Abstract
Researchers have demonstrated, across a variety of cultures and contexts, that people generally expect nurses to be women rather than men, and male nurses are presumed to be feminine in nature (e.g., Holroyd et al., 2002; Loughrey, 2008; Nelson et al., 1996; Oakhill et al., 2005; O’Connor, 2015; Tranbarger, 2007; Yang et al., 2004). Florence Nightingale’s sanitary reforms during the Crimean War led to a dramatic overhaul of nursing in the Western world (Nightingale, 1858), including a reversal of public opinion, where perceptions of nursing transformed from a menial labor job to a reputable career choice for women of social standing (Dingwall et al., 1988; Helmstadter, 2007; Young, 2008). Since that time, views of nursing have been reinforced by a long history of women numerically and culturally dominating the profession (Abel-Smith, 1960; Baly, 1980; Dingwall et al., 1988); a phenomenon also made visible in popular media (Babini, 2012; Young, 2019).
In the West, nursing profession is largely delineated as a caring profession (Watson, 2013; Boykin & Schoenhofer, 2013), further entrenching the field in characteristics stereotypically considered female and, even, subordinate (Bridges, 1990; Cunningham, 1999; Melchior, 2004; see also (O’Connor, 2015). Thus, what was once a field dominated by men (O’Lynn, 2007; Young, 2008), has evolved into a field dominated by women, to the extent that many now assume that nurses should be women—as if women are innately more qualified for the role (Bartfay & Bartfay, 2016)—and that men who pursue careers in nursing must be deviant in some way (Clow et al., 2015; Harding, 2007; Whittock & Leonard, 2003). Given their level of education and sensitization to different values than the larger society, students in general and nursing students in particular might have different, nuanced perceptions regarding nursing stereotypes as compared to the common prevalent attitudes especially regarding men in nursing. In this vein, many studies have focused on measuring nursing and non-nursing students’ attitudes towards nurses and nursing stereotypes (for example, Bartfay et al., 2010; Glick et al., 2000). Despite the varying geographical areas, cultural and temporal contexts, results of most of these studies reflect the larger sentiment prevalent in society regarding nursing being a feminine profession (see Holroyd et al., 2002; Loughrey, 2008).
Building on those studies, we analyzed what the majority gendered composition in nursing profession (i.e., women) perceived of men in nursing. We also analyzed perceptions of non-nursing female students to see if the stereotype content differed from that of nursing students given they might be less sensitized to the gendered nature of the profession. Through current study, we contribute to the literature on nursing, gender, and stereotypes by analyzing the personal attitudes and stereotypes held by young women toward male nurses through the lens of social role theory (Eagly, 1987; Koenig & Eagly, 2014), and envious and paternal prejudice (Stereotype Content Model; Cuddy et al., 2007; Fiske et al., 2002), with an emphasis on gender-based role fulfillment and congruency. While our data collection was limited to Canada, current research adds to a growing international body of literature on gendered nature of the nursing profession, and research focusing specifically on the growing numbers of men in the field.
The Gender Shift in Nursing
Over the years, scholars have established that early nurses were men with religious ties or education, such as medicine men, religious monks, and Jesuit priests (Klainberg & Dirschel, 2009; Young, 2008). The contribution of men to the practice of nursing has been chronicled in numerous historical accounts, including monastic movements in the fourth and fifth centuries (Evans, 2004); Order of St John of Jerusalem in the 11th and 12th centuries (Kingsley, 1978); Crusades of 12th and 13th centuries (Christensen, 2017); and relatively more recent accounts of male nurses in 19th century Britain leading up to the Crimean War (see Young, 2008 for more discussion). Young (2008) cites British census records from 1861 indicating that there were 1651 men working as nurses at various ranks in hospitals across the country, but those numbers dwindled remarkably over 20 years, such that in the 1881 census only a few hundred men listed their occupation as some form of nursing (see also Davies, 1980). By 1885, “women had largely won the battle for control over the organization of hospital nursing” (Young, 2008, p. 21). Throughout much of the 19th and 20th century, nursing as a discipline paid little attention to its earlier male origin, focusing instead on improved training and professionalization, political evolution, and establishing nursing as a reputable career choice for women (Mansell, 2003; Melchior, 2004; Young, 2008). By 21st century, few people are aware that nursing was historically a male-dominated occupation.
The gender shift in nursing can be traced to Florence Nightingale’s sanitary reforms during and after the Crimean War in the mid-nineteenth century, and the establishment of schools that barred men from acquiring required credentials to practice nursing (Nightingale, 1858; for discussion see O’Lynn, 2004; Young, 2008). Thus, a movement took roots that constructed the (gender) face of the nursing profession as female, the denouement of which is apparent in the latest statistical evidence. In Canada, for example, at the turn of the millennium, men made up only 4.8% of Registered Nurses and more recent reports suggest the percentage has increased but remains low at 9% (Canadian Institute for Health Information, 2020). International statistics, although higher than Canada’s numbers, also show a minority of men in the nursing profession; where only 10.9% of nurses in Australia (Australian Government Department of Health Fact Sheet, 2017), 11.4% of nurses in the UK (Williams, 2017), and 9.1% of nurses in the US (Smiley, et al., 2018) identifying as male.
Correspondingly, the occupation’s historical leaders and influential thinkers, including modern day nursing theorists deemed critical to the profession’s advancement, are overwhelmingly female—a reflection of the recent past and current demographic composition of field (Klainberg & Dirschel, 2009; Parker & Smith, 2010). The history of modern nursing, beyond the focus on the professionalization and emancipation of nursing from its lower status position to a career appropriate for women in the 19th century, has been the subject of much feminist thought (Dingwall et al., 1988; Mansell, 2003; Melchior, 2004). Melchior (2004) in this sense stated: “Similar to women’s history and in keeping with first-wave feminism, early professional discourse in Canadian nursing is revealed by written histories that celebrate progressiveness” and “the significance of nursing as an occupation based on feminine ideals” (p. 342).
Synonymity of “Nursing” with “Feminine”
Communal traits, such as caring and compassionate, stereotypically read as feminine attributes (Bem, 1974; Eagly & Wood, 2012), are core concepts in current nursing philosophy, culture, and practice (Cara, 2003; Davison & Williams, 2009; Henderson, 2001; Morse et al., 1990). Caring, here, is positioned as the very “essence” of nursing, underlying “the behaviors, actions, and attributes of nurses” required for ethical practice (see Boykin & Schoenhofer, 2013; Morse, et al., 1990; Watson, 2013). Many scholars have noted that caring or caring qualities are vital to practicing nursing and to sustaining a positive relationship between patient and “nurse”; a role often associated with women (Gray, 2009; Henderson, 2001; Morse et al., 1990). In fact, the stereotype of women as having a “caring nature” has been offered as an explanation for the seeming segregation of women into health and childcare occupations (e.g., teaching, nursing; Bartfay & Bartfay, 2016; Eagly & Wood, 2012). Scholars have found that qualities associated with women and femininity, specifically care, compassion, motherly, and helpful in nature, characterize people’s perceptions of nurses (Holroyd et al., 2002; Loughrey, 2008; Tranbarger, 2007). For example, in Ireland, Loughrey (2008) suggested the female gender role was integral to the nursing occupation and reported that even male nurses identified largely with “feminine gender role’ instead of the “masculine gender role.” Among male and female nursing students in Hong Kong, Holroyd et al. (2002) found that the typical Chinese nurse was rated like the typical Chinese woman.
Not only do feminine stereotypes dominate the profession, but the ideal nurse is also viewed as, almost exclusively, female. For example, in a study conducted by Oakhill et al. (2005), when asked to pair a relative (e.g., sister, brother, father, mother) with the nursing profession, participants were significantly faster in pairing female relatives with nursing than male relatives. In similar research, when participants were given the choice between an engineer or a nurse—even after being instructed that gender was not associated with career aspirations in the study—they were more likely to assume the nursing student was female and the engineering student male (Nelson et al., 1996). Similarly, Bartfay and Bartfay (2016) reported that over 90% of their female nursing student sample described nursing as more suitable profession for women, because of the inherently caring and compassionate nature of women. As Clow et al. (2015) argued, the problem is not that women are associated with nursing (e.g., women do dominate the occupation), rather that, “stereotypes lead people to assume that there is something about being a woman that is necessary for being a nurse” (p. 365; see also Bartfay & Bartfay, 2016; Cejka & Eagly, 1999; Clow & Ricciardelli, 2011).
Characteristics Generated by Nursing and Non-Nursing Students for Male Nurses.
Theoretical Framework
Social Role Theory
Social roles can be defined as behavioral expectations deemed suitable for persons occupying a certain social position or associated with a particular social category (Biddle, 1986; Eagly & Koenig, 2006). Social roles may be guided by
Social role theory divides attributes and beliefs associated with gender roles largely into communal and agentic attributes. Communal attributes refer to community-oriented behaviors necessary to be successful in caring for others (such as compassionate, caring, kind) and are historically and stereotypically associated with women and their traditional role as homemakers. Agentic attributes refer to more individualistic behaviors (such as aggressive, competitive, ambitious) commonly associated with men and their traditional role as providers (e.g., Cuddy et al., 2007; Glick & Fiske, 1996). Along these lines, Hall and Carter (1999) argue that as behaviors (communal and agentic) become more gender differentiated as a result of the social roles, people judge these behaviors as appropriate for only one gender, consequently constructing and confirming rigid gender stereotypes and their associated injunctive norms (see also Wood & Eagly, 2012).
An extension of the social role theory, role congruity theory addresses the perceived congruity between gender roles and other social roles an individual might simultaneously fulfill, as well as specifies key factors and processes that influence congruity perceptions and their consequence for prejudice and prejudicial behaviors (see Eagly & Karau, 2002). According to role congruity theory, when an inconsistency occurs between the behavior exhibited by an occupant of a social role and its injunctive norms, the social perceiver will comprehend it as an incongruency (Eagly & Diekman, 2005; Eagly & Karau, 2002; Wood & Eagly, 2012). For instance, a member traditionally belonging to a certain social category not conforming to or defying behaviors stereotypically associated with that category can destroy the beliefs and expectations of the perceiver and be read as incongruent. Thus, the inconsistency and perceived incongruency lowers the evaluation of the group member as an actual or potential occupant of the role presenting grounds for prejudice (Eagly & Karau, 2002; see also Eagly & Diekman, 2005).
In the case of female leaders, for example, prejudice can arise when supposedly inconsistent communal characteristics stereotypically attributed to women and the agentic qualities associated with leadership are conjoined (Eagly & Karau, 2002; Garcia-Retamero & Lόpez-Zafra, 2006; Heilman & Okimoto, 2007). Moreover, when women exhibit traits and behaviors culturally associated with men—such as aggression, arrogance, dominance—those behaviors are deemed “undesirable” and inconsistent with women’s gender role, and they experience more backlash and prejudice (Rudman et al., 2012; also see Koenig & Eagly, 2019). Schneider and Bos (2019) demonstrate that in politics, given the masculine construal of the political role, female candidates are more likely to become targets of voter prejudice. In this way, we propose that prejudice toward male nurses follows from the incongruity that many people perceive between the presumed characteristics of men and current communal conceptualizations of the field of nursing (Clow & Ricciardelli, 2011).
Stereotype Content Model
Earliest social psychology research on stereotypes addressed and documented stereotype
According to the SCM, all stereotypes are organized along universal evaluative, “Big Two” dimensions which dominate our social perception of others:
In addition to the above-mentioned prejudices, intergroup bias also possibly becomes operative in generating stereotypes and affecting perceptions of role (in)congruency which might differ across ingroups and outgroups (see Cuddy et al., 2007; Fiske et al., 2002; Hewstone et al., 2002). Extending the reasoning of ingroup favoritism in intergroup bias, in the event of a person occupying a role thought inconsistent with their gender, outgroups might be more likely to have prejudice/bias than ingroups (see Dovidio & Gaertner, 2010). Given that female nursing students may see nursing as less of solely a female career or more female-dominated (the reality in their classes), they would be more aware that some men do in fact go into nursing and might be more accepting of men in nursing. But given that intergroup bias is a general, but not universal phenomenon (see Hewstone et al., 2002), we explore if men in nursing are in fact perceived differently by outgroups (non-nursing students) and ingroups (nursing students).
Current Study
Although research has begun to present the voices of male nurses (e.g., Bartfay & Bartfay, 2016; Voss & Eldeirawi, 2017), a systematic qualitative examination of stereotype content about men in nursing has yet to be researched. As knowing the contents of people’s stereotypes can lead to effective strategies for targeting future attitude change (see Eckes, 2002), we asked nursing and non-nursing students to describe their views of male nurses. Social role theory (Eagly, 1987; Eagly & Wood, 2012) and SCM (Fiske, 2018; Fiske et al., 2002) guided analysis of participants’ responses, in the hopes of providing new insight into mechanisms behind continued obstacles before, and seeming resistance to, men in nursing.
For the present study, we asked participants to list the characteristics they associated with male nurses. These characteristics were coded according to emergent themes, determined by multiple participants listing the same attributes or expressing the same concept but in different words (e.g., intelligent, knowledgeable, and smart all coded together). These emergent themes were then grouped into categories that expressed high-competence, low-competence, high-warmth, low-warmth, or other. When we grouped according to high and low-warmth and competence, we used the specific attributes (pity, envy, admiration, contempt) Fiske et al. (2002) used to measure high and low-competence and warmth in their studies. We operationalized competence as agentic traits overall, and warmth as communal traits overall, keeping true to the literatures that Fiske et al. (2002; see also Abele, 2003) and Eagly (1987; see also Eagly & Wood, 2012; Koenig & Eagly, 2019) cite when situating their work.
One of the intents of our study was to explore the content difference between stereotypes of male nurses generated by their ingroup of nursing and outgroup of non-nursing students. More specifically, we were interested in whether or not participants described male nurses: (a) more in terms of competence than warmth, similar to perceptions Eckes (2002) found for “typical” men and career men; (b) as high in both warmth and competence, as if entering nursing might have a similar impact as Cuddy et al. (2007) found for career men becoming parents, where perceptions of men’s communal warmth increased without impacting perceptions of their agency and competence (though career women did not fare so well); (c) more in terms of warmth than competence, similar to Eckes’ (2002) findings for the “typical” woman, housewife, and secretary, and corroborating men in nursing research in other countries that has found male nurses to be rated similar to the female gender role (Holroyd et al., 2002; Loughrey, 2008), presumably because they willingly entered a female-dominated career. In sum, by investigating the specific characteristics participants ascribed to male nurses through SCM and social role theory, we explored if the descriptions of participants suggested that men, as nurses, represented the male social role (and its associated status and power). Ethics approval for the study was obtained from the University of Ontario Institute of Technology (REB File#06-004).
Method
Participants
Data for the present study is a subset of the larger data (167 participants) whose quantitative analysis is published (Clow et al., 2015). Our current study included 117 female nursing and non-nursing students (insufficient male nursing student data was available for analysis (
Participants’ ages varied slightly, where the nursing students were slightly older on average (
Materials
For the current study, the stereotype component of Esses, Haddock and Zanna’s (1993) open-ended measure served as an inspiration to assess participants’ views of male nurses. Previous researchers have successfully used the measure to explore individual differences in stereotype development (Clow & Esses, 2005) and to understand attitudes toward homosexuals and ethnic groups (Bell et al., 1996; Haddock et al., 1994). Our stereotype measure asked participants to list the characteristics they associated with male nurses. For example, on one page, participants were asked to provide a list of characteristics that they would use to describe male nurses and 10 blank lines were provided for participants’ responses. Although 10 lines were provided, participants were encouraged to provide as many or as few words as was necessary to fully convey their impression of the group.
Thematic Analysis
We analyzed the characteristics mentioned by participants using a thematic approach, whereby we grouped similar responses generated by multiple participants together into categories. Two of the authors independently coded the data based on emergent themes, such that themes were mutually exclusive and exhaustive. To ensure coding was performed in a reliable and valid fashion, coders agreed on emergent themes and categorizations of the characteristics. Before coding, both coders met to discuss coding expectation, potential biases or issues that could affect the interpretation of characteristics. Upon discussion, a set of subthemes were agreed upon—informed by SCM (e.g., Fiske et al., 2002) and Social Role Theory (e.g., Eagly & Koenig, 2006; Eagly & Wood, 2012), but driven by the data—and both authors recoded the data according to the new thematic sub-categories. Afterwards, each individual completed coding independently. Finally, both coders met to discuss their coding schemes and to resolve any discrepancies. If the researchers disagreed and agreement could not be reached (less than one percent of the listed characteristics) the characteristic was removed from the analysis.
The overarching communal and agentic themes were obvious and dominated the data. We, then, created two categories based on the “Big Two” dimensions of warmth and competence (Fiske, 2018) representing communal and agentic characteristics, respectively. Characteristics mentioned by the participants were put in either of these categories and characteristics that did not seem to fit in the warmth and competence categories were put in the “other” category. We then created sub-categories of “high” and “low” within warmth and competence categories. Characteristics, then, perceived as high in warmth (Fiske et al., 2002) were moved in the High-Warmth subcategory and so on. Once the coding scheme was finalized, we calculated the percentage of responses that fit into each category.
Procedure
A researcher visited the selected classes to explain the study and the draw (possible compensation). Students interested in participating were provided with a consent form, a booklet of questionnaires (one page of which was the stereotype measure of interest), and 20 minutes of class time to complete the study. The researcher stayed to field any questions should they arise (but no questions were asked). Once the questionnaires were completed, students were asked to place their responses in a box as they exited the classroom (to increase anonymity). A few participants chose to take their questionnaire booklets home with them, rather than completing them in class, and returned the completed questionnaires to their professors in a subsequent class.
Results
We analyzed the characteristics participants generated on the open-ended stereotype measure (Haddock et al., 1994). We explored whether participants described male nurses more in terms of competence than warmth (suggesting envious prejudice), high in both competence and warmth (suggesting admiration), or more in terms of warmth than competence (suggesting paternalistic prejudice). Additionally, we explored stereotype content difference, considering intergroup bias, between nursing and non-nursing students. Finally, we assess if male nurses were described using negative stereotype content or as deviant.
Nursing and non-nursing students’ perceptions of male nurses
High-warmth
The most frequently mentioned characteristics for male nurses were in the high-warmth category (50.6%)—both non-nursing 51.4% (195/379 mentions) and nursing students 48.5% (69/142 mentions) endorsed characteristics high in warmth. Themes in the high-warmth category included traits such as “caring,” “parental,” “calm,” “courteous,” and “physically attractive”—the very characteristics stereotypically associated with women and femininity (Bem, 1974; Eagly & Wood, 2012). “Compassionate” and “kind” were also common mentions across students, suggesting that although male nurses are perceived as non-normative in general, male nurses in Canada are still primarily attributed with stereotypically feminine characteristics (Holroyd et al., 2002; Loughrey, 2008). Below we report two frequently mentioned sub-categories namely “caring” and “calm and careful” that emerged in 195 and 69 high-warmth mentions by non-nursing and nursing students, respectively.
Low-warmth
Overall, the frequency of low-warmth characteristics was very low as compared to other characteristics. Nursing students did not mention any low-warmth characteristics for male nurses. Very few non-nursing students mentioned some negative, low-warmth characteristics about male nurses. Low-warmth characteristic mentions represented 2.9% (11/379 mentions) of all characteristics mentioned by non-nursing students. Below we outline two major sub-themes that emerged in the low-warmth category, namely “negative personality traits” and “homosexual.”
High-competence
Agentic characteristics—dominant and active traits that are commonly associated with men’s social roles (Bem, 1974; Eagly & Wood, 2012)—were also mentioned when participants described male nurses, but far less frequently than high-warmth characteristics. Two sub-categories namely “brave,” and “skilled” emerged within the category of high competence.
Low-competence
Low-competence characteristics were not mentioned by nursing students at all. Very few non-nursing students described male nurses using low-competence characteristics along the lines of “not smart enough to be a doctor” (only 0.007%, 3 out of all 379 mentions) and as “unprofessional” (0.01%, 4/379 mentions). The near absence of low-competence traits for male nurses might possibly suggest a change in people’s attitudes towards men in nursing who were once perceived as “failed doctors” (e.g., Bartfay & Bartfay, 2016; see also Clow et al., 2015).
Other
Discussion
In our study, we focus on non-nursing and nursing students’ perceptions of male nurses and interpret the findings through SCM and social role theory, simultaneously incorporating intergroup bias. SCM emphasizes that combinations of perceived warmth and competence determine our intergroup attitudes (Fiske, 2015; Fiske et al., 2002). In this sense, if male nurses are viewed high in warmth and high in competence, the SCM would predict they are admired, and that people would generally respond toward them with facilitative behaviors, both active (e.g., helping) and passive (e.g., seeking contact; Cuddy et al., 2007; Fiske et al., 2002). If high warmth is paired with low perceived competence instead, paternalistic prejudice is theorized to result which usually portrays outgroups as non-threatening and not competing with our own group for resources (Cuddy et al., 2007; Fiske et al., 2002) or as capable of posing significant harm (Fiske et al., 2002). Revolving around the emotion of pity, paternalistic prejudice can lead to active facilitation, but can also lead to passive harm, such as avoidance, inaction, and neglect (Cuddy et al., 2007; Fiske et al., 2002).
Many participants, in our study, reported high-warmth characteristics such as “caring” as core elements in nursing practice for male nurses. Participants, both non-nursing and nursing students, described male nurses as highly emotive, mentioning positive emotional characteristics (e.g., caring, compassionate, friendly) that are traditionally considered feminine and are associated with women (Eagly & Wood, 2012). These findings correspond with past research that has found when people describe nurses, they generally perceive them as feminine and motherly (Tranbarger, 2007) and with international research that found perceptions of nurses to be strongly associated with the feminine gender role (e.g., Holroyd et al., 2002; Loughrey, 2008). However, some characteristics attributed to male nurses also included descriptors suggesting conflicting stereotypical perceptions; where male nurses were confident and brave for entering a female-dominated profession, but also feminine given they desire the occupation, and for some even deviant.
Along these lines, although many of our participants expressed warmth for male nurses, very few participants mentioned characteristics related to competency. Moreover, the very words used to describe male nurses in terms of competency seemed to change from the non-nursing to the nursing sample. For example, non-nursing students generated characteristics like “brave” for male nurses, whereas nursing students used words denoting skills and abilities of male nurses. The general trend may suggest that most participants tend to like, rather than respect, male nurses possibly indicating paternalistic prejudice. This is a troubling trend for men in nursing as it has been extensively documented that paternalistic prejudice is not merely
In terms of negative stereotypes, the sexual orientation of male nurses was questioned by a few participants. Although the number of participants promoting the homosexuality myth regarding men in nursing is small, the mere presence of the “gay nurse” stereotype is telling. These findings corroborate the anecdotal experiences of men in nursing, where they fear that others assume they are homosexual just because they want to be a nurse (e.g., Bartfay & Bartfay, 2016; Harding, 2007). Stereotyping of gay men as effeminate, weak, and passive plays a significant role here. Social role theorists could suggest that some individuals are driven to perceive male nurses are gay to neutralize the role incongruity resulting from men joining a feminine profession. The assumption that male nurses are homosexuals might stem from the patriarchal belief that nursing is a women’s profession and motivated perceivers may assume that men opting to be nurses must be effeminate and hence, gay (Bartfay & Bartfay, 2016; Harding, 2007; see also Clow et al., 2015).
Limitations and Future Research
Ours is not a national sample but a convenience sample from southern Ontario as, in the present study, students from only one institution were considered. In future research, large, differing samples across Canada and/or internationally should be studied to explore the replicability of our findings. Additionally, cultural differences could be considered to see if they have any mediating effects in influencing perceptions of male nurses. Future researchers may also wish to further explore whether perceptions or stereotype content of male nurses change and how change is similar or different to changes in perceptions of female nurses. Also, since nursing and non-nursing students in our study were not the same year/age, further research is necessary to determine the true impact of age, education, and experience on perceptions of men and women in nursing. Another limitation of our study was the lack of participants’ narrative on the views they held for male nurses. Nevertheless, our study will serve as a basis for future researchers who wish to focus on a more in-depth scrutiny of stereotype content regarding men in nursing.
Conclusion
In the current study, we examined stereotype content generated by non-nursing and nursing students regarding men in nursing and analysed them through the lens of social role theory and SCM. Our findings suggest that even though, overall, the image of nursing is gradually changing to include more men in the profession (see Christensen, 2017), the traditional feminine character of the nursing profession still dominates public perceptions of nursing. As a result, men in nursing are also perceived through the predominant context and are described more in terms of communal attributes most associated with women.
Footnotes
Declaration of Conflicting Interests
Funding
ORCID iDs
