Male identity in mental health nursing

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Jul 1, 2002 - taxonomies (lists of related folk terms) regarding male nurse issues [Q2 For example?] ... torical, you know, taken from the old days of Victorian.
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Male identity in mental health nursing Holyoake D (2002) Male identity in mental health nursing. Nursing Standard. 16, 48, 33-37. Date of acceptance: July 1 2002. Abstract Aim To explore the cultural meaning associated with male mental health nurses Method An ethnographic approach was used to discover the meaning informants attach to the cultural norms, values and rules that govern their behaviour. Data were collected through participant observation and in-depth interviews with informants Results Data were analysed using emerging domains and taxonomies regarding male nurse issues. This involved grouping terms, words and everyday reflections collected from the male mental health nurses. These lists of data (taxonomies) enabled the researcher to construct in-depth cultural themes about the attitudes, behaviours and symbolism typically associated with male nurses Conclusion A number of cultural themes emerged, including the notion of ‘soft masculinity’, which provided some insight into male nurses’ experiences of working in a female-dominated workplace. A recurring themes was the need for male nurses to demonstrate gentleness and caring while maintaining a balanced sense of masculine identity

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HIS ARTICLE explores the way gender representations affect nurses’ sense of identity. Gender research in nursing has implications for understanding how male mental health nurses perceive their world, in terms of constructing their working identity. At a time when nursing is striving to become evidence based, many more questions should be posed regarding what it is like for male nurses to work in a profession that has connotations about their motives, manliness and sexuality.

Background A recent article published in a daily newspaper reported that there are only 83 male midwives registered with the UKCC (The Sun 2000). Case studies and questions were used to explore how male midwives and female patients felt about the role of male nurses in midwifery. This article provides an interesting reflection on gender in the nursing profession. The symbolism of the male midwife seems to illuminate some of the underlying desires of nursing. For example, the nursing profession appears to want to be a model equal-opportunity employer: a sexless profession in which masculinity is presented as caring in a way that is usually attributed to females. This involves adopting a soft masculine performance, which is never spoken about and is ideologically naturalised as the way to behave to maintain a male nurse identity. The notion of soft masculinity was one of many cultural themes that emerged from a larger genderfocused ethnographic research project conducted by the author. The overall aim of the project was to identify how gender-related cultural meaning affected everyday clinical experiences of male nurses. A broad overview of the research is outlined in Box 1. The cultural theme of soft masculinity gradually became apparent as the author decoded more than 200,000 words of transcripts and observations. The idea that male nurses’ identity is constituted by nursing culture, as opposed to the usual notion that men have masculine traits that they bring to practice, provided a new and novel research area. This was an area that required sensitive qualitative data collection methods, involving multiple interviews with the same male nurses. As noted in one transcript, a male nurse called Tom said: ‘I suppose I try to be more in touch with my feminine

Dean-David Holyoake RMN, PhD, MSc, PG, DipN, BSc(Hons), BA, DipCPC, Dip Child Psychol, is Nurse Consultant, Woodbourne Priory Adolescent Unit, Woodbourne Priory Hospital, Edgbaston, Birmingham. Email: deandavid@handel64. fsnet.co.uk [Q1 OK to use this email?]

Online archive For related articles visit our online archive at: www.nursing-standard.co.uk and search using the key words below. Key words

■ Male nurses ■ Gender ■ Psychiatric nursing ■ Research methods These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.

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art&scienceresearch Box 1. Ethnographic research outline Study aim To access and produce ethnographies concerning the cultural meaning associated with psychiatric male nurses Research approach Ethnography is a qualitative methodology, which is closely associated with cultural anthropology. The ethnographer is concerned to discover the meaning that informants apply to cultural norms, as well as the values and rules that govern their behaviour Research environment This ethnographic research was conducted in three nursing units unknown to the author. These were acute psychiatric units staffed by multidisciplinary teams. A total of 14 months was spent observing and interviewing informants. Each site was observed in sequence, which meant that the author became more focused as the study progressed Research sample Each of the three units was chosen because of their ease of access for the author. Two of the units were in Birmingham and one in London. In addition to the opportunist sampling used to choose the three sites, the author used a similar sampling technique to identify male nurses for indepth ethnographic interviewing. Informants that could be most useful to the author were identified following periods of randomly selected observation. In practice, this usually resulted in the researcher interviewing all of the male nurses in the three units at least once Research methods The use of observation was reduced as the author became more involved in each nursing culture. Once informants had been identified, interviewing and shadowing of them enabled large amounts of data to be collected and analysed in tandem. Each informant underwent multiple interviews – up to ten over a ten-week period for each nurse. The analysis involved developing domains and taxonomies (lists of related folk terms) regarding male nurse issues [Q2 For example?]. These were later translated into cultural themes, for example, ‘soft masculinities’ and ‘straight acting’. All of the interviews were recorded and the male nurses were regarded as being part of the research process. The author attempted to ‘learn from the natives’, as outlined by [Q3 Ref? Spradley]. Ethical arrangements Full ethical approval was gained from the regional ethics committee. In addition, each hospital was guaranteed confidentiality and full written consent was sought from each interviewee. Informants retained their right to withdraw from the study at any time. No comment or access was sought regarding patient details, notes or treatment. The names used in this article are pseudonyms side because I’m a nurse... it’s sort of expected’. This type of data invited the author to explore this issue further. In what ways did male nurses consciously attempt to be more feminine and how does the nursing culture accommodate this? What drives men to occupy this type of identity space? Was it the same as soldiers or prison wardens needing to exhibit excess masculinity? The notion of ‘soft masculinity’ was reluctantly revealed because male nurses, like Tom, do not talk openly about their feelings. The author became interested in gender ideologies while conducting observations and ethnographic interviews, during a three-year fieldwork project in acute mental health settings. He became particularly interested in the way nurses adhere to certain prescribed representations to maintain an identity. These representations relate to the typical stereotypes associated with nursing, for example, caring, high skill levels and a sense of professionalism. By using a process of semiotic analysis, that is, interpreting the cultural symbols that had a 34 nursing standard august 14/vol16/no48/2002

contextual meaning for nurses in each culture, rather than studying biological trait differences, it was possible to begin theorising that gender issues are important in the cultural identity constructed for male mental health nurses (Holyoake 2000). Constructing identity Soft masculinity is part of a constructed identity, that is, male nurses have a sense of self and, therefore, present the image they wish to portray to others. This image is fashioned within nursing culture and experiences encountered in clinical practice. I asked Ally, an experienced registered mental nurse (RMN), about identity and being a male nurse. He stated that: ‘...when I was doing my stint in general nursing, which in those days was three months, I noticed that there was a real marked difference between male and female nurses. For instance, I was called Mr Smith... while females [nurses] in my group were called student nurse.’

art&scienceresearch I also asked Bill, a staff nurse, who was a qualified registered general nurse (RGN) and a RMN, a similar question. He replied: ‘General nursing is more female orientated, but that’s no secret. There are more males in psychiatry and I think this is historical, you know, taken from the old days of Victorian asylums when the mad really did need someone to sit on them.’ If male nurses have the same responsibility and desire to uphold codes of professional practice, then it would seem that, in theory, there is no identity difference between the two sexes. However, many of the male nurses spoke about having to represent their masculinity in a type of ‘nursing way’, and how the culture within psychiatric nursing supported this. During the fieldwork, the term ‘maleness’ came to signify the way male nurses had their identity constructed for them as a sort of hybrid nursing identity. This is a mutated identity that is founded on connotations about the reproduction of expected gender traits, which have a value and meaning in a psychiatric nursing culture. Some of this value is about restraining patients, and some of it refers to getting more respect and being called Mr, as reflected by Ally. Psychiatric nursing has connotations that are related to the need for strong men to restrain aggressive psychotic patients. As noted earlier by Bill, the image of the Victorian asylum superintendents seems to be iconic for a particular type of male nurse. The key theme of gender issues in psychiatric nursing culture not only allows for this type of structural interpretation, that is, an exploration of how cultural myths and connotations circulate and sustain their influence, but also permits analysis that shows how culture is just as important as biology in theorising why and how male nurses fit into a constructed working sense of self-identity. In particular, the way male nurses try to negotiate their practice in relation to maleness (masculinity in psychiatric nursing culture). The sex-difference perspective in practice The study of sex differences and gender has a long social history (Walsh 1977). It is possible to trace the foundations of gender representation in current nursing practice by studying the historical demographics in nursing. General nursing has always been considered a female profession and still is today. Male nurses make up a small percentage of the workforce (9.75 per cent) (Thompson 2001), and nursing is generally considered a fundamentally feminine occupation. Most surveys and studies show that about 10 per cent of the nursing work force is male, and also that men tend to make up around 35 per cent of the managerial grades (Austin 1977, Dingwall 1972, Nuttall 1983, Ratcliffe 1996, Robinson 1992). These studies have tended to confirm the notions of biological difference between

the sexes, which are prevalent in the wider society, as opposed to culturally imposed determinants (Davies 1995), that is, behavioural stereotypes expected by the two sexes within nursing. Having acknowledged these hierarchical inconsistencies, it seems that the recruitment and study of men in nursing has been ignored for too long (Pontin 1988). I asked Anthony, a non-trained nurse with seven years’ experience of working in acute mental health, what he thought about the differences between male and female nurses. He said: ‘I think that society actually views women as being more sort of nurturing and caring and that it’s a special type of male that actually comes into nursing in the first place. I hope that being a male nurse is more than just being second best... I suspect that female nurses may feel more vulnerable’. Anthony is not untypical in his opinion. The assumptions that nursing is essentially expressive in its nature and, therefore, the perogative of women (Hesselbart 1977), ensures that most studies focus on male nurses as being a curious of the workforce. Hoffman (1970) found that when compared with the population at large, nurses scored below average for personality traits such as dominance, change, aggression and autonomy. Later work by Burns (1977) showed that female nurses regard male nurses as more ‘traditionally’ gentlemanly than the general male population, and that all nurses as particularly emotionally unstable and feminine. Male nurses are not only viewed as being more in touch with their feminine side than other males, but they are also viewed as being more logical and resilient than female nurses (Burns 1977). Men are also thought to be more aggressive and dominant than their female counterparts, who are viewed as being more emotional and caring (Brown and Stones 1972, Gumley et al 1979), and as a result male nurses are occupationally alienated because of their personal qualities and make up (Lynn et al 1975). Lemkau (1984) suggests that male nurses differ from non-nurse males because they possess feminine characteristics, which render them able to nurse. Thus, the sex trait difference perspective, which centres on stereotypical, biological aspects, dominates society to such a degree that it has blurred who can and what can be attributed to a ‘good’ nurse identity. Most male nurses who were asked if they thought the gender of a nurse had an effect on the value of their practice felt that they should be viewed as sexless. This is summed up by Johnny (staff nurse) who said: ‘I think male nurses should be thought of as sort of sexless, like, be able to go into female rooms and nurse like the women do. I don’t think the sex of a nurse should matter, I think it should be equal...’. Boys will be boys How do male nurses relate to a fixed sense of identity august 14/vol16/no48/2002 nursing standard 35

art&scienceresearch in an arena that views nursing as the work of wives and mothers in the physical and emotional domain of caring (James 1992, Rutty 1998, Smith 1993)? This has often been answered by arguing that the main social differences between males and females are caused by, and are reflections of, biological differences – in other words, biology is destiny. Hence, the notion that masculine and feminine identity are natural takes on a special significance within nursing. Being naturally feminine or masculine simplifies the effect of the culture on the formation of male nurse identity. It also suggests that, while men in nursing might have taken on board – or previously possessed – feminine characteristics, they still possess masculine aspects to their personalities that differentiate them from female nurses (Pontin 1988). Therefore, the ‘good’ nurse identity is stereotyped as attractive, compliant and female (Keddy et al 1986). The good male nurse is someone who needs to be aware of political correctness (Hollway and Jefferson 1996), that is, not so masculine as to warrant special feminine characteristics yet, and not too masculine as to bring the profession or his masculine practice into disrepute. There are some things male nurses do not do, as explained by Liam (staff nurse): ‘I won’t go into the female dormitories to wake females... female patients may come up to me and talk. Perhaps they relate better to males... I don’t really know’. Brian, a nursing assistant, said: ‘I always make sure that I leave the door open when I’m alone in a room with a female patient’. Soft masculinity The male nurses I observed and interviewed all comply with the valued norms that have meaning within a nursing culture. This culture unwittingly proposes the representation of a type of ‘soft masculinity’, that is, a male who appears to be more in touch with his ‘feminine side’ because of his job. This feminine side has connotations of being caring, polite and, therefore, ‘soft’. This symbolic masculinity provides the hangers on which expected masculine traits are hung, and is described by Liam as enabling vulnerable females to approach males within a trusting therapeutic relationship. Being able to recognise that nursing practice involves caring processes means that male nurses are fundamentally identifying with soft masculinity, which is a different type of masculinity to that of a soldier, factory worker or male medic. This is the first important step in attempting to understand how a male nurse defines himself and others within an environment in which he must negotiate constantly. There are rites of passage on becoming a male nurse, which include fear of failure, not being able to cope with clinical demands and emergencies, not being accepted, being too moody, failing to reproduce the symbolism of maleness to a meaningful standard. Examples taken 36 nursing standard august 14/vol16/no48/2002

from the study taxonomies of some of the simple everyday feats that male nurses try to masquerade include: ‘being firm but fair’, ‘good leadership’, ‘a sense of control’, ‘letting people know where they stand’, ‘getting to the point’ and ‘sticking together’. The fear of not being able to replicate the great feats of previous charge nurses compounds the dread that male nurses face. The nostalgic vision of male-centred rituals (partly recoverable from myths, stories and the practices of other nurses) serves to remind nurses of the expectations placed on them. Like those placed on Bob when he was a student restraining a patient: ‘The old charge nurse looked down at me as I pathetically tried to scrabble around with this patient... I don’t think I was flavour of the month... all I could say was sorry as reinforcements were called for’. If a male nurse goes beyond a representation of soft masculinity and behaves in a non-macho way or is considered too effeminate, this is not a valued soft masculine trait and is not measurable against mainstream masculinity. During the fieldwork, male nurses spoke of the ‘gossip’ in nursing circles regarding the perceived sexual orientation of male registered nurses and of their effeminacy. This highlights the way the dominant patriarchal and soft masculine culture secures its dominance. The nurse informants involved in the study articulate politically correct assumptions regarding their sexuality and that of colleagues. Being heterosexual is to belong to the dominant, safest and non-marginalised soft masculine group. Responses to questions asked about behaving in an effeminate manner and therefore, perhaps, appearing gay, elicited answers that made reference to male nurses never acting effeminately, or, as implied by Bob: ‘It doesn’t matter what orientation a person is, as long as they’re a good nurse... being gay doesn’t mean you’re any less of a man’ (Holyoake 2001). This type of response typifies the caring and understanding psychiatric nursing culture. Yet the sniggers and laughs about ‘being a shirt lifter’ or ‘not turning your back’ are the common phrases offered by males who retained their sense of identity and are attempting to protect it. Nurses in the case studies emphasised a particular cultural theme. Even though psychiatric male nurses exhibit a soft masculinity, a boundary is demonstrated by the representation of specific non-gay traits. This ‘straight acting’ theme is one that rests on the assumption that sexuality as an identity can represent the control and machismo that is represented by heterosexuality. Homosexual staff nurse ‘Steve’ said: ‘I think that there has always been an acknowledgement that most male nurses are gay and this provides many gay men with an opportunity to have an open unhassled career. Nursing is still antigay anyway, it’s just that it’s less anti-gay than any other profession, that’s all.’ The psychiatric nursing environment is a culture

art&scienceresearch that attempts to be sexually inoffensive. Thus, straight acting is a result of the sex-gender system which has cultural meaning. Soft masculine performance is specific to the caring culture of nursing because males are allowed and even encouraged to be more approachable. It seems that the construction of collective and individual identity for male psychiatric nurses is a complex web of relationships between valued cultural signs. These signs and symbols have meaning for anyone working within this culture and are affected by notions from outside the psychiatric nursing culture. Soft masculinity with its straight acting and symbols of respected machismo serve as building blocks for personal identity. Male identities are often assumed to be personal rather than culturally determined. This is evident in the way male informants believe they choose to be ‘good clinical leaders’ or wish to be ‘respected for knowing their stuff’, and so on. However, it could be that these expectations are culturally driven because they have value in psychiatric culture. Any male nurse who does not strive to achieve these highly prized cultural signs is marginalised and, therefore, the pressure to conform is great.

trends change. As members of a culture, male nurses are subject to forces that are largely invisible and silent. These forces continually invite nurses to represent and display correct cultural signs. Thus, representation of normal everyday things helps nurses to imagine themselves as ‘self-fashioned and fashioning through identification of a particular set of traits or behaviours’ (Buchbinder 1998). This creates a feeling of authenticity when we are successfully influenced by particular, and especially ideologically approved, gender representations. Soft masculine representations conceal and suppress elements that might betray individuals as being insufficiently manly, or insufficiently feminine. Mental health nurses constantly negotiate their representation of soft masculinity in a state of unknowing. They are constantly bombarded and buffeted by cultural imagery, which hides beneath the human-interest stories presented in popular culture Acknowledgement The author would like to thank all the informants involved in this research. Please note that all the names have been changed to maintain confidentiality.

Conclusion The terms ‘straight acting’ and ‘soft masculinity’ imply that male nurse masculinity is about performing. The male nurses in this study consistently reiterated valued cultural traits in their everyday practice. This performance defines who they are and what they do and represents a soft masculine identity. This research provides a fresh look at masculinity within the nursing profession, but this area requires further research. Perhaps there is some truth in the notion that male nurses act in such a way that each man performs the conventional signs or attributes of masculine identity, not only through body language, but also as a collective identity. This research highlights the vulnerability, performance anxiety and the unstable nature of gender attributes as cultural REFERENCES Austin R (1977) Sex and gender in the future of nursing, 1. Nursing Times. 73, 34, 113-116. Brown R, Stones R (1972) Personality and intelligence characteristics of male nurses. International Journal of Nursing Studies. 9, [Q5 ISSUE NO?], 167-177. Buchbinder D (1998) Performance Anxieties: Reproducing Masculinity. St Leonards, Australia, Allen & Unwin. Burns R (1977) Male and female perceptions of their own and other sex. British Journal of Social and Clinical Psychology. 16, [Q6 ISSUE NO?], 213-300. Davies C (1995) Gender and the Professional Predicament in Nursing.

Implications for practice ■ Gender studies in nursing culture should include an appreciation of how and why gender-related traits have significance in clinical settings ■ This research is an attempt to re-open debate about gender issues in nursing practice and suggests that culture and biology as important considerations ■ The way male and female nurses practice is different because of the cultural expectations placed on each sex [Q4 Is this correct I thought the male nurses are trying to conform to be more like the female nurses?].

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