Perception of Male Nursing Students about Their Maternity Clinical Practice: A Cross-Sectional Survey from a Nursing College ()
1. Introduction
The field of nursing generally remains female-dominated in many countries [1]. As the tide is certainly changing for gender equality in all professions, there has been a general increase of males embracing the nursing profession. However, males remain the minority group, with only about 12% - 13% of the nursing profession [2]. According to the 2020 statistics report from the nursing department in the Ministry of Health Kuwait, there is a total of 21,447 nurses, of which only 4973 (23%) are male. It is not surprising that increasingly, more males are embracing the nursing profession, an indication of their willingness to work across various professional fields [3]. Gender diversity in nursing is expected to enhance decision-making abilities and create a positive, competitive, and innovative work climate [2].
Fields in women’s health such as maternity care have remained a sensitive area for male nurses, being influenced by stereotypes and gender biases [4]. Males who go into the nursing profession have been reported to face obstacles in their education throughout practice, which has affected their desire to work in the field. Both professionals and the general society have reported prejudicing male nurses, labeling them as unsuitable for the profession [5]. Several studies have reported stress-related challenges experienced by male nurses during their practice, as they are often viewed as unsuitable for the care provider role [6] [7].
Maternal-newborn nursing courses are identified as a woman’s domain and create anxiety and intimidation, experiences of rejection, and fear of the unknown among male students. Although many challenges face male nurses while in maternal and newborn practice, it is agreeable that, male nurses are important to the profession [6]. A study by Jung and Park (2011) highlighted that cultural perception of gender roles, the perceived reality of male nurses, and difficulty in approaching female clients were the major issues experienced by male nurse students during clinical practice in a delivery room. In the same study, male nurses experienced embarrassment, rejection from the patient and relatives, restrictions to enter the inside labor room, blocking male students from doing any intervention for female patients, inability to help female patients, and inability to join other nurses. This caused them to think of it as impossible to be employed in delivery rooms after graduation [8].
Male nursing students and practitioners may face cultural barriers, leading to discrimination from colleagues, patients’ caretakers, and sometimes patients. This hinders their clinical practice experience and limits the acquisition of required skills, thereby creating a theory-practice gap. Indeed, it has been reported that such discrimination leads male nursing students to be less exposed to maternity settings compared with their female counterparts [9]. Zahid et al. (2015), in their study to determine how male students experienced their clinical placements in obstetrics and gynecology wards, reported that male students were more rejected by patients compared with the female, by being refused to check or carry out physical examination for female patients. This was reported to negatively affect the male students’ learning experience [10]. Similarly, a high percentage of young female patients who were cared for by male nurses stated that they felt embarrassed and stressed when male nurses touched them, especially during sensitive procedures such as perineal care, urethral catheterization, and helping with urination and defecation [2]. In Qatar, a predominantly Muslim country, male student nurses are prohibited from nursing mothers and their babies [11]. Nevertheless, some authors have reported divergent views about males engaging in maternity care. For example, Landry and Tillman (2013), in their study reported that patients preferred male nurses to female, citing that female nurses tend to be harsh unlike the male [12].
It is critical that teachers and mentors recognize and support male nurses in the nursing profession. During clinical practice experience, acts that are non-discriminative should be embraced, where faculty become sensitive to the feelings of their male nursing students and support them to engage in their clinical environments. Such acts motivate the males to engage more in the nursing profession and to be productive as their female counterparts [3]. Additionally, embracing virtual approaches to instruction such as simulation and virtual reality can enhance the training of male nurses by overcoming physical barriers to clinical practice [13].
Nevertheless, no studies are reported in the field of male involvement in maternity care in the Gulf Cooperative Council (GCC) and specifically in Kuwait. To address this gap, a quantitative cross-sectional survey was conducted in the College of Nursing Kuwait, to investigate the experience of male nursing students and their challenges in maternity clinical practice.
2. Study Objectives
The current study explored the male nursing students’ experiences and challenges in maternity clinical practice. The research questions addressed in this study were:
1) Will the male nursing students get trained in the maternity areas without any difficulty?
2) Will the comfort level of performance by male nursing students be equal in all procedures of maternity care?
3) Will the pregnant women refuse the male nursing students to provide maternity care and treat them differently, and would it affect the students’ decision to work in maternity areas after graduation?
4) Will the male nursing students’ age or marital status influence their decision to work in maternity areas after graduation?
3. Methods
3.1. Design
This was a cross-sectional study. We employed a quantitative cross-sectional survey design to answer the research questions under study.
3.2. Instruments with Validity and Reliability
Data were collected via a self-administered questionnaire which was developed by the researchers in English. Content validity was established by submitting the tool to five experts, three from maternal and child health nursing, one from obstetrics and gynaecological nursing and one from nursing education and research. Suggested minor modifications were incorporated and the tool was finalized. The tool was then translated into Arabic and back translated to English by language experts. The reliability of the tool was established using test-retest method and obtained a Pearson’s correlation coefficient, r value of 0.83. The questionnaire was piloted among eight students who had recently graduated and were found feasible. Section I consists of 7 items on background information. Section II consists of 18 items on 5-point Likert scale with responses from strongly agree to strongly disagree, to identify the challenges experienced by male nursing students in their maternity clinical practice. The tool was developed based on the knowledge and experience of the researchers, to assess the male nursing students’ perceptions of the maternity clinical practice. The responses are grouped into four categories which include, A—Male nursing students can take interest in maternity training, B—Maternity training can be done by male nursing students with others, C—Maternity training by male nursing students will not be accepted by clients, and D—Maternity training is not required for male nursing students. Section III consists of 14 maternity nursing procedures to identify how much the students are comfortable to provide nursing care in maternity unit. The procedures were grouped into two categories i.e. A—procedures involving exposure of private parts and B—procedures involving no exposure of private parts. Section IV consists of questions on support received from the clinical teachers, other male nursing students, staff in the maternity unit, clients and their relatives, and doctors on the maternity unit.
3.3. Sample and Setting
The study was conducted at the College of Nursing, Kuwait. The college has a diverse student population of approximately five hundred (500), both male and female. They come from Kuwait and other countries in the Gulf Cooperative Council (GCC) and the Middle East. The study population included male nursing students from the College of Nursing, Kuwait. A nonprobability purposive sampling technique was used. The sample comprised 93 nursing students who had completed their maternity clinical posting in different maternity clinical areas like Operating Theatre (OT), newborn care related areas like Special Care Baby Unit (SCBU), Neonatal Intensive Care Unit (NICU) and nursery, and mother care areas like labor room, post-natal ward and antenatal ward. Participants who had already completed their maternity nursing course (theory and clinical experience) and who were willing to participate in the study were included.
3.4. Sample Size and Power
The sample size was determined using the Yamane formula of:
,
where n = sample size, N = Population size (110), e = Level of precision or sampling error which is ±5% [14].
3.5. Data Collection
Before the study commenced, a research pack (including participants information sheet (PIS), consent form and invitation letter) were distributed among study participants. Participation in this study was voluntary and they were informed about their rights which were stated in the PIS. Data collection took a period of 4 months.
3.6. Data Analysis
After data collection, data analysis was performed using the SPSS v.19 software. Descriptive and inferential statistics were used.
3.7. Ethical Consideration
Ethical approval to conduct this study was obtained from the College of Nursing Research Ethics Committee (reference number: CN-19-03). Study participants were informed about the nature and objectives of the study. Written consent was obtained from the participants after being assured about the anonymity and confidentiality of all information they provide for study purposes.
4. Results
4.1. Subjects
Most of the participants 59 (63.4%) were in the age group of 22 - 26 years. The majority of participants 79 (85%) were single, whereas only 14 (15%) were married. Out of the married participants, 11 (79%) had children, whereas 3 (21%) had no children (Table 1).
4.2. Perception of Male Nursing Students Regarding Their Maternity Clinical Practice and the Challenges Faced
Figure 1 shows the Perception of male nursing students regarding their maternity clinical practice and the challenges faced. Most of the participants (57.75%) agreed that male nursing students can take interest in maternity training, whereas only 17.82% disagreed with it. About half of the participants (52.42%) agreed that maternity training can be done by male nursing students with other female staff, whereas 23.64% disagreed with it. Approximately half of the participants (53.23%) agreed that maternity training is not required for male nursing students whereas 23.65% disagreed with it. Interestingly, the majority of participants (77.78%) agreed that maternity training by male nursing students will not be accepted by clients, whereas only 6.45% disagreed with it. Chi-square analysis showed that male nursing students are not very keen on undergoing training and it was statistically significant (χ2 = 96.939; P < 0.001). The null hypothesis that male nursing students can get trained in maternity areas without difficulty is thus not accepted.
4.3. Comfort Level of Male Nursing Students in Performing Procedures in Maternity Clinical Areas
The responses of 92 participants (one participant was unwilling to answer this question) are presented in Table 2. For procedures involving exposure of private parts, only 17% were very much comfortable whereas 34% were not comfortable. For procedures involving no exposure of private parts, 37% were very much comfortable whereas only 13% were not comfortable. Chi-square analysis showed that male nursing students were not comfortable in performing procedures involving exposure of private parts and it was statistically significant (χ2 = 108.638; P < 0.001). The null hypothesis that the comfort level of performing procedures by male nursing students is equal in all procedures is therefore not accepted. The results revealed that the most comfortable procedures were baby related, for example, immediate care of the newborn, baby bath and cord care, monitoring fetal heart rate and health education of women. The least comfortable
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Figure 1. Perception of male nursing students regarding their maternity clinical practice and challenges faced.
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Table 2. Comfort level in performing procedures in maternity clinical areas.
χ2 = 108.638; df = 3; P < 0.001.
procedures were those related to the care of the mother such as performing perineal examination, vaginal examination, breast care, and episiotomy care.
4.4. Support Received in Maternity Unit as Expressed by Male Nursing Students
The participants reported receiving support from various individuals while attending maternity care practice. Eighty percent (80%) of them reported that they received support from their clinical instructor, 51% reported that other male nursing students and staff nurses in the maternity unit supported them during their experience, whereas around 40% of the participants reported that doctors and maternity clients were supportive. Only 22% of the participants reported that the client’s relatives were supportive.
4.5. Association between Selected Variables and Students’ Perception about Maternity Clinical Experience
Chi square analysis was performed to determine association between the challenges experienced and selected variables like age and marital status. Participants were classified into two age groups; less than 21 years and more than 21 years and chi square analysis was performed. Similarly, participants were classified into married and unmarried, and chi square analysis was performed. To analyze, agree and strongly agree were combined, similarly disagree, and strongly disagree were combined. There was no significant association found between the variables, suggesting that irrespective of age or marital status differences, male students taking a maternity course experience related challenges.
4.6. Association between Graduates’ Decision to Work in Maternity Areas after Graduation and Selected Variables
Out of the 93 participants, only 33 (35.5%) reported that they were refused by obstetric clients to provide nursing care, whereas 60 (64.5%) reported that no maternity clients refused them to provide care. McNemer’s test was conducted to establish the association between willingness and non-willingness (Table 3). Among the 33 participants who were refused to provide nursing care, 26 (28.0% of the total) decided not to work in maternity areas. Interestingly, among the 60 participants
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Table 3. Association between graduates’ decision to work in maternity areas after graduation and selected variables.
n = 93; McNemer’s test.
who were not refused, still 49 (52.7% of the total) decided not to work in maternity areas. These results were statistically significant (χ2 = 5.297; P = 0.021), indicating that male nursing graduates prefer not to work in maternity areas. Out of the 93 participants, the majority 77 (82.8%) reported that they were treated differently at the maternity unit because of their gender, whereas only 16 (17.2%) reported that they were not treated differently based on their gender. McNemer’s test was conducted to establish the association between willingness and no willingness (Table 3). Among the 77 participants who were treated differently, 65 (69.9% of the total) decided not to work in maternity areas. Among the 16 participants who were not treated differently, 10 (10.8% of the total) decided not to work in maternity areas. These results were statistically significant (χ2 = 47.380; P < 0.001), indicating that male nursing graduates prefer not to work in maternity areas.
The null hypothesis that male nursing students’ preference not to work directly in maternity areas after graduation is accepted. However, the collected data showed that after graduation majority of students were willing to work in newborn nurseries and operation theatre, followed by NICU.
4.7. Relationship between Age and Marital Status of Participants with Comfort Level and Support
Non-parametric test, Mann Whitney rank sum test was carried out to determine the relationship between age and marital status with comfort and support level. Though the median values showed few differences, the obtained “U” values were not statistically significant, stating that the comfort scores were not related to age or marital status. Similarly, the support scores also were not related to the age or marital status of the participants (Table 4). The null hypothesis that male nursing students’ preference not to work directly in maternity areas after graduation does not depend on their age or marital status is accepted.
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Table 4. Relationship between age and marital status with comfort level and support.
Total = 93; *The percentiles are 25 and 75. Mann-Whitney rank sum test.
5. Discussion
Increasing the proportion of males in the nursing profession is a powerful option to solve the global nursing shortage [15]. The nursing curriculum aims to provide an integrated theory and clinical experience to the students without any discrimination, thus preparing them to become qualified nurses with adequate knowledge, skills and attitudes. In a study by Calma et al. (2022), exposure to general practice in theoretical and clinical experience during a nursing training program changed the perceptions of participants across all factors and thus they could better appreciate the scope and complexity of their nursing role [16]. However, it has been reported that male nursing students do not gain sufficient knowledge and skills in maternity services, including care before, during and after delivery and family planning, and are also given little opportunity to put their knowledge into practice [17].
There are several challenges faced by male nursing students especially during their maternity clinical training period. The current study aimed to explore the challenges that male nursing students experience in their maternity clinical practice in Kuwait. While the participants in our study showed positivity towards learning maternity care, they reported significant challenges such as being treated differently because of their gender. Our findings are consistent with previous studies analyzing the experiences of male nursing students in relation to gender issues. Male nursing students undertaking practicum in female wards often felt excluded from patient care and this alienation and feelings of exclusion were most strongly experienced in the obstetrics practicum [18]. Participants reported that this exclusion from important areas of practice was so stressful and caused them to experience anxiety [19].
Indeed, male nurses face various gender stereotyping when pursuing nursing, predominantly while caring for women [20], while the female gender has been more accepted in the nursing/midwifery professions compared to the male [9]. Some societies have been reported to consider the male gender unfit for the nursing profession and often have rejected their services [8]. Zahid et al. (2015), reported that male medical students experienced a significantly higher proportion of patient rejections during medical consultation and internal examination [10]. The negative reactions towards the male nursing students have been reported to negatively affect their learning, and resulted in mental stress [6] [7] [10]. The majority of participants in the current study reported being uncomfortable performing procedures requiring exposure of private parts. This finding is consistent with those from a previous study, which showed that several male students reported increased stress and anxiety when performing procedures involving private parts (e.g., urinary catherization), or involving touch or contact with young female patients. Specifically, males expressed fear and apprehension due to the possibility of being wrongfully accused of engaging in inappropriate touch or contact [21]. Female patients prefer nurses of female gender because they may feel more comfortable and their privacy is protected, especially when intimate care is provided [20].
In the present study, participants reported that they would prefer to provide maternity care alongside female health care providers. This could be attributed to the cultural system the participants are brought up in, which was strongly supported by the findings of Matua et al. (2019), where in the cultural underpinnings in middle east countries, is a taboo for a man to look at the nakedness of a woman who is not their wife [9]. Such cultural perspectives deny male students the freedom to fully engage in maternity practice. Banakhar et al. (2021) reported the cultural issues faced by male nurses as a significant challenge for doing particular nursing procedures, as they were not able to provide care to female patients according to the faith and religious beliefs of the community [17]. It has been documented that cultural issues faced by Saudi male nurses are a common challenge, leading to a lack of clinical experience in maternity and pediatrics specialties [17]. In the current study, the majority of students agreed that religious and cultural factors negatively influence the male nursing students’ clinical training in maternity. Cultural and ethical issues in Arab countries have prevented male nurses from gaining clinical experience in hospitals, which affects their ability to manage maternity patients [17].
Participants reported receiving much of the support from the students’ clinical instructors, fellow male nursing students, and staff nurses in maternity units. Doctors and maternity unit clients/patients were moderately supportive, whereas the clients’ relatives were least supportive, in which their services were not appreciated/accepted. Previous research has shown that, it is common for healthcare professionals and clients to have negative feelings regarding male nurses as healthcare providers [22]. However, after offering the service, the feelings of negativity can be changed to positivity, and often male nurses have been appreciated for providing commendable care to patients [23].
The majority of participants in our study perceived that maternity training by male nursing students will not be accepted by clients. Half of the participants agreed that maternity training is not required for male nursing students. Similar findings were reported by Patterson & Morin 2002, wherein their studies indicated that male nursing students viewed obstetrical nursing as a female-centered specialty [24]. In another study, male nursing students shared their preconceived ideologies of women as being uncomfortable with male nurses, females being most suitable to provide such type of care, the possibility of being unwelcomed in the maternity units by the patients and even by the nursing staff, and viewing themselves as an intruder of women’s privacy [3].
However, some studies have reported preference of male nurses by clients [12], indicating that male nurses can be accepted in nursing/midwifery care. For example, in a study by Abdel-Fattah et al. (2019), patients preferred male nurses compared to the female. Nevertheless, it is observed that patients may feel comfortable with male nurses performing specific care procedures as opposed to others [2]. These results highlight the need to embrace gender diversification in nursing/midwifery education and practice, as Bly et al. (2020) observe, and emphasize the need for professionalism, protection, and gender and cultural awareness [25]. This literature is in line with the preference of our participants after graduation, where the majority stated their willingness to work in newborn nursery and operation theatre compared with antenatal wards, labor room and post-natal wards, irrespective of the age or marital status of the participants. These results indicate that, irrespective of their age or marital status, male students have preference to work in baby related areas, and their choice are majorly related to their comfort to work in those areas. In the current study, the most comfortable procedures for male students were baby related, for example, immediate care of the newborn, baby bath and cord care, monitoring fetal heart rate and health education of women, while the least comfortable procedures were those related to the care of the mother such as performing perineal examination, vaginal examination, breast care, and episiotomy care. However, the nature of nursing/midwifery practice is designed that nurses/midwives work in any assigned areas [3]. It is therefore critical that the training/placement of male nurses is not limited to specific units where one feels comfortable.
Social demographic variables such as age, marital status were not found to be associated with experiences of maternity care practice. Cultural awareness creation is critical in the training of male nurses, more especially in settings where culture may not be supportive of this role. A significant finding in our study is the revelation that feeling treated differently from their female counterparts affected the male nursing students’ decision to work in maternity care in the future. This finding resonates with research by Jung and Park (2011), which reported that the embarrassment, rejection from the patient and relatives, restrictions to enter inside labor room, blocking them to perform particular interventions for female patients, inability to help the female patients, and inability to join other nurses, caused male nursing students to think twice about their employability in maternity settings after graduation [8]. Like Budu et al. (2019), we recommend that public awareness be created regarding the role of male nurses in the healthcare delivery system to promote acceptance of gender diversity in the nursing profession [23].
There is a need for designing strategies in both academic and clinical settings to overcome the barriers in the various maternity care areas, with more efforts being directed towards areas directly associated with the care of the mother/woman. Moreover, it is important to embrace gender diversity in nursing as it is expected to enhance decision making abilities and create a positive, competitive, and innovative work climate [2].
6. Strengths and Limitations
In this study, we threw light on the perceptions of male nursing students in maternity clinical practice. Our study has established that male nursing students have an interest to learn maternity care, although they are concerned that they will not be accepted to provide care to maternity clients due to their gender difference and prevailing cultural underpinnings. Being a new study area, it was challenging to find the related literature. Nevertheless, our results provide a backbone on which further research in the area can be designed. In addition, our study was from a single site and included a relatively small sample hence the results are not generalizable.
7. Recommendations
We recommend more research in diverse cultural and geographical settings to acquire more insights into the scope of male nurses in maternity clinical practice. To promote male involvement in maternity related settings and enhance the nursing profession, it is necessary to put in place strategies, both in the academic and clinical settings that will minimize gender barriers in clinical training, learning, and practice. To promote acceptance of gender diversity in the nursing profession, public awareness should be created regarding the role of male nurses in the healthcare delivery system.
8. Conclusion
The current study highlights the experiences of male nursing students in maternity clinical practice. The study results indicated that although maternity clinical practice was found challenging to the participants, they exhibited an interest in learning the maternity course. Being accepted and receiving more specialized training in the clinical area was thought to improve the maternity clinical practice experience of male nursing students. Strategies that encourage male involvement in the nursing profession should be promoted. Cultural and gender sensitization should be undertaken in settings that discourage the male nursing practice.
Funding
The research is financed by the Public Authority for Applied Education and Training, Kuwait (PAAET, Kuwait).