Abstract

Background: The integration of male nurses into maternal health nursing, especially in culturally conservative regions such as Oman, introduces distinctive challenges and opportunities. Objective: This study aimed to investigate the experiences of male nursing students who were undertaking the maternal health nursing curriculum in Oman. Design: A qualitative study was conducted through five focus group interviews spanning five regions (South and North Batinah, North Sharqiyah, Dhahira, and Dakhiliya) in Oman between April and June 2024. Setting: The study was carried out at Oman College of Health Sciences, where male students were enrolled in the Maternity Health Nursing course. Participants: Thirty-five undergraduate nursing students participated in the focus group interviews. Methods: The focus groups utilized a semi-structured interview protocol, and a content analysis was employed to analyze the focus group interview data. Results: The qualitative analysis revealed three primary themes: (i) psychological challenges, (ii) educational/professional challenges, and (iii) the role of the college. Subsequently, a blended-learning teaching approach emphasizing planned, structured activities learning was developed. Conclusions: This study presents, for the first time, findings regarding the experience of male nursing students enrolled in the maternal health nursing course in Oman. Additionally, a proposed improvement plan for the course was suggested.

Keywords

Male Nursing Students, Nursing Education, Gender Discrimination, Culture, Oman

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1. Introduction

The history of nursing has been predominantly associated with female caregivers, a trend that has inadvertently marginalized the role of male nurses in the profession. Since the 1800s, when Florence Nightingale’s recruitment efforts led to a significant increase in the number of female nurses, the field has been largely dominated by women. This gender disparity has contributed to the shortage of male nurses, thereby impacting the diversity of the profession worldwide [1]. Female dominance has prevailed in nursing since then, and there has been a shortage of male nurses [2]. Statistics from various nursing councils and organizations indicate that the percentage of male nurses is notably low in many countries, ranging from 5% - 10% in European countries to around 10.6% in the United Kingdom and even lower in the United States and Canada. However, there are exceptions, such as Saudi Arabia and Italy, where the percentage of male nurses is relatively high. Recognizing the need for diversity in nursing, The American Association of Colleges of Nursing advocated for an increase in the number of men in the nursing profession. Despite these efforts, male nursing students continue to face challenges, including gender-biased language and limited support for specific learning needs.

The prevalence of gender stereotypes and discrimination in nursing education contributes to the underrepresentation of male nursing students and their subsequent struggles in educational and clinical settings. In numerous countries, the representation of male nurses in total student enrollment is consistently less than 10% [3] [4]. The persistence of gender-based stereotypes presents a significant barrier to men entering and remaining in the nursing profession [5] [6]. A comprehensive review of 34 studies indicated that male nurses encounter distinctive challenges in educational and clinical settings that exhibit cultural variations. Male nursing students face notable impediments in select courses, such as maternity nursing, due to gender discrimination perpetrated by female patients and their attendants. Overcoming these challenges necessitates collaborative efforts among stakeholders because unresolved issues can precipitate negative attitudes and diminished interest in nursing practices.

The challenges faced by male nursing students are further exacerbated in certain clinical courses, particularly in settings where cultural biases and gender discrimination by female patients and their attendants pose additional obstacles [7]. As a result, male nursing students must develop strategies to navigate these challenges and cultivate a supportive learning environment, with the collaboration of stakeholders being crucial in addressing these issues. Failure to address these challenges may lead to a loss of interest in nursing practices among male students, particularly in specialized areas such as maternal health nursing [8]. Understanding the experiences and challenges faced by male nursing students is essential not only to ensure the inclusivity and success of male nurses but also to address the broader issue of gender disparity in nursing. It is imperative for educational institutions, health care facilities, and policymakers to work collaboratively to create a more equitable and supportive environment for male nursing students globally.

It has been reported that many midwifery educators have encountered challenges when imparting clinical education to male nursing students because of the uneven learning environment [9]. The challenge may be attributed in part to the fact that some male students view maternity nursing as a domain in which they only see themselves as visitors. Rayan et al. (2020) [10], following a study in Jordan, concluded that nurse educators should consider these challenges when planning midwifery education for male students, especially in culturally sensitive Arab countries. Nurse educators around the world are making similar efforts to reduce gender differences in education. The Gender Equity Scale in Nursing Education was developed by Cho et al. (2022) [11] as a strategy for achieving gender equity in nursing education. Although the literature cites gender inequality as a common occurrence in nursing education, it remains unclear how male nurses perceive and experience inequity because of the lack of detailed first-hand verbatim accounts in the published literature, thus providing an incomplete picture of the extent of the issue, particularly during maternal health nursing theory and practices.

In 2016, it was established that male nursing students in Oman have access to theory and practicum courses in maternal health nursing. However, no known study has comprehensively examined the challenges faced by these male students in these courses and their recommendations for navigating these challenges while considering the Omani culture and the influence of Islam in the country. The purpose of this study is thus to delve into the perceptions of Omani male students concerning the challenges encountered in maternity theory and practicum courses and to gather their recommendations in this regard.

2. Methods

2.1. Design

The research employed a qualitative design, encompassing focus group interviews conducted between April and June 2024. The primary objective was to gain a comprehensive understanding of the relatively unexplored domain and to uncover the challenges and opportunities encountered by Omani male students when pursuing a maternal health nursing (MHN) course. The resulting insights may lead to innovative avenues for enhancing nursing curricula in Oman [12]. The study involved third-year nursing students enrolled in a Maternity Health Nursing course, with data collection occurring at the conclusion of the first semester subsequent to the completion of the course.

2.2. Participants

Participants were selected using a convenience sampling method. The inclusion criteria were those students who: (i) third-year students who are already enrolled and have completed a maternity health nursing course and (ii) were willing to provide written informed consent prior to participating in this study.

2.3. Data Collection

Focus group (FG) interviews comprised five to eight student participants per session, totaling five sessions. To facilitate the study, the FGs were conducted online, encompassing the five regions in Oman where the five branches of the OCHS are located. This approach provided a conducive environment for participants to share their experiences. Each focus group was co-led by two researchers. The researchers collectively established a semi-structured interview protocol to encourage comprehensive responses from the participants. Each session was audio and video-recorded over 40 to 60 min. Data collection ceased upon data saturation, with no emergence of new themes. Prior to analysis, participants were provided with an opportunity to review transcripts, and no new themes emerged.

2.4. Data Analysis

The interview transcripts underwent analysis using ATLAS.ti 9.0 software, entailing content analysis to achieve a comprehensive examination. The data analysis method devised by Graneheim and Lundman (2004) [13] was applied, encompassing the following phases: (i) familiarization and review of the data; (ii) coding of noteworthy features throughout the complete dataset; (iii) aggregation of codes into potential themes and compilation of all pertinent data for each theme; (iv) creation of a thematic “map” for the analysis and validation of the theme’s relevance in correspondence to coded extracts and the entire dataset. This process illuminates common patterns or trends within the data, providing (v) a thorough and comprehensive understanding of the participants’ sentiments and perspectives concerning each theme and each participant and (vi) facilitating the development of the report.

2.5. Ethical Consideration

Approval was obtained from the Omani Ministry of Health Review Committee (RERAC) and the OCHS Research Committee (CODE 27848), and all ethical principles established by the Declaration of Helsinki were followed at all stages. The data collection was designed to ensure confidentiality and anonymity, and participants provided informed consent before the study was conducted, with the possibility of withdrawing at any time. Furthermore, the participants were informed that their experiences, perceptions, and perspectives would have no impact on their academic grades.

2.6. Rigor

This study adhered to the recommendations outlined in the consolidated criteria for reporting qualitative research (COREQ) to ensure methodological rigor. Trustworthiness of the study was upheld through strict adherence to the criteria proposed by Lincoln and Guba (2006) [14]. To enhance transferability, a comprehensive account of the methodology and data collection process, including direct quotations to exemplify the findings, was provided. Additionally, participant opinions were diligently verified at the conclusion of each focus group interview to ensure the accuracy of their representation. Conformability was ensured through independent analysis of transcripts by both authors, followed by joint discussions to compare and correlate emerging themes. Moreover, to maintain the reliability and congruence of the collected data, any discrepancies were arbitrated using an analysis transcript before meeting together to compare, correlate, and discuss the emerging themes. An expert was consulted in case of any discrepancy to ensure the reliability and congruence of the collected data.

3. Results

3.1. Characteristics of Participants

Thirsty five undergraduate third year nursing students participated in five FGs. Overall, the students ranged in age from 20 to 21 years old. 100% of participants are identified as male. The qualitative analysis revealed three major themes that are summarized in Tables 1-3. The students asserted that they have no problem with the theoretical and laboratory skill assessment modules, but not the clinical settings. Therefore, all the challenges were reported in the clinical settings (maternal health nursing practicum).

Table 1. Psychological challenges theme.

Table 2. Professional/Educational challenges theme.

Table 3. College Role theme.

3.2. Theme 1: Psychological Challenges

The predominant theme revolved around male students’ experiences enrolled in a maternal health care nursing course in Oman. This theme encapsulated the essence of their overall experience. The students expressed satisfaction with the theoretical and skills laboratory components of the course, but they faced challenges during their clinical placement. They encountered difficulties in an unsupportive learning environment that hindered rather than facilitated the educational process. The subsequent sub-themes provide a detailed account of their experiences within this context.

3.2.1. Sub-Theme: Feelings of Exclusion: “We Are Foreign Bodies; We Do Not Belong There.”

Reports from students indicate a consistent sense of rejection and exclusion within clinical settings. Mothers expressed irritation when students were present at the bedside or in the same room. At the same time, some staff members also showed unacceptance at students’ presence in the receptions despite providing answers to their case-related inquiries. Additionally, husbands displayed discontent when sharing the same room with their wives. Consequently, students often found themselves in search of suitable seating within the ward.

“...I mean the course is female subject. when we go to the maternity ward all the staff there are female ...so you have to maintain boundaries. I feel uncomfortable ...also not welcomed. I feel my presence causing inconvenience for these staff. We don’t belong there” Participant #1.

“We felt that mothers need more privacy, especially in this period of time after delivering a baby, therefore, we did not have effective communication and interaction with the patients” Participant #4.

3.2.2. Sub-Theme: Lack of Support

The students revealed that the senior male students and staff had discouraged them from attending the maternity wards and antenatal clinics, considering it embarrassing. Additionally, they mentioned that female staff nurses in the wards had directed them to the male medical and surgical wards, questioning their presence in the maternity wards.

“…. there was no encouragement and support from previous batches or other senior male staff nurses we met during our clinical placement in male medical wards. They disappointed us on this course.” Participant #1.

“I have sometimes tried to ask staff nurses about certain condition but they were uncomfortable, anyhow when you asked them, they answer, when you do not ask them, they do not interact with you, no support from them too” Participant #5.

3.2.3. Sub-Theme: Living in a Conflict

The students expressed their understanding of Islamic regulations that prohibit the interaction between males and females, particularly in matters pertaining to pregnancy and childbirth. However, they expressed their desire to gain knowledge and fulfil their degree requirements by attending to such patients. This internal conflict is a daily concern for them. They also acknowledged that they would feel similarly if their mothers, sisters, or wives were in such a situation and might be uncomfortable with the presence of male students. The students find themselves torn between respecting the patient’s right to refuse and their own right to acquire knowledge.

“Mothers have the right to refuse our presence in the ward. We understand but also it is our right to learn. We have a requirement to fulfill” participant #4.

“Sometimes, I also feel for these mothers rejecting us in the ward. I also will not be able to understand why there is a man standing in the same room with mothers’ jut delivered and had babies. But the motive is that this a subject and a course that we have to do” Participant #7.

3.2.4. Sub-Theme: The Daily Hassles of Filling in Time

The students have indicated that due to the non-conducive environment, they often spend extended periods without engaging in learning activities, waiting for their teachers to initiate such activities after obtaining maternal consent. Additionally, the staff seldom involve them in the routine care of the patients. Consequently, the students arrive at the ward preoccupied with how to occupy their time until the end of the clinical day.

“I do not know what to do, we even have no place to sit, so every day when we come to the ward, we do not know what to do” Participant #5.

3.3. Theme 2: Educational/professional Challenges

3.3.1. Sub-Theme: Uneven Learning Environment

Male students have expressed concern regarding the perceived unequal learning opportunities in clinical settings compared to their female counterparts. They believe that female students have more opportunities to interact with mothers and gain their trust, particularly in procedures such as breast examination, antenatal assessment, postnatal assessment, neonatal assessment, and history taking. This differential treatment has led to a sense of disadvantage and unequal learning experiences for male students, who feel that they are not afforded the same level of trust and opportunities for clinical practice.

3.3.2. Sub-Theme: Culture as a Massive Barrier to Learning

In clinical settings, it was observed that certain cultural barriers hindered the learning process. Specifically, there was discomfort among mothers in sharing their medical information with male students. This was attributed to the conservative nature of Omani society, which adheres to strict gender segregation in line with Islamic regulations. As a result, mothers felt a lack of respect when male students were present in the same room while discussing their medical conditions. One incident involved a mother asking a male student to leave the room as she and others felt uneasy with his presence. The student complied and did not return to that specific room. While no significant incidents were reported, it was noted that husbands and relatives sometimes displayed a less-than-welcoming attitude toward the students.

“Mothers have the right to refuse our presence in the ward. We understand but also it is our right to learn. We have a requirement to fulfill” Participant #4.

“Sometimes, I also feel for these mothers rejecting us in the ward. I also will not be able to understand why there is a man standing in the same room with delivering mothers. But the motive is that this a subject and a course that we have to do” Participant #7.

3.3.3. Sub-Theme: Decline in Skills Application

Due to this condition, male students find it challenging to transfer the skills they acquire in the laboratory to clinical settings. Consequently, they lack confidence in applying these skills when treating patients.

“We are having problem in applying what we studies n the lab, there was no chance for that in the clinical” Participant #1.

3.4. Theme 3: College Role

3.4.1. Sub-Theme: We Are Ready. Is Society Ready?

Students have often questioned the rationale behind being assigned to clinical placements in environments that are not entirely receptive to their presence. They have expressed concerns that, despite their earnest efforts to alter patients’ perceptions, they sense an underlying reluctance from patients and their families to accept them entirely. A collective consensus among students is the necessity for nursing colleges to implement measures that cultivate an environment conducive to their integration within the healthcare system.

“I am totally ready to learn from maternal health areas, I mean I can learn more, I belief, but I do not think that mothers and the society is ready for us, mothers don’t acknowledge the important of our presence” Participant #2.

3.4.2. Sub-Theme: College Role in Providing Alternative Resources for Learning

The students reported that the college’s provision of alternative learning resources, particularly high-fidelity simulators, plays a crucial role in the student’s educational experience. A skill assessment laboratory equipped with mannequins will serve as an invaluable tool for male students in maternity nursing, facilitating the practical application of learned skills.

“Our college must have an essential role in helping us through it this, there must be a coordination between the college and the hospital to provide more support in maternity ward for us, we need it” Participant #4.

4. Discussion

The study underscores the necessity to address the current clinical placement procedures for male students enrolled in maternal health nursing courses. These students encounter challenges characterized by instances of rejection, stereotyping, and exclusion. The study illuminates the prevalent gender bias and discrimination experienced by male student nurses within maternity settings, leading to feelings of alienation and unwelcomeness. Notably, several researchers corroborate these findings [15]-[17]. Surprisingly, the study reveals the existence of stereotypes about male nurses in maternity care among peers and staff, creating discomfort and misunderstandings. This revelation contradicts the findings of Alshemmari et al. (2023) [18], which highlighted the support received by male nursing students from fellow students and staff. Noteworthy support for male involvement in maternity care is also evident in the study conducted by MacWilliams and Collagenous (2013) [19].

The study identified that male students perceived a lack of support from male staff and believed that they were met with skepticism regarding their capacity to perform maternity-related procedures, leading to their exclusion from such responsibilities. These perceptions were corroborated by similar observations made by other researchers [20]-[22]. Furthermore, the students underscored disparities in learning opportunities compared to their female peers, attributing this inequity to a lack of confidence from mothers. In conclusion, the study underscores the potential of male involvement in improving maternal health outcomes. However, it also highlights significant barriers such as societal norms, lack of awareness, and insufficient support systems that hinder this engagement. The study’s findings strongly advocate for changes in existing practices to promote effective male involvement in maternity care, as a crucial step towards overcoming these barriers.

It is recommended that educational institutions implement targeted interventions to promote male engagement, involving the collaboration of three key components: educational institutions, nurse educators/clinical faculty, and maternity staff (see Figure 1). Initially, nurse educators and clinical mentors should afford male nursing students with learning opportunities equal to their female counterparts as proactive measures to minimize the persisting gender gap in nursing education. This includes equitable rotations in clinical placements and consistent support from clinical mentors.

The establishment of an inclusive culture in maternal care environments can contribute to mitigating the sense of isolation experienced by male nurses and enhancing the overall work atmosphere. This effort may encompass the promotion of male nurses’ involvement in maternity care through increased visibility and recognition. Additionally, scholars in the field [23] [24] emphasized the necessity for comprehensive preclinical orientation by clinical supervisors, including a detailed discussion of potential gender discrimination occurrences during practical training, as a form of social support to mitigate the impact of “reality shock.” Another recommended practice involves pairing male and female students during clinical placements to facilitate a conducive learning environment. Feedback from participants in a recent study highlighted that such pairing could lead to equitable achievement of learning objectives for both male and female students. Moreover, findings from research by Egyptian authors Eswi and El Sayed (2011) [25] indicated that 50% of male students recommended pairing male students with female students in maternity units to ensure comparable clinical competency in maternity nursing practice.

The study participants underscored the pivotal role of educational institutions in creating a supportive learning environment for male nursing students during clinical placements. One approach involves facilitating the integration of male nurse training and education within allied health institutions’ healthcare systems. For instance, healthcare providers can inform expectant mothers during antenatal care visits about the presence of male nursing students for training purposes as part of their health education. Supplementing this with a notice attached to the green card could effectively communicate the presence of male students for training. Educating patients about the importance of both male and female nurses in maternity care may help reduce biases against male students and male nurses in general. Furthermore, educational institutions may conduct training workshops for maternity faculty on “gender diversity” and strategies to support male students’ involvement in maternity practice. Creating opportunities for ongoing engagement with the public to raise awareness about the importance of gender diversity in maternity wards is crucial for fostering an inclusive environment for male nursing students. Additionally, providing a platform for male students across various college branches to engage in reflective discussions and receive support is recommended.

We propose that policymakers within educational institutions and nursing colleges undertake initiatives to raise societal awareness regarding the involvement of male nurses in maternity care within hospital settings, particularly during critical situations (Figure 1). As an initial step, the introduction of training workshops and public events can serve as a platform for discussions surrounding the myriads of challenges encountered by male student nurses as they navigate the intricacies of the healthcare system during their clinical training within predominantly female-dominated clinical units. It is believed that such dialogues hold the potential to enlighten key stakeholders in education and healthcare, shedding light on the adversities faced by male student nurses, and offering insights into the resilience and coping mechanisms employed by male nursing students and educators to mitigate the inequities and obstacles inherent in both undergraduate and postgraduate nursing education.

Figure 1. Proposed Culturally competent educational strategies to optimize male involvement in Maternal health nursing areas (clinical).

5. Conclusion

Some patients may express discomfort or preference for female nurses in the maternity setting because of cultural or personal reasons. However, many patients appreciate the different approaches and perspectives that male nurses can bring to their care [26]. This research suggests that while male nurses may face challenges in maternity nursing, they can also bring unique perspectives and add value to the profession. With appropriate support and education, these students hold considerable potential for enriching maternity care. Culturally competent education and training can help reduce gender bias and improve the inclusion of men in all areas of nursing.

Acknowledgements

Authors thank nursing students who participated in the study and the OCHS-branches administration that facilitated the process of data collection.

Conflicts of Interest

The authors declare no conflicts of interest.

Conflicts of Interest

The authors declare no conflicts of interest.

References