Introduction

Nurses are primary-care providers and responsible for the treatment, safety and recovery of patients with acute or chronically illnessed. ¹ Since centuries, the nursing profession has been known as a profession only for females. Therefore, the history of nurses in early ages only states the curative role of the females, although males at that time also took part in patient-care along with females. ² The aim of this paper is to provide a detailed review of national and international literature available related to male nursing students, and their experiences in the nursing profession.

Male Nurses: A Historical and Feminist Perspective

In monotheistic religions, the first organised patient-care services were provided at hospitals. The followers of the monotheistic religion named Dekon to the male care-provider and Dekones to the female care-providers. ³ After that the independence and efficacy of nursing was held very high by the catholic churches in the Middle Ages. Till the 16th century the provision of health services was the responsibility of the male nurses until this field found Florence Nightingale. ⁴ Evans in a systematic literature review states the history of nursing as almost exclusively a history of female accomplishments, even though males have worked as nurses from the beginning of the profession. As male nurses never got recognised for their contribution in the nursing profession, it left male nurses with limited information about their own background. The author further explores that the historical accounts express that in fourth and fifth centuries, males started to work as nurses in military and non-military work, for which many examples could be given, such as providing nursing care and protection to the sick, injured and dying soldiers. Another example is the working of male nurses in the hospitals established by St. John after defending Jerusalem. In these hospitals, care was provided to the travelling pilgrims. History witnessed that these hospitals afterwards opened across Europe. In 1877 male nurses started to have trainings under the supervision of St. John, so they could work at St. John Ambulance Association. ⁵ There were other knights as well, where evidence of working of male nurses has been found such as, Knights of St. Lazarus, Knights Templars and Teutonic Knights. ⁵ Evan also highlighted the work of male nurses in the non-military era, such as, at the time of the outbreak of skin disease named erysipelas in 1095. In 1472 when preaching of God was given by the St. John and Alexian Brothers, it has been identified that in those days males were serving the sick people, including uneducated craftsman. During the years of the outbreak of the plague in fourteenth and fifteenth centuries male nurses worked tremendously. Afterwards, Alexian Brothers trained male nurses to work in psychiatric settings. After ending of monasteries, male nursing activities vanished till the eighteenth century when the activities of male nurses restarted with the development of charity hospitals. Although at that time males and females both were involved in the care, but males were there to provide care to male patients only. ⁵
The existence of modern nursing by Florence Nightingale (the founder of nursing) in the mid-nineteenth century ended the association of males with nursing. Florence Nightingale considered nursing as a suitable job for females because it was an extension of their domestic roles. She firmly established nursing as a female occupation. ⁶ After that, the family-based institutional model emerged in which the dominant role of father was assumed to be male physicians, nurses as females and patients as children. This completed the institutional family and was the reflection of general social values regarding the division of labour based on gender. ⁵ The concept of male as nurses was subsequently incompatible with the prevailing institutional family ideology of the time. Furthermore, the establishment of nurses\\\' homes or residences to house female nursing students further isolated males from nursing and acted as an additional and powerful barrier to exclude males from participating in nursing. ⁵ This association and demoralisation hindered males while choosing nursing as their career.

Segregation of Male Nurses

The formal segregation occurred when Royal College of Nurses in 1919 started a separate registration of males in which all qualified nurses registered to label nursing profession as the first self-determining occupation for females. ⁵ According to Mericle, segregation within the profession also took the form of a division of labour according to gender. ⁵ Following Nightingale\\\'s reform, males were excluded from general nursing registration and their labour was also limited to asylum nursing, where male nurses were supposed to utilise their superior strength to restrain violent patients. ⁵ This division of labour was also supported by the difference in education, such as female nursing students were receiving training of bodily diseases\\\', for about 30 to 36 months. Whereas, male nurses were prepared to take care of psychiatric patients encompassing half of the time the females got trained. ⁷

New Era for the Male Nurses

According to Mackintosh, in 1937 in England, Edward Glavin created the Society of Registered Male Nurses. ⁵ This society highlighted the lack of professionalism in male nurses and started training for them to keep in touch with modern techniques to solve professional problems and encouraged high standards of professional conduct. ⁵ In conclusion, many efforts till date have been made but all were done in isolation due to which male nurses got stereotyped under clinical settings. ⁸ In 1971 American Assembly for Male in Nursing was established in United States of America. The aim of the assembly was focussed on the recruitment of male nurses in the nursing profession to increase their visibility. They highlighted the issues of sexism and racism, which was hindering males in entering the nursing profession. On the contrary, in Canada no national association was made to support male nurses due to the difference in languages and professional licensing practices in different provinces. Although in 1956 an association was developed under the leadership of Albert Wedgery in Canada on a smaller scale to emphasize unity among males in the nursing profession and to gain interest of male nurses in nursing training sessions. ⁷

Gender Stereotyping

Traditionally, many professions have been gender-stereotyped as appropriate only for males or females. Gender stereotypes endorse the idea that females should pick professions which require nurturing or care-taking activities, whereas males should choose technology-oriented professions, such as accounting, business and technical fields. ⁹ Males are discouraged from entering nursing for a number of reasons, all of which have been explored in the literature, such as, public perception, images of nursing, value of nursing in society, gender stereotype, and patient preferences. In both the nursing literature and the mainstream press, sexual stereotypes are a major deterrent to males entering the nursing profession. This idea is further reinforced by the mass media, which continue to perpetuate nursing as a feminine profession. ¹⁰
McKinlaya, Cowan, Vittie, and Ion analyzed the thinking of employee nurses about the role of males in the nursing profession in United Kingdom. The aim of the study was to explore the issues of gender and occupational identity perceived by the staff nurses. The researchers underlined the stereotype of nursing profession being a female profession. The perception of male nurses as gay can limit the recruitment of males in the nursing profession. In this focus group study, the researchers examined whether nursing students had similar views about male nurses or they challenged such views. The results highlighted the fact that the stereotypical ideation for male nurses was perceived by people who did not belong to the nursing profession. On the other hand, they perceived that this stereotypical ideation was problematic to the advancement of the nursing profession.The researchers concluded that these findings indicated that nursing students were positive in their attitude towards males being a part of the nursing profession and they stood to benefit from training which emphasised the position of males and females within the nursing society. ¹¹
Brafty, Brafty, Claw, and Wu conducted a qualitative study in Canada to compare societal perception and attitude towards males working in the nursing profession with males and females, nursing and non-nursing students of the University of Ontario, Canada. The researchers recruited 82 nursing and 67 non-nursing male and female students of the university through convenient sampling. They assessed perception and attitudes of students related to the males in the nursing profession by using the Attitude Towards Male in Nursing Scale (ATMINS). They concluded that the Canadian society perceived that the nursing profession was more likely suitable for females. Furthermore, it was explored that the negative perception towards males in the nursing profession, such as gay perception, and having a less caring attitude, prevails in society. The researchers highlighted that this perception imposed negative remarks towards the nursing profession. There is need to make great efforts to change these negative perception. They recommended recruitment of larger number of males which could portray positive gender role in the clinical practice, and academia may help to engage diversity in the nursing profession. ¹²
Akansel et al. conducted a quantitative study to determine the thinking of male and female nursing students about males in the nursing profession in Turkey. This study focussed on two major aspects; one was the perception of male and female nursing students about the position of male nurses in nursing career, and the second was the effect of recruiting males on the image of the nursing profession. The data was collected from nursing students of final year, from which 60% of the students were females and 40% of the students were males. The data analysed revealed that about 31% female nursing students agreed that the recruitment of male nursing students will help enhance the quality of nursing profession, and 7% highlighted that it will also help decrease the negative image of the nursing career. On the other hand 48% male nursing students perceived that they could help to increase the quality of nursing profession and 30% male nursing students perceived that they could decrease the negative image of the health team about the nursing profession. Finally, the perception of both genders about the effects of male on image and status of the nursing profession was statistically significant (p<0.01). In conclusion, about 45% female nursing students were in favour of hiring males as the staff for bedside care providers whereas, male nursing students wanted to work on the administrative positions or work at the instructor level. ⁶

Ideological Designation of Nursing

The historical association of female with nursing work reflects the belief that males are inappropriate in the feminine caregiver role of nurse. ¹⁰ Caring is one of the most basic nursing values. In the pivotal works of Mac Williams, the concept of caring is presented as the "essence of nursing".⁷ According to Stanley, the concept of care is commonly used to define as the unique role of the nurse and is associated with womanhood. The ability of male to care is yet questioned in nursing literature and little research has been undertaken in relation to male nurse experiences and views. ¹³ The story of the Alexian Brothers and the male nurses is a testament to the power of gender in nursing history. They engraved out a system of caring that recognised caring as a responsibility not only for females, but also for males. They asserted their work as leading notions of masculinity. The Alexian Brothers challenged spatial boundaries of stereotyping and navigate male nurses in different areas, such as nursing school administrator, military soldier and professional practitioner. ¹³
A pilot study conducted by Akansel et al. discussed that Florence Nightingale considered nursing image as a subordinate, nurturing, domestic, humble, and self-sacrificing. ⁶ Similarly, the social construction of nurse has typically meant a caring and hardworking female. The study further mentioned that roles like nurturing, caring, dependency and submission given to females are opposite from the ones that are attributed to the males in society. Akansel et al. highlighted the views of sociologists about the characteristics of gender. Sociologists describe the gender role socialisation as "instrumental" for males, and "expressive" for females. ⁶ The characteristics of instrumental socialisation include the ability to compete, aggressiveness and ability to lead and to exercise a power to accomplish tasks.
Expressive socialisation includes learning to nurture, to be effective and to be sensitive towards the needs of the others. ⁶ This determines that it was natural for nursing to be provided by females and that led to excluding males from the profession.

Emotional Intelligence and Male Nurses

The emotional abilities of male nurses are widely assumed to be inferior to those of their female colleagues. ¹⁴ Researchers explored the emotional skills of male nurses by using ability model of emotional intelligence developed by cognitive psychologists John Mayer and Peter Salovey. Through this ability model psychologists identified that certain individuals\\\' integrated emotions in their reasoning process due to which they work differently. This ability was named emotional intelligence by Mayer and Salovey who developed a tool which was divided into four sub-groups. Researchers have used the ability model to measure emotional skills in nurses to identify emotions, using emotions to facilitate, understanding emotions and managing emotions. The participants of this study were 39 males compared with 213 female counterparts. Researchers gave significant evidence to prove that there is no difference of emotional abilities between male and female nurses. This study has highlighted that all male nursing students have same potentials for emotional capabilities compared to female nursing students. Furthermore, male nursing students can also develop their emotional skills during studies as female colleagues. Moreover, study also highlights that male nursing students after completing their studies are preferred to work in specialty fields where emotional care is fundamental. In conclusion, there is no difference between male and female capabilities and both can choose nursing as their career and avail the opportunity. ¹⁴

Increased Rate of Attrition

Nursing is the healthcare profession having wide numerical difference between male and female practitioners. Though confusing, it is yet to minimise these numerical differences. ^15-17 According to the American Association of Colleges of Nursing, 2006 and Statistics Canada, 2001, male nurses make up only 9% of nursing students in Canada and 9.7% in the United States. It seems that now greater number of males are choosing nursing than in the decades past, but they remain in minority. Among the smaller number of male students who enter schools of nursing, the rate of attrition far exceeds that of female student nurses and is also poorly understood. ¹⁸
An interpretive ethnographic study by Christensen and Knight et al. explored experiences of male nursing students and female nursing instructors in the context of classroom education.
Themes resulting from data analysis addressed roles of male nursing students in the nursing classroom and the culture of nursing education. The themes emerged were nursing like real man, association of male nurses\\\' role with traditional masculinities including leadership, assertiveness and risk-taking. Another theme that emerged was masculinity in a feminine place, where males saw themselves as accommodated but not integrated. Diversity between masculine and feminine genders communicated the incongruity between male\\\'s educational preferences and the techniques that predominate in nursing education. These findings suggest that nursing instructors need to consider gender in their teaching practice, avoid parody or stereotypes of masculinities, and reject assumptions that male students are homogeneous. ¹⁸
Male nursing students in Australia reported feelings of being discriminated against female nursing students. ⁷ It is observed that the lack of male representativeness in nursing textbooks exacerbates male alienation in the field. Moreover, there is ample literature about caring in nursing, whereas, limited research has been done about caring in males. ⁸
A study was conducted by White¹⁹ to identify the psychological aspects of the attrition among male nursing students. Researchers also differentiated perceptions of nursing between male nursing students who have completed nursing education with the non-completers of nursing education. Researchers highlighted that the current worldwide nursing shortage and high attrition of nursing students remain a challenge for the nursing profession. The findings of this study indicated that males were more likely to leave the course than females. Furthermore, those who have completed the course tend to view nursing as more appropriate for females, in contrast to the non-completers who had less gender-typed views. ¹⁹ It is accepted that attrition is undoubtedly a complex issue with many contributing factors, but the nursing profession needs to take steps to address this bias to ensure that the profession is open equally to both female and male recruits.

Barriers Faced by Male Nurses

Researchers have worked to explore the barriers encountered by male nurses in the nursing profession. O\\\'Lynn formulated a survey tool Inventory of Male Friendliness in Nursing Programme and conducted a quantitative research to examine the gender-based barriers faced by male nursing students in which 111 students participated and completed the mail survey. Analysis of this study indicates 30 barriers faced by male nurses in the nursing profession. Out of 30 barriers, the top-rated barriers were \\\'no mentorship programme for male nurses\\\', \\\'no history of males in nursing\\\', \\\'no male faculty\\\', and \\\'text books referred to the nurse as \\\'she\\\'.\\\' The respondents further stated that some of the barriers particularly important to them were; \\\'did not feel welcome as a male student in the clinical setting\\\', \\\'nervous that female patients would accuse male students of sexual inappropriateness when providing intimate care\\\', and \\\'anti-male remarks made by faculty in the classroom\\\'. ²⁰ Furthermore, Keogh and O\\\'Lynn²¹ replicated the study using the Inventory of Male Friendliness in Nursing Programmes instrument to examine the gender-based barriers for males, in which 100 nurses participated who completed a nursing programme in Ireland. These findings verified O\\\'Lynn\\\'s initial study. ²¹ Similarly, Kermode used a web-based survey to explore the perceived prevalence of sexism in several Australian university programmes. In this research, 221 students participated. The analysis of the study indicated that male nursing students reported that they were more affected by both sexism and discrimination within their programme of study in comparison with the female nursing students and the other non-nursing university students. ²² Using a descriptive design, Crigger, Luckman, and Galusha in the United States explored discriminatory attitudes and behaviours toward males as perceived by both male and female nursing students. In this study 265 students participated, who were completing diploma, baccalaureate, or an associate degree programme. Researchers highlighted that male students described their educational experience as sexist and discriminatory in comparison with female students (Cited in Pitt et al). ²³
Moreover, two American studies, used phenomenology to explore the educational experiences of male nursing students. ^24,25 Streubert interviewed nine students and identified eleven themes related to the relationship between the clinical experiences, and skill attainment and role development of becoming a nurse (Cited in Zamanzadeh). ²⁴ Researchers reported four themes: survival, gender differences, nursing school requirements, and career goals for the future. In another qualitative study conducted in United States by Ierardi, Fitzgerald, and Holland explored the educational experiences of male nursing students in an associate degree hospital-based collaborative college programme. In this study 7 students participated. Researchers reported four themes: wanting to care for others, leaving another career or vocation to pursue nursing, having a positive experience in the nursing programme, and being mistaken for physicians. ²⁶ In the United States, Bell-Scriber used a case study approach to study the classroom perceptions of four male and four female nursing students and seven nursing faculty. A key finding identified were male learners in comparison with female learners completing the same programme reported a "cooler" educational climate. ²⁷ This finding was attributed to the covert gender-biased characteristics and unsupportive behaviours of the female nurse educators.

Beneficial Role of Male Nurses

Male nurses are beneficial in the nursing profession in various ways. According to O\\\'Lynn, the looming nursing shortages have increased in the healthcare industry. ²⁰ One possible solution to the nursing shortage which requires greater emphasis is the recruitment of males in the profession. McKinlay et al. identified that the recruitment of male nurses could affect if stereotyping of nursing as female students and males as gay will continue. ¹¹ In the United Kingdom (UK), nursing is female-dominated profession. Only 10.7% of the nursing workforce is male. ²⁷ It is perceived that there is a need for more gender-balanced workforce. McKinlay et al, conducted a focussed group study named student nurse\\\'s gender-based accounts of males in nursing. ¹¹ It examined whether student nurses imitated or challenged such views. Results revealed that participants characterised such stereotypical constructions of male nurses as held only by other people. They themselves, however, used gender-based distinctions to problematic male nursing. ¹¹ These findings indicated nursing students would benefit from training which equalised the position of males and females within society.
There is limited literature available addressing the benefit of male in nursing.
As for the characteristics defined by sociologists for males as instrumental; males could be the strength for nursing profession. There are many areas in hospital where females feel uncomfortable to work because of long working hours such as operation theatres and critical care areas where male nurses could play a supportive role for them. Still, there is need to explore more in this genre. Oslon highlights the importance of gender diversity in nursing as beneficial in many ways such as it increases the cultural competencies which ultimately results in improving the healthcare delivery system and increases the level of patient satisfaction. ¹⁷

Male Nurses and Pakistan Nursing Council

The institutes of nursing that are currently present in Pakistan operate under the rules and regulations of Pakistan Nursing Council (PNC). PNC is responsible for allocating the number of seats to each nursing institute throughout the country. Furthermore, it also proposes the curriculum for degree and diploma programmes governed by the nursing schools.
From the list on the official website of PNC it is identified that out of 1335 seats only 383 are allocated for male nursing students all over the country which is 29% of the total seats in all programmes offered by the PNC. Moreover, the curriculum proposed by the PNC has similar deficiencies mentioned above by different authors.

Identifying Gap

Most studies analysed in this review emphasised the role of a potential candidate\\\'s gender in the decision to choose nursing as a career and the experiences of male students in nursing academia. The experiences of males working within the nursing profession have not been studied as comprehensively as those of female students, and little has been published that captures the perspectives and wisdom of male nurses who have had long careers in the field. Furthermore, there is need to conduct researches highlighting the beneficial role of male nurses in different areas and fields of the nursing profession. The most important thing is that no literature or research was found on any aspect of males in nursing in the Pakistani context.
There is a need to have concentrated efforts by all stakeholders, including professional associations, nursing unions, schools of nursing and universities. ¹⁰

Conclusion

The literature review helped in identifying the gap in the available literature. After reviewing the available literature, it can be concluded that even though males have been working in the profession for many years, there are potential barriers for men considering a career in the nursing profession. The focus on the occupation of nursing as a career needs greater development, with emphasis on the characteristic of gender neutrality. Nursing organisation and nursing education programmes can aid recruitment effort by challenging societal stereo types of femininity and masculinity and by advancing the concept of gender neutrality. If nursing is to become more diverse and meet the need of the changing population, it is up to the profession to develop ways to encourage more men to consider a career in nursing. Nursing schools also need to become more diligent in their efforts to counteract gender bias and recruit more males.

Disclaimer: None.
Conflict of Interest: None.
Funding Sources:  None.

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