Difficulties Encountered by Final-Year Male Nursing Students in Their Internship Programmes

Background : The cultural norms of the Kingdom of Saudi Arabia do not encourage men to choose nursing as a career. Understanding male nursing students' experiences of their clinical exposure to the nursing profession throughout their internship might increase their retention. This study explored the experiences of final-year male nursing students as they transitioned to the role of registered nurse. Methods : A qualitative descriptive research design with an inductive content-analysis approach was used. The experiences of 22 final-year male nursing students from three public hospitals in a major city of Saudi Arabia were explored. The data were collected using focus-group interviews and documentary analysis in March 2015 and May 2015. Results : Content analysis revealed three major themes: the societal and cultural image of male nurses, male students' engagement in nursing practice, and restructuring the internship programmes' policies to suit male students' needs. Conclusion : The findings reveal issues that mainly stem from negative social views of nursing as a male profession. Considering the students' social and cultural needs during their internship programme will facilitate their transition into the role of registered nurse and their retention in the nursing profession.


Introduction
The trend for male nurses to enter the nursing profession has been increasing universally. However, women dominate the nursing workforce, and men in this career remain a minority group (1). In developed countries, like the United States of America and Canada, around only 5% of the total population of nurses are men, whereas in Iran and Jordan, men represent 23% and 38% of registered nurses (RNs), respectively (2,3). In the Kingdom of Saudi Arabia (KSA), as in many other countries, the nursing profession remains a female-dominated profession, and male nurses represent 18% of all RNs in Saudi Arabia's public hospitals, yet only 3% are Saudis (4).
There is general agreement in the studies that have investigated the issues facing males in the nursing profession. Firstly, men in nursing are a reality and they provide a major contribution to nursing care. Secondly, some traditional beliefs about gender issues contribute to their job dissatisfaction. Thirdly, analysing and solving the difficulties facing male nurses in a female-dominated profession is important for retaining them (1,2,3).
In a qualitative study, male nursing students verbalised that they experienced low self-esteem during nursing practice due to rejection from female patients, and a decreased sense of belonging to a female-dominated profession (5). In certain societies, men who choose a nursing career experience frustration, hopelessness, and confusion about their self-nursing students' perspectives of their internship experiences. The emphasis was on practices, beliefs, and attitudes that comprise all aspects of the participants' lived experiences (17).

Sample and Setting
Purposive sampling was used to select 22 participants in the 22-25 years' age group from the College of Nursing at King Saud University who met the following criteria: (1) final-year male nursing students, (2) successful completion of the undergraduate nursing course's theory component, (3) completion of at least nine months of an internship, and (4) willingness to share internship experiences. Participants were recruited from three public hospitals in Riyadh, the nation's capital, in March 2015. They were selected from different wards to represent a range of perspectives and experiences, and to be a homogenous group (in terms of gender and being nursing students), to ensure that they shared critical similarities relating to the research question (18).

Data Collection
The data were collected using focus groups and documentary analysis. An interviewer and co-interviewer conducted four focus groups, each consisting of five to six interns. The interviews allowed for clarification and exploration of the male students' experiences during their transition period. The interview guide was based on an extensive literature review, the primary researcher's experiences as a male nurse, and consultations with two experts in qualitative research methods. The following questions were used to stimulate discussion of clinical experiences during the focus-group interviews: 1. What did you dislike about the internship programme?
2. What factors negatively affected your training in hospital?
3. What difficulties did you encounter during the internship programme?
Topic guides were announced to the students three hours before the interviews, as written prompts to ourselves, to ensure that preliminary ground was covered concerning the topic under discussion, and so that they had thought about what to say. These guides were obtained from the documents of the hospital and nursing college's internship committee, and they image and social identity (6). They encounter unequal treatment in the workplace (7,8) and prejudice from patients and society (9). They report feeling ashamed (8) and embarrassed when providing personal care to female patients (10).
The nursing workforce in the KSA relies primarily on expatriates recruited from different countries (11). Their beliefs and values differ from Saudi culture, and Arabic is not their first language (12). English is the primary language used among health professionals in Saudi hospitals. Saudi Arabia's Ministry of Health has focused on developing a health-care system with qualified and competent local nurses who can deliver culturally sensitive care in order to replace the expatriate nurses from different cultural backgrounds (13,14).
Nursing students of the College of Nursing of King Saudi University undertake internships after completing their general nursing courses to ensure a smooth transition from the role of student to RN. Academic institutions and health-care facilities are required to provide separate gender-based placements in compliance with the cultural values and Islamic religious views of Saudi Arabia (15), resulting in limited male-female interactions in the clinical setting (16). There is no national policy or guidance on formal internship programmes for nursing students; consequently, health-care facilities design their own programmes. Therefore, male nursing students (interns) typically complete their clinical training on male wards and do not receive training in obstetrics, gynaecology, or paediatrics (8).
Many issues motivated the current study's researcher to explore the difficulties facing male nursing students regarding their preparedness for practicing as RNs, such as several requests from male nursing students for transfers from assigned clinical placements, high rates of absenteeism, and many questions and inquiries regarding policies and procedures manuals. The study's aim was to explore the difficulties encountered by final-year male nursing students as they transitioned to the role of RN.

Design
The researcher employed a qualitative descriptive research design using group interviews to develop a deeper understanding of informed consent forms before the interview.
Steps were taken to ensure that participants' freedom of speech and autonomy were respected.

Data Analysis
The data were analysed using inductive content analysis to ensure that the codes were grounded in the participants' real experiences and focused on the study's aim. Graneheim and Lundman's (20) approach to the coding and categorisation of focus-group data was adopted. During the early stages of data collection, the interviews were transcribed verbatim and perused several times for a comprehensive perspective to obtain a sense of the whole. The text was divided into condensed meaningful units, which were then further condensed to represent sentences or paragraphs containing related content. Each condensed unit was then abstracted and labelled with a code. Various codes were organised into sub-themes by comparing their similarities and differences. Finally, the sub-themes were combined to create themes that were used as headings in the findings. Approximately 133 statements were divided into 11 sub-themes to develop three main themes.

Rigour
Several strategies were used to ensure the findings' trustworthiness. In this qualitative study, full descriptions of the data were recorded to reduce the chance of losing important information. Five randomly selected participants independently assessed the transcribed tapes' content and the summary with the extracted codes to confirm the researchers' interpretations (20). Two experts in qualitative nursing research conducted a peer review to establish the data's credibility and to ascertain the validity of the process-related decisions, findings, and interpretations.
Furthermore, to exclude researcher bias, reflexivity was adopted at every stage. Reflexivity is the researcher's awareness of his/her role in the research process and how it might influence the participants, process, and findings (21). In this study, the researcher disclosed the study's aims to gatekeepers and participants.

Results
The focus groups yielded a large volume of rich data regarding the internship programme. Although there was considerable variation in related to all facets of internship training, such as working with patients, the training environment, work-related reasons (e.g. hospital facilities), relationships with co-workers, and policies and procedures.
Before starting, we stated the interview rules to ensure that the discussion was not interrupted, such as indicating the toilet facilities beforehand, having cell phones turned off, contributions being confidential to allow the participants to speak openly, talking without using their identity but by using 'this happened to us' or 'this happened to them', and preventing more than one person speaking at a time so as to identify his comment with a code. The focus groups were conducted in a quiet room in the College of Nursing to ensure privacy and maintain confidentiality. Participants were allowed to speak in Arabic (their native language). They were encouraged to provide as much detail as possible to allow the interviewer to record rich descriptions of their experiences. The interviews lasted 60-90 minutes and were audiotaped for verbatim transcriptions. Nonverbal cues (nodding and maintaining eye contact) and facilitative communication skills (probing, listening, using open-ended questions, clarification, and reflecting) were used to encourage participation until new data from new cases did not contribute to a new idea or modify the stated ideas; that is, to the saturation point.
The interviews were transcribed and then translated from Arabic into written English text. Documentary analysis was conducted using the relevant documentation of the transition experience during the students' internship. Performance appraisal forms, anecdotal notes with descriptions of students' behaviors, and comments from supervisors and preceptors were gleaned from the data and analysed. Documentary analysis can help researchers to identify issues to explore and can provide a rich source of data to support data collected using other methods (19).

Ethical Considerations
Institutional review board approval (CAMS 57-3435) was obtained from the nursing college's research centre before the study. Participants were informed of the study's purpose and design. The researchers clarified that participation was voluntary, the information collected would be treated confidentially, anonymity would be ensured, and they were free to withdraw at any time. Consenting participants signed the Original Article | Male nursing students in Saudi Arabia www.mjms.usm.my 33

Distrust by patients
Participants stated that patients did not trust their care in the same way as for female nurses. They believed that male nurses were not as careful as female nurses in conducting nursing procedures. The men's capabilities in the most basic nursing principles of caring, empathy, and compassion were questioned.
One student stated 'Patients usually expect to be cared for by a female nurse … because the fact is that males are perceived as 'muscle' and as less caring than females'. NS2.

Theme 2: Engagement in Nursing Practice
The students' engagement in the clinical environment is crucial to the success of their training and retention. They perceived many factors that can hinder their engagement in clinical learning during the internship. These are represented by the following sub-themes.

Gender discrimination
Saudi culture sanctions gender-based segregation and enforces it through healthcare structures. There is no mixing of the sexes and there are different work areas for male and female nurses. A student described this issue as follows: 'It is not allowed for us to work in female departments … mixing with females is questionable … we have to work in male departments … actually, we feel more isolated'. NS7.

Lack of interpersonal communication
The participants acknowledged that interpersonal communication is a vital component of nursing care. They showed their views-depending on the departments they worked in-the major issues were similar across the groups. Three major themes and sub-themes emerged from the qualitative analysis of the focus-group data (Table 1).

Theme 1: Societal and Cultural Image of Male Nurses
There was consensus across the four groups regarding the negative societal and cultural attitudes about a nursing career for men, which was accompanied by male nurses' low social prestige and value. The majority commented that their families, relatives, friends, and the public perceived nursing as a shameful and humiliating career for males.

Negative attitude towards nursing
The participants were more vulnerable to harsh comments from the public, which may have adversely affected their interest in nursing and confidence.
'I feel embarrassed when I hear my friends' comments about nursing. They refer to nurses as subordinate to doctors … it is a career for housemaids: bed-making, bathing patients, and cleaning tables'. NS17.

Not supported by parents
Male students felt that their cultural background influenced parents' beliefs and behavior towards nursing as a male profession. The students' families feel embarrassed about disclosing their sons' identity as nursing students. The following quotation illustrates this.
'My parents were embarrassed to disclose my identity as a nursing student to others … this is what happened when I got engaged to my wife'. NS11.

Using hospital facilities
Students felt that the hospital administration did not give them priority in using some hospital facilities that may influence their training. One stated 'We had a problem with parking at the congested hospitals … many times I was delayed for half an hour or more coming on duty as I was looking for a place to park'. NS18.

Discussion
This study identified specific difficulties and challenges that affect male nursing students' attitudes and their desire to remain in the nursing profession. Nursing as a profession was not the participants' choice, and they considered it a career of the lowest social class. They were forced into this profession because of their low GPAs in the preparatory year programme. Ignoring students' interests and desires during the university-selection process will play an important role in creating a lack of sufficient students with motivation who identify with the nursing profession, and ultimately, the ability to provide high-quality nursing services (7,(22)(23)(24). This opinion is supported by Zamanzadeh et al. (2) who argue that a more rigorous selection method would enhance the recruitment of more highly motivated nursing students and decrease the turnover.
Men in Saudi society are not encouraged to become nurses. When male students enquire about nursing, their families and society remain consistently unsupportive. One male student disclosed that his father did not know that he was studying nursing. This negative attitude towards nursing causes disappointment and embarrassment among students, lowers their self-esteem and self-efficacy (22, 23), and leads to high nursing student turnover (24). Additionally, male interns avoid situations in which others dismiss their occupation in order to elevate their own self-confidence by regarding it as an embarrassing 'feminine' profession (2). Xu (9) argued that increasing the proportion of male nurses could enhance the status of nursing as a career.
Patients in clinical settings distrusted the male students. Their mistrust and refusal willingness to build working relationships with staff nurses and initiated collaborations with other health-care professionals. The students' lack of English conversation competency and cultural constraints prevent their social communication with health professionals. For example, a student stated the following: 'My English is weak, so I can't convey my thoughts and intentions to the non-native nurses properly … I like working with the Saudi male nursing staff because they understand me well'. NS6.

Not involved within a nursing team
The male students perceived their active involvement in acquiring clinical knowledge and skills as important to team development. They were not encouraged to attend professional meetings and group discussions. One student stated the following: 'I haven't been given an opportunity to attend meetings with the head nurse and her staff … I would like to be involved in these meetings … doing this would help develop my leadership'. SN15.

Theme 3: Restructuring the Internship Policies to Suit Male Students' Needs
This theme surfaced in all focus-group discussions, with almost every intern describing, in some way, the lack of programme policies, rules, and regulations regarding their personal and cultural needs.

Biased policies
The students acknowledged that they face a dilemma in biased policies that are feminine in nature and do not fit their needs. For example, they were evaluated using the same tools as the staff.
'In addition to that, the evaluation scale in the manual is confusing for us and our supervisors; they therefore used their own evaluation scale, which was developed for their staff'. NS21.

Training hours
The participants reported being scheduled for shifts of eight, ten, or twelve hours, in different patterns of morning, evening, and night shifts, according to the department's needs rather than their needs. They acknowledged that always having morning shifts gave them more training opportunities.
One participant remarked 'After one rotation in the hospital with 10-or 12-hour shifts, study in Australia (8), which reported that male students felt remote in academic and clinical settings. This study's male students expressed the desire to be part of the health-care team and to have opportunities to perform or observe new skills in addition to those assigned to them. Moreover, they indicated that their lack of fluency in spoken English contributed to poor communication, low involvement, and challenging interpersonal relationships with non-native staff nurses. Bennett (30) suggested strategies for establishing working relationships with the nursing staff and for supporting team development, such as organising an introductory meeting, conducting student orientations in the departments where they are placed, providing an effective learning environment, and offering appropriate support.
The findings highlighted the internship programmes' inadequacies regarding students' cultural and personal needs. Policies, rules, and regulations designed to solve routine and recurring problems, and evaluating students using the scales intended for employees, were inappropriate and reflected a 'one size fits all' way of thinking. Students confronted the issue of long shifts in some hospitals, which were beyond what should be expected of students, as one experienced excessive fatigue and sleeplessness for over a week. During the interview, the students suggested attending training only in the morning within an 8-hour shift. This suggestion should be discussed by the nursing college's faculty members and the hospitals' nursing administrations to increase students' exposure to various nursing situations under the supervision of mentors who are usually scheduled for the morning shift. The issue of the students' delays at the beginning of their shifts due to the parking is very important and requires collaboration and cooperation between the nursing college and the training placements to address it. Santucci (31) argued that written rules, policies, and procedures based on students' needs, beliefs, and values can substantially contribute to the training programmes' long-term stability and safety.

Limitations
This study investigated the perceptions of one cohort of male nursing students from three public hospitals in Riyadh with similar settings. Their environments may differ considerably from hospitals in other areas of the country. Although the findings might not be generalisable, not only affects the male students' self-esteem but also limits their opportunities to practice procedures and become more qualified.
Students explicitly conveyed a negative attitude towards their nursing role and clinical contribution. Because men's physical nature in terms of muscle mass and strength can cause some problems for their roles when providing nursing care, they struggle with the more physical aspects of care, such as lifting heavy patients or dealing with confused and aggressive patients. One important challenge they faced related to their caring role. They felt that patients did not trust them to provide emotional and empathy skills, as it is a female privilege. This issue caused male nurses to struggle to adjust to their affective and interaction role in order to be more acceptable than their counterpart, which may be because 'their horny hands were detrimental to caring' (25). Evan (26) argued that male nurses were drawn towards technical, non-technical, or high acuity settings to adjust to their caring abilities and their interaction role in a female-dominated profession.
The participants' reflections helped to identify the aspects of male nursing students' engagement in clinical practice that need improvement, such as gender discrimination, lack of involvement in nursing teams, and interpersonal communication. The participants experienced gender bias in nursing, and they explored many issues facing them, such as unjustified training opportunities during practice and being excluded from rotations in some work areas, such as gynaecology, obstetric, and paediatric units that are restricted to females. The following quotation illustrates this: 'They (clinical supervisor) replaced us twice in the rehabilitation department when the ward was full of disabled patients and they did not have enough staff for lifting patients and accompanying them to x-ray and laboratory departments, instead of our scheduled rotation'. N13.
The literature regarding gender stereotypes in nursing has reported many important challenges, such as unfair treatment of males by the nursing faculty in schools and clinical settings (27), nursing education authorities' lack of awareness of male students' unique needs (28), and nursing textbooks lacking contributions from male nurses (29).
Participants often felt isolated and neglected by staff nurses in their clinical placements. This finding is congruent with Stott's thematic Correspondence they do provide insight into the transition from student to professional nurse. Furthermore, the interviewers' previous experience might have influenced the nature of the questions. Future studies should include more than one cohort in different settings to allow for a more comprehensive analysis.

Conclusion
This study identified three major challenges encountered by Saudi male nursing students upon entering their internship programme: the societal and cultural image of male nurses, male students' engagement in nursing practice, and restructuring internship policies to suit male students' needs. These challenges require further interventions to facilitate male students' transition into the role of RNs and improve their retention in the nursing profession. Improving the community's view of male nurses through informational and educational programmes through different media will reduce their frustration and burnout, enhance their selfesteem, and increase retention. Moreover, considering the students' social and cultural needs when structuring their internship programme policies, and enhancing their English language and communication skills, will foster effective teams and interpersonal relationships and enable them to provide high quality and culturally sensitive care to their patients.