Stressors and rewards experienced by men in nursing: A qualitative study.

This study explored men's experiences in nursing. A qualitative research design was utilized to examine (a) the stressors experienced by male nurses, (b) the strategies male nurses use to cope with these stressors, (c) the factors that motivate men to pursue a career in nursing and (d) what motivates men to remain in the profession. Six participants were conveniently and purposively selected from a range of nursing positions including cardiac, intensive care unit, theater, and general nursing to participate in semi-structured interviews detailing their experiences. Thematic analysis of the interview data revealed that male nurses still experience gender role conflict, feelings of exclusion, and numerous other stressors working in a female-dominated occupation. Despite these challenges, participants reported that they experienced a great sense of satisfaction in their nursing careers. Further development of educational programs aimed at challenging and breaking down the perceived social stigma regarding men entering the profession may assist in recruiting more men into nursing roles. At a broader policy level, the development of more effective strategies to prevent and manage stress may assist health care agencies to deliver more gender diverse care and retain more men in the profession.

challenging occupation. 6 While many studies have explored occupational stress and coping in nurses, fewer studies have explored the link between gender and experiences of stress and coping.
Studies that have explored potential gender differences in occupational stress among nurses have resulted in somewhat contradictory findings. 6,7 Some research has suggested that male nurses, in comparison to female nurses, tend to experience less physical and mental health-related problems, 8 while other studies have found that male and female nurses experience relatively comparable levels of stress. 7 There is also research that suggests that men may experience specific stressors or obstacles that pertain to being part of a gender minority in a female-dominated occupation, including the additional stress of gender role conflict. 9 In a seminal paper O'Neil 10 described gender role conflict and role strain as psychological states where masculine, feminine, or androgynous roles have negative consequences for a person and produce considerable psychological stress. Studies have found that male nurses may experience gender role conflict given that the expectations associated with their traditional masculine role often conflicts with their role as a nurse which has traditionally been viewed as a female occupational role. 9,[11][12][13] In addition to gender role conflict, male nurses have also reported feelings of isolation and exclusion when working in a female-dominated environment. 11 To cope with these potential gendered occupational stressors, male nurses may use strategies to reframe their nursing role in a way that is more congruent with a traditionally masculine identity. 14

| RATIONALE
Research indicates that if current trends in nursing retention continue and projected retirements are taking in consideration, there will be shortages of more than 85 000 registered nurses by 2025 and by 123 000 by 2030. 15 Although the number of men entering and remaining in nursing is slowly increasing, 1,16 nursing remains a female-dominated profession. While many studies have investigated occupational stress and coping among nurses, there is relatively limited research that has specifically explored stress and coping in male nurses and what motivates them to remain in nursing despite the challenges they may face. 17,18 Therefore, the overall aim of the current study was to explore the experiences of men working in the nursing profession. The specific research questions were:

| Design
A phenomenological research design was employed in the current study to explore the lived experiences of male nurses. Phenomenological methods have proven useful for understanding the subjective elements of human experience and are consistent with values of patient-centered and holistic care intrinsic to the nursing process. 19 Phenomenological approaches are consistent with an interpretivist perspective where the understanding of a participant's experience requires the researcher to interpret experience within a certain context. 20 By engaging in semistructured interviews the researcher may come to understand the participant's experiences through a process of intersubjective communication and guide the inquiry in response to what is being learned. 21

| Participants
A convenient and purposive, snowballing sampling method was utilized to recruit participants from the researcher's extended social network. The first author asked friends and acquaintances if they knew of any male nurses who would be potentially interested in participating in the study. Thirty friends and acquaintances including former nursing student colleagues were approached. The inclusion criteria for the study was that male participants must be currently working in the nursing profession or been previously registered by the Australian Health Practitioners Regulatory Agency as a division 1 registered nurse employed in a nursing position. All of the male nurses who expressed interest in the study and met the inclusion criteria agreed to participate in the study. In total there were six participants, which according to Smith and Osborn 22 were likely to provide a sufficient sample size to achieve data saturation. The participants' ages ranged from 30 to 54 years. The participants worked in a range of areas within the nursing profession including intensive care unit (ICU), cardiac nursing, theater nursing, and general surgical nursing. Two of the participants were assistant nurse unit managers and another managed an organ donor clinic. The years of experience working as nurses ranged from 1 year to 28 years. All participants held a bachelor degree in nursing and four of the six participants had also completed postgraduate-level training.

| Materials and procedure
A semi-structured interview schedule was developed with reference to previous research and literature pertaining to the experiences of men who work in nursing. 12,17,18 The interview schedule consisted of 16 open-ended questions that focused on the participants' experiences of work related role stress and the ways in which they coped with these stressors. Other questions focused on participants' motivations for entering and remaining in nursing.
Following approval from the University Research Ethics Committee, semi-structured interviews were conducted with six participants.
The interviews were conducted individually and ran between 40 and 55 minutes. Each interview was audio recorded and later transcribed verbatim by the first author.

| Data analysis
A thematic analysis was used to analyse the interview transcripts incorporating the method and six-phase process outlined in Braun and Clarke. 23 Thematic analysis focuses on identifying and describing semantic themes in the data that represent both implicit and explicit ideas conveyed by participants. 21 It is also a data reduction and analysis strategy by which qualitative data are segmented, categorized, summarized, and reconstructed in a way that captures the important concepts within the data set as they pertain the research topic. 23 The researchers also acknowledged that a critical aspect of qualitative inquiry is the notion that researchers bring with them their own values and assumptions that can potentially bias or impact the research process. 24 In establishing rigor in qualitative inquiry Guba and Lincoln 25 suggest four criteria are required. These are credibility, transferability, dependability, and confirmability. 25 To meet these criteria a selection of transcripts were subject to analysis by all authors to identify and crosscheck common themes that emerged from the data and to ensure the rigor of the analysis.

| Overview
The present study explored the experiences of male nurses.
Participants reported experiencing numerous stressors including gender role conflict as a gender minority in a female-dominated occupation. Participants employed a variety of strategies to cope with these stressors. Despite these experiences, the participants described nursing as a rewarding career and outlined numerous motivations to enter and remain in the profession.

| Gender role conflict
Male nurses in the present study experienced a degree of gender role conflict working in a nursing role. Participants reported an awareness that by becoming nurses they may be perceived by others to have transgressed traditional gender roles.  However, participants' experiences of role conflict appeared to be less prominent when compared to reports obtained by male nurses interviewed in older studies. 26,27 This finding may be largely due to more progressive views of occupational gender equality permeating the nursing culture in Australia in recent years. 28 Still, nursing remains embedded with numerous stereotypes which have been unjustly attributed to male nurses, 4 and samples of male nurses from previous studies who internalize these concepts, 29,30 may have experienced conflict between their masculine identity and occupational identity.
In contrast, men in the present study were proud to identify as nurses and derived a great sense of satisfaction working in a femaledominated occupation. These men reported that most of the conflict they experienced resulted from being on the receiving end of opinions others expressed about them.
I guess another stereotype with men in nursing as well as is people yeah they assume that you are a doctor. You'll have people make comments like "Oh so when are you gonna become a doctor?" or you know "Oh is this just something that you do on your way to becoming a doctor?" It's like they just yeah naturally assume that you're gonna be a doctor because you're a man. Even if you're absolutely unambiguous and state "I'm not a doctor, I'm a nurse." They'll be like "Oh thank you doctor."  of an impact on the present sample of male nurses. As was identified in similar studies 13,31 role conflict may actually stem from the male nurses' frustration at other's erroneous views of them, rather than how they view themselves.
However, despite reporting low levels of role conflict, participants still reported anxiety in anticipation of the negative reactions from others when disclosing their occupational role. Furthermore, as was similarly observed in previous studies, 13,32 several participants were able to minimize this anxiety by exercising discretion when disclosing their jobs to others who they perceived to be more likely to hold negative stereotypical views of them.

| Feelings of exclusion in the workplace
Some men in the present study reported feeling excluded during regular social interactions that occur in their workplace. As was observed in previous studies by, 14 Dave's description of female-dominated workplace as a "toxic culture" and Barry's allusion to his coworkers' conversations as a "cacophony of noise" suggest that they may harbor some resentment towards female colleagues they perceive as the source of their exclusion. The language used may be a way of both expressing their frustration but also a strategy to reassert and reposition their masculinity in line with hegemonic notions of masculinity. Interestingly these participants worked on general wards that were overwhelmingly female-dominated while other participants who did not report feelings of exclusion, all worked in higher acuity areas with greater numbers of male peers.
Um no no I ah I like women. I get along with them so generally it's all pretty good I think. Where I work, I mean working in ICU I thinks it's probably there are more men there so you know there's a lot more (men) to associate with. So I just did a shift on Saturday and there were probably three or four blokes working immediately around me. So it's a bit more even. It's certainly more femaledominated but ah yeah there's quite a few blokes around. I think blokes tend to be more attracted to those sorts of ICU, theater, emergency sort of specialty things. (Travis) As was found in previous research, 18,27 working in areas of nursing that contain higher numbers of male peers may serve to buffer against feelings of exclusion.

| Apprehension providing personal care to female clients
Participants in the present study all reported experiencing apprehension when providing personal care to female patients. Personal care typically involves direct physical contact and may include assisting patients with personal hygiene. 34 As a young bloke working with kids I've often found families were a little bit ah… apprehensive with you to start with. You know like they weren't as comfortable as You think hang on a minute you know I'm doing this everyday and I know that they need to be comfortable as well but it does just put you in that um you feel a bit hopeless, you feel like "what the hell am I doing here?" You cop that a few times and you do start to think may be it's time at my age to move into another area completely and be away from that side of the direct hands on care or hygiene care and things like that so that is pretty uncomfortable at times. "I think it's because I'm a guy um… and you know…It's purely because I'm a guy." (Ollie) As has been observed in previous studies, 35 male nurses fear that female patients may unjustly perceive personal care that is provided by male nurses as motivated by sexual intentions. In the present study, all participants reported instances where their care had been declined by female patients which they all attributed to a view that women may perceive them as a potential risk for boundary transgressions of a sexual nature. This elicited fears that allegations of sexually inappropriate behavior would be made against them and led some of the male nurses to re-evaluate their suitability for the profession given the frequency in which personal care duties are required.
3.5 | Disproportionate assignment of "masculine" tasks Due to their high visibility, unique physical attributes and the masculine stereotypes attributed to them, male nurses may be entrapped into the roles of the protector and heavy lifter in their workplace in addition to the typical occupational role of a nurse. 14 In previous studies, 17,18 male nurses reported running past rooms to avoid being asked to lift patients, yet the men in the present sample were unable to provide many suggestions as to how to cope with these stressors. Despite the inequality of this arrangement, some participants suggested that this worked for the betterment of the ward. This may be viewed as a trade off for having female nurses take on more of the personal care roles, as mentioned earlier. 35 Furthermore, as was found in previous studies, 18 occupying the role of a protector or heavy lifter may also provide an opportunity for some male nurses to engage in masculine practices that enable them to reaffirm their masculine identities and reduce their feelings of gender role conflict.

| Becoming a nurse and remaining in the profession
Numerous reasons were reported for entering the profession. Male nurses in the present study cited the humanistic elements of the profession and the satisfaction of providing care for others as a primary motivation for entering the profession.
Yeah I don't know I think way back when I was 14 I liked caring for people and working with people. I suppose I was someone who always wanted to make people better. I suppose that was just my makeup, my personality as I believe nursing is not a job to get some money it's actually a vocation. It's something you're drawn to. (Ollie) One participant described nursing as a moral calling. As has been observed in previous studies, 12,36 the sense that one is doing "good" is a powerful motivator to both enter and remain in nursing. Several participants reported that they had not initially considered a career in nursing, but rather, it was an option that was presented to them by insiders to the profession from within their extended social circles.
Similar studies, 12,36 suggest that men are often unaware of nursing as a career option until presented with it through encounters with family, friends, or other nurses who are able to provide them with personal insights and advice to gain entry into the profession.  An interesting finding amongst the present sample of male nurses was that they did not directly identify the significant women in their lives who worked as nurses as role models. One participant stated how growing up around a lot of women in his home may have led to the acquisition of characteristics required for a caring role yet he identified his uncle who was a nurse as a role model. As was seen in previous studies, 12,36 these findings suggest that role models are highly influential in a man's decision to enter nursing and therefore an important factor for health care agencies and educational providers to consider regarding recruitment.
Similar to findings in previous studies, 37  The findings also reflected those in previous studies that have found that an interest in the more technical aspects of the profession and a desire to pursue higher level qualifications and higher-paying nursing roles often motivates men to enter and remain in the profession. 16 Therefore, as has been suggested in previous studies, 12,16 creating more opportunities for men to enter into more advanced and more autonomous nurse practitioner roles may encourage more men to consider a career in nursing and improve gender diversity in the profession.

| CONCLUSION AND IMPLICATIONS FOR PRACTICE
Despite reporting a great sense of career satisfaction, the participants in the current study reported facing gender role strain and stereotyping when fulfilling their nursing responsibilities. They reported that they felt they were disproportionately assigned more "heavy lifting/protector" roles than their female colleagues. However, there was an underlying tension when providing personal care for female patients in terms of how they were being perceived by patients. This study's findings also suggest that male nurses experienced feelings of exclusion.
Despite these findings, the role conflict reported by men in the current study was relatively minimal, particularly when compared to the findings of studies published in the 1970s and 1980s. 26,27 In contrast to these earlier studies, men in the present study were proud to identify as nurses and derived a great sense of satisfaction working in a femaledominated occupation. This finding could also be largely attributable to more progressive views regarding gender equality permeating nursing 28 and the broader Australian culture in recent years.
A multifaceted approach is needed to help ameliorate these sources of stress. Improving education and awareness of the specific stressors faced by male nurses is paramount to develop effective strategies to prevent and manage stress. It is important that nurses be actively involved in discussions of how nursing roles continue to some extent be gendered. Opening up a respectful dialog between colleagues is imperative in helping to critically reflect upon, challenge and change what is happening within the work context. At a broader policy level, strategies need to be implemented to challenge and breakdown perceived social stigma regarding men entering nursing.
Health care agencies may benefit from the development of formal processes to enhance professional conduct among staff and assist nursing leaders in identifying, responding to, and documenting issues pertaining to occupational stress among male nurses as they arise in their workplace. In the long term, increased participation and visibility of male nurses will help challenge long held stereotypes of nursing as a "women's role" and in turn may encourage more men to consider nursing as a profession. Exploration of how a greater number of men entering nursing may potentially impact on broader society's views of nursing as a profession also warrants further discussion and research.