Degendering Male Nursing Students’ Intimate Care Provision: A South African Perspective

Background : Male nursing students remain a minority group in nursing education and training programmes. They are thought to have diverted from their prescribed roles as men, leading to professional stereotypes and fear of providing intimate care. In addition, the lack of role models and support for male nurses adds to their frustration during clinical placement. The aim of this study was thus to understand male nursing students’ experiences when providing intimate care to diverse patients during clinical placement. Methods : A descriptive phenomenology design was employed. Male nursing students from two nursing education institutions in Gauteng province, South Africa, were purposively sampled based on their experiences and their exposure to providing basic nursing care requiring physical closeness and touch. Twelve (12) male nursing students participated in individual semi-structured interviews. Data were analysed using phenomenological analysis of horizontalisation, creating meaning and essence of intimate care experiences. Results : Four themes emerged from intimate care experiences, which were (1) helping others with basic physical care; (2) cultural issues related to touching naked bodies of diverse patients; (3) adherence to basic nursing care principles; and (4) discomforting reactions during intimate care and touch. Conclusions : Male nursing students are willing to provide quality care to diverse patients. However, some do not accept intimate care and touch based on gender. For male nursing students to be competent in caring for patients, they must be able to provide intimate care to diverse patients confidently and comfortably. Thus, degendering intimate care provision is essential for male nursing students—to provide care without fear of being stereotyped and misinterpreted as sexual predators. Instead, they must be accepted as nurses who are helping patients with their physical needs.


Introduction
In the nursing profession, care is the essence, the moral idea and the foundation of the practice. As a caring process, nursing care needs to be skilled, safe, holistic, ethical, collaborative, individualised, interpersonal, and of high quality planned and designed based on the patient's health problem and positive outcomes [1]. Even though nursing is a female-dominated profession, male nursing students are part of the nursing profession and should provide quality nursing care to all patients. In South Africa, the visibility of men in nursing is gradually increasing. In the 2019-2020 geographic statistic of nursing students in South Africa, 10.5% of nursing students were male. Most African communities ascribe to patriarchal ideologies segregating roles and responsibilities according to gender. Gender means the socially defined people's attributes and capacities are assigned based on sexual characteristics [2]. Gender role stereotypes still prevail in South African societies, suggesting that men are less caring [3] and pose a sexual threat [4], especially to female patients. Thus, men entering the nursing profession experience socio-cultural stereotype roles of emasculated, deviant or sexual predators [3]. Therefore, providing intimate care to female patients is problematic in a country where gender-based violence is rising, with increased rape statistics for women and young girls [5]. There are few incidences of South African male nurses being accused of heinous acts against young girls. For instance, in 2019, a male nurse appeared court for allegedly murdering a four-year-old girl [6]. Early 2020, a 52-year-old male nurse was arrested for allegedly raping his two-yearold stepdaughter [7]. In 2021, the South African President enacted laws to strengthen efforts to end gender-based violence with a victim-centred focus on combating the dehumanising pandemic. Despite the gender-related issues, male nursing students should provide culturally and religiously acceptable nursing care when patients seek healthcare.
Basic nursing care requires nurses to touch patients. This touch is used to communicate and provide patient care to convey respect and comfort during care interaction. Intimate care is an intimate physical touch used for the inspection of and possible physical contact with those parts of the body whose exposure can cause embarrassment to either patient or the nurse [8]. O'Lynn and Krautsheid [9] expanded the definition of intimate care as task-oriented touch to areas of patients' bodies that might produce discomfort, anxiety and fear or be misinterpreted as having a sexual purpose. It also involves physical and psychological closeness between a nurse and a patient; a nurse touches a stranger, and a patient allows a nurse to touch their body [10]. The areas of the body that are touched during intimate care provision include genitalia, buttocks, perineum, inner thigh, lower abdomen and breasts [11]. Consequently, intimate care may cross the boundaries of physical and psychological safe spaces due to gender, cultural background, and previous touch experience [12]. Even though touch is essential during the provision of intimate care, it poses challenges for male nurses because society normalises women's use of touch as caring behaviour. The female patients' gendered discomfort experienced during intimate care may lead to the sexualisation of male nurses' touch [13]. However, male nurses sometimes experience sexual harassment during intimate care. A study [14] conducted in Greece reported that 40% of male nurses experienced sexual harassment, including unwanted attention; these experiences were not reported, as the nurses feared disbelief. In the patriarchal society, men are thought to be the perpetrators of sexual violence, not the other way round. Therefore, the male nursing students' sexual harassment incidence may not be attended to promptly. In the male nurses' harassment, the female patients were attracted to the male body, not the nurse, making intimate care provision a daily struggle [4]. Female patients sometimes reject and distrust the nurses' care [15] because their intentions are questionable. As indicated earlier, South African male nurses may find it difficult to report harassment as the focus is on genderbased violence against women and young girls.
Intimate care transforms a private personal activity into a social process shaped by the complex nurse and patient attributes, behaviours, and physical environment [16]. People's characters can be affected by their socialisation, and the new environment may lead to a new paradigm shift from customs learnt in childhood [2]. Male nursing students would have to familiarise themselves with the nursing environment and norms. Intimate and personal care may be considered profane and repellent yet remains hidden in nursing practice [17] and curricula [18]. Nursing students do not have sufficient time to adjust to their nursing roles, leading to increased stress when providing intimate care based on prescribed gender roles [19]. Therefore, nursing education should create awareness, open discussion and teaching on intimate care and touch for patients of different cultures, religions, ages, gender and sexual orientations. This paper aimed to understand male nursing students' experiences when providing intimate care to diverse patients.

Design
A theory-generative study was conducted, with multiple phases published elsewhere [10,18,20] this manuscript presents descriptive phenomenological experiences of male nursing students in providing intimate care to diverse patients. A phenomenological study focuses on the conscious experiences of the participants and gains meaning from a phenomenon [21]. It encourages the researchers to get to the heart of the specific events as humanly experienced [22]. Descriptive phenomenology assists the author in describing or interpreting the meanings of the phenomenon experienced by participants during the investigation [23]. The author adhered to bracketing, intuiting, analysing, and describing the principles of descriptive phenomenology. The author is a Health Sciences educator; before data collection, she bracketed the identified beliefs, opinions and ideas about intimate care using a reflective journal. After each semi-structured interview, the author applied intuiting by focusing on the meaning of intimate care described by the participants and immersed in verbatim transcription and data analysis. Analysing focused on the phenomenological analysis method for the author to make sense of the meanings and experiences of intimate care by male nursing students and to create the emergence of the essence and universal themes. The meaning of intimate care was described by providing comprehension and extracting from participants' voices.

Sampling
The non-probability technique entails systematically selecting a relatively small number of individuals from a defined population [24]. Purposive sampling was used to seek male nursing students with experience providing intimate care to diverse patients. Male nursing students registered for a four-year qualification in comprehensive nursing, who were in their second or third academic years, participated in the study. The study included the participants because they had been allocated for more than six months in general medical and surgical wards and provided basic nursing care requiring touch to diverse patients. The firstyear nursing students were excluded as they were in clinical placement for less than six months, and the fourth-year students were busy with their psychiatric clinical assessments. The participants were between 21 and 28 years of age.

Data Collection
Individual semi-structured interviews were conducted with twelve (12) male nursing students. Data were collected in two Nursing Education Institutions (NEIs) classrooms secured for the interview session during April-June 2016. The researcher collected data before lectures and on weekends as the participants resided in the students' residential apartments. The duration of the semi-structured interview was 15-20 minutes. All participants signed informed consent before the interview, and voluntary participation was emphasised. Three open-ended questions were asked to all participants: (1) please explain your understanding of intimate care and touch, (2) discuss the principles you use when providing intimate care to diverse patients, and (3) describe the experiences of providing intimate care to diverse patients". In addition, probing questions were asked for the participant to simplify or provide clarity, such as "Can you please elaborate on …".

Data Analysis
The author physically and mentally immersed herself in the data analysis while reading transcripts, bracketing her prior knowledge of intimate care. Data were analysed using verbatim transcription for all 12 interviews. The author and coder analysed the data independently. The refined steps of phenomenological analysis were used [25]. During horizontalisation, the author and independent coder listened to relevant expressions and grouped similar experiences of intimate care. The data reduction was made by eliminating phrases that did not contain necessary or sufficient experiences of intimate care. Next, the thematic labels were applied to invariant constituents. The consistent constituents were checked against the participants' explicit expression and compatibility. Finally, the construction of individual textual descriptions was executed to create meaning and essence regarding the male nursing students' experiences of intimate care. The author and coder discussed the identified and modified themes as necessary and agreed on the final themes presented in this article.

Trustworthiness
Trustworthiness was established using the principles of credibility, dependability, conformability, and transferability, as proposed by Lincoln and Guba (1985) cited in [26]. Credibility was enhanced by recruiting male nursing students who had experience in providing basic nursing care requiring touch. To ensure dependability, semi-structured interviews were conducted using an interview guide for all the participants. Each step of the research process was described in depth to allow the reader to determine whether proper research practices have been followed and whether similar studies can be repeated [26]. Conformability was established by the researcher and the coder analysing data independently. The emerging themes and meanings were compared and verified. For transferability, detailed, indepth descriptions of the findings, research contexts and data were used to represent different aspects of the phenomenon.

Participants' Characteristics
Twelve (12) male nursing students registered for a four-year diploma in comprehensive nursing qualifications were interviewed to understand their experiences of providing intimate care. All participants were Africans ranging from 21 to 28 years of age and were in their second or third academic year. Table 1 displays the summary of the participants' characteristics.

Semi-Structured Interview Finding
Four distinct themes were identified during data analysis: firstly, the understanding of intimate care as helping others with physical needs; secondly, cultural issues related to touch during intimate care provision; thirdly, the adherence to basic nursing care procedural principles; fourthly, the discomforting reactions to intimate care provision. These themes are discussed in depth below. Fig. 1 presents the participants' interconnected experiences when providing intimate care to diverse patients.  When providing intimate care, touch cannot be avoided. When assisting a patient with basic physical needs, the participants had to touch to communicate care.
"For me, intimate care will be putting it, in essence, it will include touching and empathising with a patient in a sense that you will be available for the patient, in a sense that physical touching will be more comforting than arousing the patient […]." (M6-2016) Intimate care is provided in a confined space in a ward; the patient and a nurse must be able to negotiate and use it to give and receive care. Even though intimate care is related to helping patients with their physical needs, a nurse should maintain certain boundaries. For example, the touch and what is spoken must be related to the care offered: "When a nurse cares for a patient and makes a patient feel good about themselves, you should not come close to the patient while touching him/her, and you should not talk about any other things other than the patient's condition." (M5-2016) The participants emphasised the need to consider the patient's uniqueness during touch. Therefore, socialcultural and religious values and beliefs should be included in patient care.
"As a nurse, you need to assess the patient's needs and beliefs, give necessary patient care, and don't go deep, but at the same time, you will make a patient feel better, including touch areas that need to be touched for care." (M7-2016) "Patients come from different cultural backgrounds, so, when providing intimate care, you need to consider their response to the care that you will be giving, and you need to consider their feelings." (M3-2016) In this theme, providing care for the physical bodily needs of a patient includes elimination, hygiene and nutrition. These needs are provided in a confined space where a nurse and patient a physically close. During the execution of intimate care, the nurse must touch the patient, and the patient must permit the nurse to touch their fragile body. In addition, there is an emphasis on respecting the patient's socio-cultural uniqueness and providing intimate care safely. Safe intimate care includes listening and observing the patient's response to the touch.

Theme 2: Cultural Issues Related to Touch during Intimate Care Provision
The socio-cultural diversity of the nursing students and the patients may not encourage touch during intimate care provision. For example, all participants in this study were South African male nursing students with different upbringing based on socio-cultural values and beliefs on caring for the human body. Yet, the issue of touching a stranger had similar sentiments regarding parts of the body touched, gender, and age. Hierarchy and gender roles are well defined in South African cultures; for example, cross-gender care is unacceptable, meaning that male nurses' caring for female patients and female nurses caring for male patients are frowned upon.

"[…] there is a thin between a male and female touch; it is not acceptable for males and females to touch each other. If an elderly male is sick, males in the family are the ones to attend to him. Same as in females." (M4-2016)
"touch is a sensitive thing; when it comes to elders, you don't just touch them, whether they are aggrieved or happy, even when sick. You don't just touch them unless they touch you first or when you are greeting using a handshake." (M7-2016) Patients are autonomous beings and have the right to refuse care based on their socio-cultural beliefs. However, the participants attest that the patient's acceptance of their care is crucial.
" Each society values the exposure of the body differently. Therefore, the male nursing students need to understand the meaning attached to the body based on the patient's socio-cultural and religious affiliations. As well noted, South Africa is a democratic country that values the dignity, integrity and life of its people. Therefore, the participants knew the patient's right to decide on their bodies.

Theme 3: Adherence to Basic Nursing Care Procedural Principles
The first step in executing basic nursing care is giving a patient enough information to make an informed decision about the care to be provided. The participants understood the importance of informing the patients about the nursing procedure.
"…explaining what you are going to do to the patient. I know that I have to provide care to all patients, and they must give me permission […] that is why we have to tell them about the procedure first." (M6-2016) "... we need to explain the procedure to a patient to create rapport, and gain cooperation from the patient, that way it makes things easier when providing sensitive care." (M3-2016) Once the procedure is explained, the patients should permit the nurse to care for their bodies. Participants expressed that the patients have the right to be involved in the decision-making.
"… ask permission from the patient before doing the procedure; the patient has to agree first because it's one of the patient's rights that they need to be involved in the decision on their care. Their cultural beliefs need to be respected. So the patient needs to permit receiving care from a nurse." (M7-2016) "

[…] before bathing [the patient] you should ask for permission and you should ask if the patient is comfortable like if a male nurse and a patient is a female, I should ask the patient if she is comfortable with me bathing her." (M1-2016)
When providing intimate care, the nurse should provide physical privacy by pulling the screens or using mobile screens. During the intimate care, the participants provided privacy and did not expose the patient unnecessarily by only seeing and touching the areas of the body requiring care.

"[…] give privacy to patients by screening so that other patients will not see what is happening, and should not expose other areas [of the body] or take off the whole blanket, you must do it step by step […]." (M2-2016) "[…] you must expose the patient's body part for provision of care, not the whole body, always respect the patient's body." (M8-2016)
Adherence to procedural principles means nurses can negotiate care with the patients. Nursing students have been taught autonomy as it provides the patient with information about the procedure. It is also crucial to discuss with the patients how and the body part that will be touched. This will create an environment where respectful and transparent relationships will be developed and offer a patient an opportunity to discuss their preferences regarding the gender of the nurse and body exposure.

Theme 4: Gendered Intimate Care Reactions
Providing intimate care to young female patients posed challenges and triggered unpleasant experiences for the male nursing students. Two participants shared their moments of discomfort during the provision of intimate care.
" […] the procedure was the insertion of the [urinary] catheter. When I was busy explaining the procedure to her, she seemed to joke for a moment, but the things she was saying like they were including sexual references, like me as a male looking at her private parts, asking me how I feel when doing that to her. Do I get aroused, or do I blackout and just become a nurse when doing it?" (M5-2016) "I had an incident when I was giving a bed bath to a female patient: we were of the same age; during the bath, I observed her reaction towards me; I ended up asking myself was my touch was professional or not because the patient ended up having a form of attraction towards me." (M6-2016) Men are often considered emotionally strong and confident, yet when providing intimate care, self-doubt and confusion are experienced: "Every time I touch a female patient, I ask myself how she feels; does she feel like I am harassing her or feel safe with me? These feelings come when I bathe or serve a bedpan, but worse when inserting a urinary catheter; I ask myself, am I being disrespectful, intimate, or just a nurse?" (M9-2016) Male nursing students can experience sexual harassment when providing intimate care. In addition, the experience of female patients expressing sexual attraction adds pressure on male nursing students.
"She ended up having physical attraction towards me, in the sense that I don't know, and I don't know where she ended up having my personal details; she ended up calling me wanting to meet with me. Ever since that day, I always have this dilemma if touching this patient is going to give care that is health-related or is it going to be intimate leading the patient misinterpreting my intention towards them." (M6-2016) The age and gender of the patient are critical in the execution of intimate care. As the participants and female patients were younger, one part expressed physical and sexual attraction. Therefore, the male nursing student should be prepared for various discomforting experiences during intimate care and touch. When they have provided intimate care with respect and dignity, self-doubt and confusion are unnecessary. Patients' responses to their care are beyond their control. Hence, the focus should be on creating a conducive and safe physical and psychological environment for themselves and their patients.

Discussion
The study aimed to understand the experiences of male nursing students when performing intimate care of different ages, cultures, religions, gender, and sexual orientation. The male nursing students identified intimate care as helping others with basic physical needs that require touch and experienced cultural issues related to touch during intimate care. When providing intimate care, they adhered to basic nursing care procedural principles, and when providing intimate care to young female patients, they encountered gendering intimate care reactions.

Intimate Care: Helping Others with Basic Physical Needs
The participants viewed intimate care as helping the patients with their physical needs. Harding [27] affirms this view as they indicate that men enter the nursing profession to help people make a difference in their lives. Assisting patients with their daily needs, including hygiene, elimination and nutrition, is a fundamental role of the profession, leading to the intimate physical closeness between a nurse and a patient [19]. While helping the patient, the male nursing students should be physically close to the patient and touch sensitive or private areas of the patient's body. However, the intimate touch provided during basic nursing care was task-oriented. Therefore, touch is an intrinsic component of intimate care and a medium to connect with a patient to achieve nursing care goals [19].

Cultural Issues Related to Touch during Intimate Care Provision
This study found that touch during intimate care provision created cultural dilemmas that stimulate discomfort and fear as the male nursing students cross the gender roles and norms boundaries. The touch of a male nurse crosses boundaries during the provision of intimate care; thus, a safe space is required. The dressing and undressing of a patient to give or receive intimate body care cross physical boundaries [12]. Most participants in this study expressed the unacceptability of touch, especially on body parts considered private and sensitive. In the South African context, care of the body is confined to family based on gender and occurs within the safe environment of their homes [28]. At anntimate care provision a daily strug girls are taught to perform motherly roles of caring for the family (cleaning, cooking and attending to sick members). Boys are taught to provide security for the elderly and family name [2]. Therefore, the care provided by female nurses is acceptable based on the feminine personality attribute [29] and their touch is considered natural and maternal [12]. The participants experienced rejection by some female patients based on being men as society does not accept cross-gender care. These experiences are not isolated, men are perceived to lack the capacity to care, and their touch is sexualised [9]. Traditional gender roles and norms are imposed and reinforced in nursing practice, potentially limiting diversity and innovation in nursing [30]. All nurses should provide sensitive and culturally appropriate patient care [31]. Dowdell [32] asserts that nursing students should be sensitive to patients' diversity in identity, culture, religion, age, gender and sexual orientation.

Adherence to Basic Nursing Care Procedural Principles
During intimate care, the participants informed the patients about the procedure to obtain consent. To adhere to the ethical principle of autonomy, a nurse must inform the patients about what will be done to their bodies, even if it may cause discomfort. Any touch can be interpreted as unwanted or threatening to a patient. Therefore, patients need to know in advance that they will be touched, how they will be touched and why they will be touched [33]. The participants emphasise the importance of getting permission to execute nursing care. Getting approval before touching the patient gives them a choice and control over their body [34] and reduces the sense of helplessness [33]. In another study [9], patients wanted to be informed about the care provided and their gender preferences to be taken seriously. The study participants also explained the importance of maintaining physical privacy. Privacy is relative to providing a physical and psychologically safe non-discriminatory environment where a nurse and a patient develop a relationship based on trust [32]. Based on the participants' responses, they received training on the basic nursing care procedural principles to create a nurse-patient relationship grounded on trust, respect and dignity [18]. The South African Nursing Council Education and Training Standards [35] emphasise that the curriculum content and clinical experience should promote and support nursing practice, such as social inclusion, respect for individual choice and diversity. The honours are on the nurse educators to create a safe environment to practice intimate care and touch exposure.

Gendered Intimate Care Reactions
Sadly, when the male nursing students provided intimate care to young female patients, they often misinterpreted their provision of intimate care as they developed a sexual attraction. The sexualisation of men's touch is well known in most societies [8], mainly when male nurses care for the body's most sensitive and private parts [9]. The female patients' development of sexual interest may account for sexual harassment. These experiences are confirmed in Baker's [4] findings that female patients could not look beyond the male nursing students' gender during nursing care. In a Sub-Saharan Africa study on sexual harassment, male nursing students experienced 61.3% of sexual jokes and 48.4% of unwelcome touching and hugging [36]. In Greece, 30% of male nurses' sexual harassment incidents were not reported due to fear of disbelief [14] as this experience can be viewed as a sign of weakness as men should be strong [37].
The misinterpretation of intimate care by young female patients created self-doubt and confusion for the participants. Despite social changes and efforts to promote gender equality, many societies in South Africa still reinforce gender roles and expectations [2]. Degendering of male nursing students' intimate care and touch is required for male nursing students to provide quality care without fear of misinterpretation. Gendering and misunderstanding during intimate care and touch may lead to male nursing students avoiding providing intimate care to female patients. Avoiding basic nursing procedures such as intimate care and touch may compromise the male nursing students' competencies. This study confirms that men in nursing are willing to provide care in conjunction with women and do not intend to violate women's right to quality care. However, in some Nursing Education Institutions, male nurse educators are not available to role model the possible quality care that male nurses can provide to diverse patients. Intimate care and touch teaching should not be taken for granted, as the students may not be familiar with negotiating safe spaces for intimate care provision for themselves and their patients. The nursing fraternity should work toward understanding gender role stereotypes to create gender neutrality. Inclusion of intimate care and touch in the prescribed textbooks and procedure manuals is critical to producing male nurses who are conscious of the needs of the individual patients.

Conclusions
Male nursing students need to be supported in their willingness to provide quality care to all patients regardless of gender, age, culture and religion. Nursing education and practice must neutralise the socio-cultural gender stereotypes that inhibit male nursing students from implementing intimate care competently. It is clear that patriarchal values and norms still exist in societies. Thus, during nursing training, male nursing students need to be oriented to provide safe care for female patients and should be aware that their touch may be misinterpreted and rejected in clinical practice. Creating intimate care conflict awareness will assist them in developing strategies to deal with uncomfortable intimate care incidents without losing their identity as men. They should be encouraged to reflect on their sociocultural values and be open to listening and learning from their patients.

Author Contributions
The manuscript is single-authored; SS performed the research, collected and analysed the narrative data, and wrote the manuscript.

Ethics Approval and Consent to Participate
The researcher obtained an Ethical Clearance Certificate (HSHDC/496/2015) from the Higher Degrees Committee of the University of South Africa in December 2015. The approval to conduct the study was obtained from the Gauteng Department of Health (GP_2016RP31_379). The two selected nursing education institutions permitted the researcher to collect data from the male nursing students. Participants were informed about the nature of the study, the researcher emphasised voluntary participation, and the male nursing students signed informed consent forms before participating in the individual semi-structured interviews.