PHENOMENOLOGICAL STUDY ON THE EXPERIENCE OF MALE NURSES IN CARING FOR FEMALE PATIENTS

Nurses provide care equally and do not discriminate between men and women. However, male nurses face challenges and obstacles, especially when they take care of female patients. This study aimed to explore the experiences of male nurses who look after female patients by using a descriptive qualitative design with a phenomenological approach. Ten male nurse participants aged 26–43 years and having an experience of caring for female patients for at least 2 years were included in this study. Seven themes were identified: the discomfort of female patients and male nurses; patient’s trust and privacy; the identification of factors affected by body image, age, and types of sensitive areas and actions; attention to the religion, personal beliefs, ethics, and culture of patients; professionalism, role, and competencies of nurses; communication strategies and asking for female nurses for assistance based on team methods; and the view of males in the nursing profession. This study focused on two of the main themes: attention to the religion, personal beliefs, ethics, and cultures of patients and communication strategies and asking female nurses on the team for help. Results suggest that nursing facilities need to improve their patient-focused services by considering a patient’s ethical and cultural concerns, using communication strategies, and seeking team assistance when needed in accordance with a hospital’s national accreditation standards.


Introduction
When providing health care services, nurses do not discriminate patients in terms of nationality, ethnicity, color, age, sex, political or religious affiliation, and position (Central Board of the Indonesian National Nurses Association, 2017). However, male nurses face various challenges and obstacles when they take care of female patients. These challenges and obstacles have been felt by male nurses after the news regarding the alleged sexual abuse of female patients by male nurses broke out in early 2018.
Every provision of nursing care involves a proximity of a nurse to a patient, i.e., they are so close to each other that the Central Board of the Indonesian National Nurses Association (2017) described it as being like a mother close to her child. Aranda et al. (2015) and Bouret (2016) indicated that nursing has been traditionally considered a woman's profession, and this field is not for men. Nevertheless, some men still choose nursing as a profession, and the number of men choosing nursing as a career has increased (Tzeng et al., 2009).
Studies on male nurses treating female patients have generated different results. For example, Nipuli and Salmon (2015) conducted a qualitative research that involves five themes regarding male nurses and intimate care: (1) definitions, (2) experiences, (3) personal feelings, (4) strategies, and (5) professional support. They demonstrated that participants use two main strategies, namely, self-comfort and patient comfort. Zhang and Liu (2016) showed that stereotypical beliefs still exist in nursing, so nursing faculty members should create an atmosphere that encourages male students and nurses by ensuring that they believe that nursing is a profession suitable for both men and women.
A physical touch that is involved with nursing care can be felt at the start of a treatment, during treatment, and after hospital discharge. Although providing nursing care is essential, physically touching a patient's body can lead to feelings of discomfort, anxiety, or fear among patients, especially those from the opposite sex of nurses. Nurses who provide direct care to patients should be more aware of a patient's attitude toward physical touch.
In connection with touching, news about improper sexual behavior by male nurses toward female patients in hospitals in Surabaya have spread; as a consequence, a large number of opinions have disseminated in this community. This news has been a cause of concern for male nurses in hospitals throughout Indonesia. This study aims to explore the experiences of male nurses when they look after female patients.

Methods
A qualitative method with a descriptive phenomenological approach was used (Streubert & Carpenter, 2011). The participants were 10 male nurses who provided care to female patients at the X Regional Government Hospital in Indonesia and who were selected through a purposive sampling technique. These 10 participants were included because they reflected the phenomenon being studied.
Data were collected in three locations: an emergency ward, a theater ward, and medical and surgical wards, where male nurses might treat female patients. All of the participants had D3 nursing education; among them, three had a bachelor's degree in nursing and did not take Ners professional education. Data were collected via in-depth interview techniques with semistructured open questions by using recording devices. The results of the recorded interviews were transcribed verbatim, and data analysis was performed.
The male nurses involved in this study were protected by strictly adhering to research ethics, including anonymity, confidentiality, privacy, dignity, autonomy, beneficence, non-maleficence, and justice. This study passed the ethical review of the Research Ethics Committee, Faculty of Nursing Universitas Indonesia (No. 102/UN2.F12.D/HKP.02.04/2018).

Results
Seven themes are identified and depicted by the participants, Both female patients and male nurses experience a feeling of discomfort. An example of a patient's discomfort is described, "The patient does not feel comfortable in situations like being treated for a wound in the breast area." (P1) An example of a nurse's discomfort is as follows: "If a patient feels uncomfortable, then we feel uncomfortable as well." (P7) Nurses must maintain patients' trust and privacy. The importance of maintaining trust is demonstrated in the following example, "I think to myself, 'does she lack faith in me because I am a male nurse?'" As nurses, we must maintain their trust by acting in accordance with our duties." (P10) The importance of maintaining privacy is revealed by the following: "If a female patient refuses to accept our service, we must respect her privacy." (P9) Many factors are affected by body image, age, and types of sensitive areas and actions in female patients. For example, some factors interfere with body image: "A patient might be upset because male nurses would be the one looking after her, and we could see her body, including her genitals." (P7) The identification of age sensitivity is shown in the example below: "I have never had a female patient who is still young, but if she is over 40 years old, I have." (P6) In addition, the identification of the sensitive area of the body is revealed, "Similar to the news in the media, sensitive areas, specifically around the breasts and genitals, must be carefully treated." (P4) An example of sensitive actions is revealed below: "Actions such as catheter insertion are sensitive." (P1) The religion, personal beliefs, ethics, and culture of patients should be considered. The impact of religion is presented in the following example: "Religion has an influence. If patients are fanatics, they do not want to be treated by male nurses." (P5) The effect of beliefs is described below: "If the patient is a female patient, she is more concerned with her beliefs." (P10) The impact of ethics can be seen in the following example: "I have to respect the patients whom I care for in accordance with our work ethics as a nurse." (P9) The influence of cultural factors is demonstrated below: "In our country with an Eastern culture, it is not unusual to be like that-to rarely open up like that." (P6) The professionalism, role, and competencies of nurses in caring for female patients are important factors, as revealed by the following example: "In my view, male nurses can care for female patients, i.e., in my opinion, it is okay as long as you are working professionally." (P6) The importance of the nurses' role is revealed by the following:

"I really enjoy my role as a nurse because I can help people and know about health." (P10)
In addition, the significance of the competencies of nurses is shown below: "That is what my actions have, my competence." (P8) Several communication strategies are provided, and the importance of asking for help from the female nurses on the team is highlighted. The first strategy, i.e., communicating, is demonstrated as follows:

"Until now, Alhamdulillah, I have no problems because I communicate first with my patients and their families." (P10)
The second strategy of giving an explanation is described below: "Before an action is taken, we have to clearly explain it to a patient." (P1) The third strategy of asking for approval is shown in the following: "If I want to install a catheter, I ask for approval, if I am a male nurse who will install it; if they do not want me to, I call a female nurse who will install it instead." (P5) The fourth strategy of requesting permission is revealed below: "If a patient is in postoperative care, before inserting the suppository cathrofen, I get permission from her family." (P1) The fifth strategy of making a contract is described below:

"The point is that we have a contract with patients first, what kind of contract should we do, what is its purpose, keeping the time of the contract." (P6)
The sixth strategy of establishing relationships is revealed in the following:

"If I go further into this approach, it is related to nurse-patient trust." (P7)
The seventh strategy of using humor is observed in the following: "We make the atmosphere more intimate. For example, we try to be humorous so that she feels less awkward." (P7) A strategy to ask for help from female nurses on the team is presented below: "As long as we have a limitation on what we can do, we must know when we should ask for help from our female colleagues." (P3) The view of male involvement in the nursing profession is also described. This theme includes three categories, namely, the motivation of male nurses to enter the nursing profession, their views on the nursing profession, and the label of a male nurse. The motivation for becoming a male nurse is revealed by the following: "I chose to work as a nurse myself because in the past it was easy to get a job as a nurse. Also I got advice from my uncle if I wanted to work quickly better nursing school…" (P4) The views on the nursing profession are revealed below: "I disagree that nursing should be considered a woman's profession because the action that we do is a professional one, not because of being a man or a woman." (P6) Patients call male nurses with the following terms: "We are often called mas, while we are called brothers, sisters, or doctors in other instances." (P3)

Discussion
Seven themes were obtained in this study, and the results were interpreted and discussed on the basis of a literature review.

Uncomfortable Feeling between Female
Patients and Male Nurses. The need for comfort is one of the most basic human needs. In this study, the participants believed that some female patients felt uncomfortable when they were receiving treatment from male nurses. Chan (2014) stated that a majority of patients prefer female nurses, because they feel more comfortable with them. Female patients who feel the most uncomfortable are the young ones.
This study also considered the uncomfortable feelings of male nurses. Nipuli (2015) indicated that the first feeling of discomfort can be felt when a urine catheter is inserted into a female patient's body. This procedure is a challenge for male nurses.
The characteristics of the participants included a variety of ages and ethnic groups. Roussel et al. (2016) stated that different labor forces are advantageous for an organization because they allow variations in opinions and experiences that can lead to innovation. A share of nursing managers acting as leaders is necessary to manage a diverse workforce.
Feelings of discomfort in both female patients and male nurses should not occur if a hospital implements the Patient and Family Rights Standard (PFR) of the Hospital Accreditation Standards (KARS, 2018). In other words, hospital regulations are in place to support the rights of patients/families during care. Male nurses likely experience conflicts, and the head of a room is expected to facilitate conflict resolution so that a conducive work environment can be established (Sitorus & Panjaitan, 2011).

Maintaining of Patients' Trust and Privacy.
This study also noted the importance of maintaining trust. According to the PFR, a hospital builds trust and open communication with patients to understand and protect their cultural, psychosocial, and spiritual values. Trusting that one is being told the truth is the basis for fostering a relationship of mutual trust between patients and nurses.
This study also noted the relevance of maintaining privacy. According to PFR standards, information about patients must be kept confidential, and hospitals must maintain the confidentiality of patient information and respect the privacy needs of patients. Privacy involves preventing the leakage of information about the health status of a patient.
Maintaining patient privacy according to Hospital Governance/TKRS involves the following; managers create and support a safety culture in hospitals. Healthcare professionals avoid inappropriate behaviors, such as using words or body language to demean or offend, cursing, disruptive or improper verbal and nonverbal behavior, and harassment related to race, religion, or ethnicity, including gender and sexual harassment (Hospital Accreditation Commission/ KARS, 2018).
Nursing managers should focus on their staff to ensure that they are maintaining patients' trust and privacy. Huber (2014) mentioned that staff co-managers should meet the demands of patient-focused care to improve quality and safety and to develop an organizational culture that enhances innovation and evidence-based practice.

Identification of Factors Affected by Body
Image, Age, and Types of Areas and Actions that are Sensitive to Female Patients. These factors should be identified at the initial assessment of a patient. A patient's assessment standard (AP) indicates that a hospital determines the content, number, and type of initial assessments made for patients based on medical and nursing disciplines, including a physical examination, analysis of the medical history, and assessment of the biological, psychological, social, economic, cultural, and spiritual traits of patients. The concept of patient-focused service is the basis for providing patient care in hospitals. Grogan (2018) indicated that body image refers to the perception, thoughts, and feelings of individuals about their own body. Nurses should realize how a patient's body image can lead to feelings of discomfort because of the beliefs and values that they have about sensitive body parts.
This study revealed that the participants referred to their sensitive areas as "intimate areas" and related actions in these areas as "intimate care" (Nipuli & Salmon, 2015). Some kinds of sensitive care can be carried out by patients/ families/trained caregivers, but their implementation must be coordinated among all care providers (PPA) in accordance with Patient Care and Care (PAP). Nursing managers play an important role in optimizing managerial functions, especially in providing direction and considering all operations.

Attention to the Religion, Personal Beliefs, Ethics, and Culture of Patients.
This study focused on the religion, personal beliefs, ethics, and culture of patients. Hospitals provide care in accordance with the standards of the PFR by respecting the religion, beliefs, and personal values of patients and by responding to requests related to spiritual guidance. Every religion offers a moral teaching that influences the behavior of followers (Bertens, 2013). In everyday life, our most important and strongest motivation is found in religion.
Respecting patients through nursing ethics aims to support other ethics-related subjects (Central Board of the Indonesian National Nurses Association, 2017). In this study, the related subjects were male nurses with female patients. According to the TKRS, the hospital framework for ethical management supports ethical decisionmaking in clinical and nonclinical services. A hospital can establish a committee or a team that manages hospital ethics. The ethics and professional discipline subcommittees of the nursing committee are described in the Minister of Health Regulation No. 49 of 2013.
The cultural factors identified by participants are generally associated with the Eastern cul-ture and conservative ideas about interactions between the sexes. Culture is related to a patient's habits. Similarly, Hart and Mareno (2014) stated that nursing care must overcome the challenges of caring for culturally diverse groups.
Nursing managers should have strong team leadership skills. Roussel et al. (2016) indicated that managers working with teams should consider the thoughts and needs of the staff by focusing on patients. The aims of the Communication and Education Management Standards state that hospitals should determine the population that they serve in terms of the demographics of age, ethnicity, religion, education level, and language used. They should also assess communication barriers and provide translators as needed on the basis of the MKE assessment.

Professionalism, Role, and Competencies of Nurses when Caring for Female Patients.
The results of this study were in accordance with the Standards of Competency and Staff Authority. In particular, hospitals should ensure that they have a competent nursing staff in accordance with the mission, resources, and needs of patients; nurses must be competent to provide care and be specific to the type of nursing care. Professionalism must always be maintained by every nurse. Alligood (2017) defined a nurse's role as a set of behaviors expected from people who have a social system, rights, and obligations. The nurses who participated in this study are devoted professional or vocational members of a staff in accordance with Law No. 38 of 2014. In addition, the related topic of nurse competencies is in accordance with Article 18 of Law No. 38 of 2014. Practicing nurses must have an STR, including a competency certificate or professional certificate (Ministry of Law and Human Rights, Republic of Indonesia, 2014). Competence is needed to distinguish competent nurses from incompetent ones.
To protect patients and keep them safe under nursing care, nurses must perform interventions in accordance with their competencies (Central Board of the Indonesian National Nurses Association, 2017). Advocacies should be performed to ensure that interventions provided by male nurses are always safe. According to the Ministry of Health, Republic of Indonesia, Regulation No. 40 (2017), nurse competencies have four types, namely, clinical nurses, nurse managers, educator nurses, and research nurses. All of the participants were clinical nurses. The majority had a diploma education, but they did not take NERS. Nurses need to undergo continuing education to improve the quality of care. Hariyati (2014) stated that nurses are obliged to have an awareness of competencies, careers, and organizations that have policies in career development.
Nursing managers contribute to the professionalism, role, and competencies of nurses. The researcher believed that the organization related to the professionalism, role, and competencies of nurses w the field of nursing. Hariyati (2014) stated that one of the nursing tasks is nurse mapping, and researchers argued that this mapping should include setting shift schedules so that an equitable composition of male and female nurses would be available in each team in consideration of work distribution. Mapping should also consider the physical and psychological conditions of nurses.

Some Communication Strategies and Asking for Help from Female Nurses on the Team.
This study showed that several communication strategies could be implemented to communicate with patients and ask for help from female nurses on the team. Communication is the process of directly or indirectly spreading information from one person to another (Alligood, 2017). It is a component of information developed through interactions.
The first strategy is maintaining direct communication. Nurses must speak softly and use polite words when they begin to communicate with patients. The Central of Board of the Indonesian National Nurses Association (2017) indicated that nurses must show a professional behavior and speak softly; they must always be friendly and courteous in accordance with the nurses' code of ethics.
The second communication strategy is providing an explanation to patients. According to Article 37 of Law No. 38 of 2014, nurses are obliged to provide complete, honest, correct, clear, and comprehensible information regarding nursing actions to patients and families within the limits of their authority (Ministry of Law and Human Rights, Republic of Indonesia, 2014). This communication strategy can be carried out by nurses when they are performing and explaining procedures and when they are obtaining a patient's approval.
The third communication strategy is asking for approval. According to Article 38 of Law No. 38 of 2014, patients have the right to give consent or reject nursing actions to be received (Ministry of Law and Human Rights, Republic of Indonesia, 2014). Nurses must respect their patients and their autonomy to decide on a nursing action.
The fourth communication strategy is asking for a permission. Menendez (2013) stated that nurses must ensure that legal, voluntary, and informed permission is given by competent people. Before taking an action, a nurse must ask permission from patients/families.
The fifth communication strategy is creating a contract. A nurse's contract is exemplified when a nurse begins work by telling a patient about working hours and says goodbye when the working hours end.
The sixth communication strategy is establishing a relationship. According to PFR standards, when a patient is admitted and registered for outpatient/ inpatient care, he or she is asked to sign a general consent form. Introducing oneself creates a close relationship with patients.
The seventh communication strategy is using humor. Sheldon (2009) mentioned that humor can help create a calm environment, relieve tension, and become a useful communication tool for patients.
Asking for help from female nurses on the team was included among the strategies male nurses used when they were caring for female patients. Male nurses are working for the welfare of their patients in accordance with the Central Board of the Indonesian National Nurses Association (2017), which stated that asking for assistance meets the beneficence principle. In other words, an activity is beneficial to patients. Fisher (2009) also indicated that the presence of a companion is important for counteracting the occurrence of sexual abuse between patients and nurses from the opposite sexes. This study further found that treatments were more efficiently given by nurses who have the same sex as their patients. The TKRS standards are intended to ensure nondiscriminatory practices in employment relationships and provisions of patient care by remembering the legal and cultural norms of the Indonesian state.
In response to the results of this study, nursing managers must improve the effectiveness of their communication with their staff in accordance with the SKP standard. According to this standard, hospitals should establish regulations to implement processes that increase the effectiveness of verbal and telephone communication between PPAs.

View of Male Involvement in the Nursing
Profession. This study focused on increasing male involvement in the nursing profession by exploring the motivation of the participants before they chose the nursing profession, the views of male nurses on nursing, and what male nurses are called by patients. The results were consistent with those of Blair (2016), who described the main themes and subthemes of motivational factors (job opportunities, work flexibility, and financial stability) and eliminated gender barriers. Male nurses various motivations about choosing the nursing profession.
This study related the views of male nurses on the stigma of the nursing profession. Frimpong (2016) stated that men consider the stereotypes to be caused by the stigma that nursing is a female profession, not a male profession, with white clothes and stamps.
This study also found that the nursing profession requires great energy for male nurses who conduct various procedures, such as resuscitation and referring. O'Lynn and Krautscheid (2011) mentioned that male nurses are suitable for physical tasks. Male nurses often serve in the ED, ICU, and areas with a large amount of medical equipment. Roth and Coleman (2008) mentioned that many men in nursing are drawn to emergency rooms and mental health facilities because these places are not historically perceived as areas requiring feminine roles.
This study found that the number of men pursuing nursing increased, but the number of women was still greater than that of men. Blair (2016) stated that the number of men in the nursing profession has significantly increased, but the proportion is still predominantly composed of women. Barrett-Landau and Henle (2014) revealed that the demand for male nurses in the labor market is high although male nurses in hospitals are considered as "scarce human resources." This study included data on what male nurses were called: including brothers, mas, fathers, rarely mantri, sometimes doctors in white uniforms, and even mas nuns. Male nurses are often mistaken for doctors. Considering the results of this study on the views about the involvement of men in the nursing profession, nursing managers need to focus on this condition. Huber (2014) and Roussel et al. (2016) indicated that changes in the role of work and gender differences occur, and nursing managers must be able to create a work environment based on specific needs and responses to different workforce requirements.

Conclusion
This study obtained seven research themes that supported the experiences of male nurses when they took care of female patients. Two main factors based on these themes were mainly observed: (1) focusing on the religion, personal beliefs, ethics, and culture of patients and (2) using several communication strategies and asking for help from female nurses on the team. This study suggested that nursing services should improve patient-focused services by paying close attention to ethical factors and patient culture and by implementing communication strategies and asking for team assistance in accordance with a hospital's national accreditation standards.