EXPERIENCE BEFORE AND THROUGHOUT THE NURSING CAREER

The concept of care in male nurse work: an ontological hermeneutic

study in acute hospitals
Frank Milligan BA MSc RN RNT
Senior Teaching Fellow, Department of Health and Social Organization, Faculty of Health Care and Social Studies,
University of Luton, Bedford, UK

Submitted for publication 10 January 2000

Accepted for publication 14 March 2001

Correspondence: MILLIGAN F. (2001) Journal of Advanced Nursing, 35(1), 7±16

Frank Milligan, The concept of care in male nurse work: an ontological hermeneutic study in acute
Department of Health and Social hospitals
Organization,
Aims. The aims of the study were to facilitate re¯ection upon an aspect of practice
Faculty of Health Care and Social Studies,
chosen by the participants, to explore and analyse these experiences and compare
University of Luton,
Britannia Road, them with current literature on the concept of care in nursing practice.
Bedford MK42 9DJ, Background. The concept of care is commonly used in the attempt to de®ne what is
UK. unique about the role of the nurse, and both nursing and the concept of care are
E-mail: frank.milligan@luton.ac.uk frequently associated with womanhood. Little research has been undertaken in
relation to male nurse experiences and views on the concept.
Methods. The study used ontological hermeneutics to explore the concept of care in
male nurse work in the acute general hospital setting. Eight male voluntary subjects
from acute general hospital areas participated in the study and were asked to
complete a summary of an experience from their practice that they felt exempli®ed
care. Data for the study included the participants choice of practice experience, their
subsequent re¯ections, the interview itself, the ®eld journal and relevant literature
and research.
Results. Six of the participants selected positive experiences in which they felt that
their performance was satisfactory even though the events chosen for re¯ection were
dif®cult and/or sad. The remaining two participants chose to re¯ect further on the
dif®culties they had within the experience. A conceptual model was constructed
showing that the meeting of needs, effective communication and information giving
were central to these nurses' explanations of care within their practice. All but two
of the participants broadened their gaze to include the signi®cant others of the
patient.
Conclusions. The re¯ections of these participants emaphsise the emotional load of
practice and a sensitivity on their part to the male stereotype of being able to cope
with such pressures. It is suggested therefore that those providing and managing
clinical supervision take into account the possible reluctance of male nurses to seek
such support. Issues of gender should be emphasized in nurse education, as these
nurses were sensitive to the impact of gender on their practice, both with patient/
clients and their signi®cant others, and with colleagues.

Keywords: acute illness, care, dying, emotion, gender, male nurse work,
phenomenology, stereotype

Ó 2001 Blackwell Science Ltd 7

F. Milligan
Introduction
The study attempted to clarify the concept of care in male
nurse work within the acute hospital setting. It consisted of
semi-structured interviews with eight participants from a
range of acute general hospital areas. A qualitative research
process using ontological hermeneutics was selected as it
provided a means through which the experiences of these
men could be described and interpreted. The hermeneutic
circle of fore-understanding, coconstitution and interpret-
ation was followed (Allen & Jensen 1990).
Philosophical and methodological underpinnings
An important task in the attempt to formulate a useful
research project is to use a research methodology suitable for
the task. Selection of the methodology is in itself an aspect of
fore-understanding (Ashworth 1987), an element of the
hermeneutic circle. As my understanding of research meth-
odology deepened so I became aware of the diverse nature of
phenomenology, its potential limits, and the possibilities
inherent in hermeneutic phenomenology. In ontological
hermeneutics, sometimes referred to as Heideggerian or
hermeneutic phenomenology (Leonard 1994), a circle is
followed to facilitate analysis that acknowledges what is
known as the ontological shift as described by Heidegger
(Steiner 1992).
Although phenomenology is arguably more a school of
philosophy than a research method (Paley 1997, 1998,
Corben 1999), it has been used extensively in nursing
particularly in the attempt to clarify the concept of care
(Benner & Wrubel 1989, Forrest 1989, Clarke & Wheeler
1992). Its appeal has been based on the potential to gain
insight into lived experience in order to lead to more
thoughtful, considered nursing care (Taylor 1993).
The hermeneutic circle consists of fore-understanding,
coconstitution, and interpretation (Koch 1995). The aim of
ontological hermeneutics is not to provide a reductive
de®nition of a concept, but to let the nature of the concept
stand forth, to show itself (Malpas 1992). Such a view is
consistent with the aims of the study in that the concept of
care was interpreted through structured re¯ections and
interviews, and the intellectual insights derived from them
(Holden 1991).
Fore-understanding relates to the knowledge that both
participant and researcher have of the topic under study.
Co-constitution followed with the participants attempting to
explicate their experience. Co-constitution involves a process
in which understanding works back through interpretation,
just as interpretation begins with prior understanding (Allen &
8 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
Jensen 1990). Within interpretation, a new understanding is
developed. In the attempt to clarify the nature of a concept
a horizon of understanding exists: the place that the
individual starts from. The notion of horizon has been used
by the philosophers Husserl and Heidegger, although in
slightly different ways (Malpas 1992), and helps to explain
the purpose of ontological hermeneutics. Through the
process of fore-understanding, coconstitution and interpret-
ation, understanding of that horizon is deepened, but as the
analogy suggests, moving back the horizon simply leaves a
view of another, albeit new horizon. The task within
interpretation is to show how the horizons of the interpreter
(researcher) and the interpreted (participants) are fused and
to illustrate the new horizon which is created through this
process (Thompson 1990).
Fore-understanding
The number of men in all ®elds of nursing in the United
Kingdom (UK) remains relatively small. Statistics from the
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC, 1998) show that the percentage of
males on the effective register has risen from 8á37% in 1990
to 9á38% in 1998.
In 1993 I completed a literature review of British material
relating to male nurses as part of an honours degree (Milligan
1993). Literature examining the position and experiences of
men in nursing proved to be scarce. No research on the
concept of care and male nurses was available. The literature
concentrated on areas such as men in midwifery, the dispro-
portionate numbers of men in senior management, and the
often expressed wish to encourage men into the discipline.
Not surprisingly, empirical research was also limited to men
in midwifery, their numbers in senior management and
demographic information on students.
However, the concept of care in relation to male nurses has
been addressed in more recent literature. Paterson et al.
(1995) undertook a phenomenological study, based upon the
approach used by Benner (1984), into the lived experiences of
20 male nursing students as they learned to care in their
Canadian programme. The authors point out that a gender
link between care and womanhood is frequently made and
that, increasingly, it is seen as necessary somehow to transmit
care to students through the education process. Narratives
were used as data with the students writing about an
experience that helped them learn to care as nurses. The
interviews were analysed using Colaizzi's procedure (see
Moustakas 1994) and theme clusters were developed. The
students viewed learning to care as an evolutionary process:
they had a trait of care that was developed further through-
out the course and the experiences involved.
Experience before and throughout the nursing career
Phillips (1993) is critical of the recent interest in the
concept of care in nursing, commenting that the current rise
of debate and research mirrors previous waves of interest
such as the nursing process in the 1970s and nursing models
in the 1980s. Davies (1995), a sociologist who has written
extensively on the impact of gender in nursing, similarly notes
that caring has a relatively short history of enquiry within the
social sciences.
The study
Research design
The aims of the study were to facilitate re¯ection upon an
aspect of practice chosen by the participants, to explore and
analyse this experience and to compare the ®ndings with
current literature on the concept of care in nursing practice.
Participants were therefore asked to choose an experience
from practice that they felt exempli®ed care within their
nursing work and to complete a written re¯ection using
Johns's (1998) model of structured re¯ection. This re¯ection
was typed and returned to the participants for veri®cation
and used to structure the subsequent interview. The re¯ec-
tion, interview transcript and ®eld notes written during the
study were then subject to qualitative analysis. Details of
the analysis were also discussed with the participants and
the feedback gained was treated as further data.
Ethical issues
Approval for the study was obtained from the relevant local
ethical committees. Con®dentiality with regard to both the
patient/clients referred to and the participants was main-
tained throughout. Written consent was obtained from the
participants before the research process commenced.
Sample ± participants in the study
The participants were selected using purposeful sampling
methods (Coyne 1997). First level staff nurses below charge
nurse grade with at least one year postregistration experience
were approached. No other criteria for selection, in terms of
ethnicity or educational background, were used partly
because of the fact that there are few male nurses in the
general ®eld. All the male nurses (a total of 25) within the
chosen clinical areas were approached by sending them an
introductory letter, a copy of the consent form, and an
outline of the structured re¯ection required. Three different
hospitals were selected: two were average sized district
general hospitals and the third a large teaching hospital.
They were situated within two neighbouring counties in
Eastern England.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
The concept of care in male nurse work 1
Ten men consented and 8 completed the research process.
The other two failed to attend for interview. Although a
relatively small number, this is consistent with the participant
group size in other qualitative studies completed over a
similar time period. The participants had between 1á2 and
21 years of quali®ed nurse experience, with an average of
9á8 years, and had worked in a wide variety of clinical areas.
Their ages ranged between 23 and 46 years, with an average
age of 33.
Data collection techniques
A range of data collection techniques were used to enhance
the con®rmability of the study (Guba & Lincoln 1989). The
problems evident within the literature in relation to de®ning
the concept of care called for an adaptive research method
that would help, as Guba and Lincoln (1989) put it, to ferret
out insights into the nature of care for these men. Data
collection included the structured re¯ection on a practice
episode, the semi-structured interview and ®eld notes.
From an ontological hermeneutic perspective, the researcher
and fore-understanding were also data within this study
and constituted the horizon from which data collection
progressed.
Data analysis
In hermeneutic research, data collection and analysis go hand
in hand; there is continuous re¯exive interplay between the
two (Ashworth 1987, Guba & Lincoln 1989). Dey presents a
practical approach to the problem of data analysis and goes
back to the Greek roots of the word ana, meaning from
above, and lysis, meaning to break or dissolve (Dey 1993).
Inevitably qualitative data analysis is an interpretation, even
though coconstitution has been undertaken, a breaking of the
materials gathered, and as such may be interpreted differently
by different people (Ayres & Poirier 1996). This potential
variation in interpretation is not a weakness if the means by
which the interpretation was formulated is clearly described.
Indeed, interpretation is necessary, for without it a text is
inert and meaningless (Ayres & Poirier 1996, Rose & Webb
1998) and the interpretations of others may bring useful
insights (Guba & Lincoln 1989). Data analysis should be
trustworthy in that the processes used are clear for the reader
and these are now explained.
Data analysis frameworks
Rose and Webb (1998) in their study into the experiences of
caring for a terminally ill person from the perspective of the
lay carer, found criteria borrowed from grounded theory
useful in the attempt to establish rigor in their data analysis
process. The following were used in this study:
9
F. Milligan

· Being present at the interview In relation to the steps described above by Wertz (1983),
· Listening to the tape these strategies were used when reviewing the data. Steps 3, 4
· Transcribing and 5 were discussed with the participants once the tran-
· Reading the transcription scripts and preliminary ®ndings had been returned to them.
· Repeating steps a and b to ensure familiarity Opacity, in the sense of issues felt to be unclear during the
· Thinking/assimilating/intuiting analysis process, were discussed and clari®ed both with
· Interpretation and understanding. participants and a number of senior educational colleagues.
Similarly, the guidance offered by Wertz (1983) informed
the data analysis process: Structured re¯ection
1 Seeing relationships Each participant was asked to pick an exemplar from practice
2 Utilizing an existential baseline ± related to the context of that illustrated the concept of care for him. The participants
the participants completed a re¯ection using the Johns' (1995, 1998) model of
3 Thematizing recurrent motifs structured re¯ection which was typed and returned to them
4 Imaginative variation for comment and amendment. The choice of a re¯ective
5 Interrogating opacity model was made to facilitate insight into the chosen experi-
6 Employing concepts and models ences. Re¯ective practice is a tool by which insights into the
Rose and Webb's (1998) steps were followed with one complexities of practice can be accessed (Johns & Freshwater
minor exception. All the interviews were undertaken by 1998). These re¯ections were then scrutinized and used as the
myself but, for lack of time, the eighth was transcribed by an basis for the interview to give it some structure. Not all the
experienced interviewer. All the transcriptions were then read participants completed an extensive re¯ection with two
through while listening to the tape in order to enhance giving summaries of around one hundred words. The other
interpretation. six gave extensive written accounts of the event they had
chosen.

Table 1 Summary of the scenarios chosen by the participants

Participant Clinical area Brief description of the scenario

Participant 1 28 bed surgical ward A man in his late ®fties suddenly became unwell showing signs
of hypovolaemic shock. He had undergone major abdominal surgery 7 days
earlier for a pancreatic cancer. He was subsequently discharged to a hospice.
Participant 2 Accident and emergency A young woman was admitted with multiple injuries, including major burns
and head injuries, following a road traf®c accident. She subsequently
died in the department.
Participant 3 Medical ward (hepatology) A middle aged man with alcoholic liver disease was admitted after taking
a paracetamol overdose. This led to liver failure which was being actively
treated even though his prognosis was poor. He died on the ward some
8 weeks after his admission.
Participant 4 Neurological intensive care A man in his late forties was dying following a major brain haemorrhage. His son
was reluctant to come in and see him seeming not to appreciate the seriousness
of his condition.
Participant 5 Medical neuro-sciences ward A man in his early ®fties is admitted to the ward after being diagnosed with
an advanced brain tumour. His wife was closely involved in his care.
The participant felt the care they received could have been improved upon.
Participant 6 Accident and emergency An elderly man is admitted with chest pain accompanied by his wife. Soon
after admission he has a cardiac arrest and dies. The participant takes
responsibility for informing and supporting the wife.
Participant 7 Accident and emergency A man in his ®fties is admitted with an abdominal aneurysm from which he
bleeds and quickly dies. The relatives, who live some distance away are unaware
of these events and must be supported when they arrive at the department.
Participant 8 28 bed surgical ward A partially sighted man in his forties was admitted to the ward for a hernia repair.
His recovery was uneventful but upon his return home he wrote back to the ward
to thank them for the excellent care he received. The participant was thus
reminded that his interventions had been effective and caring.

10 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16

Experience before and throughout the nursing career
Findings
The selected scenarios
The range of scenarios picked by the participants was in itself
interesting (see Table 1). Most participants picked experien-
ces in which they were caring for people who were very sick,
and participants 2, 3, 4, 5, 6 and 7 all chose experiences in
which the patient died. In scenario 1, the patient subsequently
moved into the terminal stages of a pancreatic cancer.
The acute nature of the experiences perhaps re¯ects the
types of clinical areas in which participants worked. Having
said this, concern for the patient and their signi®cant others
raised important emotional issues for these men. With the
exception of participants 1 and 8, all showed a great deal of
concern for the signi®cant others, who were frequently
viewed as the main focus of care.
The themes
The themes that emerged from the data analysis are listed
below, with brief examples of comments made by the
participants. Data were divided into ®ve main themes, with
subthemes. The reference given refers to the participant and
line number of the transcript.
Theme 1: Care and caring
Care: a dif®cult concept to de®ne. None of the participants
had a quick answer to the question, `What is care?' Indeed,
de®nition was perceived to be a problem:
I don't think there are any set or hard rules to de®ne it. I don't think
nobody can really sum it up, in a way, because it's so easily
interpreted, it's such a broad ± it's interpreted by people very
differently (P6-161).
General and bio-physical needs. The meeting of needs was
commonly mentioned. Participant 1 stated that acute surgical
work allowed him to get his caring across to the patient:
For me it [the scenario he chose] exempli®ed the critical care aspect of
the ward which I work on at the present time. We're an acute critical
care environment, and¼it's the part of the job that perhaps I enjoy
most. Where I feel I can get the most caring across (P1-001).
Participant six explained care thus:
I mean¼when you ®rst mention what care is yeah¼I immediately
think of having perhaps an elderly lady from a nursing home, who's
perhaps had a fall or something, and actually doing the phys-
ical¼stuff initially and progressing on to¼chatting to her and
building up kind of like a relationship between the nurse and the
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
The concept of care in male nurse work 1
patient. And then if you're looking after them long-term, then going
further ± getting further involved with them. But my initial thoughts
are, I don't know why, but it's a physical thing (P6-169).
Psychological care and the type of work. Attempts to clarify
the nature of care went beyond physical needs and the
traumatic events chosen by the participants as examples of
care. The psychological support required by patients and
signi®cant others, especially when the patient was unwell,
was a high priority for these nurses. Participant 2 highlighted
the people with minor injuries that went through his depart-
ment as a way of showing that it was not just the occasional
major injuries that were important. Care involved the process
of anticipating and responding to patient needs thereby
helping people to regain their independence. This included
problem solving and prevention as acting pro-actively was
better than reacting to problems once they occurred.
Barriers to care. Although they found care to be dif®cult to
de®ne, some participants were able to identify barriers to
care. Lack of time was one of these:
I think that we don't have time, with our extended roles in nursing, to
provide the psychological and social support that nurses used to
provide (P3-309).
Similarly, participant 4 felt that although they were striving
for what he termed more holistic care in the intensive care
environment, lack of time, along with some poor communi-
cation and documentation, led to situations in which:
I feel we sometimes just dig under the surface, we don't really go deep
enough (P4-183).
For participant 3, lack of time and the pressure of work on
the ward was a signi®cant barrier and he linked this to
changes in society generally:
We haven't got the time. We run around continually in¼life as a
whole, chasing our own tails, and we don't relax or slow down for a
minute. Whereas I believe my grandfather's generation¼they were a
lot more relaxed and they had the time ± they didn't have the cars,
they didn't have the technology, they didn't have the things today
(P3-139).
Theme 2: Communication with patients, signi®cant others
and the multidisciplinary team
Patients. Effective communication with the patient (where
they were in a position to communicate) was a recurrent
theme in the interviews. Participants 2, 7 and 8 emphasized
the importance of clear information giving within their role.
Patients going through an accident and emergency (A/E)
11
F. Milligan
department frequently need a great deal of information in a
short period of time, and both participant 2 and 7 empha-
sized this aspect of communication.
Multidisciplinary team. All the participants made some
reference to operating and communicating within a team.
Participant 1 saw good communication with the medical staff
as crucial:
`You know you might have seen a poor outcome to the patient
episode [in his re¯ection] because of lack of communication or
dif®culty with personality¼' (P1-089).
Participant 3 saw the nurse's role as central to the multi-
disciplinary team:
¼you are the advocate as such for the patient and you're the only
person that sees what the other teams are doing (P3-339).
Signi®cant others. It was the problems encountered in trying
to communicate with the son of a dying man that led
participant 4 to pick his scenario as an example of care. His
concerns about the episode centred on communication, and
in trying to explain this he said:
¼possibly because of lack of time, lack of communication ± not lack
of communication but dif®cult communication and, perhaps, I think
documentation is probably a thing that I think we [staff of the unit]
need to address a bit better (P4-185).
Although some form of communication had occurred with
the patient's son, it was the quality of this that he wished to
see improved.
Theme 3: Signi®cant others and the shifting focus of care
Signi®cant others as the focus of care. It was striking how the
patient was not the focus of the interview with participants 4,
6 and 7. Indeed, they had chosen the scenario because it
showed how the focus of care could shift in their practice. For
participant 6, the trauma of being present when the elderly
man had a cardiac arrest became overshadowed by concern
for the wife who was beside her husband as he became
acutely ill and died:
It was so sudden and, I think more to the point, the¼wife of the
patient that died was ± there was nobody else for her¼and I felt that
it needed, you know, more follow up (P6-007).
Questioning the medical focus of treatment. The focus of
concern was also broad enough at times to question the
goals of medical treatment. Like participant 3, participant 4
perceived a need to move towards a more palliative
approach and support of the son; a son unable to cope
12 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
effectively with his own impending bereavement. Although
participant 3 acknowledged that his previous experience in
palliative care in¯uenced his approach to the person he was
nursing with terminal liver failure, he still felt that in an
acute area it can be dif®cult to withdraw aspects of medical
treatment:
I believe that you should give quality rather than quantity of life. This
man, we were treating excessively even though they were near
enough certain that the outcome was that he was gonna die (P3-025).
Theme 4: The nature and limits of emotional work
Emotional work with signi®cant others. The acute nature of
the scenarios chosen by the participants hinted at the
emotional work involved. In addition to the potential trauma
of caring for these patients, it is clear that participants 4, 5, 6
and 7 were concerned about the emotional impact of the
illness event on the signi®cant others. Similarly, participants 2
and 3 felt it important to focus their efforts on the next of kin
once hope for the patient had faded.
Participant 4 was concerned about the emotional impact of
the patient's death on the son and the focus of care shifted
correspondingly. This participant also mentioned another
situation and the emotional trauma of seeing small children
visiting their dying father on the unit. He said:
But there are times when you're in a car, piece of music, and you ¯ick
back and you can actually think of things, but I often think of that
particular episode, and how all that panned out. It was just very
dif®cult for me. I felt that I dealt with that fairly well¼even though I
felt inside I didn't, but it came out (P4-203).
He felt he had hidden his inner feelings from his colleagues.
Levels of emotional involvement and support. The level of
involvement felt by these participants sometimes developed
over time, and sometimes was there simply because of the
intensity of the experience. Evidence that some nurses seemed
able to put emotional work into perspective came from
several participants. Both participants 6 and 7 made it clear
that although the situations described had been traumatic,
they still felt a positive outcome had been achieved:
¼it's an awful situation but you try your best to make it, you know,
as comfortable as possible (P6-127).
and
¼looking at it quite coldly, it actually went quite smoothly (P7-157).
Attempts to limit emotional commitment were found. Parti-
cipant 3 felt he needed to pull back from the patients because
of the emotional work involved:
Experience before and throughout the nursing career
¼cos we have to keep away to work ef®ciently, and I think that I got
drawn in too much (P3-071).
and
I believe that as nurses, and this a belief that doesn't work because of
how busy we are, that we should know our patients and¼I think I
probably know too much at times about the patients (P3-091).
Similarly, participant 1 said:
¼we're here to facilitate other people needs, you know, and I'm not
saying that we should run ourselves ragged or into the ground
because of that role, but if we're not able, because we've been run
ragged, we can't facilitate what their needs are (P1-085).
Contrasting emotional work with female nurses. One of the
few aspects of their practice identi®ed as being potentially
different to that of female nurses was in the area of emotions.
Participant 6 felt that female nurses might be more sensitive
to patients' feelings; that they may pick up on these quicker.
Several participants commented that they did not think others
expected them to express emotion:
¼whether they (female nurses) may be more ± I mean, are they able
to show their emotions easier than males because of the¼back-
ground of our society. I mean, for males you've got to¼have a stiff
upper lip and it's not seen that a man should cry (P2-225).
Participant 7 made a similar comment:
I've spoken to a couple of other male nurses down there [A/E], and
obviously it's not uncommon, say during a death, for the female
nurses to cry. It's not uncommon at all. For us [male nurses], if it's
going to upset us, speaking about me personally and I suppose I
should, it's when the relatives get involved (P7-273).
Participant 7 was emotionally drained as a consequence of
dealing with the relatives. Participant 4, in relation to the
children mentioned above, could only cry once he left the
unit. Participant 2 put it this way:
¼because of being male you tend to have to suppress your emotions
because it's expected of you (P2-243).
Theme 5: Gender and being a male nurse
Physical tasks. Several participants noted that as male nurses
they were associated with manual handling, were perceived
to have more strength and subsequently were often called
upon to help deal with confused patients. Participant 7 put it
thus:
Sometimes we are bracketed as, we're the strong ones¼we can sort
that one out. An example, the drunk and aggressive patient (P7-261).
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
The concept of care in male nurse work 1
He also gave examples of heavy work, such as holding a
patient's leg whilst it was plastered, and also holding children
while they had procedures such as suturing. Participant 3 felt
that this additional contact, both in terms of time and
physical contact, increased his sense of connection with the
patients. Both nurses and patients looked to him to do this
type of care:
They see you as somebody to go and help them a little bit more, you
know¼they assume that you like, lift more or you move more¼and
that way you get patient contact (P3-213).
Explaining differences. The participants often found it dif®-
cult to separate out factors within their practice that were
directly linked to their being male. Participant 3 made this
comment:
Whether being male adversely affects your functioning or is a positive
bene®t, is not that easy to say and possibly impossible to say. I think
it's more in terms of your almost uniqueness, or differentness is more
important than the fact that you are male to be honest (P5-315).
Participant 6 commented on a duty shift in which male
nurses outnumbered their female colleagues and said
that the department was messier and more relaxed.
However, as with so many other examples in the interviews,
he was again not sure if this was as a result of gender or
simply the fact that there was no senior nurse on duty. He did
feel that a persistent comment from colleagues was that male
nurses were not as tidy as their female colleagues who may
have more hindsight into patient problems, by which he
meant that they could identify problems sooner. He added
that for nurses generally this skill would improve with
experience.
The reactions of patients and signi®cant others. The fact that
they were male could restrict their access to patients, as in the
case of participant 4 who worked as a part-time Marie Curie
nurse. He could not gain entry to the house of a dying man as
the wife had not expected a male nurse. Participant 2 also
commented on this:
¼if you go into some female patients they say, `I want a nurse'. `Well
I am a nurse'. `No, I want a proper nurse'. `Well what's a proper
nurse?'¼And then they'll say, `I want a female nurse'(P2-253).
Several participants claimed that with experience sensitivity
to such perceptions developed further. Participant 4 felt that
such comments, the speci®cation of maleness which he called
a stigma, were inappropriate and that ®rst and foremost he
was a nurse. Participant 5 had quite complex ideas in this
area, but did feel that patients saw the maleness of male
13
F. Milligan
nurses ®rst, whereas with female nurses a similar emphasis on
their gender was not common.
Discussion: conceptual framework of care
within these nurses' work
A conceptual model was constructed to explain the concept
of care as derived from the data (see Figure 1). The central
circle, Care and the male nurse, represents the various
participants and moving out from this, two other circles
encapsulate the key aspects of the concept as described. The
®rst of the two outer circles represents issues raised by all
the participants and the second outer ring, that of signi®cant
others and a critique of medical treatment, are those
mentioned by only some participants. Using the responses
of participant 1 and 8 it seems reasonable to suggest that
not all nurses may progress from circle one to two, or that
they may be more able to make such progression with
experience. Benner's (1984) work on the importance of
experience in effective nursing practice would support this
assertion.
Cutting across the factors seen as integral to care were
elements associated with the social context and socializa-
tion processes that men ®nd themselves operating within
(shown as arrows in Figure 1). These are: a perceived
Figure 1 Conceptual framework of care within male nurse work.
14
expectation that they should cope with emotional work and
not show feelings in public; an association with the more
physical aspects of work, such as manual handling and
confused/aggressive patients; issues related to their gender,
or social perceptions of their gender; and an association
with technical tasks. This latter point arose several times in
the data.
Viewed as a whole, the re¯ections and transcripts show
that emotional labour (James 1992, 1993), the signi®cance of
communication, information giving and for the majority of
the participants meeting the emotional needs of the patient
and their signi®cant others, were important factors in the
attempt to explain the concept of care. Emotional work
appeared to be increased for some participants as their
association with manual handling tasks and dif®cult patients
could actually enhance the depth of their relationship with
those patients.
Issues for future consideration
The ®ndings from the research raise the following issues.
First, that structures and systems put into place for clinical
supervision (UKCC 1996) should take account of the fact
that men may be reluctant to seek such support, or may feel
pressured into a role which encourages them to make do
without support. The socialization process, put simply in
terms of the adage `men don't cry', may disable them from
seeking support. Second, that further study into the concept
of care in relation to nursing practice should broaden its gaze
to include the signi®cant others of the patient/client. Even a
simplistic de®nition of care, for example, that it involves
assisting patients to meet their needs, involves inclusion of
signi®cant others as they will be, in the vast majority of cases,
an integral part of those needs. Third, in terms of nurse
education, this research supports the need to explore gender
issues within nursing practice (Lawler 1991). The partici-
pants felt the in¯uence of gender through expectations placed
upon them, and were sensitive to the gender perceptions of
patients and their signi®cant others. Essentially, gender was a
signi®cant variable in the nurse/patient/signi®cant other
relationship(s).
Conclusion: towards a new horizon
The nature of the hermeneutic circle is such that it is never
closed. Although interpretation has been undertaken the
culmination of this work is another horizon, another place
from which to begin the process of fore-understanding
(Palmer 1977, Allen & Jensen 1990). Such a claim, and the
use of ontological hermeneutics to structure that claim,
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
Experience before and throughout the nursing career
remains controversial. Authors such as Paley (1997, 1998)
remain highly critical of the use of such philosophical works
in nursing and health related research. However, attempts to
clarify the concept of care should not be separated from the
socio-historical context within which they are undertaken.
Within the context of patriarchy such attempts are unlikely to
be valued, and assaults upon the methodology used should be
critiqued with this in mind. In a postmodern world a
systematic attempt to clarify an issue of concern or interest
is better than no attempt at all (Hall et al. 1992). This study
shows that philosophical and methodological complexity
need not stand in the way of interesting research and of new
horizons.
This study provides a rare insight into the thoughts and
values of men working within the acute hospital setting.
When asked to de®ne what the concept of care was within
their own practice they generally chose scenarios in which
the patient was very ill. This draws attention to the acute
nature of many nurses' work and the realities, in terms of the
trauma that they may face, of working in a hospital setting in
which people can and do die. Having said this, and even
though most of the patients were very ill, biomedical issues
did not dominate the explanations of care given. These men
did seem to want to ¢get the job done', to complete the period
of care with that patient, and this frequently included the
attempt to resolve matters with the signi®cant others of that
patient.
The study gives further insight into what practitioners do
in practice, and what they think is important. It informs
practice as the ®ndings suggest that, for these men at least,
emphasis on just the patient in terms of the attempt to clarify
the concept of care, is a distraction as most were also
concerned about the signi®cant others. They picked the
scenarios, with the exception of two participants, because
they went beyond the patient. This is striking and begs the
question, how much nursing work is signi®cant other work?
The open format used in this research of asking the partic-
ipants to pick an experience that exempli®ed care gave a
¯exibility that allowed them to express concern for those
signi®cant others. Looking back over a good deal of the
literature on the concept of care it omits this dimension, and
future discourse around the concept of care should probably
include signi®cant others.
Acknowledgements
This research was undertaken as part of a MSc in Nursing at
King's College, London. I would like to thank Lindy King,
lecturer at King's College, for her help and advice in
completing the study.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 7±16
The concept of care in male nurse work 1
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