline attitudes and ways of thinking—all of which are rooted in femininities. The men's strong responses to these interactions also reveal a sense of vulnerability. Being in a minority position means that even though they feel generally respected, the times when they feel that this is in jeopardy stood out as highly significant. 49 The nursing literature is rich with evidence attesting to the fact that men encounter a variety of stereotypes in their choice td become a nurse and in the processes of becoming one (Cyr, 1992; Kelly, Shoemaker, & Steele, 1996; Stott, in press; Wilson, 2005). The notion of parody in the classroom is not a phenomenon that has been documented in the literature, but one that is certainly not incongruent with the litany of negative and inaccurate perceptions and experiences of men who choose to become nurses. The gay stereotype As noted in the literature review, the stereotype of the gay male nurse is nearly ubiquitous. While I did not directly ask any questions about this stereotype during the interviews, it was again an issue that nearly all the men mentioned spontaneously, especially when they discussed their initial choice to come into the profession. Alex related his thoughts around this identity for male nursing students and male nurses: I had to explain 'no, I'm not gay, I'm just here because I think it might be a good job and I'm liking it' but I had to do some of that, you know. No, I'm not, its okay, and a lot of the conversation I've had with my girlfriends and they were like 'do you think the other guy is gay?' and I'm like 'no, I don't, he never told me i f he is or not, I've never sensed it; why don't you ask him, he might tell you,' that kind of thing. So that's the standard society stereotype. Nate talked about the same issue in his own experience: I think there's this weird mix of it's getting okay for men to be nurses, but there's still some of the residual jokes that go along with that in that, you know, you're either gay or the whole, some of my friends refer to like the Meet the Parents movie, the male.nurse, I've heard the joke call you a 'murse,' right. 50 Interestingly, the character in the movie that Nate referred to was, like Nate, suspected of faking his heterosexuality and of embodying a failed masculinity by not becoming a physician, performing poorly at sports and, most significantly, by virtue of his career choice as a nurse. Paul similarly acknowledges the stereotype of the gay male nurse, and expresses resignation at the inevitability of facing it, and the powerlessness of avoiding the stereotype: A lot of my friends joke around about it and I know that they're completely joking but they do make the comments like 'oh yeah, you're totally gay because you're a nurse and you're not married' and whatever and stuff like that so but, you know, I mean it's, I guess I sort of knew that that's what 1 was going to get into and you can't really expect a guy going into nursing not to expect that. This stereotype was also acknowledged by nursing instructors, and they bemoaned its resilience and the negative role they saw it having on recruitment and on the men who are in nursing school. Sandra talked about how difficult it is to change a stereotype as pervasive as this: There's a whole perception out there that i f you're a guy and you go into nursing, you must be gay and I actually have come across that. Even sitting around our dinner table with these four teenage boys, you know, I ' l l say, 'oh yeah, one of my students blah, blah, blah and he . . . ' and they'll go, 'oh a guy, [making sounds] he's gay'; 'well, how do you know?' I'd say to them, 'you know, nurses do make really good money and it can be really worthwhile work.' 'Yeah, but you wouldn't do it because people wil l think you're gay and they are gay anyway.' So how do you change that when an eleven-year-old thinks i f you go into nursing you're gay? Amanda lamented this stereotype and perceptibly noted that it does a disservice both to students who are gay (relegating them to a caricatured status) and those who are not (ascribing to them a sexual orientation that they do not self-identify with). 51 What is telling about these statements is not so much the resilience of society conflating men in nursing with homosexuality, but the fact that the men talking about it were apparently resigned to the fact that it is inevitable and should be expected by any man who is considering becoming a nurse. One is reminded of stories of women making their first forays into the workplace in the mid-twentieth century when sexual harassment was considered an inevitable consequence of breaking new ground vocationally and culturally. What is different with the gay nurse stereotype is the fact that while men becoming nurses is not a particularly recent or innovative phenomenon, stereotypes like this suggest how much of an anomaly it remains for men entering a profession so entrenched in femininities. It is important to note how helpless male students are to counter this stereotype despite feeling that they are pioneers, iconoclasts and forerunners by being men in nursing. In terms of their identity, it is evident that the men in this study felt that i f their sexuality was both a valid concern (i.e., it is not a non-issue) and suspect. They see themselves as not necessarily victims of culturally-based stereotypes of who exactly enters nursing, but certainly as objects of these stereotypes and as powerless to change them. This powerlessness was revealed by the tone of neither anger nor frustration around stereotypes of their sexual orientation, but by their tone of resignation and inevitability. Accommodation rather than integration Several of the men told stories about what they perceived as contrived and artificial efforts on the part of instructors to elicit the 'men's perspective' or 'male input' into the class. This expectation to represent the dominant, and presumably homogenous, opinion of men was a source of considerable frustration. Male students expressed respect for instructors' attempts to include input and perspective from men in their discussions and classes, but felt that overtly asking to "hear from the guys" (as one instructor repeatedly stated during classes) made the men feel not included but rather excluded from the culture of the class. This was not a practice that was 52 isolated to the particular classes I observed, and Nate summed up the sentiment of some of his colleagues: I don't think that teachers should be singling out guys just because they're guys, so I can't see that, it should be equal, just whatever. I mean, it's fine to ask for someone's perspective because they are a guy but to really drill it in, no. Others talked about how contrived efforts to represent gender equality in classroom discussion made them feel accommodated, rather than truly integrated. Tom explained how these efforts felt to him like he were a 'token male' in the class and was expected to provide a novel or exceptional opinion. In their discussions around classroom teaching, the nursing instructors acknowledged that this was a fairly common practice, and they did not perceive that it might be counterproductive to creating an inclusive and gender-neutral place for learning. One instructor spoke of how she systematically attempted to bring out the "men's perspective and the women's perspective on stuff and how she tries to "develop questions that would elicit differences in terms of gender response." Implicit in exchanges where an instructor asked to hear from a particular minority group is a reinforcement of two things: that the person who has been singled out is indeed in the minority, and that the minority group is an exception to the dominant character of the group. In the case of nursing education, the minority group is men, but singling them out for their views, or for those of men in general, reinforces them as exceptions to the norm of femininities in nursing education. The absurdity of asking one man to represent the view of men in general is no less than asking one student, or a small group of students, to provide the Asian perspective or the gay perspective to a discussion or issue. Doing so would hardly contribute to creating an integrated 53 and heterogeneous climate in a classroom, but would likely make Asians or gays feel 'othered,' exceptional or anomalous, not truly integrated. In a truly integrated environment that represents the diversity of the outside world, it would not likely be necessary to actively elicit a counterpoint or representative view. To do so in nursing classrooms may well accommodate alternative views, but the very fact that there is a clearly defined dominant position, and an alternative to it, is reinforced by this process. The male students made it clear that this was indeed the case, and that singling them out reinforced their identity as outsiders in the culture of nursing. Assumptions of familiarity with the feminine A final indication of the feminine culture of nursing education was revealed in the way nursing instructors assumed that students were familiar with female experiences, anatomy and priorities. I observed an example of this during a class on urinary catheterization technique. The instructor addressed the female genitourinary and perineal anatomy very briefly, stating that "you all know this," but then went into much greater detail on the male anatomy. Alex addressed this event and the broader assumption of female experiences that he perceived from teachers: It's all sort of understood: 'oh, well, you know what the trimesters are, you know, sort of what to expect, you know the symptoms of a mother' and that kind of stuff and what it means to go through all that and the hormonal changes, the attitude. I don't know any of that, I don't have any sisters, I wasn't exactly around when I was born or when my mom and dad conceived me . . . I didn't know any of that. Actually, no I haven't had my first period and I don't know what that's like. The instructors were aware that they sometimes had this tendency to default to a female perspective. Lauren said that "I do have to still watch myself sometimes that I'm not making an assumption that they're all women." Interestingly, Alex's instructor who taught the component 54 on inserting a Foley urinary catheter used the same incident that Alex referred to as an example of what she needs to be careful of in her teaching: I do present more in terms of a female perspective like talking about things like catheterization and things like that... because I am female I talk about it from my perspective. It's a little bit different than i f I was a male talking about the same thing; I would have presented differently. These types of assumptions on the part of nursing instructors were not seen as trivial by the male students. The fact that a shared female experience and familiarity with uniquely female issues is both assumed and reflected in teaching practice is likely indicative of the strong ties that exist between nursing education culture and femininities. The Culture of Nursing Education: Incongruence between Masculinities and Femininities In addition to being a gendered culture which heavily influences men's identities, nursing education, both in the classroom and in clinical domains, is characterized by a disparity and lack of harmony between masculinities and femininities. The men identified how these two gendered ways of being often came into conflict. Overfeeling and underdoing One of the long-standing, and resilient, characterizations of gender relations and comparisons involves the often-cited tendency for men to be task-focused and efficient, with women characterized as being more verbal and focused on relationships. These stereotypes are a theme that male nursing students elucidated, and demonstrated, in numerous contexts during the study. Male students expressed frustration at the emphasis their female colleagues placed on talking about relationships, feelings and personal experiences at the expense of directly and efficiently accomplishing tasks and meeting learning needs. Paul characterized the sentiments of several of 55 the other men with whom I spoke, in the context of a particular classroom exchange and also in his nursing education experience in general: We all just kind of chatted about feelings and stuff like that, and it's not like I said it was not a bad thing and the program certainly has a lot less of it than other programs, but at the same time I think that i f there were more guys there it would have been more focused on the task at hand. Andrew spoke in the same vein, but more bluntly: I would love to know if there's a statistic on it or something like that but the conversations of nursing students is i f there's a guy involved in the group, chances are its going to be either life- or nursing-related, with women it wi l l be entertainment or boyfriend or something like that. Similarly, other men spoke about the perceived overemphasis on matters affective, relational and psychosocial; a complaint that they coupled with the perceived lack of task focus and efficiency on the part of their female colleagues. They spoke of women's tendencies to get sidetracked from time-dependent tasks and to often veer towards topics of conversation that the men believed were frivolous and extraneous. The men also ascribed to the women an overemphasis on feelings and emotions as opposed to facts and solutions. Tom summed this up when he talked about a debriefing session that took place in his clinical group following a tragedy on the unit: "It seemed like it was one person started crying, they all started crying and it became into this, you know, cry thing and we didn't really get to any of the meat of it, right?" This task focus that the men ascribed to themselves, and the supposed inefficiency of their female colleagues, was a theme that was echoed by the nursing instructors. Arlene shared what she had noticed during the small group work in the classes she teaches: 56 It does seem to affect the norms, particularly when they work in the practice hours, when they work in groups and stuff, they tend to like there's usually a male and a female that work together and they just interact differently than when there's groups of two girls and three girls: they focus more. Sandra talked about a classroom interaction she had recently witnessed that summed up this tendency: I actually did witness at one point at the end of last week's class one of the men got quite, he got quite annoyed with his group when they completely disintegrated into social talking. I was watching his non-verbal and he was really annoyed, in fact he removed himself from the group and went and started to pack up his bag. He looked annoyed, the non-verbal was quite clear and he left and he distanced himself from the group. Another aspect of the perceived overemphasis on emotion over task was the men's repeated opinion that nursing curricula and expectations of nursing instructors require an inordinately high level of personal reflection, emotional expression and introspection. In many cases, success or failure in the course rested on the man's ability to self-disclose and reflect. The men felt that to not do so invited ostracism at best, and failure at worst. Tom said that: Unless you write what they're looking for then they're not pleased with us, and it reflects in poorer grades and I didn't really expect as much sort of self reflection and checking in, journal writing and stuff like that. The frustration they felt was related to both what they had to do (writing journals, reflecting and such) and what those types of activities displaced in the curriculum: I personally found that a little sort of wishy-washy kind of. I mean I can see the value in it, but at that point especially being second semester when we're doing 57 our first surgical I'm mprethinking 'okay, how do I do a dressing change as to not ki l l the patient?' The instructors were aware of how the men were reluctant to reflect and express emotion. Inversely, the instructors had distinctly different interpretations of this phenomenon. While the men talked of doubting the utility of these practices, the instructors believed that it reflected the fact that men find it difficult or uncomfortable to do so. Pauline addressed this in the context of the weekly journals she requires of her students: I have a sense that some of them are struggling with some of the family nursing stuff, and I get that sense from them in terms of their reflective journals . . . they're theoretically way off somewhere else and I'm thinking 'why is it so much easier for them to go on page after page after page with this theoretical perspective and psychology? What is the difficulty with bringing back some of what they've learned in class and what's going on when they're visiting the families?' In my research with families it's often harder for men to articulate the emotional piece of what's going on. When Tom spoke of his clinical group failing to get the 'meat'of the matter, he characterized the opinion of several of his male colleagues, in that what they believed to be the essence or main priority in nursing education often differed from the women, including their instructors. This tendency was also recently identified among other male nursing students by Ellis, Meeker and Hyde (2006) and Stott (in press). The men in this study placed priority on the step-by-step and fact-based analysis of problems and solutions, and while they acknowledged that nursing does and must have a vital affective component, they felt that efficiently identifying and solving problems trumped emotional and relational concerns. Moreover, they explained that women displaced central concerns to the 58 periphery and made the peripheral central. The men's reliance on traditional masculinities is an example of masculinities i f not in conflict with femininities, certainly in contrast to them. It is clear from these data that there are different priorities, diverse ways of minking, and likely multiple realities at play in this context. The men made it clear that they perceived a male way of seeing tasks and experiences and a female way, and that being constantly exposed to the female way was a source of frustration due to its perceived inefficiency. While it is not possible to determine exactly what underlies these assumptions, it is certain that men believe the culture and norms of nursing education to be thoroughly feminine and outside of their own preference and lived experience. This clear dichotomy that both students and teachers identified is indicative of a gender-based characterization of differences in nursing education; the men did not complain that nursing in general promoted or prescribed what they believed to be inefficient decision-making, but rather they saw it in terms of an 'us versus them' characterization. They did not believe that they were being explicitly taught to make decisions or behave in a manner consistent with femininities, but that this was an aspect of the culture and character of the nursing learning environment. The men generalized male students as being efficient, task-oriented and less verbose then the women. However, by their own admission and as confirmed in my observations, the differences in communication and decision-making were perhaps not as clearly mediated by gender as some of the men perceived. The field notes and participant observations showed numerous examples of women who appeared to be linear and task-focused in small group work, as well as men who were happy to talk in their group about last night's karaoke. What is clear is that the lens through which men assessed these issues was collective, gender-based rather than individual-based. 59 Different risks: The potential for rejection in the maternity rotation As noted in the earlier discussion on the research questions, the original scope of this study was limited to phenomena within the nursing classroom. However, one of the most striking aspects of the interview data was how often and to what extent male students related their experiences and fears around their obstetrics/maternity clinical rotation. I had no questions in my interview guide that addressed any aspect of clinical experience, but without exception the men related to me how their maternity rotation was fraught with risks and high-stakes experiences, an issue that has been explored and identified by numerous nursing scholars (Okrainec, 1993a, 1993b; Patterson & Morin, 2002; Sherrod; 1991; Streubert & O'Toole, 1991; Trachtenberg, 2000). The dominant theme in terms of the men's identities in these narratives was that of being an outsider or guest in an environment that ultimately excluded them. The men characterized their maternity rotation as variously stressful, uncomfortable and risky. Paul summed up the sentiment of several of the men I interviewed: When I did maternity, obstetrics, that was uncomfortable for four weeks .... Well , I luckily lucked out with all of the moms that I was taking care of were open to it. I could see that they were a bit uncomfortable but they were open to it and, you know, like they were still very cool and but I have heard of some students that couldn't work with a patient. The men spoke at length of how the maternity venue and culture was inextricably rooted in femininities and how it was an environment in which they felt profoundly out of place and, in many cases, unwelcome. What made them uncomfortable and stressed was not, as one might guess, the physical interaction involved in caring for and assessing their female patients and the infants, but rather the very real risk of a patient rejecting them as a caregiverand nurse. Most of the men had first- or second-hand accounts of being unable to provide any hands-on care in their 60 maternity rotation. Needless to say, this contributed clearly to their identity as outsiders in this particular aspect of nursing education: "I know my friend that's been in a nursing program somewhere else, the four weeks that they did obstetrics couldn't [get any patients]; 'just stay in the nurse's station.' It wasn't going to happen". Chris shared similar thoughts: I asked my obstetrics instructor, you know, because I had heard from previous students that some guys, like one guy didn't even get to do anything care for any women because they just didn't want a guy. Some women they don't want, you know, them to inspect their parts and he didn't, the whole semester he didn't do any caring. The pervasiveness of male students' fears around the maternity rotation was underlined in an exchange I had with two male students after one of my classroom observations. These men, who did not volunteer for interviews and whom I had not previously met, approached me after the class and told me how one of their male colleagues in their class had not been able to provide any care in his maternity rotation which was then in progress, and how his instructor had been either unwilling or unable to facilitate any hands-on learning for him. The men asked me for advice and for help in resolving the situation, and told me how the actual student was too embarrassed to come speak with me himself. The risk that men identified in their maternity rotation was exactly what these men had identified: the risk of rejection by patients. The possibility of being rejected by a patient and/or her family as a caregiver resonated powerfully with the men I interviewed and, as illustrated by this example, with other men as well. Tales of other men's negative experiences in maternity were widespread and seemed to take on nearly legendary status as cautionary tales. 61 What is equally distressing in each of these examples is the fact that the men did not feel that their clinical instructor either prepared or advocated sufficiently for them to mitigate this risk and provide a just and useful learning experience. While none of the instructors I spoke with were responsible for teaching obstetrics in either the classroom or in clinical, it is still perhaps significant that this was not a point that came up during their interviews when they discussed real and potential issues that men in nursing education face. The risk that these men identified underlines the fact that male nursing students in obstetrics remain outsiders, strangers in a strange land. They feel that they are in an exceptionally vulnerable position in maternity and are subject to arbitrary exclusion from the learning experience, a situation which their instructors are unlikely to prepare them for ahead of time or resolve i f needed. The maternity rotation is one of the acmes of femininities, rooted as it is in childbirth and the experiences and health concerns of women. As such, it is not surprising that a considerable proportion of what literature exists on men in nursing education addresses these clinical situations. But what is apparent in the men's narratives is that it is not just a feminine domain but one that excludes males. This need not necessarily be the case, as recent history offers numerous examples of environments that have changed from being the exclusive domain one gender to one of neutrality, equity or androgyny. Within maternity wards, the acceptance of an appropriate role for men as physicians is nearly unquestioned, as is the more recent development of fathers attending their children's deliveries. Given that medicine and nursing coexist geographically, the acceptance of male doctors simultaneous to the rejection of male nurses can only be attributed to culture, both broadly considered and of each profession. It is a sad commentary on the culture of nursing that men must approach this important aspect of care with such trepidation owing to the real possibility of rejection and sanction, with little hope of advocacy from their instructors. 62 Disparate caring and touch The disconnect between nursing culture and masculinities was also evident during discussions around the topics of caring and touch. The nature of men's caring and the way that they develop their own expression of caring has been the topic of previous research, often findings that there are differences in the way men consider and act out their caring (Evans, 2002; Hilton, 2002; Meadus, 2000; Stott, 2003; Villeneuve, 1994). The male students in this study attested to the fact that the question of caring, so central to nursing practice, took different gendered forms. Like issues around the maternity rotation, this was a clinically-based issue, and one which required a judicious expression of masculinities. One risk around caring that men perceived in their clinical interactions was the potential for misinterpreted touch, or of making a patient uncomfortable by touching him or her. Nate addressed this in the context of giving hands-on care to a patient: [I felt] just uncomfortable sort of worried that I would get shot down, I had no problem doing it—I had so many years of giving care to people and putting my hands on people . . . nothing about being grossed out, it's totally just about being rejected or making the other person feel uncomfortable. This risk of making others uncomfortable with the use of touch was linked to the potential misinterpretation of their touch as being sexually motivated. Paul talked about a time when this fear came to fruition: I was touching her shoulder to help her, to get her gown off just to give her a bath and she just freaked out and said 'you're a pervert, get out of my room.' I was totally freaking out because I didn't know what to do. 63 While this narrative was the sole first-hand account I heard of a male student being sanctioned for his use of touch, it was an issue that was of concern to each of the men and a real risk that each faced. Research has indicated clearly how firmly rooted in gender and culture are the norms of touch. The men are acutely aware of this and see themselves as highly vulnerable should their touch be misinterpreted in clinical practice. This is likely what caused Paul to be "totally freaking out." Therapeutic touch (in the generic sense, rather than the particular complementary practice) is a practice that is firmly rooted in femininities, and for men to express caring, as expected in nursing education and practice, while avoiding potential sanction is a delicate and risky task. What is required is a creative and careful expression of masculinities. The men I interviewed talked about the creative and compassionate ways that they were able to achieve this balance and enact masculinities their care. Alex spoke about this: When I see someone in pain and stuff like that I still feel that someone is in pain and stuff, but me putting my hand on them or something isn't something I do, but something that gets told to you to do. But it just wouldn't really be my way. M y way is 'well, it hurts like a bugger, eh?' or something like that. Alex's response to a patient in pain is apparently rooted in masculinities, and he identifies it as a counterpoint to what he "gets told . . . to do" in his nursing program, implying a more hands-on, femininities-based approach. Paul explained the nature of this approach: Whenever we're talking about responses to communication or how nurses are supposed to react it was all very, sort of the traditional kind of a female, you know, put your arm on the shoulder of the patient, and 'It's okay, sweetie, it's okay' and stuff like that. The guys don't necessarily do that but it's probably more likely that a female would do that. 64 Underlying Paul and Alex's statements is the fact that they perceive a disconnect between the approach to caring that they prefer as a male student and the approach that is predominant in nursing education. Few of the other interviewees gave specifics of how they manifested their care in a way consistent with masculinities. What was clear from other informants was that their failure to buy into femininities-based caring or integrate it into their practice was a source of anxiety and caused them to doubt their actual ability to care. They were unsure of the validity of masculinities-based caring styles, given the femininities-based style that is taught and assumed. Tom spoke about the self-doubt that his lack of emotional expression caused him in a culture that apparently expects it: I wonder i f it's just a strength that [women] have or i f it's sort of a deficiency I have. I don't know, right, like I just wonder, am I just missing a point here? Or am 1 cold and calculating, like I don't really care? I think I've always tried to stay removed I guess in situations and just not involve myself so emotionally . . . I don't know if it's just me or my tin heart. Tom was not alone in trying to create an expression of caring that was different in character from the norm, and verbalizing whether this expression was as valid as what they are taught to be the gold standard in care, which is rooted in femininities. The nursing instructors did not speak at great length about the ability or inability of male students to care, but they did make some interesting statements. Lauren had this to say: I guess I wouldn't think that a male would be as sensitive or something to, when they're interviewing a patient. I don't know why I would think that! I'm always impressed at how supportive and kind and empathic some of the [male] students are in their interviewing and in their interactions. 65 Other instructors also had this notion of being pleasantly surprised at just how empathic or caring the men were or could be. This idea of expecting that they would not be, however, is quite telling. The fact that the baseline assumption is that the man would not be as caring in then-approach gives rise to the feeling of being taken aback but pleased when this is found not to be the case. The challenge faced by male nursing students around caring and therapeutic touch involves reconciling traditional masculinities with what they believe to be the femininities-rooted practice and expectations of the culture of nursing education. They also face the challenge of manifesting their caring in a way that does not risk sanction from patients or instructors, and assuring themselves that their alternative approach is both valid and meets the needs of patients. This is another situation in which men are required to either rework traditional expressions of masculinities and use these expressions in their caring, or reject masculinities and adopt the approach advocated by their instructors. Implicit in their narratives are the men's beliefs that the femininities-based approach is not only the most common approach, but that it is both advocated and presumed in nursing education. While the men spoke of there being more than one way to care—a fact that is reflected in their practice and opinions—it would seem that they are having to draw this conclusion independently, rather than being taught this fact. This could be the reason for the men's doubt around whether they emotionally deficient or somehow less than compassionate by virtue of their less overtly emotional and low-touch approach to caring. 66 Chapter 5 Discussion Having now introduced and explained the three key themes that addressed the study questions, this final chapter wi l l provide a broad view of these findings and draw conclusions with the goal of providing an overall picture of the role of men in nursing education and the culture of the nursing classroom. I wil l also examine some of the limitations of the study and conclude with implications, recommendations and suggestions for further research. Overall Picture of the Findings The data from both students and instructors confirmed that nursing education is highly gendered, and that masculinities and gender relations influence the acts that men choose to perform and not perform, the roles that they adopt in the nursing classroom and in the culture of nursing education in general. The most salient finding around the roles that men perform in nursing education was how closely aligned these were with traditional masculinities. In this domain of traditional masculinities, some of the central and most commonly cited expectations of behaviour involve decisiveness, leadership, risk-taking and assertiveness. As numerous nursing and sociology scholars have asserted, there exist culturally and socially constructed obligations for men to assume a position of control, implement new initiatives and be leaders rather than followers. The counterpoints to these expectations exist in the traditional norms of femininities, characterized by acquiescence rather than assertiveness, following rather than leading, subservience rather than control, and passivity rather than activity. It was striking the degree to which the themes of stepping up, stepping out and stepping in, seemed almost a 67 throwback to an earlier era, one in which the behaviour and roles of men and women aligned more closely with gender expectations, and were more unquestioned, than is currently the case. Relationship to Research Questions The observations, field notes and interview data that were collected over the course of the study spoke in detail to the three research questions that guided the research process. The first research question was largest in scope asking "How does gender inform and influence nursing cultures and education?" The data revealed a great deal about nursing education cultures more broadly (though informants did make mention of the larger contexts, in such area as maternity clinical and stereotypes). From the broadest perspective, the answer to this question can likely be that gender has a significant impact on the culture of nursing education. Two conclusions can be drawn with regard to gender and nursing education: firstly, that it is a place where traditional masculinities are largely adhered to and displayed; and secondly, that the norms, expectations and priorities of femininities constitute the background culture to which masculinities must either blend into or exist in contrast. Men's most common response to this was to rely on masculinities and form a counterpoint to femininities. It is possible that the numerically unequal dichotomy between men and women in nursing education creates a desire or obligation for men to assert traditional masculinities. It is possible that men may be hypermasculine to make audible their culture and contest the potential to be a muted minority. Whether this is the case or not, the data suggest that these men in their nursing classrooms must receive a 'payoff for the behaviour described, be it internal, external or both. While femininities per se were not a focus of the study, it was apparent that women, and not only men, aligned to dominant cultural expectations. The culture of nursing education with regard to gender is a throwback to an earlier era where gender roles were clearly defined and played out. 68 For the men this took the form of the "playing a different role" that constituted the first theme of the findings. For the women, this existed in the establishment of a feminine culture that provided the context for the second and third themes of the findings (masculinities in a feminine place and incongruence between masculinities and femininities). Femininities dominate the culture of nursing education. This is reflected in the demographics of schools of nursing and the priority that is placed on psychosocial material and self-reflection, the assumptions that are made around being familiar with feminine experiences, the jokes that are made and the way that caring is taught. Women's learning styles and ways of knowing are the paradigm, emphasized and taken for granted. Into this femininities-based culture, male students make a way for themselves that is a counterpoint to this, and in doing so they tend to rely heavily, or even possibly exaggerate, traditional masculinities, something that takes the form of speaking up, making jokes, leading, protecting women and asserting. They also interpret their role and identity in light of the minority status, something that manifests itself in the sexualized tone that they allude to, the salience of their suspect sexuality, and their frustrations around their instructors' lack of insight into the risks and different experiences they encounter. The end result of this is a culture that is not gender-neutral or particularly inclusive, but one where masculinities exist as an appendix or anomaly. The culture of nursing education as exemplified in this study does not necessarily exclude men and masculinities, nor is it overtly antagonistic to them, but more that it fails to adequately include them. The data did not suggest that masculinities are punished or vilified, but that they are the exception rather than the rule or ruler. This also extended beyond the classroom. When men spoke of their experiences outside the classroom and in their clinical placements, there was a consistent theme of having to exist in 69 amongst femininities, whether in the maternity rotation or in the minds of elderly clients who question men being in the nursing profession. Inevitably, this carried over into the classroom venue that was the focus of the study; a place that while not as overtly feminine as a maternity ward, was likewise not gender-neutral or inclusive. This outsider status of masculinities in the culture of nursing education is also evident in the way that men saw themselves as accommodated rather than integrated. In many ways, this thematic finding addresses the second research question about the way that men perceive and interpret their experiences in nursing education. In light of the femininities-rooted culture of nursing education, it was perhaps surprising that men did not feel wholly excluded. Rather, they expressed overall satisfaction with their educational experience as a whole and acknowledged the extent to which their instructors attempted to create an inclusive environment. What they noted, however, was that these efforts were sometimes misguided. This was the case when, for example, instructors went out of their way to elicit the viewpoint of the men, a practice that typified this sense of being accommodated but not necessarily integrated effectively. Overall, the men did not attest to being treated unjustly, but rather ineffectively. While outsiders may see the jokes made at the expense of masculinities or the parodies as being unjust, these seemed to result in more frustration than indignation. Much like the male students spoke well of their educational experience as a whole, the nurse educators spoke highly of the contributions that men made to the dynamic in their classrooms. This relates to the third research question of "How do classroom nursing educators describe teaching a small number of men nursing students?" They described the contribution of men in positive terms and attested to many of the same roles that my classroom observations and interviews with the men identified. Overall, the instructors described an appreciation for these masculinities-based behaviours such as leadership and assertiveness, provided they were not 70 taken to an extreme. Ultimately, the instructors were unanimous in expressing a desire for more men in nursing education and in the nursing profession. When they spoke of what it was exactly that men added to the character and culture of the nursing classroom, instructors agreed that having men in the class changed the dynamic. It was interesting that while instructors all spoke at length about the positive contributions that they believed men made to the dynamic of the classroom, they were at a loss to explain exactly what characterized this contribution. While words they used such as "balance," "perspective" and "focus" gave some indication of what it is that the instructors perceive, when I asked them to elaborate, they were unable to narrow down the nature of this contribution or give exemplary statements or narratives. What was clear when they described teaching a small number of men nursing students was that the instructors perceive a binary between the female contribution and the male contribution, even implying that each is relatively homogeneous. While this may well have been a consequence of the study's design, there is an implication that men constitute a counterpoint or alternative within nursing, and that the baseline dynamic without their contribution would be rooted in dominant feminine ideals. Again, the exceptionalism of what men bring to the class is emphasized and, by extension, the implication that the nursing classroom is not a gender-neutral environment. Relationship to the Literature While some aspects of this study's findings have not previously been identified in the literature, there were other themes that confirmed the findings of other nursing scholars. Each category wi l l be briefly examined. 71 One addition to the existing literature that this study contributes relates to the role that men play, specifically in the nursing classroom, and the close relationship between this role and traditional masculinities. This finding was likely a result of the fact that participant observations constituted a data source in the study as opposed to interview data alone. While interview data would have addressed the thoughts and experiences of men in their nursing education, I would have been unable to see first-hand their roles enacted if participant observation had not been included in the study design. The study findings reveal the sexualized identity of men in the nursing classroom, which to this point in history has not been described in detail. This is significant given that gender and sexuality are certainly not synonymous. The phenomenon of parody of stereotyping within the nursing classroom was also a new finding, as was the theme of assumptions of familiarity with the feminine. For the most part, however, this study confirmed several of the findings of other nursing and non-nursing literature in the modest body of knowledge around men in nursing education. One point of similarity related to the gay stereotype that has been well-documented for many years, and which has just been confirmed in a large study of male nurses (Evans & Cameron, 2007). Men also attested to being questioned about their career choice and having it be the subject of questioning or mockery (Brady & Sherrod, 2003; Davis & Bartfay, 2001; Evans, 2003, 2004b; Villeneuve, 1994). The complicated nature of caring and of touch for men in nursing education and practice was also evident here (Evans, 2002; Hilton, 2002; Meadus, 2000; Stott, 2003; Villeneuve, 1994). Specifically, this involved the fact that men perceived of caring and enacted it in a way that is different from that of their female colleagues. As an expression of caring, men in this study also considered the issue of touch in a way that was different from women. The significance—and risks—of the maternity rotation that has been demonstrated in the literature 72 was also confirmed by the men in this study (Okrainec, 1993a, 1993b; Patterson & Morin, 2002; Sherrod; 1991; Streubert & O'Toole, 1991; Trachtenberg, 2000). The culture of nursing education has not been studied to a great extent. In this study, however, it was found to be closely aligned with the findings of numerous researchers who have identified the feminine identity of the culture of nursing (Anthony, 2004; Ellis, Meeker, & Hyde, 2006; Kelly, Shoemaker, & Steele, 1996; Mcintosh, 2002; Okrainec, 1994; Paterson et al., 1996; Schoenmaker & Radosevich, 1976; Wilson, 2005). While some scholars have identified feelings of isolation as a significant problem for male nursing students (Anthony, 2004; Kermode, 2006; O'Lynn, 2004), the men in this study did not attest to this. They also did not claim to encounter non-inclusive practices and materials such as texts, articles and instructors that used the pronouns "she" and "her" to refer to all nurses (O'Lynn, 2004). Limitations While all efforts were made to enhance and ensure the scientific rigor of this study, like all research projects there were limitations inherent in the conceptualization and execution. Among these, perhaps the most significant was the fact that I, the student researcher, belong to the demographic that was the focus of the study. As an undergraduate nursing student in the fairly recent past, I brought my own experiences, preconceptions and ideas to this study from the outset. Efforts were made to mitigate or minimize these influences, including reflective journaling throughout all stages of the research process and debriefing with colleagues and the thesis committee, but it is nonetheless impossible to unpack and set aside this body of subjective knowledge and experience, both positive and negative. As such, it is possible that my own experiences were an influence on any or every stage of the study. 73 My own gender was also an inevitable variable in a study in which the chosen lens of analysis and data collection was gender. In my lifetime of experience as a male, it is not realistic or even possible to set aside my own lived masculinities and examine masculinities from a bias-free or objective point of view. This, coupled with my experience of being a nursing student in the classroom, made my linkages to the student participants exceptionally close. Even the students' ages differed little from my own, and we generally belonged to the same generation with all its accompanying mores and assumptions. While this may well have facilitated trust and rapport with the students I interviewed and observed, the downside to this similarity could have been that it influenced the way that data were gathered and interpreted. What I had in common with the student participants (gender, educational experience and even age), I lacked with most of the instructor participants. They were of a different sex and most often a generation older than myself. While we shared a common occupation as nursing instructors, there was certainly a greater dissimilarity than with the students; a fact that may have affected the interpretation of the findings. The study was also limited by characteristics of the sample. For example, all the students were in their third year of nursing education. The quality of the data might have been enriched if at least some of the men had been in their last semester or two of nursing school, as it would have given them a larger body of experiences to draw on. Additionally, the findings are based on a fairly small sample size. While issues of sample size in qualitative research have a different meaning and different parameters compared with quantitative research, they are not irrelevant. The original conceptualization of this project involved parallel, but relatively independent, data analysis of the student interview data and the instructor interview data. However, a decision was made in light of the research questions and 74 the emerging data analysis to focus on the student interviews and to use the instructor data as an additional source of data to inform the findings from the observations and the student interviews. Consequently, the core of the interview data was centred on the six student interviews, which even for qualitative research could ideally have been larger in order to enhance breadth and richness of data and the believability of the findings. Implications and Recommendations While imperfect and certainly not without limitations, the findings from this study add to the existing knowledge base about the role of men in the nursing classroom and the culture of nursing education. Beyond adding to that knowledge, however, there are concrete implications that can inform the practice of nursing education. One conclusion drawn from the study findings was that gender is an important consideration in nursing education from the perspective of male students. It is an issue that underlies many of the behaviours and roles that men adopt, as well as the overall culture of the nursing classroom. However, instructors tended to not acknowledge gender at all (e.g., assumptions of familiarity with the feminine) or acknowledged it clumsily (e.g., accommodation, not integration). Thus the findings suggest it would beneficial if nursing instructors were more aware of gender as a dimension of their preparation and practice of teaching. This is especially true in light of the fact that all but one instructor acknowledged that, with all the other considerations that go into the planning and teaching of material, the gender of the participants was simply not something they considered. A starting point for this would be the reminder that not all students in the class share the same body of gender-based experiences and knowledge that the instructor might, and to ask if the examples, time allocation and choice of materials presume a familiarity with the experiences of the feminine, as was often the case in the study. Even though planning to teach is 75 a complex undertaking with numerous variables and necessary considerations, findings here suggest it is important to remember that gender must be considered. Even more broadly, it may be a helpful practice for nursing instructors to be reflective of, and question, the role that their own gender has in what they choose to teach, not teach, emphasize or downplay. For the large majority of nursing instructors, this involves an awareness of femininities and the role that they play in the choice of activities and expectations. This is certainly not to say that femininities should be downplayed and masculinities fostered or preferred, but rather to remind instructors that they, like everyone, bring a complex array of experiences and assumptions to the nursing classroom. This type of reflection might be useful when choosing the weighting and emphasis of psychosocial and reflective content and of technical and problem-solving aspects of learning. This type of reflection would also be useful when instructors are choosing exactly how to conceptualize and teach caring and the use of touch in nursing curricula. What was clear from the data was that men felt their instructors defaulted uncritically to material and assumptions rooted in femininities and were often not reflective of this practice. As noted in the findings, male students often felt that when gender was made explicit in the nursing classroom, it was presented as a binary counterpoint to femininities, as evidenced when the 'men's perspective' was elicited in discussions. Along with this was the perceived assumption that men represented a homogeneous group that shared a unitary opinion or perspective. Rather than presuming that men in the nursing classroom represent a united front and can speak for all members of their sex, it would perhaps be more just and accurate to simply seek a variety of perspectives from as many students as possible and to not explicitly ask for men to speak for themselves and others. 76 In light o f the data on parody and stereotyping, it is worth noting that when educators parody, stereotype or caricaturize men—whether i n jest, seriously or inadvertently—it resonates powerfully wi th male students and represents a negative dynamic that overrides any previous acts o f inclusion and respect. This was evident by the fact that even though i n m y o w n observations and i n the interviews with the men, the vast majority o f interactions, comments and examples that had a gendered-based element were positive and respectful, the few times i n which this was not the case stood out markedly i n the minds o f male students. This suggests that nursing instructors acknowledge the power o f words when they choose humorous elements for their classes or find themselves tempted to parody or poke fun at men. They might also question why it is sti l l somewhat acceptable to joke at the expense o f men while it is taboo to make light o f most other groups or visible minorities i n western cultures. F inal ly , the data around different risks, disparate caring and the salience o f maternity rotation suggest that it is important for nursing educators to be cognizant o f the fact that men face risks i n nursing education that are, for the most part, not shared by female students. This was most evident i n c l inical situations rather than i n the classroom per se, but what underlies it again were the men's opinions that their instructors neither considered nor addressed gender. Numerous students felt their teachers d id not realize or acknowledge how risky or awkward some situations could be, an opinion based on the fact that their instructors d id not initiate discussions about these issues and appeared to be unaware o f and unprepared for them. The potential solution to this is rooted in the students' suggestion that nursing instructors acknowledge these realities and initiate open discussions around them. W h i l e male students d id not expect their teachers to remove these stressors, they stated that they appreciate it i f teachers acknowledge that they exist and advocate on their behalf when they found themselves unable to give care or being subject to a patient's prejudices. 77 Recommendations for Future Research One of the most significant conclusions of this study was the complexity of the issues in question. This fact, combined with the relatively small body of literature on gender and nursing education, indicates a need for further research. While the interpretive ethnographic approach chosen for the study was useful for describing the phenomena involved, there is room for a grounded theory analysis that would help to generate nursing-based theory as to exactly why the nursing classrooms, and the men in them, are the way they are. There is an almost complete lack of literature that provides theory on these questions and while this would be an ambitious and complex undertaking, it would go far to gaining a deeper understanding of roles and cultures that are multifaceted and likely in a state of flux. A n advantage of a grounded theory approach would be that we could assess how men's sensitivities change over the course of their tuition, with a view to anticipating and/or targeting interventions to overcome some of the challenges at discrete points in time. A determination of whether in fact, or to what degree, nursing education cultures are indeed in flux could be determined by means of a longitudinal, quantitative study. While this study provided a snapshot of nursing education, a survey-based study that questioned men regarding gender in the nursing classroom over the entire course of their four year education involving several cohorts would help to establish the fluidity and common themes of these phenomena. This would be especially valuable given that social mores and expectations around gender in other contexts have often changed significantly, and rapidly, in recent decades. Another inherent shortcoming of this study's ethnographic methodology was the lack of comparison or student counterpoints for men who participated. Points of comparison would be valuable and could be obtained in further qualitative study by including men from various years 78 in the nursing program. Even more useful would be to elicit the input of female students. It could well be that women share many of the same experiences, insights and frustrations that the men revealed, and an exploration of viewpoints would be a welcome addition to nursing knowledge. Conclusion This study thoughtfully considers and describes the connections between nursing education and masculinities within the classroom context, an area that has been scrutinized by comparatively few nursing scholars. The means to this end was the qualitative methodology of interpretive ethnography. The main findings were that men enact roles in their education that are closely aligned with traditional masculinities, but that gender was a factor that had more complex ramifications than simply describing or dictating how men should comport themselves in the classroom. Men's gender was a factor in the way that they saw their relationships with both their colleagues and the nursing curriculum, and many of the frustrations that men experience in nursing education were rooted in gender—such as the perceived inefficiency of their female colleagues, the overemphasis on psychosocial concerns and the presumption on the part of their instructors that all students have familiarity with feminine experiences. The culture of nursing education vis-a-vis gender was also explored, and the close alignment of nursing education with traditional femininities was confirmed by observations and interviews with both male students and their female instructors. This study opened with a statement of two problems: the global shortage of RNs and the high attrition rate of men in nursing education. 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International Council of Nurses (2004). The global shortage of Registered Nurses: An overview of issues and actions. Retrieved June 23, 2005, from Johnson, L. (1989, November). Male nurses: Victims of discrimination or "the privileged few?" NSNA/Imprint, 23-27. Kelly, N . R., Shoemaker, M . , & Steele, T. (1996). The experience of being a male student nurse. Journal of Nursing Education, 35(4), 170-174. 83 Kermode, S. (2006). Is nursing education sexist? A n exploratory study. Contemporary Nurse, 22(1), 66-74. Leonard, V . W. (1994). A Heideggerian phenomenological perspective on the concept of person. In P. E. Benner (Ed.), Interpretive phenomenology (pp. 43-64). Thousand Oaks, C A : Sage. Macintosh, J. (2002). Gender-related influences in nursing education. Journal of Professional Nursing, 18(3), 170-175. Mackintosh, C. (1997). A historical study of men in nursing. Journal of Advanced Nursing, 26, 232-236. MacPhail, J. (1996). Men in nursing. In J. R. Kerr & J. MacPhail (Eds.), Canadian nursing: Issues and perspectives (3rd ed.), (pp.74-81). Toronto: Mosby. Malone, R. E. (1998). Whither the almshouse? Overutilization and the role of the emergency department. Journal of Health Politics, Policy and Law, 23(5), 795-827. Malone, R. E. (2000). Dimensions of vulnerability in emergency nurses' narratives. Advances in Nursing Science, 23(1), 1—11. Meadus, R. J. (2000). Men in nursing: Barriers to recruitment. Nursing Forum, 35(3), 5-12. Morse, J. M . , & Field, P. A . (1995). Qualitative research methods for health professionals (2nd ed.). Thousand Oaks, C A : Sage. Moynihan, C. (1998). Theories of masculinity. British Medical Journal, 317(11), 1072-1075. 84 Okrainec, G. (1990). Male nursing students' satisfaction with nursing education in Alberta. AARNNewsletter, 46(U), 20-22. Okrainec, G. (1993a). Canadian male nursing students. AARN Newsletter, 49(7), 3. Okrainec, G. (1993b). Male nursing students in obstetrics. AARN Newsletter, 49(11), 26. Okrainec, G. (1994). Perceptions of nursing education held by male nursing students. Western Journal of Nursing Research, 16(1), 94-107. O'Lynn, C. E. (2004). Gender-based barriers for male students in nursing education programs: Prevalence and perceived importance. Journal of Nursing Education, 43(5), 229-236. Packer, M . J. (1985). Hermeneutic inquiry in the study of human conduct. American Psychologist, 40(10), 1081-1093. Paterson, B L. , Tschikota, S., Crawford, M . , Saydak, M . , Venkatesh, P., & Aronowitz, T. (1996). Learning to care: Gender issues for male nursing students. Canadian Journal of Nursing Research, 28(1), 25-39. Patterson, B J., & Morin, K . H . (2002). Perceptions of the maternal-child clinical rotation: The male student nurse perspective. Journal of Nursing Education, 41(6), 266-272. Poliafico, J. K . (1998). Nursing's gender gap. RN, 61(10), 39-42. Polifroni, E. C , & Welch, M . (Eds.) (1999). Perspectives on Philosophy of Science in Nursing. Philadelphia: Lippincott. Polkinghorne, D. E. (1988). Narrative knowing and the human sciences. Albany, N Y : S U N Y Press. 85 Rochelle, R. (2002). Recruiting men in nursing: Insights for the profession. Unpublished master's thesis, Gonzaga University, Spokane, W A . Schoenmaker, A . , & Radosevich, D. M . (1976). Men nursing students: How they perceive then-situation. Nursing Outlook, 24(5), 298-303. Sherrod, R. A . (1991). Obstetrical role strain for male nursing students. Western Journal of Nursing Research, 13(4), 494-502. Sprouse, D. (1996). Message from the president. Inter Action, 14(3), 1. Sims, G. P., & Baldwin, D. (1995). Race, class and gender considerations in nursing education. Nursing and Health Care: Perspectives on Community, 16(6), 316-321. Snavely, B . K. , & Fairhurst, G. T. (1984). The male nursing student as token. Research in Nursing and Health, 7, 287-294. Soerlie, V . , Talseth, A . , & Norberg, A . (1997). Male nurses—reasons for entering and experiences of being in the profession. Scandinavian Journal of Caring Sciences, 11, 113-118. Statistics Canada. (2000). Education in Canada. Retrieved June 30, 2005, from Stott, A . (2003). Issues in the socialisation process of the male student nurse: Implications for retention in undergraduate nursing courses. Nurse Education Today, 24, 91-97. Stott, A . (in press). Exploring factors affecting attrition of male students from an undergraduate nursing course: A qualitative study. Nurse Education Today. 86 Streubert, H . J., & O'Toole, M . (1991). Review of research on male nursing students. In National League for Nursing, Review of Research in nursing education (pp. 31-50). New York: National League for Nursing. Sullivan, E. J. (2000). Men in nursing: The importance of gender diversity. Journal of Professional Nursing, 16(5), 253—254. Trachtenberg, I. H . (2000). Hear our voices: A phenomenological perspective of male nursing students' experiences in obstetrics. Unpublished doctoral dissertation, Widener University, Chester, PA. Villeneuve, M . J. (1994). Recruiting and retaining men in nursing: A review of the literature. Journal of Professional Nursing, 10(4), 217-228. Williams, C. L. (1995). Hidden advantages for men in nursing. Nursing Administration Quarterly, 19(2), 63-70. Wilson, G. (2005). The experience of males entering nursing: A phenomenological analysis of professionally enhancing factors and barriers. Contemporary Nurse, 20(2), 221-233. 88 Certificate of Approval Columbia 2005-20 B r i s h Cofutr i ia to British Columbia N/A N/A Nursing Inslrudors' and mate nursing students' perceptions of undergraduate, classroom nursing education- An interpretive ethnographic study • i w M B R R { TEBH <Xa> I a i c A . None The protocol and consent form for the above-named project have been reviewed by the BCIT Research Ethics Board and were found to be acceptable on ethical grounds for research involving human subjects. Any variations/changes to the protocol or consent form v^lch,are;i*0t,a» the.-BCIT REB . .wi l t r«io>r.^ of App iwa l hull a no voiu. This GaritcatS>& Approval valid for the above term provided there are no <stan§e$ in theJeapenrner^r procedyies, protest Or consent form. 91 in order to perform participant observation, I would like to briefly present my study and distribute an information letter in a class one week prior to the first class. Students who wish to be excluded from observation need to be able to withdraw themselves without being answerable to me, the researcher; as such, I request that you allow them to contact you by phone, email or in person and that you in turn inform me. As well, should any students be absent on the day that I present the research, I would ask that you email them a copy of the information letter. Following this observation, I would like to interview you for approximately one hour at a time and place of your convenience, with the possibility of informal follow-up contact i f necessary. The interviews wil l be tape-recorded, transcribed and the themes analyzed for meaning. I wil l also interview at least one of the male students who attended the class, focusing on the interactions I observed in the class and on his perceptions around gender and classroom nursing education. There are no identifiable benefits to your participation in this study. There is a potential risk that the data may reflect negatively on your teaching practice. At all points in the research process your identity, the identity of your students and that of your employing institution wil l be solely accessible to Jeff Dyck, the student investigator; this information wil l be kept from the principal investigators and wil l not appear in any communications or the dissemination of the findings. Thank you for considering a contribution to this course of research. Sincerely, Jeff Dyck 93 There are no potential benefits to your participation in this study. Your performance in the classes wil l not be scrutinized, and you wil l not be the sole object of my observation: the behaviours of all your fellow students and of your instructor wil l also be observed and recorded. Thank you for considering a contribution to this course of research. Sincerely, JeffDyck 95 This project is being undertaken as the thesis component of a Master of Science in Nursing degree at the University of British Columbia by Jeff Dyck. Thank you for considering a contribution to this course of research. If you have any questions or concerns, please do not hesitate to contact Jeff at the phone number or email address above. Sincerely, Jeff Dyck 102 Appendix H: Participant observation guide 1. The Course • What is the course matter, format and level? What is today's subject? What is the agenda for today's class? 2. Demographics • How many students are present in the class? • How many are male? • How many are female? • Are any teaching assistants or guest speakers present? If yes, what is their gender? 3. Geographies • How large is the room? How is the classroom laid out? (Sketch map) Individual desks? Tables? Clusters of students? Was their any change in layout during the teaching session either to facilitate a learning activity or to accommodate numbers? • Where in the room have the male students chosen to sit? (Note on sketch map of room layout) 4. Interactions • How many times does the instructor ask questions or elicit input, feedback or examples from the class in general (open elicitations)? Which students respond? In what order? How much does each student speak (approximate number of words and time)? Do students respond solely to the instructor's question or probe, or do they introduce their own line of thinking, opinion or question? Which students do this? • Are any tangents or specific agendas introduced by students? How are these addressed or followed up by other instructor? By other students? • Is anyone (instructor or student) cut off or interrupted by anyone else? What is the response on the part of the instructor and/or other students? • Are any questions or requests for other input directed by an instructor to a particular student or group of students in the class? To whom? • What materials (written materials, multimedia or props) are utilized in the teaching session? Could any of these be construed as not being gender inclusive? Why? • Does the instructor appear to make eye contact with any particular student or group of students more than any others? • Does the instructor defer any student questions back to the students themselves? To any particular student or group of students? • Is language used by the instructor gender inclusive (e.g. does the instructor generalize to nurses as "she"? "they"? "he or she"? • Is language used by students gender inclusive? If not, is this addressed by the instructor? By another student? • Are there any behaviours that could be construed as preferential demonstrated by the instructor toward any student? (describe in detail) 103 Do any students approach the instructor at the conclusion of the class either individually or in small groups? In what order are these students addressed/accommodated? How could the sum total of interactions between the instructor and the students be characterized on conclusion of the teaching session? Are any patterns of interaction evident along lines of gender? t 104 Appendix I: Interview guide (instructors) Introduction: • Explanation of the study • Offer to answer any questions • Written consent wi l l have been obtained prior to participant observation phase Relevant research questions: 1. How does gender inform and influence the culture of the nursing classroom? 3. How do classroom nursing educators think about, plan for and address the fact that men constitute a small number of nursing students? Interview questions: • What is it like for you to teach in a class with many women and few men? Can you think of a time when the reality of this was really brought home? • Can you think of a time when the dynamic in the classroom was influenced by the gender split? In general, how do you think the gender split affects the dynamic in the nursing classroom? • Can you think of a time when you accounted for the gender split in the way that you planned out a teaching session? Is there a time when you hadn't planned for this and wished you had? Vice versa? Is it even something that should bear weight when you plan your lessons? • Is there a time when the fact that there are far more women than men in a class affected the way that you carried out your teaching in the classroom? In general, how do you think that the gender split influences the way you execute your teaching? • Can you think of a time when it seemed evident to you that male nursing students have an advantage by virtue of being so small in number? How about the converse - is there a time when you concluded that men might be at a disadvantage for the same reason? Overall, how would you characterize their position? Or are they on an equal footing with their female counterparts? If there is a difference, why do you think this is the case? • Can you think of a time when you came across materials (texts, handouts, pictures, videos etc.) that you evaluated in light of gender? How would you characterize nursing education materials overall in light of what we've been talking about? Why do you think this is? • Can you think of a situation that spoke to the success or lack of success of male students in the nursing classroom? What is your perception of the success or lack of success of male students in the classroom? Why do you think this is? • What are your thoughts around achieving gender equity in nursing education? Is gender equity in nursing education an achievable goal? Is it a desirable goal? • Are there accommodations made to male students? Can you think of a time when this was the case in your own experience? Should accommodations be made? What should this look like? • How might you describe the culture of your nursing classroom? (Also discuss the data from PO of the classes I observed) 105 Appendix J: Interview guide (students) Introduction: • Explanation of the study • Offer to answer any questions • Consent wil l have been obtained prior to participant observation phase Relevant research questions: 1. How does gender inform and influence the culture of the nursing classroom? 2. How do male undergraduate nursing students perceive and interpret their experiences in the nursing classroom? Preliminary question: • Tell me about your experience of being a male student in your classroom education to this point. Interview questions: • What is it like for you with so many more women in the nursing classroom? • Has your classroom learning experience differed from that of your female counterparts? Is so, can you think of a time when this was evident to you? • Do you think that men students are at an advantage, a disadvantage, or on an equal footing with women in classroom nursing education? Can you think of an experience that speaks to this? • What effect does the gender split in nursing classrooms have on the way classes are taught by your instructors? How does it affect the dynamic in the classroom? What factors do you believe underlie this? • How do you think that professors recognize, plan for and execute their teaching in light of the gender split in the classroom? What works? What doesn't work? • Do you have any personal identification with any of these positive and negative experiences that other researchers have identified? (I wi l l list some of the more common ones - both positive and negative - including hidden advantage, patriarchal dividend, isolation, lack of role models, stereotyping etc.). Do you have any stories that speak to this? • What experience, i f any, do you have with role strain as a male student nurse? (I wi l l explain the concept i f it hasn't come up yet). • What significant interactions occurred in the classes that I observed? (Probe for elaboration as necessary) What was typical or atypical in those classes? 


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